About cervical cancer IIIB and its treatment plan, counselling and diet

1. CERVIX CANCER IIIB
BY:
GOUTHAM
612171602008
IIIRD PHARMD
CASE PRESENTATION ON

2. PATIENT PROFILE FORM
• NAME:CH.ANANTHA LAXSHMI
• AGE:32 YEARS
• WARD: CANCER WARD
• WEIGHT:40KGS

3. REASONS FOR ADMISSION:
• WHITE DISCHARGE- 3MONTHS
• PAIN IN ABDOMINAL REGION +
• PELVIC PAIN, BACK PAIN
• ABNORMAL BLEEDING

4. PAST MEDICAL HISTORY:
• HISTORY OF NORMAL DELIVERY TWICE AT HOME
WITHOUT ANY SUPER VISION DOCTOR.
• TUBECTOMIZED

5. DIAGNOSIS:
BIOPSY REPORT:
MICROSCOPIC EXAMINATION:
MICROSCOPICALLY SECTIONS SHOW TUMORS MADE UP OF
MALIGNANT SQUAMOUS EPITHELIAL CELLS DISPOSED IN
SHEETS AND CORDS. THE CALLS ARE POLYGONAL SHOWING
PLEOMORPHIC VESICULAR MUCOLET WITH PROMINENT
MUCOLOID AND AMPLE EOSINOPHILC DEFUSE CYTOPLASM.
OPINION:
MODERATELY DIFFERENTIATED NON-KERATINIZING LARGE
CELL SQUAMOUS CELL CARCINOMA CERVIX.

6. PROVISIONAL DIAGNOSIS:
CARCINOMA CERVIX IIIB

7. CARCINOMA CERVIX IIIB

8. SUBJECTIVE EVIDENCE:
• WHITE DISCHARGE- 3MONTHS
• PAIN IN ABDOMINAL REGION +
• PELVIC PAIN, BACK PAIN
• ABNORMAL VAGINAL BLEEDING
• CHANGES IN MENSTRUAL CYCLE
PHARMACEUTICAL CARE PLAN

9. OBJECTIVE EVIDENCE:
• DEPENDING ON CONDITIONS CERVIX BIOPSY IS DONE.
REPORT SHOW THE PRESENCE OF MODERATELY
DIFFERENTIATED NON-KERATINIZING LARGE CELL
SQUAMOUS CELLS CARCINOMA.
ASSESSMENT:
• BASED ON SUBJECTIVE AND OBJECTIVE EVIDENCE THE
PROVISIONAL DIAGNOSIS IS DONE AS CARCINOMA
CERVIX IIIB

10. TREATMENT OPTIONS:
TREATMENT OPTIONS DEPEND ON THE
FOLLOWING:
• THE STAGE OF THE CANCER.
• THE SIZE OF THE TUMOR.
• THE PATIENT'S DESIRE TO HAVE CHILDREN.
• THE PATIENT'S AGE.
 AS PATIENT IS SUFFERING WITH IIIB STAGE CERVIX
CARCINOMA EXTERNAL AND INTERNAL RADIATION
THERAPY WITH CHEMOTHERAPY IS FOLLOWED IN
ADVANCED CONDITIONS RADICAL HYSTERECTOMY IS
DONE.

11. CHEMOTHERAPY
o ALKYLATING AGENTS
CISPLATIN(PLATINOL-AQ)
CARBOPLATIN
IFOSFAMIDE
o ANTI METABOLITES
5-FLUOROURACIL
FLUOROURACIL(FLUOROPLEX)
CYTARABINE

12. o Antibiotics
Mitomycin
Bleomycin(Blenoxane)
Epirubicin(Ellence)
Topotican
o Monoclonal Antibody's
Bevacizumab(Avastin)
Rituximab
 Paclitaxel(Taxol)
 Docetaxel(Taxotete)

13. o Anti ulcerative
Ranitidine
Pantoprazole
o Anti emetic
Omeprazole
Granisterol
o Diuretics
Mannitol
o External radiation therapy

14. GOALS TO BE ACHIEVED
RELIEVE SYMPTOMS AND IMPROVE QUALITY OF
LIFE.
SLOW DISEASE PROGRESSION
PREVENT METASTASIS OF CANCER TUMORS
RELIVE PAIN AND EXCESS VAGINAL BLEEDING

15. B.P-110/70mm/Hg
PR-128/min
CNS-S1 S2 +
LUNGS-clear
P/A-soft
Presence of tumor on uterine walls with 9×4 cm in size.

16. LABORATORY TESTS
MICROBIOLOGY:
• NEGATIVE TO HUMAN PAPILLOMA VIRUS (HPV)
• COAGULASE NEGATIVE STREPTOCOCCUS ISOLATED.
BIOCHEMICAL TESTS(10/10/12):
• TOTAL W.B.C COUNT:12,200CELLS/CM³
• DIFFERENTIAL COUNT
POLYMORPHS:77%(N-20-70%)
EOSINOPHIL'S :0.4%(N-0-6%)
LYMPHOCYTES:16%(N-15-40%)

17. Monocytes:03%(N-0-8%)
Hemoglobin:9.4gm(N-11.5-16.0%)
Platelet count:3.0laks/cm(N-1.5-4.0)
Serum creatinine:0.6 mg/dl
 Ultra sound abdomen
Liver: slightly increased in size
Gall bladder: increased size 15-16cm
Pancreas: visualized head and body. Rest poor window
Urinary bladder: partially filled.
Prostate/Uterus:
right & left ovary not visualized
low lying uterus
Impression:Choloentiritis
Low laying uterus

18. DRUG CHART:
DRUG DOSE ROA FREQ 5/9/13-
21/11/13
Inj.
Decadron
8mg IV I-0-I 
Inj.Doxorubi
cin
60mg IV I-0-I 
Inj.Granisetr
on
3mg IV I-0-0 
Inj.Mg
sulfate
1amp IV infusion I-0-0 
Inj.Cisplatin 45mg IV infusion I-0-I 
Inj.Mannitol 100ml IV I-0-I 
IV Fluids 1RL
1DNS
IV 

19. CYCLES:
DRUG DOSE ROA FREQ 12.10.13-
16.10.13
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubic
in
60mg IV I-0-I
Tab. BC Oral I-0-I 
CYCLE-1
Hb%:9.4gm
DRUG DOSE ROA FREQ 17.10.13-
18.10.13
Tab.
Diclofenac
120mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
CYCLE-2

20. CYCLE-3
DRUG DOSE ROA FREQ 20.10.13-
25.10.13
Tab.Diclofena
c
120mg Oral I-0-I 
Inj.Doxorubici
n
60mg IV I-0-I
Tab. Rantac 50mg Oral I-0-I 
DRUG DOSE ROA FREQ 26.10.13-
27.10.13
Tab.Diclofenac 120mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubicin 60mg IV I-0-I 
CYCLE-4

21. CYCLE-5
Tolerated CT cell
Blood Urea:30mg/dl
Serum creatinine:1.0mg/dl
DRUG DOSE ROA FREQ 30.10.13-
2.11.13
Tab.Diclofen
ac
120mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubi
cin
60mg lV I-0-I 
Tab.Zofer 8mg Oral I-0-I 
Prolapse reduced completely

22. CYCLE-6
DRUG DOSE ROA FREQ 3.11.13-
6.11.13
Tab.Diclofen
ac
120mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubi
cin
60mg IV I-0-I 
DRUG DOSE ROA FREQ 8.11.13
Tab.Diclofen
ac
110mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubi
cin
60mg IV I-0-I 
Tab.Zofer 8mg Oral I-0-I 
CYCLE-7
Tolerated CT cell

23. CYCLE-8
Blood urae:35mg/dl
Serum
creatinine:1.0mg/dl
DRUG DOSE ROA FREQ 9.11.13-
16.11.13
Tab.Diclofen
ac
110mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubi
cin
60mg IV I-0-I 
CYCLE-9
DRUG DOSE ROA FREQ 17.11.13-
19.11.13
Tab.Diclofen
ac
110mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubi
cin
60mg IV I-0-I 
Tab.Zofer 8mg Oral I-0-I 

24. DRUG DOSE ROA FREQ 20.11.13-
22.11.13
Tab.Diclofen
ac
110mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubi
cin
60mg Oral I-0-I 
CYCLE-10
DRUG DOSE ROA FREQ 24.11.13
Tab.Diclofenac 110mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubici
n
60mg Oral I-0-I 
Tab.Ondensetr
on
4gm Oral I-0-I 
CYCLE-11

25. DRUG DOSE ROA FREQ 26.11.13-
29.11.13
Tab.Diclofenac 110mg Oral I-0-I 
Tab. Rantac 50mg Oral I-0-I 
Inj.Doxorubicin 60mg IV I-0-I 
Inj.Ciprofloxaci
n
200mg IV I-0-I 
Tab.Metronida
zole
250mg Oral I-I-I 
CYCLE-12

26. AT THE TIME OF DISCHARGE
• GC-ANEMIC
• TEMP.-NORMAL
• PR-86/MIN
• BP-110/80mmHg
• CVS-S1 S2+
• LUNGS-CLEAR
• P/A-SOFT
• ABDOMINAL PAIN AND BACK PAIN ARE REDUCED.

27. GOALS ACHIEVED
• TUMOR SIZE IS REDUCED
• VAGINAL BLEEDING IS REDUCED BY 8TH CYCLE
• NORMAL MENSTRUAL CYCLE BY 7TH CYCLE
• PELVIC PAIN IS REDUCED

28. MONITORING PARAMETERS
• HEPATIC AND RENAL FUNCTION ARE MONITORED
• AUDIOMETRIC TESTING.
• PAP TEST SHOULD BE CONDUCTED TO ESTIMATE THE EXTANT
OF CANCER.
• COMPLETE GI CHECKUP
• CONCURRENT USE OF DOXORUBICIN AND GRAPEFRUIT JUICE
MAY RESULT IN INCREASED DOXORUBICIN EXPOSURE.
• HEPATIC FUNCTION TESTS, INCLUDING BILIRUBIN, AST, ALT,
AND ALKALINE PHOSPHATASE; AT BASELINE AND DURING
TREATMENT
• INJECTION SITE REACTION, INFILTRATION, OR EXTRAVASATION
DURING ADMINISTRATION OF CISPLATIN.

29. Problems Identified:
 Concurrent use of CISPLATIN and DOXORUBICIN may result in
leukaemia.
 Concurrent use of CIPROFLOXACIN and DICLOFENAC may
in increased ciprofloxacin plasma concentrations.

30. PATIENT COUNSELING
ABOUT DISEASE:
STAGE IIIB CERVICAL CANCER: FORCERVICALCANCER,THEREAREFIVE
STAGES:STAGE0(ZERO)ANDSTAGESITHROUGHIV(ONETHROUGHFOUR).THESTAGEPROVIDESA
COMMONWAYOFDESCRIBINGTHECANCER,SODOCTORSCANWORKTOGETHERTOPLANTHE
BESTTREATMENTS.
CANCERHASSPREADTOTHEPELVICWALLANDTOLYMPHNODESNOTTOOTHERPARTSOFBODY;
AND/ORTHETUMOURHASBECOMELARGEENOUGHTOBLOCKTHEURETERS(THETUBESTHAT
CONNECTTHEKIDNEYSTOTHEBLADDER).THEDRAWINGSHOWSTHEURETERONTHERIGHT
BLOCKEDBYTHECANCER.THISBLOCKAGECANCAUSETHEKIDNEYTOENLARGEORSTOP
WORKING.

31. About drugs:
Inj Doxorubicin: Doxorubicin blocks nucleotide replication and action of
DNA and RNA polymerases. It also interacts with topoisomerase II to
DNA-cleavable complexes, which is believed to be an important
mechanism of its cytocidal activity.
 Dose- 60mg IV BD reconstitute vial with NS to obtain 2 mg/mL
concentration
 Adverse Effects: Alopecia, Pancreatitis, Injection site extravasation,
Cardiovascular and haematological problems.
 Drug may cause premature menopause in females
Tab Diclofenac: Diclofenac is an NSAID with potent anti inflammatory,
analgesic, and antipyretic properties.
Dose-120mg orally BD
Tab Rantac: It is an Anti Ulcerative drug for preventing ulcers.
 Dose-50mg orally BD
 Adverse Effects: Abdominal pain, Constipation, Diarrhoea

32. Tab Metronidazole: Metronidazole is a nitro imidazole antibiotic that
appears to selectively produce cytotoxic effects in anaerobes by a
reaction.
 Dose-250mg orally TID
 Side effects: may include seizures, nausea, diarrhoea, headaches,
dizziness, metallic taste, rash, pruritus, or leukopenia (mild)
Inj Ciprofloxacin: It is an Antibacterial.
 Dose-200mg IV BD dilute in D5W, NS, or LR to concentration of 1 to 2
mg/mL, infuse over 60 minutes.
 Side effects: may include nausea, vomiting, rash, headaches, confusion,
restlessness, or injection site reactions .
Inj Ondansetron: Ondansetron is a selective 5-hydroxytryptamine-3 (5-
HT3)-receptor antagonist used for the prevention of chemotherapy-
nausea and vomiting.
Dose-8mg orally BD
Side Effects: constipation, diarrhoea, headache, drowsiness/sedation

33. Inj Granisetron: Granisetron is a selective 5-hydroxytryptamine-3 (5-HT3)-
receptor antagonist used for the prevention of chemotherapy-induced
nausea and vomiting.
Dose-3mg IV OD
Inj Cisplatin: It is an alkylating agent. They impair cell function by forming
covalent bonds with amino, carboxyl, sulfhydroxyl and phosphate groups.
Dose-45mg IV infusion BD slowly for 6-8hrs
Reconstitute dry powder vials with sterile water for injection, yielding a 1
mg/mL solution. Dilute reconstituted or aqueous solution in 2 L of D5W 1/2
NS, or D5W 1/3 NS containing 37.5 g Mannitol.
Adverse effects: myelosuppression, nephrotoxicity, neurotoxicity.
Inj Mannitol: Mannitol is an osmotic diuretic. It promotes diuresis by
increasing the osmolarity of the glomerular filtrate and thereby blocking the
tubular reabsorption of water.
Dose-100ml IV BD
Adverse Effects: cause chest pain, hypotension, palpitations,
diarrhoea, nausea, vomiting, xerostomia, headache, rhinitis, or urinary
retention

34. Inj Magnesium Sulphate:
Dose- 1amp IV infusion OD
Adverse Effects: hypotension, hyporeflexia, or CNS depression
Inj Dexamethasone: Dexamethasone is a synthetic adrenocortical
steroid with potent anti-inflammatory effects.
Dose- 8mg IV BD
Adverse Effects: Hyperglycaemia, Osteoporosis, Cardiomyopathy,
Pancreatitis

35. About Life Style Modifications:
 Patient is acknowledged about signs and symptoms of disease
 Stop using birth controlling pills.
 Should take high calorie food to maintain a healthy weight.

36. PREVENTION
• VACCINES ARE NOW AVAILABLE TO WARD OFF THE TWO
TYPES OF HPV MOST STRONGLY LINKED TO CERVICAL
CANCER. BOTH CERVARIX AND GARDASIL REQUIRE THREE
DOSES OVER A SIX-MONTH PERIOD. STUDIES SUGGEST THE
VACCINES ARE EFFECTIVE AT PREVENTING CHRONIC
INFECTIONS WITH THE TWO TYPES OF HPV THAT CAUSE
70% OF CERVICAL CANCERS. GARDASIL ALSO PROTECTS
AGAINST TWO TYPES OF HPV THAT CAUSE GENITAL WARTS.
• PAP-TEST FOR EVERY 3YEARS TO DETECT ANY SIGNS OF
ABNORMAL CELLS

37. THANK YOU
