Case Conference September 19th 2012

19-Sep-2012, Divisi Ginekologi Onkologi RSCM

Cervical carcinoma progressif, post HR ( march 2012) continue with adjuvant radiation (8/5/12)

Metastasis to right inferior ramus pubis destruction (CT-scan ), bilateral hydronephrosis ec UVJ stenosis ec mass infiltration to vu posterior wall,

Limphadenophaty para  aorta (form US exam)

 

Identity

Mrs. D, 3534974

10/1/12

patient came to policlinic, refered by RSUP Prof Kandou-Manado with cervical carcinoma IIB.

Post coital bleeding since 4 months before admission, bleeding look  like spotting, irregular. White smelly odour discharge (+). Mixturition and defecation were normal.

 

Previous illness :-

Menarche 13 yo, married 1x,

P2A1

Contraception : DMPA, OC

 

Physical examination :

 

Gen state : wnl

Gyn state :

I : v/u normal

Io: exophytic portio, bulky polyploid, 6x4x5 cm

V/RT : cervical lession polypoid,  5x5x3 cm, smooth parametrium, uterine corpus normal

stagging : cervical; carcinoma IB2 (polipoid)

 

 

Biopsy result ( RSUP Prof Dr.RD Kandou no 1322/12/11)

Scuamos cel carcinoma with low differentiated ( anaplastic)

 

Cystoscopy ( 11/1/12)

Susp cystitis

 

Rectoscopy (12/1/12)

Rectal metastase (-)

 

Biopsy result  11/1/12 (PA no 1200271)

Adeno scuamosa carcinoma . light limphocyt reaction. No limphovascular invasion.

 

BNO-IVP (13/1/12)

Normal secretion and excretion both of kidneys

 

 

12/1/12 US (FM)

inhomogen mass in posterior of the cervix, irreguler, undistinguished border, 52x39mm, with hypervascularisation corespon to cervical malignancy, both of parametrium and oui were free of invasion

 

5/3/12

Performed : radical hysterectomy, bilateral pelvic lympadenectomy,para aortic ylmpadenectomy

Pre op dx: Stage I B2 (bulky polypoid tumor) cervical cancer

Post op dx: Stage I B2 (bulky polypoid tumor) cervical cancer at intercaval area until IMA level

Surgery report :

ü After peritoneum was opened, normal sized uterus and both ovaries, no infiltration to both parametrium

ü There was enlargement of right pelvic LN at the level of external illiaca artery, 2.5x2x1 cm, de bulked à FS: no metastasis

ü Right pelvic LN dissection was continued to chepalad direction, enlargement of LNs at the level of common iliac artery 5x3x2, de bulked à FS: metastasis(-)

ü Pre sacral LN was enlarge as 4x3x2 cm, de bulked à FS: metastasis(-)

ü Enlargement of para-aortic LN, 4x3x2, debulked à FS: metastasis(-)

ü Enlargement of pelvic LNs at the level of common illiac artery 4x2x2 cm, and left external artery 3x2x1 cm, debulked à FS: metastasis(-)

ü Fresh tissue post operative evaluation : tumor sized 8x8x5 cm, border of incision : anterior :3 cm, LL :2 cm, RL :  2 cm, post 2,5 cm

 

 

PA (post HR, 6/3/12 no. 1201893)

Concusion:

ü Adenoscuamosa carcinoma, moderate differentiated, with limfovascular invasion

ü Margin of  vaginal cutting 1,3,5 mm, free of tumor

ü The deepest invasion ( from cervix ) up to lower segmen of uterine

ü The deepest invasion to parametrium, close  to parametrium

ü Late  proliferatif phase of endometrium, normal myometrium

ü Right tube was free of tumor

ü Endometriosis left tube , free of tumour

ü Right parametrium contains tumor

ü Endometriosis at left parametrium, free of tumor

ü Columnis and para-aorta  LN (24 LNs), right  pelvic LNs (8), left pelvic LNs (8 LNs), pre-sacral LNs(10 LNs), iliac externa LN (1LN), inter-cava LNs(7 LNs) and  common iliac LNs(3 LNs), free of tumor

 

26/3/12

Discussion with Dr.Laila,obgyn (C) :

Patient cervical carcinoma IB2, post HR with PA result:

ü Adenoscuamosa carcinoma, moderate differentiated, with limfovascular invasion

ü  Right parametrium contains tumor

Planning : adjuvant radiation

 

 

Performed external radiation ( 4/4/12-8/5/12)

Early Clinical respons  was good

 

4/9/12

patient controled with complained bleeding in mixturition, white discharge (+), smelly odour (+)

Gen Stat :

Non palpable LN inguinal, axilla and supraclavicula.

Gyn state:

I0 : smooth vaginal stump, mass (-)

V/RT : mass (-)

A : Cervical cancer stg IB2 , post HR ( march 2012) continued with adjuvan radiation (end may 8^th 2012)

P: USG, cystoscopy.

 

US (6/9/12)

6 mm VU wall, contain fluid and echogenic mass, lumen VU : 60 mL.

Limphadenophaty para-aorta (18 mm)

Hydronephrosis dextra grade ( severe pelviocalises dilatation with cortex thickness 8 mm)

Hydronephrosis sinistra grade mild

No mass at stump of vagina

Intra VU mass susp vu metastasis

 

Cystoscopy (5/9/12)

Susp metastasis à PA

 

PA  cystoscopy  ( no.1207169)

Acute cictitis, no malignancy

 

CT-whole abdomen (11/9/12):

Mass on vaginal wall with the thickness of vesica urinaria  posterior wall with indistinguish border with rectum, susp rectovesica fistula

Right inferior ramus pubis destruction with involvement of musculus  right obturator susp  direct invasion of cervix mass dd/ metastasis

Bilateral hydronephrosis ec UVJ stenosis caused by mass infiltration to vu posterior wall

Suggest : uretrocystography

 

Chest x-ray  (10/9/12):

Normal cor and pulmo

No metsatasis

 

 

 

 

Assessment :

Cervical carcinoma progressif, post HR ( march 2012) continue with adjuvant radiation (8/5/12)

Metastasis to right inferior ramus pubis destruction (CT-scan ), Bilateral hydronephrosis ec UVJ stenosis ec mass infiltration to vu posterior wall,

Limphadenophaty para  aorta (form US exam)

 

Discussion with dr.Sigit obgyn (C) :

Confirmation CT-scan

Metastasis to right inferior ramus pubis destruction à paliatif phase

Discussion about next treatment