Case Conference November 14th 2012

14-Nov-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE                  

 

Mrs. Y.40 yo.348-59-58,        GAKIN

cervical carcinoma stage IIA progresif,  post radical hysterectomy , lost follow up, with vesico vaginal fistula.

 

 

1/3/11

 

Patient came to  policlinic with  complained of vaginal bleeding since October 2012, post coitalbleeding (+) since September 2010. Patient was refered from Elisabeth Hospital, Bekasi with biopsy result :scuamos cell carcinoma.

 

Menarche 13 yo

P2, married 1 x

 

Clinical examination :

 

Gen state :

within normal limit, no  inguinalsm axilla and supraclavicula LNDs  were palpabe

Gyn state :

Io : exophitic mass 4 x5x2 cm,fragile, easily bleed.

VRT :exophitic mass 4x5x2  cm until 1/3  proximal part of anterior vaginal wall. Loose parametrium.

 

Supportive data findings

 

PA result  (1/3/11 no.1101564)skuamos cell carcinoma unceratinized, moderate differentiation

 

US (14/3/11)

Cervical carcinoma

 

 

Cystoscopy (2/3/11) : normal

Rectoscopy (7/3/11): no rectal metastasis

BNO-IVP  (11/3/11) : normal

Chest x-ray (21/6/11) :  mild cardiomegaly, suspected left pleural efusion

 

 

Staging prof Andrijono : Cervical Carcinoma stage II A2

 

Planning :

NAC 3 series

 

15/3/11-5/4/11-26/4/11

Patient got NAC 3 series with PVB

 

Follow up

 

24/6/11

S : post PVB 3 series

 

O:gen state : normal

Gyn state :

I : v/u normal

Io : portio with exophitic mass 3x2.5x2 cm

VRT :  endophytic mass was palpated 3x2.5x2 cm, loose parametrium

 

Assessment : cervical carcinoma IIA post PVB 3 series with  partial respons

 

Planing : radical hysterectomy

 

 

	Pre NAC	Post NAC
Clinical examination	Portio diameter 4 cm	3x3x2 cm
US	3.4x2.6 cm

 

Performed radical hysterectomy (30/6/11)

 

Pre op dx :

Cervical carcinoma stage IIA , post NAC 3 series, partial respons

 

Post op dx :

Cervical carcinoma stage IIA , post NAC 3 series, partial respons

 

Operative  procedure :

Radical hysterectomy + SOD

Bilateral pelvic kymphadenectomy

While bladder was pushed, there were amount of fluid in the abdominal cavity, leaking from bladder was considered and after checked the bladder 2 point of leaking were noted than repaired using safil 2.0 continous and overlapping simple interupted.

Fresh tissue post operative evaluation : tumor sized LL:1.2 cm, AP: 1.7 cm; CC:2,2 cm

Border of incision : ant 1.5 cm; right lat : 2.3 cm; left lat : 1.3 cm post : 2.4 cm

 

 

 

 

 

PA result (1/7/11 no. 1105019)

 

Miroscopic :

Specimen from istmus uteri revealed same appearance with cervix mass.  Tumor invason reached 10-13 mm from  inner surface of canalis cervicalis.

Tubes and ovarian were normal, right and left parametrium were free of tumor.

There were 5 right pelvic LNds , 1 of them was positive metastasis

. Free margin vaginal cutting (1,3,5 mm)

 

 

Conclusion

Scuamosa cell carcinoma

Positive emboli lymphatic, hard lymphocyte

Free margin vaginal cutting

1   right pelvic LNDs  was positive metastasis

 

 

Patient was hospitalized until day-9  (8/7/12) post HR, on suprapubic catheter and bladder training

 

28/7/11

 

Patient came to ER theatre with complained of mixturition dificulty,  after 1 day before, the cystofix was taken out. There was lekeage from vaginal stump , methilen blue test was positive and was assessed with retentio urine, vesico vaginal fistula,

 

CC discussion (3//8/11)

1.     The present of vesicovaginal fistulas could be from :

·        Laseration durante operation

·        Necrotic proces at vesica area caused by monopolar disection

 

2.     Very important  to understand bladder training process

3.     If the fistula  was still small and just happened , not in a long timeà directly conservative

4.     Could be given indigo carmin for assessing conservative therapy effectiveness

 

 

15/8/11

performed cystoscopy :

fistula was present at posterior wall of the bladder , 2 cm from left ureter ostium, diameter fistula was 1 cm

à biopsy

 

PA biopsy : chronic cystitis

 

 

 

16/8/11

patient was discharge after given the information that patient most probably had to get the radiation after operative procedure ( at that time  PA result had not finished yet), if biopsy had negative result , patient must do repair first. But if the result positive , patient must do the radiation. Patient must controled in policlinic onco gyn

 

Patient controled to  urology policlinic  and had  been planed for  fistula repair 10^th october 2010 but  many times  canceled caused by  full operative  schedules.

 

 

24/5/12

S : patient controled to onco gyn policlinic

O : gen state : no palpable LNds on supraclav,axilla and inguinal

Gyn state :

Catether (+)

Io : mass on vaginal stump ,  fragile, easily bleeding, patient felt pain while was iserting inspeculo

RVT : rectal mass (-)

 

CT-whole abdomen

 

·        Unvisible function, size and excresion of right kidney

·        Left hydronephrosis ec. ‘kingking’ of left proximal ureter

·        Residive mass that coming from tumor bed ( cervix-uteri) , infiltrated the bladder (postero-inferior bladder and rectum anterior )

 

A: cervical carcinoma stage IIA post radical Hysterectomy

Vesico vaginal fistula

P: consult to urology depart. for repairing fistula, pro radiation after fistula repairing.

 

30/8/12

 

Assessment dr.Irfan, urologyst :

 

1.     Planning cystoscopy after 3/9/12

2.     Planning to perform surgery at 11/10/12 ( workshop)

 

PA result (10/9/12):

Metastasis/ direct invasion adenoscuamosa carcinoma , could be from cervix. How about the last patology result?

 

6/11/12

Patient was consulted from urology departement, about probability for giving chemo-radiation. They canceled repair procedure as long as malignancy is still present.

Clinical exam :

Gyn state   : Io : there was fragile mass on vaginal stump,

RVT : necrotic mass was palpated on 1/3 anterior vaginal wall with fistulas d. 1 cm that were surounded by necrotic mass

 

Assessment : cervical carcinoma stage IIA progresif,  post radical hysterectomy , lost follow up, with vesico vaginal fistula.

 

Discussion with dr.Hariyono,OBGYN (C):

 plan to do radiation à discussion in CC