Case Conference July 20th 2011

21-Jul-2011, Divisi ginekologi onkologi RSCM

Mrs. N/ 41 yo/ P2A1/ SKTM

Recurrent cervical cancer stage IIB

 

 

HISTORY

August 26^th 2010

Patient complained of having  smelly vaginal discharge since one year before admission, getting worse since 2 months. She also complained of having vaginal bleeding  and post coital bleeding since 3 months before admission.

She didn’t smoke. Defecation and also urination was normal          

She was married 2x, having  first sexual intercourse  in 20 years old.

The 1^st husband had sexual multipartners.

The 2^nd husband married 2x.

P2A1, the youngest child was 16 years old

 

PHYSICAL EXAMINATION

General status :

•      Enlargement of lymph nodes (-)

Gynecological status             :

•      I : v/u  normal.

•      Io : exophytic mass was seen, measuring 5x5x4 cm, fragile, easy to bleed.

•      RVT      : exophytic mass was palpated measuring 5x5x4 cm, fragile, easy to bleed. Both parametrium were rigid.

 

LABORATORY FINDING

August 11^th  2010

CBC : 10,2/32/7.050/551.000             SGOT/SGPT : 15/8                   Ur/Cr : 12/0,6            

RBG : 132                                            CCT : 141                                 Na/K/Cl : 136/4,09/97

 

ADDTITIONAL EXAMINATION

August 11^th 2010

Cystoscopy  : cystitis.

 

August 12^th 2010

Rectoscopy (12/8/2010) : no metastasis in rectum.

 

 

August 16^th 2010

BNO-IVP :

Secretion & excretion of both kidneys were good, no sign of obstruction.

 

August 18^th 2010

Histopathology  from biopsy :

·         Squamous  carcinoma cell, not keratinized, moderate differentiated.

·         DD/: adenoskuamosa carcinoma.

Chest X-ray:

·         Heart and pulmonary wnl.

·         No metastasis on pulmonary.

 

Analysis :

Cervical cancer stage IIB

 

Plan :

Chemoradiation with platosin

 

Follow Up

Patient was already given chemoradiation.

The last chemotherapy (platosin 5^th cycle, 30 mg) : 7/2/2011; the last radiation : 8/2/2011

 

27/4/2011

Patient complained of having vaginal discharge.

Gen status : no enlargement of lymph nodes.

Gyn status :

I : v/u normal

Io: portio atrophy, mass (-).

RVT : portio was atrophy, mass (-).

 

28/4/2011

Pap smear result : malignancy cell (-)

 

8/7/2011

Patient complained of having vaginal discharge and post coital bleeding.

Gen status : no enlargement of lymph nodes.

Gyn status :

I : v/u normal

Io: exophytic mass size 3x2x2 cm on right lateral portio

RVT : exophytic mass size 3x2x2 cm was palpated, both parametrium rigid à performed biopsy

 

12/7/2011

Histopathology result of biopsy : squamous cell carcinoma with viable part.

 

Analysis

Recurrent cervical cancer  stage IIB

 

Management : chemotherapy