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Vulvar cancer
let's assume 60 yr old woman came to office with itchy vulva.
OFFICE
HO, complete PE
CBC
BMP
LFT
UA
Accucheck
Papsmear
Vaginal swabs for culture
Counsel for vulval biopsy
Personal hygiene
Review 3 days with all results
Consult Gynecologist for vulval biopsy
Review with biopsy
Admit to floors
EKG
CXR
Consult anaesthesia
Pt/ptt
HBS ag,
HIV
Biopsy confirmed vulval cancer
CT chest, abdomen, pelvis for clinical staging
Surgery…Modified radical vulvectomy only… if there is no lymphnode, invasion less than 1 cm
....If more than 1 cm invasion…modified radical vulvectomy plus lymphadenectomy
Antibiotics
post op wound care
ambulation
spitometry
compression stalking
heparin IV if she has risks
morphine
5min screen
Reassure
Counsel family, patient
No smoking
No alcohol
Papsmear one year later
Mammogram later
Influenza later
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41 yr old lady-pregnant 14 th week- presented with a breast nodule in left breast & palpable axillary nodes in left side. The breast nodule is not movable. She has 3 kids at home.
office visit
complete PE---show fixed mass in left breast
if the hx doesnt give you the detail of her pregnancy or record or it is her first time to ur office...then we do the following
order
cbc
bmp
cxr ( it is safe)
tsh
bhcg urine
bhcg quantitative ( we order this one if there is no record or data in her hx)
ultrasound of breast ( mamogram is ok but ultrasound is better as initial since mamograms are harder for doctors to read during pregnancy because the breast tissue becomes denser)
( if there is no record of lab order during first trimester, then we can add these tests, i am not going to list them)
send the patient home and appt in few days when her ultrasound will be ready)
Pt arrived to her appt, ultrasound show solide mass suspicious of breast cancer.
Focus exam
order
surgery consult ( breast mass suscipious of cancer )
FNA
schedule appt in few days and pt arrive to her appt
if pathology report shows breast cancer stage 1 or 2
Transfer the pt to the ward
order
pulse oxi
IVA
npp
pnuematic stocking ( hypercoag issue in pregancy)
fetal heart rate by doppler
fetal heart monitor
cancer diagnosis
pt
ptt
cbc
bmp
ua
lft
type and cross
unasyn
OByGN, oncology and surgery consult
order lmph node removal (lymphadectomy) and lumpectomy, usually done after 12 weeks gestation (not in first trimester)
if you have done this much, i believe the case will end. if not then you continue f/u
order counseling , family support
Women who have breast-saving surgery, like lumpectomy, often need radiation therapy afterward to reduce the chance that the cancer will come back. The need for radiation is an important issue for pregnant women when choosing which surgery to have. Radiation could affect the fetus if given during the pregnancy, so it is not used until after the birth.
Chemo usually is not given during the first 3 months of pregnancy.When a pregnant woman with early breast cancer needs adjuvant chemo after surgery, it is usually delayed until at least the second trimester. If a woman is already in her third trimester when the cancer is found, adjuvant chemo may be delayed until after birth.
Pregnant women who choose lumpectomy or partial mastectomy can usually have surgery during the pregnancy and wait until after the baby is born to have radiation therapy.
The safest chemo used in 2nd or 3rd trimester are adriamycin and cyclophos
additonal information if the pt discover that she had breast cancer in 3rd trimester then
Chemo should not be given 3 to 4 weeks before delivery. This is because one side effect of chemo is that it lowers the mother's blood counts. This could cause bleeding and increase the chances of infection during birth. Holding off on chemo for the last few weeks before delivery allows the mother's blood counts to return to normal levels before child birth.
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cardiac tamponade
follow pericardiocentesis by pericardial window
