| Mrs.
XYZ 24 years old married housewife was referred from Palghar as a primigravida
with 7 months amenorrhoea with huge subserous pedunculated fibroid. On
USG report came as single dead intrauterine foetus of average 30 wks period
of gestation with a huge mass separate from the uterus 20 x 16 cms. FNAC
of the mass came as dysgerminoma. |
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Introduction
Ovarian cancer is the second most frequent gynaecologic cancer complicating
pregnancy.1 Although the overall
incidence of ovarian cancer in pregnancy is low, the increased use of
ultrasond in early foetal evaluation has led to more frequent findings
of adnexal mass in pregnancy. The average estimated incidence of ovarian
tumours in pregnancy is approx. 1 in 100 deliveries.2,3 The vast majority
of tumours detected during pregnancy are benign. Approx. 2 to 5% of
adnexal masses are the malignant neoplasma.2 |
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Fig. 1 : Ultrasound film showing the mass
separate from uterus
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Fig. 2 :
Ultrasound film showing mass pushing the cervix high up and obstructing
the foetal head |
CASE HISTORY
Mrs. XYZ 24 years old married housewife residing at alghar was
referred to our OPD as a primigravida with 7ma with a huge subserous
pedunclated fibroid. LMP 7.2.2001 and EDD 14.11.2001. No other
significant past medical or surgical history was found. On examination
: General condition was fair and all vitals within normal limits.
On obstetric examination uterus was 32 wks and foetal heart sounds
were not heard. On per speculum and per vaginum examination: Cervix
was very high up (not seen) and there was foul smelling discharge
present. All her investigations were sent which came within normal
limits except S. creatinine : 1.75, Prothrombin time: 14 sec,
Prothromboin index: 78.5%.
Ultrasound abdopelvis (Figs. 1 and 2): Single dead intrauterine
foetus of average 30 wks period of gestation with spalding’s
sign present. A large isoechoic mass is seen in abdomen pushing
the gravid uterus to the left measuring 20 x 16 cms, also extending
to left side and going behind the uterus pushing iliac vessels
anteriorly, free fluid in abdomen was present, left sided ydronephrosis
present. As the mass appears separate from uterus an impression
of broad ligament fibroid was given but as ovaries were not seen
ovarian origin had to be ruled out. In view of deranged coagulation
profile decision of termination of pregnancy was made and as cervix
was not visualized hysterotomy was the only option left. But patient
went in labour spontaneously and aborted a macerated female baby
weighing 1.3 kg. Placenta had to be removed manually with difficulty
in OT as it was adherent and the cervix was high up and not seen.
Two bottles of fresh frozen plasma and one bottle of whole blood
was given to the patient. Patient was advised detail workup for
the mass but patient was discharged against medical advise on
27.8.2001. She came back on 4.2.2002 with complaints of distension
of abdomen and loss of weight. Patient was readmitted and all
her investigations were sent which came within normal limits except
Hb: 9 gms% and S. creatinine: 1.1. Specific investigations specific
to the mass were as: Alpha feto protein: 2.6 (N=0.5-35), beta
hCG 737 (N=below 25), Ca 125:253 (N=0-35) CT.
Abdopelvis showed a solid ovarian neoplasm causing compression
of both ureter with bilateral hydroureter and hydronephrosis.
FNAC of the mass showed a dysgerminoma. Case was discussed with
Oncologist and 3 drugs chemotherapy regime of Bleomycin / Etoposide
/ Cisplatin was started on 26.2.2002. Patient complained of breathlessness
on Day 2 and inspite of all resuscitative methods died on 28.2.2002
at 6.30 pm, DC was given.
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DISCUSSION
Dysgerminomas are derived from the primordial germ cells of the ovary
that have not differentiated to form embryonic or extraembryonic structures.
Dysgerminoma tumours grow rapidly and present with pelvic pain. A significant
number of patients are asymptomatic and are found to have an adnexal mass
on physical examination, during routine ultrasound or at the time of caesarean
section.4 However, other presentations include abdominal pain, abdominal
distension, bstructed labour and emergency laparotomy due to torsion or
rupture of the mass.4 Management of malignant pathology depends on tumour
type, gestational age and patient's wish. Although serum tumour markers
remain important in the preoperative assessment of all women with adnexal
mass, their interpretation in pregnancy is not always reliable since they
are often elevated and fiuctuate with gestational age.5
Treatment options available are: 1) surgery, 2) chemotherapy and 3) radiotherapy.
The literature describes successful pregnancy and preservation of normal
ovarian function, in cases of advanced-stage metastatic low malignant
potential tumours treated by successful tumour debulking.7 For those patients
with advanced disease, decisions regarding debulking procedures should
take into account foetal viability, patient health and patient desires
at the time of surgery hysterectomy during pregnancy is rarely indicated
unless it contributes significantly to the tumour debulking. A recently
published retrospective study of 174 patients undergoing adnexal surgery
during
pregnancy showed no evidence of increasing risk of foetal loss when surgery
was performed after the seventh week of gestation.6
Cancer chemotherapeutic drugs are very potent teratogens. Currently, there
is very little information on the effect of cancer chemotherapy on the
foetus.8 The risk of malformations when chemotherapy is administered in
the first trimester has been estimated to be around 10% for single agent
chemotherapy and 25% for combination therapy. Use of these agents in second
and third trimesters has been associated with risk of stillbirth, intrauterine
growth retardation, and low birth weight. Although limited but there are
case reports of cytotoxic treatment for germ cell tumours in the second
and third trimesters using agents such as vincristine, vinblastine, actinomycin,
cyclophosphomide, bleomycin, cisplatinum and etoposide.9 Foetal outcome
was good. There is no published data regarding the use of Taxol during
human pregnancy.
Dysgerminomas are extremely radiosensitive, but generally radiation is
used as a second line treatment because of the desire to maintain fertility.
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CONCLUSION
Association of ovarian cancer with pregnancy is a rare occurrence. Early
diagnosis and appropriate treatment offers the best prognosis for the
patient.There is no evidence that pregnancy alters the prognosis of the
ovarian tumours to the nonpregnant population when patients are matched
for tumour histology and stage. In general, pregnant patients with ovarian
cancer have a better overall prognosis due to the age related tumour distribution
and early stage of diagnosis in a significant number of patients. |
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REFERENCES
1. Boulay R, Podczaski E. Ovarian cancer complicating pregnancy. Obstetric
and Gynecology Clinics of North America. 1998; 25 (2) : 385-99.
2. Beischer NA, Buttery BW, Fortune DW, et al. Growth and malignancy of
ovarian tumours in pregnancy. Aust N Z
Obstet Gynaecol 1971; 11 : 208.
3 . White KC. Ovarian tumours in pregnancy: a private hospital 10 years
survey. Am J Obstet Gynecol 1973; 116 : 544.
4. Norton JA, Levin B, Jensen RT. Cancer of the endocrine system. In:
De Vita VT, Hellman S, Rosenberg SA, ed.
Cancer: principles and practice of oncology. 4th ed.Philadelphia: JB Lippincott,
1933 : 1333.
5. Zanotti K, Belinson J, Kennedy A. Treatment of gynecological cancers
in pregnancy. Seminars in Oncology 2000; 27 (6).
6. Wang PH, Chao HT, et al. Ovarian tumours complicating pregnancy. Emergency
and elective surgery. Journal of
Reproductive Medicine 1999; 44 (3) : 279-87.
7. Miller DM, Ehlen TG, Saleh EA. Successful term pregnancy following
conservative debulking surgery for a stage IIIA
serous low-malignant potential tumour of the ovary : a case report. Gynecologic
Oncology 1997; 66 (3) : 535-8.
8. Zemlickis D, Lishner M, Koren G. Review of fetal effects of cancer
chemotherapeutic agents. In: Korean G, Lishner M,
Farine D, ed. Cancer in pregnancy. 1 ed. Cambridge: Press syndicate of
the University of Cambridge. 1996 : 168.
9. Buller RE, Darrow V Manetta A, et al. Conservative surgical management
of dysgerminoma concomitant with pregnancy. Obstet Gynecol 1992; 79 :
887. |
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BOTULINUM
TOXIN - ROLE IN HEADACHE PROPHYLAXIS
While pain reduction was initially thought to be due to a release
of muscle contractility in spasm-related conditions,
recent research suggests that botulinum toxin may inhibit release
of substance P calcitonin generelated peptide (CGRP and glutamate.
Physicians are therefore now beginning to explore the potential
benefits of botulinum toxin for a variety of conditions
characterized by pain including different headache disorders,
cervical myofascial pain, low back pain, and post-herpeticneuralgia.
Migraine affects 10-20% of the world's population and has significant
consequences on patients' functional quality of life. Patients
may find treatment with botulinum toxin an appealing option because
it has an excellent side effect profile and treatment may need
to be repeated only once every 3-4 months.
In all the studies reviewed by the authors there were no reported
serious adverse events due to botulinum toxin therapyand overall
very few adverse events.
K Ravishankar, JAPI, 2003; 51 : 851-52. |
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