Case Conference June 15th 2011

15-Jun-2011, Divisi ginekologi onkologi RSCM

Mrs. C/ 36 yo/ P4
Jun 9  th   2011

Chief complaint :
 Patient controlled to policlinic with  Histopathology result  result

History :
April 24 th 2011 :
Patient  came to Cipto Mangunkusumo Hospital with diagonsis : cervical cancer stage I B 2

Mei 26 th 2011 :
Operation was done with procedure : Radical Hysterectomy, Salpingooovorektomi sinistra, Right ovarian transposition, bilateral pelvic lymphadenectomy.

Jun 6 th 2011 : histopathology report:
Non keratinizing Squamous cell carcinoma, moderate differentiated
Lymph vaskular invasion
Border  vaginal incision free of tumor
Deef invation less tha ½ layer
Right parametrium (2 nodes) and left prametrium (8 nodes) all of nodes are free of  tumor
Ovarian teratoma matur
Right Pelvic lymph node (12 nodes) and 1 node contain tumor mass
Left pelvic lymph node (12 nodes) all of tumor are free

General status : BP :110/80 mHg, P: 82 x/m, RR : 18 x/m, T : 36,2 C
• Conj: anemic -/-
• Thorax: Within Normal Limit 
• Abdomen : supel, midline operation scar 2 finger  above umbilicus
• Extremities : warm, edema -/-

Gynecological states
• Inspection  : v/u calm
• Io :  vaginal stump calm, fluxus (-), flour A(-)
• RVT : there was palpable vaginal stump calm, vaginal wall smooth, Ampulla rectum not collaps

Supportive examination
• Laboratorium (26-4-2011) : HB : 10, WBC 10400, plt : 437.000, SGOT/SGPT : 16/13 , Ur/Cr : 19/0,6  HbsAg (-)
• Histophatology (4-5-2011) : Non keratinizing Squamous cell carcinoma, mild differentiated
• Thorax PA (9-5-2011): within normal limit
• BNO IVP : (9-5-2011)
o Secretion and function Both of kidney is normal
o Left Hidroureter mild cause obstruksi partial of mass 
USG  (13-5-2011) Impression : Malignancy Cervical, letf dermoid cyst
• Rectoscopy (24/2/11) : Metastasis (-)
• Cystoscopy (23/2/11) : within normal limit

Diagnosis :
Cervical cancer stage I B 2, post hysterectomy radical

Problem :
Cervical cancer stage I B 2, post hysterectomy radical with lymphovascular space invasion  (+) and 1 node positive pelvic lymph node