Case Conference April 11th 2012

11-Apr-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

APRIL 11^TH 2012

 

Mrs. M, 44 yo

Vaginal cancer susp std IVA (susp vesical metastase)

320-51-35, Jamkesmas

 

 

HISTORY

 

February 24th, 2012

 

•      Reffered by Islamic Hospital by OBGYN

•      Chief complain of pain in genital area since 2011

•      History of vaginal discharge (-)

•      Difficulty in urinary à went to Koja Hospital

 

Previous history: DM (-), HT (-), cor/pulmo disease (-)

                               History of tumor /cancer(-)

Previous history in family: DM (-), HT (-), cor/pulmo (-)

Marital history: 1x

Obstetrical history: P6, youngest 5 yo

 

PHYSICAL EXAMINATION

 

General status

Compos mentis

BP 120/80 mmHg Pulse 98x/min RR 18x/min T 36.7⁰ C

 

Conjunctiva    : pale +/+

Heart/lung     : wnl

Abdomen       : wnl

Extremities     : edema -/-

Lymph node     :enlargement in left inguinal lymph node

 

 

 

Gynecological status

Inspection      : smooth vulva, exophitic mass in uretra and anterior vagina (+), right major labia bulging, pus (+)

Inspeculo       :  can not be done due to vaginal anterior mass

RVT                 : there was exophytic mass along anterior vaginal until 1/3  proximal vagina. Smooth portio, uterus N, AF, both parametrium was smooth, smooth rectal mucose

 

Laboratory :

CBC:

Hb                          : 7.9 gr/dl

Hct                         : 24.1 %

Erytrocyte         : 3.00 x 10⁶

MCV/VER           : 80.3 fL

MCH/HER          : 276.3 pg

MCHC/KHER     : 32.8 g/dL

Trombosit          : 520 x10³

Leucocyte          : 8.80 x10³

URINALYSIS:
color                     : yellow

Sediment

-          Leukocyte          : 5-7/LPB

-          Erytrocyte         : 1-2/LPB

-          Cilinder                : negative

-          Ephitel cell         : +2

-          Crystal : -

-          Bacteria               : -

 

PA Result Koja Hospital, January 18th, 2012:

Histologically transtitional cell carcinoma, well to moderate differentiation, clinically from urethral biopsy

CXR, February 2nd, 2012:

Bronchitis, no sign of pneumonia or active pulmonary TB, cor wnl

BNO-IVP February 3rd, 2012:

Both renal in good function

No sign of obstruction

Spina bifida

sacralisation

Pelvic and Abdominal CT scan, February 3rd, 2012:

Pelvic cavity tumor from uterus until vagina

àsusp uterine tumor spreading towards vagina

Meteorismus with fecal mass in colon

 

Rectoscopy February 27th, 2012:

No metastase on rectal mucosa

Cystoscopy February 29th, 2012:

Evaluation can not be performed due to tissue obstruction in urethra, fragile, easily bleed

 

Review slide March 6th, 2012, PA no. 1201889:

histologically squamous cell carcinoma, keratinized, well differentiated

 

Oncology US March 22nd, 2012:

Vaginal cancer

Left inguinal lymphadenopathy

No metastase to liver and spleen

 

ASSESMENT

Vaginal cancer susp std IVA (susp vesical metastase)

Assessment by consultant: Prof.Dr. dr. Andrijono, OBGYN (C)

From clinical staging, patient was diagnosed as vaginal cancer susp std IV A planned to check urine cytology and cystoscopy.

The next plan will be discussed in clinical conference, whether will be performed chemoradiation therapy.