The Left Ischium Etc.

Mildly generous uterus care of
http://www.eatdancelive.com/2011/03/yes-your-period-can-be-fun.html

This is my 75th post on this blog. Who knew that all it would take was cancer to make me prolific...

I got a 120 page PDF file recently containing some of my medical records from Kaiser. It doesn't include a lot of things, such as email correspondence. It's mostly about the scans. Anyway, apparently I have a "mildly generous uterus", so that's something. I had no idea how many doctors there were behind the scenes interpreting scans etc.

It is very technical so some of it probably won't make any sense but I will try to post some pictures that will help. It clarifies what kind of info comes from each scan.

Gynecologist's note from my visit from last week:
"My exam as compared to last exam by gyn oncologist suggests significant shrinking of tumor."

The cut-and-pastes are below. I bolded stuff I was interested in or that summarized more cryptic stuff. 

FINAL PATHOLOGIC DIAGNOSIS
VAGINA, PROXIMAL ANTERIOR WALL BIOPSY (this was done on 11/14/11)
- INVASIVE MODERATELY-TO-POORLY DIFFERENTIATED ADENOCARCINOMA

The urologist wrote:
Anterior vaginal tumor involving the right posterior bladder neck; this appears to be a tumor eroding into the bladder base from an external primary source.

CT SCAN - CHEST ABDOMEN AND PELVIS
11/21/2011

The lungs are clear with no pulmonary nodules.  The heart and mediastinal structures are unremarkable.  There is a 3 cm left breast cyst.
There is 1 cm cyst in the inferior aspect of right hepatic lobe.
There is a 4 mm hypodense focus in the medial segment of left hepatic lobe, just anterior to the gallbladder, which is too small to characterize. There is wall calcification of the gallbladder.

There is heterogeneous attenuation within the gallbladder. There is no biliary ductal dilatation. The spleen, pancreas, and adrenal glands are unremarkable without focal mass.  Kidneys demonstrate  symmetric uptake of iodinated contrast and are without focal mass or hydronephrosis.
Stomach and bowel are unremarkable.
The aorta and its major branches are unremarkable. Urinary bladder is unremarkable.  The uterus is mildly generous in size. The ovaries are grossly normal.
No aggressive osseous lesions are seen.

** IMPRESSION **:
1. No evidence of metastasis in the chest, abdomen, and pelvis.
2. Abnormal gallbladder, with wall calcification and heterogeneous attenuation within it. Ultrasound is recommended for further evaluation.

From here http://home.comcast.net/~wnor/pelvis.htm

12/20/11 PET/CT SCAN
[not sure why there is so little info with this one.]

1. The vaginal mass is metabolically active in keeping with malignancy.
2. There is one hypermetabolic right presacral lymph node in the pelvis which is probably metastatic.
3. There are several hypermetabolic lytic lesions suggesting metastatic disease in the pelvis involving the right inferior pubic ramus, the left inferior pubic ramus and left ischium.

12/28/11 XRAY PELVIS


** FINDINGS **:
There is some mild mottling in the ischium and inferior pubic rami bilaterally but there are no discrete lytic or blastic lesions seen. There is no evidence of cortical disruption. The soft tissues are unremarkable. No soft tissue calcification.

** IMPRESSION **:
Slight mottling of the inferior pubic rami and ischii.  No frank destructive lesions

01/13/12   MRI PELVIS WITHOUT AND WITH CONTRAST

** HISTORY **:
Newly diagnosed stage IV B. (T3/4, N1, M1)* adenocarcinoma of the vagina, status post biopsy. [see note at end about staging]


** FINDINGS **:
...There is a heterogeneous mass that seems to be centered at the anterior aspect of the lower third of the vagina, also with involvement of the middle third of the vagina. Upper third of the vagina and cervix not definitely involved. It is located immediately posterior to the inferior/posterior bladder wall, which appears somewhat irregular with suggestion of tumor erosion through the bladder wall at this location. Urethral involvement cannot be excluded. Tumor extends inferiorly to the level of the lower aspect of pubic symphysis. Exact measurements are somewhat difficult to delineate but tumor appears to measure at least 6 cm superior to inferior extent, 5 cm left to right extent, and 2.8 cm anterior to posterior extent. No definite involvement of cervix or uterus. Endometrial lining appears normal. At least 2 small intramural uterine fibroids present, neither larger than 15 mm in size. Ovaries appear normal bilaterally.

There is a mildly enlarged and homogeneously enhancing abnormal lymph node in the right posterior perirectal/presacral region, for example image #1 on series #10, measures roughly 11 mm in size.
Other pelvic and inguinal lymph nodes are likely within normal limits for size and appearance, including a 6 mm right pelvic sidewall lymph node.

Several bone lesions are present concerning for metastatic disease. For example there is T1 hypointense focus with enhancement in the mid to anterior aspect of right inferior pubic ramus. There are similar T1 hypointense foci with increased enhancement involving the mid and posterior aspects of left inferior pubic ramus as well as left ischium and left ischial tuberosity.

In addition there is a 2.5 cm circumscribed T2 hyperintense, T1 hyperintense lesion [bright spots show areas where the tissue contains more fluid than normal for the tissue type and pools of free water. Tissue that has a higher concentration of water indicates that some form of damage has occurred in the area causing the edema that is part of the body’s repair process.] in the sacrum at the  S1 level, slightly to the left of midline. There is also a small subcentimeter T1 hyperintense, T2 hyperintense focus immediately adjacent to this in the sacrum at the S1 level. Both of these lesions have characteristics consistent with hemangiomas [an abnormal buildup of blood vessels], and do not have the  T1 hypointensity of the lesions seen in the pubic rami and are not felt to represent metastatic foci, particularly in the absence of abnormal FDG [Fludeoxyglucose, radioactive sugar injection for contrast PET scan] activity at this location on the prior PET CT scan.

** IMPRESSION **:
Heterogeneous malignant appearing mass centered at the anterior aspect of the lower third of the vagina with probable extension into the posterior aspect of the bladder base, and with probable metastatic right posterior perirectal lymph node and with several bone lesions consistent with metastatic foci.

*More About Vaginal Cancer Staging (from cancer.org)
(Mine is T3/4, N1, M1) 
...If it has any T and N rating, and M1, then it's Stage IVB.

Tumor extent (T)
T1: The cancer is only in the vagina.
T2: The cancer has grown through the vaginal wall, but not as far as the pelvic wall.
T3: The cancer is growing into the pelvic wall.
T4: The cancer is growing into the bladder or rectum or is growing out of the pelvis.

Lymph node spread of cancer (N)
N0: The cancer has not spread to lymph nodes
N1: The cancer has spread to lymph nodes in the pelvis or groin (inguinal region)

Distant spread of cancer (M)
M0: The cancer has not spread to distant sites
M1: The cancer has spread to distant sites.