Case Conference September 12th 2012

12-Sep-2012, Divisi Ginekologi Onkologi RSCM

Stage II A with PA result HGSIL

 

Identity

Mrs. SM, 38 yo, P2, 372 00 25,

 

August 14^th 2012

Patient  came to Policlinic RSCM. She was referred from Pasar Rebo Hospital with suspected squamous cell carcinoma. Patiet  complained about her vaginal bleeding since 1 month ago. Fluor  albus (+) with no smelly and itchy. Post coital bleeding (-), pain (-), weight loss (-). Normal defecation and mixturition.

Patient came to  PHC à referred to YKI for Pap’s test exam. The result (PA no 1206765)  was positif, there were hard dysplasia cells, with possibility of  squamous cell carcinoma. She was suggested to perfomed colposcopy, but since there’s no colposcopy at Pasar Rebo Hospital, the patient was refered to RSCM.

 

Menarche 12 yo, P2 (the youngest is 10 yo)

Contraseption : IUD from 2011 until now

Husband : private employee, patients is housewife

 

Gen state : wnl, no palpable lymph node (inguinal,axila and supraclav)

Gyn state :

Io: erosive portio, easily bleed, IUD filament (+), at  posterior part there’s thickened mass Ø 2 cm, acetowhite (+)

VRT : uterus normal size and shape, palpated mass at posterior fornix Ø 3 cm, buldging to the right parametrium. Left parametrium was loose. No mass at both adnexas.

From RT : the mass was palpated at anterior part size 3x2 cm, buldging to right. Anal sphincter normal, smooth mucosa

 

Supportive data :

US  FM  (August 15^th 2012) :

Uterus RF normal size and shape. Homogeny miometrium.  Endometrium regular, with IUD inside the uterine cavity, good position.

IUO, endocervix and EUO normal.

At posterior part of cervix (posterior fornix), there’s hypoechoic mass with inhomogen texture, undistinct border, size 19x12x16 mm. mass wa contained arterial type vascularization.

Both ovaries normal size and shape.

No enlargement of paraaota dan parailiac LNDs

Liver, spleen, both kidneys, bladder and rectm normal.

No ascites

è IUD insitu. Irregular mass in posterior fornix, malignancy cannot be excluded

 

Assessment :

Suspected Cervical carcinoma II B

 

Planning : colposcopy and targeted biopsy

 

August 16^th 2012

The patien had Colposcopy exam with the result ;

IUD filament (+), IVA test à acetowhite (+) at whole area of cervix and the mass. It seem that the mass awas fragile and easily bleed.

Performed targeted biopsy.

 

Discussion with dr. Hariyono W, OBYGN (C ) :

From the colposcopy, the IVA tes (+) with fragile and easily bleeing mass  à clinical staging stage II A cervical cancer.

If the biopsy result (+) plan for another supportive examination.

 

August 27 ^th 2012

PA (no 1206783) result :

Chronic cervicitis with mild dysplasia metaplastic epithelial cervix ( NIS II = HGSIL)

 

Discussion with dr. Sigit Purbadi, OBGYN (C): discussion in CC the method to  diagnose pre cancer lesion