婦癌腫瘤
教學與工作規範
Uterine
Cervical Carcinoma
Cervix
carcinoma is the most common cancer of female reproductive tract in
Clinical
symptom and sign:
1.
Asympomatic: most often in the early stage.
2.
Irregular vaginal bleeding: Intermenstral vaginal bleeding, post-coital vaginal
bleeding, post-menopausal vaginal bleeding.
3.
Obstructive uropathy: uremia in stages IIIb
Diagnosis:
1.
PAP smear: acurate rate, 85 - 90%
2.
Colposcopy: abnormal vessels, irregular surface epithelium, acetowhite lesion,
mosaic, punctation epithelium.
3.
Punch biopsy of cervical tissue: When frank tumors are seen. Fr D&C is only indicated with
abnormal uterine bleeding and no apparent cervical lesions or unsatisfactory
colposcopy.
4.
Duplex sonography: new equipment, on investigation.
5.
Pelvic examination: PV + PR Bimanual exam with rectovaginal
technique.
Histology:
1.
Squamous cell carcinoma: most common
Oncologic
Surveys for new patient:
1.
Pelvo-abdominal CT scan: liver, pelvic L/N, para-aortic L/N,
hydronephrosis
2.
MRI: tumor size, invasion depth
3.
Tumor markers: SCC, CEA, TPS, CA-125
4.
Duplex sonography
5.
Cystoscopy, Proctoscopy: In advanced stages (>IIb)
6.
Chest X-ray
7.
CBC, biochemistry, U/A, S/A
8.
Bone scan (>IIb)
Stage:
clinical stage (FIGO)
Preinvasive
Carcinoma
Stage 0 Carcinoma in situ, intraepithelial neoplasia (cases
of Stage 0 should not be
included in any therapeutic
statistics).
Invasive
Carcinoma
Stage I* Carcinoma strictly confined to the cervix
(extension to the corpus should be
disregarded).
Stage Ia Preclinical carcinomas of
the cervix, that is, those diagnosed only
by microscopy.
Stage
Ia1 Minimal
microscopically evident stromal invasion.
Stage
Ia2 Lesions detected
microscopically that can be measured.
The upper limit of the measurement should not show
a
depth of invasion of more than 5 mm taken from
the
base of the epithelium, either surface or
glandular, from
which it originates, and a second dimension, the
horizontal
spread, must not exceed 7 mm. Larger lesions
should
be staged as Ib.
Stage Ib1
Lesions of greater dimensions than Stage Ia2 whether seen
clinically
or not.
Preformed space involvement should not alter the
staging
but should be specifically recorded so as to
determine whether it
should affect treatment decisions in the future
and cervical tumor < 4
cm.
Stage Ib2 When greatest dimension >
4 cm.
Stage II The
carcinoma extends beyond the cervix but has not extended on to the pelvic
wall.
The carcinoma involves the vagina, but not the lower
third.
Stage IIa No
obvious parametrial involvement.
Stage
IIb Obvious parametrial
involvement.
Stage III The carcinoma has extended on to the pelvic
wall. On rectal
examination,
there is no cancer-free space between the tumor
and the pelvic wall.
The
tumor involves the lower third of the
vagina. All cases with
hydronephrosis or
nonfunctioning kidney.
Stage IIIa No
extension to the pelvic wall.
Stage IIIb
Extension on to the-pelvic wall and/or hydronephrosis
or
nonfunctioning kidney.
Stage IV The carcinoma has extended beyond the true
pelvis or has clinically involved
the mucosa of the bladder or rectum. A bullous edema as such does not
permit
a case to be allotted to Stage
IV.
Stage IVa Spread
of the growth to adjacent organs.
Stage
IVb Spread to distant
organs.
Management
of new patient: All the new patients should enter the proper study
protocol
*
子宮頸癌治療之中有許多因素可能影響治療的結果，所以同樣是一期"B"的病人，不一定都適合手術，必須依照淋巴腺的有無、腫瘤大小等因子訂出最恰當的治療。為了提高病人的治療成效，也為了臨床醫學研究，婦癌科內有許多研究計劃(protocol)正在進行之中。
IVb:
原則上以palliation為主，視病患之general
condixtion來決定是否追加化學治療。
*
開完RAH後病理報告中pelvic
lymph node有轉移時，若病人為stage
IIa
Ib，則進入以下之protocol。
*
RAH後須加Adjurant
R/T的情況:
1.
The invasion depth of cervix＞2/3
and lymphatic permeation (＋)
full thickness stromal invasion。
2.
Parametrial involvement。
*
Neo-adjuvant chemotherapy之修訂:
現行方法中若第三次化學治療前發現腫瘤並無反應之病患擬更改為提早手術或換藥再作一次化學治療。
*
Concurrent chemoradiation(CCRT)二年經驗中發現：在R/T同時給予combination
regimen對於疾病的控制並沒有明顯的幫助，但卻增加了併發症的機會，部分病患更因併發症而延誤了R/T的治療計劃，所以現正研究中，將來CCRT將改成single
agent (cisplatin)，俟進行近接治療(brachytherapy)時，依照新protocol規定有必要者才用combination
regimen。
RAH的Post-Op
Care:
1.
傷口:
術後第一天換藥，之後每天檢視傷口，滿7天拆線(autosuture
clip, michele clip)，傷口若有異常分泌物及紅腫現象，則須以normal
saline (或kanamycis加於normal
saline中)
wet dressing。假如無法改善，則懷疑傷口感染，此時應提早拆除患部之suture再行wet
dressing，並取傷口分泌物作厭氧及嗜氧之細菌培養。
2.
Vacuum ball: 每天總計引流出的量(左、右分開計算)，day
total小於50ml才能管，拔管後皮膚的切開傷口只須以乾淨紗布覆蓋，俟其自然癒合。
3.
呼吸治療:
為了減少因長間的手術導致肺泡擴張不全(atelectasis)，術後第一天起須接受呼吸治療(IPPB)，持續3天。
4.
尿管:開完RAH的病患手術中，因為我們是採用骨盆腔神經保護的新式手術方法，
所以膀胱的神經不會受傷，所以尿管可以在手術後的第五天拔。同時不用作膀胱訓練(bladder
training)。
5.
不需要催排氣，24小時就可以喝水進食。48小時可以洗澡，只給一天的抗生素。
6.
第5天例行作U/A、U/C。
自解及導尿：拔尿管當日（手術後第五天）起實施
1.
請病人自己解小便，並記錄自解量，自解後15分鐘內請小姐測量膀胱餘尿，請用膀胱測量儀測量，不需要導尿。
2.
每次自解加導尿最好不要超過400ml，以免膀胱因為過度脹尿而失去知覺，無法有效用力解尿。
3.
當每次的導出尿量都<50ml，則可不用再測量。
4.
不需安排IVP檢查院。
7.
可以用Urecholine加強膀胱收縮力量及Dibenylene促使urethral
sphincter relax。
Bladder
Training膀胱訓練：因為我們是採用骨盆腔神經保護的新式手術方法，
所以膀胱的神經不會受傷，所以尿管可以在手術後的第五天拔。同時不用作膀胱訓練(bladder
training)。
如果解尿不良，
或是沒有執行骨盆腔神經保護的新式子宮根除手術，則需要執行膀胱訓練，
其過程如下：
住院前3天：把尿管綁起來，每一個小時放開15分鐘重覆操作一天。
把尿管綁起來，每二個小時放開15分鐘重覆操作一天。
把尿管綁起來，每三個小時放開15分鐘重覆操作一天。
住院日(術後第21天)：1.
拔尿管。
2. urine analysis: 若有UTI則須加antibiotics。
3. urine culture: culture長菌必須根據Sensitivity給藥。
4. 自解及導尿。
自解及導尿：拔尿管當日起實施
1.
每天9:00AM,
12:00AM, 3:00PM, 6:00PM, 9:00PM, 2:00AM, 6:00AM請病人自己解小便，並記錄自解量，自解後15分鐘內請小姐導尿，也記錄導尿量。
2.
每次自解加導尿最好不要超過400ml，以免膀胱因為過度脹尿而失去知覺，無法有效用力解尿。
3.
當每天的自解量總和>導尿量總和，則可改成5次(9AM,
12AM, 3PM, 6PM, 9PM)。
4.
當每次的導出尿量都<100ml，則可改成2次(9AM,
8PM)。
5.
當每次的導出尿量都<50ml，則可不用再導尿(訓練完成)。
6.
改2次時，同時安排IVP檢查，IVP沒問題則病人可以出院。
7.
自解訓練時，可以用Urecholine加強膀胱收縮力量及Dibenylene促使urethral
sphincter relax。
*Recurrent
cervical cancer: 放射治療完成後
Recurrent以其位置可以分為:
1.
Local regional recurrence: 復發在vagina,
vaginal cuff, parametrium及近端的pelvis稱之，為最常見的recurrence方式。再發者在主動脈上淋巴腺者治療時須同時檢查胸部電腦斷層(chest
CT Scan)及頸部淋巴腺以排除同時合併遠端轉移(distal
metastasis)。
¬
如果病人未曾作過放射治療。則以放射治療為主，視病灶大小(一般是以大於4公分)輔以化學治療。
如果病人以前作過放射治療，則以手術為主，經常是臟器摘除手術(pelvic
exenteration)，視腫瘤的位置施行anterior
exenteration; posterior exenteration或是total
exenteration，病人選擇得宜exteneration後的病患5年存活率仍有50%，有淋巴腺轉移的病患不適合此手術，以往腫瘤若已侵犯骨盆腔壁(pelvic
sidewall)也被視為exenteration
surgery的contraindication。但是最近兩年和放射腫瘤科合作手術中預埋管，術後近接治療(combined
operation radiotherapeutic; COBRT)使得某些pelvic
sidewall侵犯的腫瘤也可以經由手術治療加放射治療治癒。
2.
Distant metastasis: distant metastasis的預後較差、存活率較低。治療的目標大多是以延緩腫瘤生長、減輕症狀的palliative
treatment為主，治療模式則以化學治療輔以局部放射治療或單獨使用化學治療為主。但也有少數病患經治療後維持disease
free。
3.
Perineal and inguinal lymph node metastasis: inguinal lymph node
metastasis經常是在vagina的下1/3或外陰有腫瘤後才發生。
¬
perineal lesion: 仍然可以作external
radiation。
inguinal lymph node: 通常以electron
beam和photon混合作放射治療加上化學治療。
*
Cervical cancer post-treatment follow-up: Cervical cancer的F/U以PV
+ PR檢查，Pap
smear及tumor
marker為主。tumor
marker (SCC; CEA)的postive
predictive value相當高，昇高立刻recheck若確認則須詳細檢查可能的病灶。
另外，病人若主訴背痛腿腫，體重減輕則必須立即想到復發的可能性。
【彩色超音波於子宮頸癌的臨床應用價值】
*
彩色超音波近年來應用於卵巢腫瘤的手術前評估有相當的成就。對於子宮頸癌則沒有很好的報告。本科也設計了protocol研究子宮頸癌在化學治療中腫瘤內血液的變化及臨床應用。
material:
stage Ib. IIa. bulky (protocol No.)之病患。
method:
Acuson XP 128三次transrectal
sonography檢查(項目:
126)
1.
化學治療之前。
2.
第二次化學治療後(第三次化學治療之前)。
3.
手術之前一日(第三次化學治療之後)。
初步結果如下：
1.
經肛門超音波不直接碰觸子宮頸腫瘤、不會出血，病人也不會疼痛，為一項理想的檢查方法。
2.
以超音波測定腫瘤大小的正確性令人滿意。
3.
化學治療過程中，腫瘤縮小程度和血管密度成正比。
4.
化學治療過程中，腫瘤血管之阻力係數(RI,
resistance index)不因腫瘤大小之縮減而改變。
最後的結論仍有待更多的case
number才能獲得，此項研究現仍進行之中，若有符合條件的case，應通知NSP進入protocol。
*彩色超音波對放射治療中之腫瘤則為下一個研究的目標。
Paeients:
Stage Ib. IIa bucky tumor randomize到R/T的病患。
Method:
Acuson HP 128 transrectal sonography.
檢查時間：
1.
治療前。
2.
完成4,400
cGy之後(brackytherapy之前)。
3.
近接治療(brackytherapy)之後。
4.
所有治療全部完成之後一個月。
希望能得到結論，並實際在臨床中用以判定放射治療中之腫瘤反應如何？是否仍有存活之癌細胞，需不需要再追加其他治療。
結論：
子宮頸癌雖是台灣婦女癌症死亡率之第三位，只要詳細檢查、接受治療，仍有很高的治癒機會。
Vulvar
Cancer會陰癌
顧名思義Vulvar
Carcinoma是指由會陰部長出來的cancer，部分vulvar的cancer事實上的原發部位是子宮頸，會陰部份的病灶是轉移而來的，所以診斷vulvar
cancer必須排除cervical
cancer。
Vulvar
Ca最會發生於labia
majora，其次是labia
minora。
Etiology and Risk
Factors:
1. No definitive
etiologic factor has been identified
2. Risk factors:
multiple sexual partners, history of genital warts, smoking,
HPV
3. Previous vulva
intraepithelial neoplasia (CIS)
Classification of vulvar
disease
_______________________________________________________________
Nonneoplastic epithelial
disorders of skin and mucosa
Lichen sclerosus
et atrophicus
Squamous
hyperplasia, not otherwide specified (formerly _
hyperplastic dystrophy
without atypia_)
Other
dermatoses
_______________________________________________________________
Mixed nonneoplastic and
neoplastic epithelial disorders
_______________________________________________________________
Intraepithelial
neoplasia
squamous
intraepithelial neoplasia ( formerly _
dystrophies with
atypia)
VIN
1
VIN
2
VIN 3
(severe dysplasia or carcinoma in situ)
Nonsquamous intraepithelial neoplasia
Paget's𠏋
disease
Tumors of
melanocytes, noninvasive
_______________________________________________________________
Invasive
tumors
_______________________________________________________________
adapted from Int J Gynecol Pathol 8: 83,
1989
Invasive Vulvar Cancer: most
often in menopausal female, meas age of diagnosis is 65
y/o
* Post Radical
Vulvectomy的Care:
1.
術後前3天除藥物外須禁食(術前須colon
prepare以利術後延遲解便時間)。
2.
使用paregonic
tincture使病人在前5天不排便，不免污染傷口，減少infection機會。
3.
第6天起給軟便劑，以防病用力排便傷口裂開。
4.
術後病人的腳不要張得太開，以減少傷口縫合的張力。
5.
術後一週內病人不穿褲子，而以"罩子"(打燈籠)外面蓋被子蓋住下半身。
6.
每日記錄每一個Vaccum
ball的日排出量，小於5cc才能拔除。
7.
術後立即給two
combined antibiotics，一般是選用一種broad
spectrum加上一種aminoglycoside
(eg cefamezine + GM)。
8.
Vaccum ball流出液體若有異味或異色則立即採集液體作嗜氧及厭氧之細菌培養，並依細菌培養報告之藥物敏感性測驗結果更改消炎藥物之選用。
9.
每日檢查傷口看植皮或皮瓣部分有無壞死，若有紅腫等發炎徵兆，則以生理食鹽水紗布作wet
dressing, q4hr。
10.
若傷口癒合良好，第8天起可以拆線鼠蹊部淋巴腺分離切法傷口部份，至於外陰的傷口視療合情況由主治醫師決定。
11.
第4天須查病理報告，以便規劃後續治療。
*
Adjuvant R/T: 以下情況術後須追加放射治療。
1.
Pelvic lymph node有轉移。
2.
Groin lymph node有轉移(包括cloquet's
node)。
3.
會陰部之surgical
margin仍有cancer或precancer
lesion。
4.
會陰部的病灶已深及骨膜(periostum)而無法全部拿乾淨。
5.
淺部之轉移淋巴腺≧2個以上。
Clinical
features:
1. Vulvar lump or
mass
2. Vulva itching,
pruritus (vulvar dystrophy)
3. Vulvar
bleeding, discharge, dysuria
4. Groin mass
(metastatic lesion)
5. Vulvar wart,
fleshy, ulcerated, leukoplakic appearance
6. Site of
occurrence: labia majora is most often, labia minora, clitoris, and then
perineum
7. 5% of the
cases are multifocal
8.
早期會陰癌的臨床表現都只有搔癢及破皮或潰瘍，所以，如果有會陰部潰瘍或破皮經治療後(一個月後)仍然不會好，一定要考慮會陰癌，並安排切片檢查。
Diagnosis: pathology is
required
1. Wedge biopsy:
better include surrounding skin and underlying dermis to determine the invasion
depth or stromal invasion, especially in early cancer
2. Excisional
biopsy in lesion less than 1 cm in diameter
3.
Pelvo-abdominal CT scan: to determine the lymph node status of the inguinal,
external iliac and even common iliac and paraaortic area.
4.
CXR
5. Tumor markers:
only SCC-Ag in some squamous cell carcinoma
6. Fine needle
aspiration cytology of suspicious inguinal LN.
Routes of
spreading:
1. Direct
extension: vagina, urethra, anus
2. Lymphatic
spreading:
1) to the
regional lymph nodes first, superficial ingunal lymph node ® deep inguinal
lymph node (cloquet𠏋 node)
® femoral nodes
® external iliac
lymph node
2) The incidence
of lymph node spreading is related to the tumor size, stage of disease, and
depth of invasion.
3) Pelvic lymph
is rare in the absence of groin node metastasis. About 20% patients of with
positive groin nodes have positive pelvic nodes.
4) Clinical
evaluatin of groin lymph node is inaccurate in about 25 - 30% of the cases.
(microscopic metastasis, inflammatory but negative
node)
5) The spreading
of lymph node is usually limited to the ipsilateral group if the leison does not
cross over midline.
3. Hematogenous
spread to distant sites: lung, liver and bone.
Staging:
The entire vulva,
perineal and inguinal area should be examined carefully and thoroughly to make
a exact staging.
FIGO (1995) Staging of
vulvar carcinoma
STAGE
Clinical Findings
STAGE
0
Carcinoma in situ;
intraepithelial carcinoma
STAGE
I
Tumor confined to
the vulva or perineum; 2 cm or less in greatest dimension; no nodal
metastasis
Stage 1A: stromal
invasion≦1.0
mm
Stage 1B: stromal
invasion＞1.0
mm
STAGE
II
Tumor confined to
the vulva or perineum; more than 2 cm in greatest dimension; no nodal
metastasis
STAGE
III
Tumor of any size
with adjacent spread to the urethra, vagina, or the anus, or with unilateral
regional lymph node metastasis
STAGE
IVA
tumor invades upper
urethra, bladder mucosa, rectal mucosa, pelvic bone, or bilateral regional node
metastases
STAGE
IVB
Any distant
metastasis, including pelvic lymph nodes
Treatment:
1. Prior to any
surgery or treatment,
all patients should be surveryed thoroughly to rule out the
possibility of being a metastatic cancer
or the existence of synchronous second primary
cancer.
2. Stage I:
無suspicious groin
nodes.
1) Primary lesion: radical
local excision with the surgical margin of 1 cm at least.
2) Groin lymph node: linear
incision to save the skin bridge
If the primary
lesion is not periclitorical or not cross midline, do the ipsilateral side node
first. The contralateral groin node will be dissected when the froaen section of
the ipsilateral node proven positive.
if the invasion
depth of stroma is ≧1 mm, groin lymph
node dissection is not necessary.
All patients with
> 1mm stromal invasion require inguinal-femoral lymph node
lymphadenectomy.
For microscopic
lymph node involvement: observation
For two or more
positive lymph nodes: post-op radiation
3. Stage
II:
1) Primary
lesion: En Bloc
radical vulvectomy. Partial resection of vagina,
urethra, anus is required if they are involved.
2) Groin lymph node:
For early
metastatic groin nodules: separate linear incision wound to save the skin bridge
is necessary.
For big node or
advanced
lesion: butterfly incision to clean the cancer cell in the skin
bridge.
3) Myocutaneous
graft is better way to decrease the tension of wound and to facilitate the
rehabilitatin.
4) Pelvic lymph
node dissection: when ≧3 groin lymph
nodes including Cloquet𠏋 node
(+)
4. Advanced
disease Stage III, IV:
1) Large T3 or a
T4 primary tumor: Treatment is selected according to patient disease and general
condition.
* Pelvic exenteration
combined with radical vulvectomy and bilateral groin
dissection.
* Palliative radiation:
radiation alone is not easy to cure an advanced disease.
* Concurrent
chemoradiation: add chemotherapeutic agent (eg cisplatin, 5-Fu) as
radiosensitizer to potentiate the effect of radiation.
* Combined
radiosurgery: Preoperative radiotherapy + vulvectomy; Modified radical
vulvectomy + radiation to eradicate the microscopic
lesion.
* Preoperative
concurrent chemoradiation + vulvectomy can be used for
cases of locally advanced tumor to save pelvic
exenteration.
2) Bulky positive groin
nodes:
Full groin dissection
combined with groin radiation : often produces severe
leg edema.
Limited groin lymph node
dissection followed by external groin irradiation in
cases.
The positive pelvic lymph
nodes should be removed by extraperitoneal approach.
Prognosis:
1. The 5 year
survival rate of stage I disease is 90.4%, stage II: 77.1%, stage III: 51.3%,
stage IV: 18%.
2. For pateints with negative lymph node:
90%
For patients with positive
lymph node: 50%
Complication:
1. Following
surgery
1) Early complications:
Wound infection, necrosis
and wound breakdown. The incidence can be reduced by separate incision wound.
(85% ®
44%)
Urinary
infection, seroma in the femoral triangle, deep vein thrombosis, pulmonary
embolism, myocardial infarction, hemorrhage and ostitis
pubis.
2) Late complications:
leg edema, recurrent
cellulitis, urinary stress incontinence, genital prolapse, vaginal introitus
stenosis
2. Following
radiation:
1) Radiation
dermatitis
2) Leg
edema
3) Poor healing and the
subsequent infection
Endometrial
Carcinoma
Diagnosis
1.
Fr D&C + cervical biopsy
2.
Hysteroscope directed biopsy
Risk
factor
1.
Obesity
2.
Nulliparity
3.
Late menopause
Stage Ia
G123 Tumor
limited to endometrium
Ib G123 Invasion of less
than half of the myometrium
Ic G123 Invasion of more
than half of the myometrium
IIa G123
Endocervical glandular involvement only
IIb G123
Cervical stromal invasion
IIIa G123
Tumor invades serosa and/or adnexae and/or positive peritoneal
cytology
IIIb G123
Vaginal metastases
IIIc G123
Metastases to pelvic and/or paraaortic lymph nodes
IVa G123
Tumor invasion of bladder and/or bowel mucosa
IVb
Distant metastases including intraabdominal and/or inguinal
lymph node
Histopatholgoy: Degree of
differentiation
Cases
of carcinoma of the corpus should be grouped according to the degree of
differentiation of the adenocarcinoma as follows:
G1
= 5% or less of a nonsquamous or nonmorular solid growth
pattern
G2
= 6% to 50% of a nonsquamous or nonmorular solid growth
pattern
G3
= more than 50% of a nonsquamous or nonmorular solid growth
pattern
Pre-operative
survey
1.
Sonography
3.
MRI (optional)
4.
IVP
5.
LGI
Primary
treatment
1.
Comprehensive surgery
washing
cytology + ATH (or Extended ATH) + BSO + Bilateral pelvic lymph node dissection
+ paraaortic LN sampling analysis (when Gr3 or deep myometrial
involvement)
2.
specimen sent for hormone receptor and flow
cytometricDNA ploidy
Risk
factor (indicators for post-operative therapy)
1.
Histologic differentiation
2.
Stage of disease
3.
Myometrial invasion
4.
Peritoneal cytology
5.
Lymph node metastasis
6.
Adnexal metastasis
7.
Hormonal receptor
8.
DNA ploidy
Adjuvant
therapy
1.
Radiotherapy:
a.
whole pelvis with/or without vaginal brachytherapy
b.
whole pelvis + entended PA field
2.
Chemotherapy:
a.
splatin, adriamycin, epirubicin, paciltaxel
3.
Hormone therapy:
a.
megestrol acetate: 160 mg/d-320 mg/d
b.
tamoxifen: 20-60 mg/d
c.
GnRHa: Lupron depot 3.75 mg SC/month
Ovarian
Cancer
Histogenetic
classification of ovarian neoplasm
I. Neoplasms derived from
coelomic epithelium
A. Serous
tumor
B. Mucinous
tumor
C. Endometriod
tumor
D. Mesonephroid
(clear cell) tumor
E. Brenner
tumor
F.
Undifferentiated carcinoma
G. Carcinosarcoma
and mixed mesodermal tumor
II. Neoplasms derived from germ
cells
A.
Teratoma
1. Mature
teratoma
a. Solid adult teratoma
b. Dermoid cyst
c.
d. Malignant neoplasms secondarily arising from mature cystic
teratoma
2.
Immature teratoma (partially differentiated
teratoma)
B.
Dysgerminoma
C. Embryonal
carcinoma
D. Endodermal
sinus tumor
E.
Choriocarcinoma
F.
Gonadoblastoma
III. Neoplasms derived from specialized gonadal
stroma
A.
Granulosa-theca cell tumors
1.
Granulosa tumor
2.
Thecoma
B. Sertoli-Leydig
tumors
1. Arrhenoblastoma
2. Sertoli tumor
C.
Gynandroblastoma
D. Lipid cell
tumors
IV. Neoplasms derived from nonspecific
mesenchyme
A. Fibroma,
hemangioma, leiomyoma, lipoma
B.
Lymphoma
C.
Sarcoma
V. Neoplasms metastatic to the
ovary
A.
Gastrointestinal tract (Krukenberg)
B.
Breast
C.
Endometrium
D.
Lymphoma
Stage
of ovarian cancer
Stage
I
Growth limited to the ovaries
Stage
Ia Growth limited to
one ovary; no ascites present containing malignant cells; no tumor on the
external surfaces; capsule intact
Stage
Ib Growth limited to
both ovaries; no ascites present containing malignant cells; no tumor on the
external surfaces; capsules intact
Stage
Ic Tumor
either stage Ia or stage Ib but with tumor on the
surface of one or
both ovaries; or with capsule ruptured; or with ascites present
containing malignant cells or with
positive peritoneal washings
Stage
II
Growth involving one or both ovaries with pelvic
extension
Stage
IIa Extension
and/or metastases to the uterus and/or tubes
Stage
IIb Extension to
other pelvic tissues
Stage
IIc Tumor either
stage IIa or stag IIb but with tumor on the surface of one or both ovaries; or
with capsule(s) ruptured; or with ascites present containing malignant cells or
with positive peitoneal washings
Stage
III Tumor
involving one or both ovaries with peritoneal implants outside the pelvis and/or
positive retroperitoneal or inguinal nodes; superficial liver metastasis equals
stage III; tumor is limited to the true pelvis but with histologically
verified malignant extension to small bowel or omentum
Stage
IIIa Tumor grossly limited to
the true pelvis with negative nodes but with histologically confirmed
microscopic seeding of abdominal peritoneal
surfaces
Stage
IIIb Tumor of one or both
ovaries; histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2
cm in diameter; nodes negative
Stage
IIIc Abdominal implants 2 cm
in diameter and/or positive retroperitoneal or inguinal
nodes
Stage
IV Growth
involving one or both ovaries with distant metastasis; if pleural effusion is
present, there must be positive cytologic test results to allot a case to stage
IV; parenchymal liver metastasis equals stage IV
Pre-operative
survey
1.
Tumor markers: CA-125, AFP, CEA,
β-HCG,
LDH, CA19-9 (for mucinous tumors)
2.
Lower GI series survey
3. Panendoscope
4.
Fr D&C + cervical biopsy
5.
Breast exam (and/or mammography)
Surgical
therapy in ovarian cancer
1.
Peritoneal washing cytology
2.
Determination of extent of disease
a.
pelvis
b.
peritoneal surface
c.
diaphragms
d.
omentum
e.
lymph node
3.
Remove all tumors possibly plus pelvic, para-aortic lymph node sampling and
omentectomy
Adjuvant
therapy
1.
Chemotherapy as ovarian cancer protocol.
Requirements
for conservative management in epithelial ovarian
cancer
1.
Stage Ia
2.
Well differentiated
3.
Young woman of low parity
4.
Otherwise normal pelvis
5.
encapsulated and free of
adhesions
6.
No invasion of capsule, lymphatics, or mesovarium
7.
Peritoneal washings negative
8.
Adequate evaluaiton of opposite ovary and omental biopsy
negative
9.
Close follow-up probable
10.
Excision of residual ovary after completion of childbearing
(optional)
Gestational
Trophoblastic Disease
Hydatidiform
Mole:
Complete
mole
Partiale
mole
Gestational
trophoblastic neoplasia:
Nonmetastatic
trophoblastic disease
Good
prognosis metastatic trophoblastic disease
Poor
prognosis metastatic trophoblastic disease
Placental
site trophoblastic tumor
Management
of hydatidiform mole:
1.
Beta-hCG determination every 1-2 weeks until negative two
times
a.
Then bimonthly for 1 year
b.
Contraception for 6-12 months
2.
Physical examination including pelvic every 2 weeks until
remission
a.
Then every 3 months for 1 year
3.
Chest film initially
a.
Repeat only if hCG titer plateaus or
rises
4.
Chemotherapy started immediately if:
a.
hCG titer rises or plateaus (determined by 3 tests) during
follow-up
b.
Metastases are detected at any time
Classification
of gestational trophoblastic neoplasia:
1.
Nonmetastic disease: no evidence of disease outside uterus
2.
Metastatic disease: any disease outside uterus
a.
Good prognosis metastatic disease
¬
Short duration (last pregnancy < 4 months)
Low pretreatment hCG titer (< 100,000 IU/24 hr or
< 40,000 mlU/ml)
®
No metastasis to brain or liver
‾
No significant prior chemotherapy
b.
Poor prognosis metastatic disease
¬
Long duration (last pregnancy > 4 months)
High pretreatment hCG titer (> 100,000 IU/24 hr or
> 40,000 mlU/ml)
®
Brain or liver metastasis
‾
Significant prior chemotherapy
°
Term pregnancy
WHO
Scoring System
Score
Prognostic
factors
0 1
2
4
Age
≦39
>39
Antecedent
pregnancy
HM Abortion
Term
Months
from last pregnancy
4 4 to
6
7 to 12
12
hCG
(IU/L)
103
103-104
104-105
105
ABO
(female×male)
O×A
B
A×O
AB
Largest
tumor (cm)
3 to 5
5
Site
metastases
Spleen
GI
Brain
Kidney
Liver
Number
of metastases
1 to 4
4 to 8
8
Prior
chemotherapy
Single
2 or more
drug
drugs
≦4: low
risk
5-7: middle
risk
≧8: high
risk
FIGO
Staging for trophoblastic tumors
Stage
Disease confined to the uterus
Stage
Ia Disease
confined to the uterus with no risk factors
Stage
Ib Disease
confined to the uterus with one risk factor
Stage
Ic Disease
confined to the uterus with two risk factors
Stage
II GTT extends outside of the uterus
but is limited to the genital
structures (adnexa, vagina, broad
ligament)
Stage
IIa GTT involving genital structures
without risk factors
Stage
IIb
GTT extends outside of the uterus but limited to genital
structures
with one risk factor
Stage
IIc GTT extends outside of the uterus but
limited to the genital
structures with two risk factors
Stage
III GTT extends to the lungs with or
without known genital tract
involvement
Stage
IIIa GTT
extends to the lungs with or without genital tract
involvement
and with no risk factors
Stage
IIIb GTT
extends to the lungs with or without genital tract
involvement
and with one risk factor
Stage
IIIc GTT
extends to the lungs with or without genital tract
involvement
and has two risk factors
Stage
IV All other metastatic
sites
Stage
IVa
All other metastatic sites without risk factors
Stage
IVb All
other metastatic sites with one risk factor
Stage
IVc All
other metastatic sites with two risk factors
Risk factors affecting
staging include the following: (1) hCG > 100,000
mlU/ml; (2) duration of disease > 6 months from termination of the antecedent
pregnancy. The following factors
should be considered and noted in reporting: (1) prior chemotherapy for known
GTT; (2) placental site tumors should be reported separately: (3) histological
verification of disease is not required.
Single-Agent
Chemotherapy
1.
Methotrexate 20-25 mg IM every day for 5 days (with a minimum 7-day rest if
possible)
2.
Methotrexate 1 mg/kg IM on days 1, 3, 5, and 7
Folinic
acid 0.1 mg/kg IM on days 2, 4, 6, and 8 (with a minimum 7-day rest if
possible)
EMA-CO
Chemotherapy
Course
1 (EMA)
Day
1
Etoposide, 100 mg/m2,
IV infusion in 200 ml of saline
Dactinomycin, 0.5 mg, IV stat
Methotrexate, 100 mg/ m2,
IV
stat
200 mg/ m2,
IV
infusion over 12 hours
Day
2
Etoposide,
100 mg/m2,
IV infusion in 200 ml of saline over 30
minutes
Dactinomycin, 0.5 mg, IV stat
Folinic acid, 15 mg, IM or orally every 12 hours for 4
doses
beginning 24 hours after start of
methotrexate
Course
2 (CO)
Day 8
Vincristine, 1.0 mg/m2
IV stat
Cyclophosphamide, 600 mg/m2,
IV infusion
Chemotherapy
Clinical
triale: phases and goals:
Phase
I •To
determine the maximally tolerated dose of drug
•To
determine the schedule for administration
•To
define toxic effect to normal tissue
•To
generate data about the clinical pharmacology of the agent
Phase
II •To
identify antitumor activity in a spectrum of common
metastatic
tumors
•To
explore ability to achieve increased rates or response with
changes
of dose or schedule
•To
extend phase I data on toxicity
Phase
III
•To
compare the investigational therapy against an established
form
of treatment in
previously untreated patients
Performance
Status
Karnofsky
performance status
100＝Normal;
no complaints; no evidence of disease
90＝Able
to carry on normal activity; minor signs or symptoms of
disease
80＝Normal
activity with effort; some sign or symptoms of disease
70＝Cares
for self but unable to carry on normal activity or do active
work
60＝Requires
occasional assistance but is able to care for most personal
needs
50＝Requires
considerable assistance and frequent medical care
40＝Disabled;
requires special care and assistance
30＝Severely
disabled; hospitalization indicated, although death not
imminent
20＝Very
sick, hospitalization necessary; active support treatment
necessary
10＝Moribund;
fatal process progressing rapidly
0＝Dead
Zubrod
status
0＝No
symptoms
1＝Symptoms;
fully ambulatory
2＝Requires
nursing assistance or equivalent; bedridden less than 50% of normal
day
3＝Bedridden
more than 50% of normal day
4＝Bedfast
病房常見問題—Gross
hematuria
手術後病人血尿須想到下列問題
Ø
是術後第幾天血尿，若手術剛從POR回來，可能是手術過程引起(可能bladder
or ureter injury)，處理方式record
urine output, on Foley, I/O, fluid challenge, or Transamine use 且須注意病人是否anemia，是否coagulation
abnormalities.
Ø
若是手術後幾天才發生，則考慮病人是否
urethral catheter inserted? If yes, Why? What are the vital sign? Fever? Or
other infection sign? Is the patient receiving anticoagulant
drugs?
1.
Urethral
trauma---Inadvertent or partial removal of the catheter with the balloon still
inflated.
2.
Drugs—heparin
or warfarin use
3.
Coagulation
abnormalities---Sepsis or DIC sign, thrombocytopenia
處理—check
CBC/DC, U/A, even blood culture or urine culture if any infection sign, and
antibiotics use, or 輸血(PRBC
or FFP or platelet)
Ø
通常術後發生之gross
hematuria不太會有因血塊引起Foley阻塞情形。
Ø
若非手術病人，則考慮是否曾或正接受radiation
therapy或為cancer合併bladder
invasion
1.
Hematuria
due to bladder invasion supportive treatment，缺甚麼就補甚麼,
PRBC or FFP or platelet
2.
若是radiation
cystitis 則須密切注意，check
U/A, CBC/DC，如果有infection
sign，則blood
culture or antibiotics use if appropriate，且必須on
Foley or even使用three-way
Foley keep irrigation with L-R
3.
如因Foley
tip被bladder
內的blood阻塞，則先milking
foley tube，若無效則先用Normal
saline irrigation
病房常見問題
diarrhea（腹瀉）
腹瀉是指腸道蠕動情況較平常時來得頻繁，量多或液體成份較多的情況。
常見的原因有急性腸胃炎（acute
gastroenteritis）（包括病毒、細菌或原蟲類的感染），呼吸道感染的合併症。其他的原因包括有激躁性腸道症候群（irritable
bowel syndrome），使用抗生素、消炎藥，含鎂制酸劑（如MgO）或其他刺激腸道蠕動藥物造成。有些糖尿病患或內科疾病（包括hyperthyroidism,
Addison’s disease, endocrine tumor, small bowel tumor, colon cancer, carcinoid
syndrome, inflammatory bowel disease（包括ulcerative
colitis及Crohn’s
disease）及腸道手術後（如postgastrectomy之dumping
syndrome）都會造成腹瀉。在癌症病患，經過骨盆腔放射線治療，可能引起radiation
enteritis或radiation
colitis及proctitis，而造成腹瀉；某些病患經過化學藥物治療之後免疫力變差，而受腸道感染，造成腹瀉。
急性腸胃炎或感染造成的腹瀉可分為Toxin-mediated
diarrhea (small bowel diarrhea)及Infectious
diarrhea (colonic diarrhea)。Toxin-mediated
diarrhea常於吃了污染的食物後數小時發生，通常沒有fever產生；Infectious
diarrhea是因virus,
Salmonella，或Campylobacter造成腸道黏膜被侵犯，可能造成fever,
general malaise, watery diarrhea，其便中可見黏液（mucus）或血。二者均可能併有nausea,
vomiting, crampy abdominal pain。
抗生素引起的腹瀉，可發生在各種抗生素使用後，但常見的有ampicillin,
tetracycline, linomycin, cephalosporins, clindamycin及chloramphenicol。腹瀉的程度由輕微的水樣便（watery
diarrhea）至嚴重的偽膜性腸炎（pseudomembranous
enterocolitis）均有可能。偽膜性腸炎典型的致病菌是對clindamycin有抗藥性的Clostridium
difficile。
其他會引起腹瀉的藥物有：magnesium-containing
antacid, guanethidine, methyldopa, digitalis, beta blocker, systemic
anti-inflammatory agents, iron-containing compound, laxative abuse, colchicine,
quinidine, phenothiazine agents, high doses of salicylates等。
壓力或情緒緊張，可能造成functional
diarrhea (irritable bowel syndrome)。
糖尿病患併有neurologic
dysfunction者，可能會因gastric
stasis及腸蠕動較少，造成小腸內細菌過度增生，使得患者於飯後產生突然的腹瀉，利用tetracyclin可以抑制腸內菌過度增生，可能對某些病患有幫助。
放射線引起的radiation
enteritis或proctitis，一般以腹瀉、排便疼痛或出血來表現，通常並不嚴重，以症狀治療為主，可給予軟便劑，低渣飲食，及局部緩解的藥物（包括hydrocortisone
enema, analgesic rectal suppositories）。
實驗室檢查：
1.
CBC
& WBC DC: WBC增加及shift
to left表示可能是感染，blood
loss可能造成貧血，dehydration可能造成Hct增加。
2.
Electrolyte:
diarrhea造成K減少，dehydration可能使Na上昇。
3.
Bun,
Cr, Sugar。
4.
PH:
可能呈現hyperchloremic
acidosis。
5.
Stool檢查:
(1)
Loffler’s
alkaline methylene blue stain針對fecal
leukocytes檢查，可能對Salmonella,
Campylobacter, Yersinia, Shigella, invasive E. coli造成之inflammatory
diarrhea有幫助。
(2)
Stool
culture。
(3)
針對C.
difficile作toxin
assay，以排除pseudomembranous
colitis。
乙狀結腸鏡檢查（sigmoidoscopy）
針對Bloody
diarrhea或懷疑pseudomembranous
colitis患者，可作Sigmoidoscopy看病灶是何種病變。
治療：
1.
NPO:
輕微的腹瀉或IBS或substance
intolerance通常不需要治療。
2.
IV
hydration: 疑有脫水之病患。
3.
Correct
electrolyte abnormalities。
4.
Discontinue
possible causative agents (eg. Magnesium containing antacid,
antibiotics)。
5.
使用antiperistaltic
agents: 在懷疑有inflammatory
bowel disease者或infectious
diarrhea者需小心使用。對於較輕微的diarrhea,
Imodium (loperamide)可能有幫助，本院尚有Kaopectin
(Kaolin-pectin)可用，Imodium使用劑量為
6.
(
(
7.
Radiation
proctitis的處理方法如前述。
push
chemotherapy時應注意事項
1.
check
IV Line通暢後，Full
Run。
2.
push時勿反折set讓輸液及藥物一同注入血管。
3.
採slowly
push並且push時間要大於十分鐘以上。
4.
病患若主訢疼痛則立即停止，並報告上級醫師。
5.
若發生外漏時，需立即停止IV注射，利用原針頭儘量反抽藥液，並push藥物如下：
當Adriamycin
Epirubicin DTIC外漏時，則予push
Jusomin & Solucortef。
當Vinblastin
Vincristin外漏時，則予push
solu-cortef。
6.
外漏患部，予冰敷。
※
若打前臂時，手肘須放直，以避免血液循環不好
問題：術後寡尿或無尿？
1. 定義：寡尿（oliguria）：尿量
無尿（anuria）：沒有尿排出。
2. 分類：
腎前（prerenal）：由於流血、腹泄、嘔吐、脫水等造成血容積減少、血壓下降，使腎血流供給不足，而致尿量減少。
腎（renal）：腎本身器質性傷害，可由缺氧或對腎有毒物質所引起。
腎後（post
renal）：輸尿管、膀胱、尿道的阻塞，包括外科傷害。
·
尿液分析：
|
pre-renal |
renal |
|
尿比重> |
< |
|
U/P比值： |
|
|
肌酐酸> |
< |
|
尿素> |
< |
|
滲透壓> |
< |
|
尿鈉濃度< |
> |
※ 術後或產後的無尿，表腎後阻塞或膀胱無力，而術後或產後幾天，才發生的寡尿，則表腎內部的因素。
3. 處理：術後無尿或寡尿：
(1)
合併血尿，疑ureter
injury ®
打Lasix
check urine output。
(2)
恥骨上部可摸到漲大的膀胱®foley阻塞。
(3)
噁心、嘔吐造成的腎前寡尿，應補充液體。
(4)
合併血壓下降，疑internal
bleeding®
check Hb/Hct及Sonar，給IVF
challenge並備血。
(5)
OPD手術完，常因塞紗布compression造成無法解尿®
remove紗布或intermittent
catheterization。
(6)產後無法解尿，常因neurogenic
bladderintermittent catheterization。
問題
Adranced
stage of ovarian cancer常合併腹水，故產生腹脹不舒服，疼痛等症狀，臨床上處置：
1. 測量AC
qd及BW
qW
2. monitor
I/O q
3. 不要只顧著給予Lasix拉出水份，而應評估病人的intracellular
fluid量是否足夠：skin
turgor, sunken eye. 適時給予輸FFP補充再打Lasix。
4. 測A/G
ratio，若Alb
£
5. 若已為terminal
stage，則需要症狀處理。Check
abd sona: 定位fluid最多的地方予以皮膚消毒，再用
問題
cancer
with radiation後術腳腫情形，臨床上要先區別是否因chronic
venous insufficiency產生的lymphedema還是產生deep
vein thrombosis (DVT)症狀，臨床上處理前者：先將肢體作局部抬高，加強靜脈回流。若是因lymphatic
duct obstruction造成lymphedema，就要考慮病人是否已有淋巴轉移。透過影像學的診斷，有需要的話就可排CT-guided
lymph node biopsy來做tissue
proof。治療方法可能只有期盼chemoradiation
therapy能讓腫瘤體積縮小，減少局部淋巴組織受壓機會。要確定DVT：先評估
問題
CxCa的病人產生vaginal
bleeding在臨床上多見於bulky
exophytic tumor（>
病房常見的問題：fever
幾度算發燒？口溫大於
首先要清楚病人是什麼case？fever時間多久？vital
signs如何？最近是否剛開完刀？是否有fever
history…等，接著仔細推敲，查出最可能的原因，加以處理。
Þ開完刀的病人常會有fever，隨開刀完時間的不同會有不同的原因：
<
Post-OP
因為lung
atelectasis, suputum排不出來…
假如病人的breathing
sound正常，病人沒有喘，鼓勵病人咳痰deep
breathing，睡一下冰枕，一、二天fever就會subside。
<Post-OP
常也是因為atelectasis沒好好處理所致
臨床症狀一般在開刀完
積極去除病人的sputum，讓collapsed
lung能reexpansion，若有pneumonia可能要加用antibiotics。
<Post-OP
day
可能是wound
infection或urinary
tract infection造成，或甚至phlebitis,
intrabdominal abscess（腹腔開刀的病人）。
處理：wound
infection的話，病人會complain傷口愈來俞痛（wound
pain）這可能是wound
infection最早的症狀，之後若有erythema,
elevated skin temperature, tenderness…甚至wound持續oozing時，要懷疑wound
infection的可能。檢查Foley放多久了，看看urine的color,
turbid與否，問病人解小便痛不痛，有burning
sensation與否，懷疑UTI的話，可急做urine
routine: 看Nitrite是否+，看WBC是否升高，若是urine
routine有問題，Nitrite
(+), WBC,
要做urine
culture。檢查有否IV
line, arterial line, CVP line…etc.注意針頭處是否有紅腫、熱痛，是的話要懷疑phlebitis，處理：
病人的一般處理方式：
病人fever時，除非很肯定不是由於infection造成，不然應該先做：
Urine
culture可等urine
routine出現Nitrite
(+)或WBC再做，由於收集時易受污染，放久的話細菌易生長，所以收集要小心，而且要及早送檢。假如病人已在使用抗生素時，在下一次加藥前抽血，讓antibiotics濃度降到最低，且少量多瓶，抽的血量相同，但分到每瓶的血量減少
Neutropenia After Chemotherapy – With or Without
Fever
Definition
Neutropenia is the most frequent cause of
leukopenia. Neutropenia is termed
severe if there are fewer than
Febrile neutropenia is
defined as absolute neutrophil count (ANC)＜
Virtually all cytotoxic
drugs (chemotherapeutic agents) cause a profound transient neutropenia
Symptoms
1.
Mild and moderate
neutropenias may be clinically asymptomatic. When the neutrophil count falls below
2.
Symptoms are usually
associated with infection. Common
localizing signs of inflammation may be absent.
3.
Common pathogens include
gram-negative bacilli, Staphylococcus aureus, S. epidermidis, Candida species,
and Aspergillus species.
4.
The most likely source of
bacteremia in a neutropenic patient with a fever and without an indwelling line
is endogenous flora of the mouth and gut.
Key
Symptoms | |
|
★
Fever |
★ Inflammation |
|
★
Odynophagia |
★ Lethargy |
|
★ Painful
defecation |
★ Skin Lesions |
|
★
Respiratory
distress |
|
WARNING
Fever in a
neutropenic patient is a medical emergency
Clinical
Findings
1.
Findings frequently depend
on the duration and severity of neutropenia.
2.
Severely neutropenic
patients frequently have oral thrush (postchemotherapy neutropenia) and perianal
erythema or perirectal abscesses.
3.
In addition, these patients
frequently are found to have dullness to percussion and auscultation on lung
examination. Hepatomegaly and
splenomegaly also can be seen.
Frequent findings in long-term neutropenic individuals include multiple
poorly healed skin abscesses.
4.
Patients may present with
any combination of signs of the sepsis syndrome, including fever, tachycardia,
cool clammy skin, hyperventilation, and postural
hypotension.
Key
Signs | |
|
★
Fever |
★ Skin abscesses |
|
★
Lymphadenopathy |
★ Tachycardia |
|
★ Oral
thrush |
★
Postural hypotension |
WARNING
Digital rectal examinations
are strongly contraindicated in neutropenic patients
Laboratory
Tests
1.
The peripheral smear is
important. A left-shifted
differential (＞
2.
Serial determinations of the
complete blood count (CBC) may be most useful in documenting the course of a
mild neutropenia rather than other more invasive, expensive, or esoteric
tests.
3.
The bone marrow is the “gold
standard” for assessment of neutrophil production. When neutropenia is caused by a toxic
insult, near absence of immature forms will be seen.
4.
Macrocytosis (mean
corpuscular volume ＞
5.
Blood cultures are mandatory
in patients with neutropenia and fever.
Urine, sputum, or other body fluid cultures are suggested if clinically
indicated.
Key
Tests | |
|
★ CBC with
WBC differential |
★ Folate B |
|
★ Bone marrow aspiration
and biopsy (Gold standard for
differential diagnosis) |
★ Body fluid cultures in febrile patients |
Differential
Diagnosis
1.
Decreased production: drug
or toxic effect, infection, hematologic neoplasm, metastatic disease,
miscellaneous (chronic idiopathic neutropenia, cyclic
neutropenia)
2.
Peripheral
destruction/margination: drug effect, auto-immune phenomena, splenic
sequestration, sepsis, cardiopulmonary bypass,
hemodialysis.
Treatment
1.
First, determine the
underlying pathogenesis (drug, toxin, infection, neoplasm, vitamin
deficiency). All possible drugs
should be stopped immediately.
2.
Folate is available in many
forms and in deficiency states should be administered at a dose of
3.
Granulocyte colony
sti
4.
Febrile neutropenia is a
medical emergency and demands hospitalization, culturing of body fluids, and
intravenous antibiotics.
Prophylactic antibiotic therapy is a controversial issue.
Diet
A low-bacteria diet is necessary in patients with prolonged neutropenia.
Activity
Patients should avoid individuals with known communicable diseases in the home and in the workplace. Most hospitals have infection-control departments and have specific requirements for the care of neutropenic patients.
Key
Treatment | |
|
★ Folate (For chronic ill
patients) |
★ G-CSF
or GM-CSF |
|
★ Vitamin
B (For chronic ill
patients) |
★ Prophylactic antibiotics |
(Adapted from “Saunders Manual of Medical
Practice", edited by Rakel, Chapter
Radiation Therapy in
Gynecologic Malignancies
Basic principles of
Radiobiology
Radiation Techniques:
radiation therapy is delivered in three ways
Radiation Therapy in
Gynecologic Malignancies
A. Cervical
Cancer:
parametrium involvement (+),
pelvic lymph node
metastases (+),
cervicix invasion depth
>
section margin with
cancer,
Section margin
with CIN III in patient receiving neoadjuvant chemotherapy (bulky
tumor)
inadequate surgical
margin
Brachy therapy:
to achieve a higher cintral tumor dose
Point A:
Point B:
Hematuria,
radiation cystitis: Tx with normal siline irrigation,
hyperbaric oxygenation
Hemorrhagic
proctitis: Tx with cort-enema
Fistula:
rectovaginal fistula is most often, Tx with colostomy.
Vesicovaginal fistula, Tx with long term foley
catherization and repair, PCN.
Stricture: of
ureter, PCN if hydronephrosis occurs.
perforation of hallo organ:
rectum, sigmoid, small bowel, pyometra.
a) Abdominal
cramping and diarrhea in (
b) Anorexia,
nausea, vomiting (
c) General
fatigue (
d) thrombocytopenia and neutropenia (
e) Pneumonitis
(
f) Liver damage(
g) Abdominal
bloating (
B. Endometrial
Cancer:
C. Ovarian
Cancer:
D. Combined
Operative Brachy Radiation Therapy (COBRT): for focal residual tumor (mainly CX
Ca) after a debulking surgery (most often exenteration surgery) in patient who
had reciieved full dose external radiation
E. Vulva
Cancer:
F. Vaginal Cancer: advanced
stage
The side-effect and its
management of radiation therapy
* Radiation Cystitis
(hemorrhagic cystitis)的處理原則:
* Hemorrhagic
proctitis
以上文章工作守則由魏添勇醫師、吳俊興醫師、林益豪醫師、祁穎思醫師、陳美淇醫師、阮良圖醫師、周宏學醫師、王俊傑醫師、洪志宏醫師、周宏學醫師、黃寬仁醫師、曾志仁醫師等撰寫，
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