Case Conference June 15th 2011

15-Jun-2011, Divisi ginekologi onkologi RSCM

Mrs. Y/ 49 yo/ P1A2/ Jamkesmas

Chief complain

Vaginal bleeding since 1 years  before admission (was referred from RS Cibinong :Dx Cervical Cancer gr Ia).

 

History

One  years  before admission : patient complained vaginal bleeding, bleeding was getting worse 1 month B.A , 4-5  pads perday. Contact bleeding (+), Abdominal pain (+) decrease of appetide (+), Nausea(+) vomiting (-). Weight loss (+). History of white discharge (+) . Urination and defecation problem (+). No abdominal enlargement.

LMP :  forgot

History of lung TB complete resolution

P1A2. Married 3x.  I. 13 yrs old II. 16 yrs old III. 39 yrs old

History of Pil contraception. Smoking (-).

 

Physical examination (March 10^th 2011) :

Gen  st;  CM   BP: 120/80 bpm   HR: 80 bpm 

WNL

Gin st:

I: v.u wnl, bleeding (+)

Io: exophytical mass

RVT: exophytical mass, fragile and bleeding 1/3 distal vaginal, right/left adnexa -/-. Both parametrium were nodulated. Rectal mucosa wnl

 

Biopsy was performed. Result (February 17^th 2011)

Squamous cell carcinoma without keratinizing, moderately differentiated. limfo vascular invasion (-)

 

Rectoscopy:

 no metastase, ECG WNL

 

Cystoscopy could not performed due to mass compression

 

BNO-IVP

 Both kidney function WNL. Hydronephrosis and Hydroureter right kidney due to total obstruction right distal ureter, left kidney (-), hydroureter left distal due to partial obstruction.

 

1^st Chest X-ray (February 17^th 2011)

Athelectasis superior lobe left lung, susp  lung metastasis (multiple noduler) à Plan : Chest CT Scan

 

           Chest CT Scan Fibroinfiltrat with calcification in left lung à long active specific process

multiple noduler both lung with lymph nodes L2 and both axilla

 

PCR M TB

 negative,  Sputum BTA 3x (-),  cytology of bronchus lavage : no malignancy

 

Bronchoscopy

 fluid retension in trachea, total occlusion at the Right Brochus 1,2,3, multiple nodes at left main bronchus size 1-3 mm, fibrotic lesion (+). Left 7-8 bronchus nodule (+).

 

Laboratory Results:

CBC: 10,5/32/6.000/274.000/76/24/31

OT/PT : 17/9, Albumin : 4,5, Ur/Cr : 17/0,5, BG: 96, BT/CT : 3/12.3

Urinalisis : Eritrosit : full, Bacteria : positif, Prot : +, Blood : +++, LEA : -

 

Staging by consultant on duty: tumour size 4x43 cm, Endophytical

Uterus wnl RF

Mass spread to vaginal anterior,posterior and lateral wall,

Heavy Noduler right and left parametrium until pelvic floor

Staging : cervical cancer stage IVB (lung metastase)

 

Problem :

Cervical Cancer stage IVB (lung metastasis)

 

What the best therapy for this patient?

PLAN : Palliation Radiation therapy only or Radiation therapy  and Chemotherapy ?

 

1^st Case Conference

 Patient can be given choices of different types of chemotherapy. The first choice is the full dose and the second choice is chemotherapy for sentisizer. This will then be followed with radiation therapy.

          Patient should also be explained about the cost and benefit of this treatment.

      After discussion with the patient and husband, taking into consideration about cost and benefit of the therapy.

Bronchoscopy   

               No malignant cells present.

Therapy

Patient was given PVB for 2 cycles.

  

2^nd Case Conference

      Does the patient needs radiation and chemotherapy considering that the patient is cervical cancer stg IV B with lung metastasis ?  

      The lesion in the CT scan is not very clear. It still can be cervical cancer stage III B with no metastases to the lung. Therefore the CT scan should be shown to the radiologist and brought the case into the case conference. After the decision regarding the staging is final, then further management can be discussed.

  Discussion with radiologist will be done in this conference and the CT scan will be shown by the radiologist in the Case Conference on the 15^th of May 2011.