Case Conference Jan 25th 2012

25-Jan-2012, Divisi Ginekologi Onkologi RSCM

Case Conference

January 25^th  2012

Resume

Mrs. J, 61  yo

330-91-21

 

January 18^th 2012

CC: Vaginal bleeding

 

History :

Referred from Budhi Asih Hospital on April 26^th 2009 due to cervical cancer. PA examination from POLRI Hospital revealed squamous cell carcinoma, bad differentiation with mild lymphocyte reaction. Review slide at RSCM showed squamous cell carcinoma, unceratinized cervix, bad differentiation, with mild lymphocyte reaction. Performed consultant staging on May 5^th 2009 (Dr. dr. Laila Nuranna, OBGYN (C)), assessed as cervical cancer stage II B, plan for chemoradiation. Already given chemotherapy with Platocyn for 3 series since 15-6-2009 until 14-7-2009 and given external radiation (linier accelerator) since 16-6-2009 until 21-7-2009 and brachytherapy 30-7-2009 until 13-8-2009 with total dose 71 Gy (50 RE + 21 BT). Follow up after complete chemoradiation with clinical examination and Pap Smear 3 monthly since November 2009 until June 2011 showed normal result; assessed as complete response.

On September 2011 the patient was suffered from cvi of the right leg, treated but no improvement. Performed abdominal CT Scan with contrast, showed right adnexal mass that caused right hydronephrosis and right leg edema. Suspected due to tumor residu. Gynecology ultrasound confirmed the cervical mass malignancy that invade both of parametria and left adnexa, suspected active malignancy mass (arterial hypervascularization and the cervix not atrophy). Doppler examination of the leg showed cvi at common femoral vein and superficial femoral vein. Biopsy of the mass on January 2012 revealed cervical adenosquamous carcinoma with mild lymphocyte reaction, mild necrotic, and no invation of lymphovascular. Having complaint of pain with cancer pain 2, decreasing apetite, nausea, but still can sleep well and normal daily activity.

Married 1x, 17 years old.

P6, spontaneously, youngest 18 years old. Menopause 10 years.

 

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 84 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         : supple (-). Inguinal lnn not palpated.

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

•      Gynecological status

–     I           : v/u normal

–     Io         : mass at portio size 2x1, performed biopsy.

–     RVT      : Palpated cervical mass 2x1 cm, right parametrial was nodulated. Left parametrial was normal. Rectal mucosa was smooth, mass (-).

 

Laboratory result, 18-1-2012:

CBC 12,4/39,6/15.350/594.000 // 82,7/25,9/31,3. Albumin 3,77.

Ur/Cr 60/2,3. RBG 131. AST/ALT 13/8. Electrolyte 133/3,42/90,4.

 

Gynecology Ultrasound (Fetomaternal Clinic), January 10^th 2012 :    

Uterus anteflexed, fundus and corpus were normal. Myometrium homogen. Endometrium, basal layer regular, thin. Cervix enlarged with inhomogen mass, irregular site , unclear border, size 50x29 mm, consist of arterial vascularization, came from malignancy mass. The mass invade to both of parametria and left adnexa. Both of the ovaries hard to defined. There was no lnn enlargement, para aortic and para iliac. Liver, spleen, bladder, rectum and left kidney were normal. Right kidney was hydronephrosis. No ascites.

Conclusion: Cervical malignancy mass. Invade to both of parametria and left adnexa. Suspected active malignancy mass (arterial hypervascularization and unatrophic cervical mass).

 

Chest X-ray, 20-1-2012:

Cardiomegaly. Both lungs were normal. No metastatic sign.

 

Abdominal CT Scan with contrast (4-1-2012):

Right adnexal mass reached pelvic side wall, that caused right hydronephrosis and right leg edema, possibility of residual tumor.

 

PA result (No. 1200214) :

cervical adenosquamous carcinoma with mild lymphocyte reaction, mild necrotic, and no invation of lymphovascular.

 

Assesment :

Cervical cancer stage II B post complete chemoradiation, with locoregional residive;  right hydronephrosis and decreasing of renal function.

 

Plan :

Due to locoregional residive plan for re-radiation and plan for inserting DJ Stent or nephrostomy.