ULTRASOUND Messages for January, 1999: Re: clinical problem

Re: clinical problem

From: James S Smeltzer MD

gaperina@mindspring.com

Wed Jan 6 15:44:57 1999

How would you perform a sonohyst when the gynecologist can not find the cervix? I agree that a TVS is a good way to start answering what this is in the first place.

If you are going to do this case prepared to do whatever is necessary for nodes, ureters, bladder and bowel regardless of source and type of neoplasm you could argue that there is no additional work-up needed, including a pipelle and Pap I have done using TVS in such a case (Large leiomyoma & simple hyst, no prep).

How do you know that this is NOT cervical cancer, better treated by EBT and cavitary Rx than a tumor crossing hysterectomy followed by bowel fried by EBT and vaginal insert? Are there two kidneys or are you going to spend 60 minutes looking for a ureter that isn't there? Is there a thick omental cake? Are you going to perform an extensive bowel prep pre-op? Do you need to be prepared to perform an ileal conduit? What about a colectomy and pull-through?

If you are just a little curious about defining what you will be trying to treat before you go in to treat it, imaging may help avoid unnecessary preparation. The CTS would do a better job on adenopathy, dense & calcified leiomyomata, with contrast for ureteral placement, bladder invasion, bowel lesions. TVS or MRI is better for evaluation of endometrium in ca of corpus, TVS for ovaries with doppler. What is the size of the overall mass? Is there parametrial induration? Has she ever had an abnormal Pap? Hypertension? Obese? As a gynecologist I would start with TVS guided PAP & pipelle, ovarian evaluation and uterine and parametrial evaluation, check of kidneys, and order the CTS if still unsure that this was a benign large leiomyoma.

Of these preop diagnostic tests I would consider essential, the Pap smear is numero uno, since what you plan to do is far from optimal management for a stage 3b cervical cancer, IMHO. Jim Smeltzer MD

At 10:57 PM 1/5/1999 -0600, you wrote: >At 09:06 PM 1/5/99 -0600, you wrote:
>>I would like to hear some expert opinion on the following case:
>>64 year old post menopausal female in good health getsreferred by her
>>primary care doc ( actually the nurse practitioner) for post menopausal
>>spotting. Pap, mammo all normal. My exam reveals a mass which
>>displaces the cervix way upward ( you cant visualize it at all with the
>>speculum--and endo biopsy is impossible. Rectal exam reveals the mass (
>>and/or uterus?) above the rectum and shes guiac neg. There is no
>>ascities and ca125 is wnl. The radiologist wanted me to order a ct scan
>>but I dont feel this is necessary since this most likely uterine or
>>ovarian neoplasm clearly needs to come out.(Ido these cases with a
>>gyn-onc who can stage these tumors adequately.)I am not sure if this is
>>malignat or benign. r/o colon tumor ?-although this seems highly
>>unlikely. My one reservation about ordering these tests is that the the
>>hmo medical directors might delay my case ruling out distant spread when
>>none exists. ( such a thing happened recently to me and there was a 4
>>week delay-- that woman had ovarian cancer. Any insights? My point here
>>is how would additional testing in this case alter management?
>>
>>--
>>nsohn
>>
>Natalie -
>
>How about ordering a transvaginal pelvic ultrasound exam to see if this
>patient has a retropositioned uterus or possibly a uterine fibroid? I've
>done many transvaginal ultrasounds for a possible cul de sac mass that
>turned out to be a retropositioned uterus. Also, with a transvaginal
>ultrasound exam, sonohysterography could be performed as needed to see if
>there may be a polyp or fibroid within the endometrial cavity as a cause for
>the PMP spotting. Just a thought.
>
>Deb Richert, AAS, RDMS, RVT
>La Crosse, WI
>

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