Quiz time

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1 Quiz time Morbidity Scoring Workshop 2018 Remi A. Nout Kathrin Kirchheiner Astrid De Leeuw Ina M. Jürgenliemk-Schulz

2 Case 1 at presentation 36 year old FIGO stage IIB cervical cancer, referred for radio(chemo)therapy: I went to my GP because during the last months my menstruations became irregular, lasting longer and in between there was sometimes quite some blood loss so I use a pad now almost every day.

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4 Q1. How to grade? A. These are menstruations and should not be taken into account B. Hemorrhage/bleeding, vaginal G1 C. Hemorrhage/bleeding, vaginal G2 D. Vaginal discharge G2

5 Case 2 - at presentation I always used to have normal stools once every morning, but now often I don t have stools for a few days in a row. I tried eating more fruit but that did not help. This gives me a bloated feeling with cramps and prevents me from going out.

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7 Q2. How to grade? A. Abdominal pain or cramping G1 B. Constipation G1 C. Constipation G2 D. Abdominal pain or cramping G2 and constipation G1.

8 Case 3 4 weeks after starting EBRT + Cisplatin I used to have 1 stool per day. Last week I started having diarrhea, but since taking Imodium (anti-diarrhea) once every other day, I am back to 4 stools a day.

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10 Q3. How to grade diarrhea? A. Grading during treatment is not required B. Diarrhea G0 C. Diarrhea G1 D. Diarrhea G2

11 Case 4 6 months after treatment I go to the toilet for stools every morning about 3 times, I need to keep close to the toilet in the morning because when I feel that I need to go I have to go immediately. Sometimes I had a small accident because I was too late, so I still use a pad for this.

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13 Q4. How to grade? A. Fecal urgency G1 B. Incontinence anal G1 C. Fecal urgency G1 and incontinence anal G2 D. Proctitis G2

14 Case 5 1 year after treatment Despite using estrogen and a dilator now for quite a while, using the dilator is painful, everything has dried up, and the thought of having sex stresses me a lot so I haven't had intercourse during the last 6 months. When using the dilator I still notice some blood once a while.

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16 Q5. How to grade? A. Vaginal dryness G1 and hemorrhage G1 B. Vaginal stenosis G1 and hemorrhage G1 C. Vaginal dryness G2 and hemorrhage G1 D. Vaginal stenosis G2 and hemorrhage G1

17 Case 6 1 year after treatment Gynaecological examination shows no signs of recurrence, with narrowing and some shortening of the upper part, examination is painful and ostium not visible. The mucosa in the upper part is pale and the the mucosa towards the cervix/parametria is firm.

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19 Q6. How to grade? A. Vaginal stenosis G1 B. Vaginal stenosis G2 C. Vaginal stenosis G1 and vaginal mucositis G1 D. Vaginal stenosis G1 and vaginal mucositis G2

20 Case 7 5 years after treatment You know I have had trouble holding up my urine now for the last 3 years. At first this was just a little, but it has been increasing. The last 6 months I have been wearing pads now during the day and night and I am afraid to go out of the house, I have my mom bringing me food now. Isn't there anything that can be done about this, it is really affecting my everyday life now.

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22 Q7. How to grade? A. Urinary incontinence G2 B. Urinary incontinence G3 C. Urinary incontinence G2 and urinary urgency G1 D. Urinary incontinence G3 and urinary urgency G1

23 Case 8 Ureter stenosis 39 year old cervix cancer patient FIGO IIIB Parametrial invasion distal left parametrium with hydronephrosis; on MRI invasion of bladder wall; cystoscopy: no tumor infiltration into bladder mucosa; normal serum creatinin. Successful uncomplicated placement of JJ-stent

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25 Q8. How to grade baseline morbidity? CTCAE v3.0 ureter stricture A. Ureter stricture is tumor related, no morbidity B. Ureter stricture G1 C. Ureter stricture G2 D. Ureter stricture G3

26 Case 10 Ureter stenosis 3 months after treatment the JJ stent is still in position. At this point patient notes some leakage of urine, especially when lifting / carrying heavy loads at her work in a green house; wears pad for urine changes 3 times per day.

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28 Q10. How to Grade morbidity? Ureter stenosis CTCAE v3.0 and urinary incontinence CTCAE v3.0 A.Ureter stenosis G3, urinary incontinence G1. B.Ureter stenosis G2, urinary incontinence G2. C.Ureter stenosis G2, urinary incontinence G3. D.Ureter stenosis G1, urinary incontinence G2.

29 Case 11 Lymphedema 73 year old cervical cancer patient FIGO Ib2 Bilateral pelvic lymphadenectomy, intra-operatively one node positive right obturator region, therefore no hysterectomy performed Postoperatively some small lymphocysts lower pelvis

30 Case 11 Lymphedema At first FU 4 weeks after treatment complaints of slowly progressing edema both legs, mainly lower limbs, right leg somewhat painful By clinical investigation both legs with signs of edema, thighs comparable, lower right calf more swollen than left with some erythema and pitting oedema, both legs painful by palpation

31 Case 11 Lymphedema Measurements both upper limbs comparable size 41 cm Circumference right lower limb 35 cm, 3 cm bigger than at left side Ultrasound, no signs of thrombosis both legs Conclusion lymphedema both limbs, right>left

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33 Q11. How to grade? CTCAE v3 A. Limb edema G1 B. Limb edema G2 C. Limb edema G3

34 Case 12 3 years after treatment It is years after the diagnosis, but I don t have the feeling of being fully recovered, I still need to rest during the day and don t have the energy to fully go back to normality. Sometimes, I just need to cancel all my plans and lie down to take a nap.

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36 Q12. How to grade? A. Fatigue G1 B. Fatigue G2 C. Fatigue G3 D. Fatigue G4

37 1B 2D 3C 4C 5C 6B 7B 8D 9 out 10B 11A 12B