A 21 year old woman with a rapidly growing mass on palate. Dr. Elizabeth Bigger and Dr. Memory Bvochora 18 March 2015

Transcription

1 A 21 year old woman with a rapidly growing mass on palate Dr. Elizabeth Bigger and Dr. Memory Bvochora 18 March 2015

2 History of present illness 21 year old woman G2P1 admitted to the Princess Marina Hospital female orthopedic ward with a large mass on her palate Reportedly first noticed small swelling on palate/gingiva in 2012 Progressively increased in size, associated with pain and spontaneous bleeding Underwent surgical biopsy of mass at PMH in 2012 Pathology report from September, 2012: Kaposi s sarcoma versus sarcoma

3 History of present illness At follow up on Oct 2012, dental surgeon noted that the tumor had increased in size within the past month Referred to oncology in Nyangabgwe; notes indicated the diagnosis was squamous cell carcinoma Received 4 cycles of cisplatin + 5-fluorouracil from October 2012 through March 2013 Referred to Gaborone Private Hospital for radiotherapy in May 2013

4 Due to discrepancy about histopathology in notes, Dr.Bvochora requested clarification Note by Dr.Kamal: lesion morphologically does not appear to be Kaposi. Primary sarcoma is a possibility but due to the high prevalence of squamous cell cancer at gingiva, and clinical response to 5FU and Cisplatin, we think it can be treated as an SCC of the hard palate/gingiva. We request concurrent chemoradiation with cisplatin. Dr.Bvochora agreed to proceed and planned to give her radical radiation to the palate

5 History of present illness 2 weeks post-treatment initiation, observed that the lesion was growing 4 weeks post treatment initiation, a significant increase in size At 50Gy, treatment was stopped Was due for boost to 70 Gy but concern about persistently growing tumor and compromise of future surgical resection Pathology review and surgical opinion requested by Dr.Bvochora Excisional biopsy July 2013: tumor infiltrated the palate into the bone

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7 History of present illness After surgery, patient disappeared to her home village and never returned She did well until October 2014 growth reappeared and began growing rapidly with bleeding Intermittent SOB Blocked nostrils Tumor partially occluded oral cavity

8 History of present illness Admitted to PMH orthopedic ward in January 2015 Underwent excisional biopsy of gingival tissue on February 2015 Also noted to be pregnant, with current gestational age 33 weeks

9 Past medical history HIV negative January 2015 Allergies: No known drug allergies Medications Took no medications at home prior to admission Currently on paracetamol, amoxicillin, iron, folic acid, vitamin C, dexamethasone Family history Negative

10 Social history Unmarried, not working Previously imprisoned for 6 months (around the time of initial diagnosis) Denies tobacco or alcohol use Has a 3 year old child; not in contact with the father of her children Supported by her parents Review of systems Notable for weight loss. Not eating well but able to swallow soft foods.

11 Exam Temp 36 C, HR 96, BP 127/93, RR 20, O2 sat 98% RA Alert, conversant, no distress HEENT: Exophytic growth on upper anterior segment, lobulated. Extending into palatal mucosa, obstructing nares, tender to palpation with spontaneous bleeding Cardiovascular and pulmonary exams unremarkable Abdominal exam notable for gravid uterus Extremities without edema No palpable cervical, axillary, or inguinal adenopathy noted

12 Labs WBC 8.99 with normal differential, Hemoglobin 7.2, Hematocrit 22.1, MCV 78.4, Platelets 314 Urea, creatinine, and liver function tests normal

13 Abdominal ultrasound January, 2015 Liver, pancreas, spleen, and left kidney normal Mild right hydronephrosis Singleton viable cephalic with gestational age 26 weeks, 6 days. EFW +/- 975 grams. FHR 158 bpm. CT head - January x 3.89 x 3.54 cm hyperdense mass in central maxilla extending into anterior buccal cavity and abutting the tongue. There is associated lytic bone destruction of anterior maxilla. No significant lymphadenopathy or naso/pharyngeal compromise.

14 CT of head/neck

15 Initial Pathology Report

16 April 2013

17 After 50Gy radiation June 2013

18 March 2015

19 WASTED

20 FEEDING AND AIRWAY COMPROMISE

21 Viable fetus 32 WEEKS GESTATION. No gross abnormalities

22 CT chest with No Metastases

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24 HYDROURETERONEPHROSIS

25 CT IMAGES for radiotherapy planning

26 TUMOUR VOLUME

27 Patient started radiotherapy March 2015 Questions: How should we manage the patient considering the pregnancy? Should we add concurrent or subsequent chemotherapy to radiation therapy for management of the patient s tumor? Is it feasible for the patient to undergo complete resection?