CASE CONFERENCE APRIL 11th 2012

11-Apr-2012, divisi ginekologi onkologi RSCM

CASE CONFERENCE

APRIL 11^TH 2012

1 OUTPATIENT

 

Mrs. E, 60 yo, P4, JAMKESMAS

Cancer cervix Stage IVa (metastasis to vesica urinaria) Post complete radiation

3438275

 

 

HISTORY

 

November  4^th, 2010

 

•         CC : vaginal bleeding since 2 years (referred by RSU Karawang with Cancer cervix 4/11/2010)

•          Leucorrhoe (+),foul odor (+), menopause since12 years

•         PA 1007774 (10/11/2010):

•         à moderate to poor differentiated Ca cervix unkeratinized. Moderate limfocyt reaction. Minimal necrosis

•         Cystoscopy: Susp metastase to Vesica urinaria

•         PA result (vesica urinaria):

àSquamous cell carcinoma probably  metastasis from cancer servix

 

Previous history: DM(-), HT (-), cor/pulmo disease (-),history of tumor/cancer(-)

Previous history in family: (-)

 

Menstruation history:

Regular menstruation, 28-29 day, long of menstruation 6 day,  dismenorrhea (-), change pad 2-3x, already menopause 14 years ago

Marital history:

She was married when she was 15^th years old. First marriage for both patient.

 

 

Obstetrical history : P4: Youngest : 32 yo.

               

 

              

Family Planning history : Pill

Social history:  Housewife

 

PHYSICAL EXAMINATION on admission

 

General status :  Compos mentis

BP 120/80 mmHg Pulse 98x/min RR 18x/min T 36.7⁰ C

Conjunctiva    : pale +/+

Heart/lung     : wnl

Abdomen       : soupel

Extremities     : edema -/-

Lymph node     :no enlargement in supraclavicular, inguinal lymph node

 

Gynecological status

•      Inspection            : wnl

•      Inspeculo : exofitic mass diam. 5x5x4 cm, fragile,bloodly. The mass until half of vaginal wall

•      Gyn RVT   : intact vaginal wall, parametrium was rigid, uterus not palpable, adnexal mass not palpable

 

Laboratory :

CBC : 6.5/22/7.210/450.000/72.8/21.3/29.3

BT/CT : 2.30’/12.00’

SGOT/SGPT : 22/7

Albumin : 3.39

Ur/Cr : 31/1

RBG : 103 mg/dl

Na/K/Cl :140/4.11/106.1

 

PA Result (5-11-2010) :

Skuamous cell carcinoma cervix unkeratinized. Moderate to poor differentiated Ca cervix. Moderate limfocyt reaction. Minimal necrosis

 

CXR ( 8-10-2010) : Cardiomegali, no metastasis

 

Cystoscopy (8-10-2010) : Suspect Metastasis to vesica à Biopsi : Skuamous cell carcinoma cervix, moderate differentiated. Moderate limfocyt reaction. Minimal necrosis

Rectoscopy (9/10/2010) : No metastase

 

External Radiation : 1/12/2010 untill 5/1/2011

BT : 10/1/2011 untill 24/1/2011

 

21/02/2011 untill 9/01/2012 :

è Routinely control

è NED

 

Follow up (14/3/2012)

CC : Haematuria

 

Gynaecological status

•      Inspection      : wnl

•      Inspeculo       : synechia vagina untill half of the vagina.

•      Gyn RVT         : mass in the cervix (-), parametrium D/S was stiff

•      Cystoscopy (21-03-2012) : Suspect Metastasis to vesica à Biopsi : Skuamous cell carcinoma with metastasis

 

 

ASSESMENT

Cancer cervix Stage IVa (metastasis to vesica urinaria) Post complete radiation

 

 

April, 4^th 2012

Discussion with dr. Gatot P,SpOG(K):

è Modality choice for this pts

è 1. Radiation

è 2. Chemotherapy

è 3. Chemoradiation

è Will be discuss in CC