Case Conference May 12th 2011

01-Jun-2011, Divisi ginekologi onkologi RSCM

Mrs. S/ 60 years old/ P5A0/ JAMKESMAS

January 28. 2009

Anamnesis :
She was referred by RSAL Mintohardjo with condyloma of the right labium suspected as malignancy. Since 1 year ago, she had suffered from pain on her vagina during micturation. Her vagina also stank whenever she swapped her vagina. Hematuria was not reported, nor foul vaginal discharge or vaginal bleeding. Vaginal or vulvar mass was not reported as well. She has been to GPs for treatment but no improvement. She then went to RSAL Mintohardjo and was diagnosed as condyloma of the right labium. She was then referred to RSCM.

Physical examination :
General status   : within normal limit
Gynecological status :
• I : redness vulva with exophytic mass and easily bled,  measuring 2 X 1 cm close to clitoris,
  biopsy was performed.
• Io : smooth vaginal wall, smooth portio, flx(-), flr (-)
• RVT : CUT within normal limit, no adnexal mass, loose parametrium, smooth rectal mucous.

Assessment :
Suspected as vulvar cancer.

Histopathology result :
Vulvar squamous papiloma, no sign of malignancy.
 
October 7. 2009

Vulvar mass was reported.
General status within normal limit.
Gynecological status :
  I : ulserative mass at the vulva, expanding to 1/3 distal vagina
 Io : polyp cervix 0,5 cm in diameter  extirpated and examined, pap smear was perfotmed
  RF, loose parametrium.
  

October 15. 2009

Histopathology result  : endocervical polyp
Pap smear result : no malignant cell

She was then referred to polyclinic of venereology department, but she never went to.

October 2009 – May 2010 : no follow up

May 10. 2010

She was refereed by RS Fatmawati with vulvar cancer (histopathology result : squamous cell carcinoma), for radiotherapy.
General status  : no enlargement of inguinal nodes
Gynecological status  :
I :  ulserative mass at the vulva, measuring 10X5X3 cm, suspected expanding to urethral.
RVT : smooth cervix, smooth 2/3 proximal vaginal wall, CUT within normal limit, AF, smooth  rectal mucous. 

June 6. 2010
Review slide : vulvar squamous cell carcinoma, good differentiation.
Planned for radiotherapy.

August 27. 2010 – October 27. 2010 :
Radiotherapy (27 X 2 Gy)

January 10. 2011 : follow up
No complaints.      
I : vulvar mass shrank to 5X5X3 cm

March 23. 2011 : follow up
No complaints.
I : vulvar mass shrank to 3X2X1 cm.
Planned for internal radiation

April 7. 2011 :
Discussion at the Radiotherapy Department :
Due to the size of the mass is too big, internal radiation is not possible to be performed. Meanwhile, external radiation can’t be performed either due to increased risk of side effect (considering the last external radiation was October 27. 2010)

May 10. 2011 : follow up
Chief complaints : foul discharge from the mass.
No inguinal nodes enlargement.
I : ulcerative vulvar mass measuring 8X4X2 cm, foul odor and discharge.
 
Assessment :
Vulvar cancer stage III

Plan options :
1. Follow up for possible radiotherapy in the future.
2. Surgery.