Case Conference 18th Jan 2012

18-Jan-2012, Divisi Ginekologi Onkologi RSCM

Case Conference

January 18^th  2012

Resume

Mrs. E, 54  yo

348-72-20

 

January 17^th 2012

CC: vaginal bleeding

 

History :

Firstly patient came to RSCM on March 11^th 2011, referred from Tangerang General Hospital due to vaginal bleeding since 7 months before admission. PA result from Tangerang General Hospital revealed squamous cell carcinoma, non ceratinized grade I and performed review PA at RSCM (1102140) at March 12^th  2011, result squamous cell carcinoma non ceratinized grade II. Gynecology ultrasound from Fetomaternal clinic showed that cervix enlarged ~ cervical cancer, infiltrating mass to rectum. Cystoscopy, rectoscopy, chest X-ray, and BNO-IVP examinations were normal. Performed consultant staging (Prof. Dr. dr. Andrijono, OBGYN (C)), stated as stage II B, planned for chemoradiation or radiation only. The patient underwent external radiation and brachytherapy without sensitizer, completely (April 7^th – June 2^nd). The first and second outpatient visit after radiation (July and October) showed complete response. On the next visit, November 2011, there was cystic mass at vagina. On December 2011, portio was erythem. On January 2012, the mass looked necrotic and reddish, performed biopsy. The PA result revealed squamous cell carcinoma, non ceratinized grade III; no lymphovascular invasion and the US examination showed suspected cervical malignancy mass.

Now the patient complain of vaginal bleeding, spotting since 1 month ago. No pain. The patient can sleep well. No disturbance in micturition nor defecation.

Married 1x, 19 years old.

P5, spontaneously, youngest 20 year old. Menopause 7 years.

Contraception: pills. Insurance: Jamkesda.

Past history:

Hipertension (-), DM (-), heart/lung diseases (-), tumor/malignancy (-).

Family history:

Hipertension (-), DM (-), heart/lung diseases (-), tumor/malignancy (-).

 

Physical examination

•      General status 

–     CM, BP 110/80 mmHg, HR 80 x/min, RR 18x/min, T 37 C.

–     Head    : conjunctiva pale (-/-), sclera icteric (-/-), thyroid and lnn not palpated

–     Thorax : Cor normal. Lung: vesiculer, wheezing (-). Supraclavicular and axillary lnn not palpated.

–     Abdomen         : enlarged until umbilicus, limited mobility, pain (-). Inguinal lnn not palpated.

–     Extremity        : edema (-/+) left inferior extremity

•      Gynecological status

–     I           : v/u normal

–     Io         : reddish and necrotic mass at portio, performed biopsy 3x; stiffness at vaginal wall (+)

–     RVT      : Palpated mass mainly at right parametrium until pelvic side wall. Left parametrial was normal. Rectal mucosa was smooth, mass (-).

 

Laboratory result, 4-1-2012:

CBC 11,2/33,8/7.590/347.000 // 87,6/29/33,1

Ur/Cr 43/1,2. RBG 108. 

PT 11,1 (11,7) / APTT 30,2 (32)

CA 125 (19-9-2011) 729,2 U/ml.   (CA 125 4-1-2012) 3906 U/ml.

 

Gynecology Ultrasound (Fetomaternal Clinic), March 21^st 2011 :

Uterus enlarged from cervical region to corpus, size 73x46 mm, mainly to the posterior direction, reached proximal rectovaginal septum (RI 0,35), uterine cavity distorted. Right parametrial border was unclear. Both ovaries were normal.

Liver, spleen, both kidneys were normal.

Conclusion : Uterine cervix carcinoma with infiltration mass to the rectum.

 

Gynecology Ultrasound (Fetomaternal Clinic), January 5^th 2012:

Uterus anteflexed, fundus and corpus of utery were normal. Myometrium homogeny.

Endometrium basal stratum was thick and regular. Cervix enlarged, consist of inhomogen mass, irregular and unclear border, size 35x20 mm, malignancy mass (invade to right rectovaginal region). With color Doppler, there was arterial, vein vascularization and neovascularization inside mass. Both ovaries were normal. No enlargement of para aortic and para iliac lnn. Liver, spleen, rectum and left kidney were normal. Right kidney was hydronefrosis.

 

Chest X-ray, 18-3-2011:

Heart and lung were normal.

 

BNO IVP, 18-3-2011:

Secretion and excretion function both of kidneys were normal. No signs of obstruction.

 

Cystoscopy (18-3-2011): normal.

 

Rectoscopy (14-3-2011): No sign of metastasis to the rectal mucosa.

 

PA result (No. 11T0782, 12-3-2011) :

Squamous cell carcinoma non ceratinized, well differentiated, invasive uterine cervix.

 

PA result (No. 1102140, 28-3-2011):

Squamous cell carcinoma non ceratinized, moderate differentiated. Mild lymphocyte reaction. Necrosis (-).

 

PA result (No. 1200084) :

Squamous cell carcinoma non ceratinized, grade III. Mild lymphocyte reaction. Limfovascular reaction (-).

 

 

Outpatient visit 21-11-2011:

Patient complaint of bloating and pelvic pain. Micturition and defecation were normal. General status was normal. From the gynecological status: while performed inspeculo came out yellowish clear fluid, ± 300 ml, less likely was urine. From further exploration there was no cystic mass at vagina. At the posterior fornix found necrotic tissue, mass (-). RVT, uterine corpus was normal, tenderness (-), adnexal mass (-). Plan to evaluate for 1 month.

 

Outpatient visit  2-12-2011:

Same findings, yellowish liquid came out from inspeculo examination, vagina was normal, mass (-).

 

Outpatient visit 4 -1-2012 :

Reddish and necrotic mass at portio, there was stiffness at vaginal wall, performed biopsy.

Mass at the right parametrium until right pelvic wall; left parametrium was normal. Rectal mucosa was smooth.

 

Assesment      :

Cervical cancer stage II B post complete radiation only, with local residive

 

Discussion

Due to residif mass at posterolateral site of fornices with PA result squamous cell carcinoma after radiotherapy, interval < 1 year, suspected progressive cancer; this case will plan for palliative treatment.