Case Conference November 14th 2012

14-Nov-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE                  

 

Mrs. E, 54 yo. 3729444

Vaginal carcinoma

 

Anamnesis

 

 

 

Patient  came to policliinic with chief  complained had been have vaginal bleeding since 2 years before admission ,sometimes it was only spot bleeding but sometimes it was heavy bleeding ( changed  pad  until 10 pads/day). Patient had the papsmear in 2010, it was revealed normal result. Patient also had  normal result of US in October 2012. Patient had  performed biopsy at Fatmawati Hospital and the result was carcinoma in vaginal wall.

History of post coital bleeding (+), and also had complained of dyspareunia.

Patient has been had  lower abdominal pain and decreased body weight (6 kg in 2 year)

History of past  illness was unremarkable, only allergy for few of drugs

History from the family also unremarkable.

 

Patient had menarche at 11 yo, with regular menstruation cycle (28 days), no pain, changing pad 2-3 x/day

Married 1x at 1986, until now

Parity 2, born normally, the smallest 24 yo

Patient is a house wives, and her husband is working at private company.

 

Patient looks in good condition, with BW 55 kg, Height 156 cm (BMI 22.6)

Normal vital sign.

 

General status :

within normal limit

Gynecology status:                                

Inspection: vulva and urethra was unremarkable

Inspeculo: At the left lateral wall of vagina (at 3 o’clock) there was a vegetation growth size 2 cm in diameter, ulcerated, easily bleed, portio was smooth, ostium was closed, no fluor neither fluxus à taken for PAP SMEAR

RVT: CUT size and shaped wnl, palpated mass at left lateral wall of the vagina a solid mass size 2 cm in diameter, no induration. Parametrium was loose, no adnexal mass palpated, smooth mucosa recti, not palpated mass at the rectum.

 

Histopathology result from YKI Lebak Bulus

Sample: from mass at left lateral wall of vagina, size 1x0.8x0.5 cm, brown blackish, firm.

Tumor mass that surrounded by squamous epithel which shown dysplastic view. Most of the mass à glandular secretion.

 è Carcinoma with suspected adenocarcinoma solid type, probably an adenosquamos carcinoma has to be considered

adv: IHC to confirmed type of tumor

 

Cytology   (5/11/12)(122834) : High grade squamous intraepithelial lesion (HSIL) with suspected invasive

 

US  oncology (13/11/2012)

 

Endometrial thickness susp malignancy

There’s no metastasis vaginal carcinoma to liver and lien

 

Chest x-ray : normal

 

Assessment:

Vaginal carcinoma

 

Discussion  with prof Andrijono.OBGYN ©

Discuss in CC for further treatment