CASE REPORTCervical cancer stadium IB2 with anemia

Preseptor : dr Hesty Duhita, SpOG

Arranged by : Annisa Kartika (2011730007)

Introduction Cervical cancer is malignancies strike

cervix or cervix , that is the lowest part of the uterus prominent to the top of the copulation.

Cervical cancer is the second most common cancer in women in the world.

prevalence of cervical cancer in indonesia is 28,66 %.

Patient’s identity Name : Mrs. A Age : 45 years old Nationality : Indonesian Education : Junior High school Marital status: Married Occupation : Housewife Religion : Moslem Date of admission : 12 June 2015

Husband’s identity Name : Mr L Age : 45 years old Nationality : Indonesian Education : Senior High school Marital status : Married Occupation : Private employees Religion : Moslem

Anamnesis Chief complaint Patient complained of bleeding from her

genital organ since 3 months ago

History of present illnessBleeding with clots, fresh red, and accompanied by abdominal pain

Patients also complained of weakness (+) and dizziness (+).

History of past illnessHave history of hipertention No history of DM No history of urinary or kidney

disease No history of allergic No history of hematologic disease No history of trauma No history of operation

History of family Sister of patients suffering from diabetes

mellitus and heart disease. Younger brother of patients died because

of glands cancer. No history of allergic No history of hematologic disease No history of epilepsy

Habits Smoking habits :

Denied Drinking alcohol :

Denied Taking any medication or “jamu” :

Denied

Contraceptive history Contraceptive use is 3-month injectable

contraceptives and pills

Menstrual history

Menarche : 13 years

Cycle :28 days

Duration : 5 days

Dysmenorrhea : (-)

Obstetric historyNumber of pregnant

Gender Age of children

Mode of delivery

Place of birth

helper Weight of birth

1 Abortus

2 abortus

3 M 21 years old

Spontaneus vaginal

Midwives practice

Midwives

3100 gr

4 M 14 years old

Spontaneus vaginal

Midwives practice

Midwives

3100 gr

Marriage history Patients were married two times. Married with current husband now 15

years old

Physical examination

Generalis status

•General condition: Moderate ill•Conciusness: composmentis

Vital signs

•blood pressure: 130/90 mmHg•Heart rate: 68x/minute•Respiratory rate: 20x/minute•Temperature : 36.5 ° C•Body weight : 48 kg•Body height : 155 cm•BMI: 19,97

•Head : normocephal, deformity (-)•Faces : symmetric•Eyes : anemic conjungtiva (+/+), icteric sclera (-/-)•Mouth : the oral mucosa moist•Neck : not palpable mass, lymphadenopathy (-)

General physical

examination

•Heart : Heart sounds regular I & II, gallops (-), murmur (-) •Pulmo : vesicular breath sounds + / +, ronkhi - / -, wheezing - / -•Mammae : within normal limits

Thorax •Inspection: flat •Auscultation: bowel (+) sounds, 4-5/minutes•Palpation: mass(-), pressure pain (+), ascites (-)• Percussion: Timpani

Abdomen

•Superior: Edema (- / -), Akral warm (+ / +), RCT <2 seconds (+ / +)•Inferior: Edema (- / -), Akral warm (+ / +), RCT <2 seconds (+ / +)

Extremities

Gynecology examination

External examination• Vulva : no

abnormality• Vagina : no

abnormality

Inspekulo • Vulva: no

abnormality• Vagina: no

abnormality• Portio: smelling

discharge (+), irregular portio

Vaginal toucher• Vulva: no

abnormality• Vagina: no

abnormality• Portio: Palpable

mass bumpy, rough surface, iMobile, tenderness (+), ± 2-3 cm in size, fragile, easily bleed

• Parametrial left-right: infiltration (-)

• Rectal Touche: CFS 100%

Laboratory examination(12th August 2015) Examination Value Units Normal Routine bloodHemoglobin 7,3 g/Dl 12 – 14

leukocytes 5.300 /μl 4.000 – 10.000

hematocrit 23 % 37 – 47

erythrocyte 3,0 Juta/μL 3,8 – 5,2

Platelet

Erythrocyte index

432.000 /μL 150.000 – 45.000

MCV 77 fL 80 – 100

MCH 24 Pg 26 – 34

MCHC 32 g/dL 32 – 36

Laboratory examination(14th August 2015)

Examination Value Units Normal Routine bloodHemoglobin 10,6 g/dL 12-14leukocytes 6.600 /ml 4.000-10.000hematocrit 33 % 37-47erythrocyte 4,3 Juta/Ml 3,8-5,2Platelet 307.000 /ml 150.000-

450.000Erythrocyte indexMCV 75 Fl 80-100MCH 24 Pg 26-34MCHC 33 g/dL 32-36

Laboratory examination(15th August 2015)

Examination Value Units Normal Routine bloodHemoglobin 11,3 g/dL 12-14leukocytes 5.400 /ml 4.000-10.000hematocrit 35 % 37-47erythrocyte 4,6 Juta/Ml 3,8-5,2Platelet 256.000 /ml 150.000-

450.000Erythrocyte index

MCV 76 Fl 80-100MCH 25 Pg 26-34MCHC 33 g/dL 32-36

Anatomical Pathology Biopsy Results

Macroscopica network size of 3 cm x 2 cm x 1 cm, brownish white color rather

fragile. Padalam elasi appear brownish white solid masses

Microscopic biopsy dosage form of the tumor

mass is composed of oval cells that grow between the solidified hyperplastic stroma. Pleomorfi core, hiperchromatis, mitosis

found. Bersebukan stromal PMN cells, partially fibrotic. On the

outside is covered with stratified squamous epithelium which has

the form of a tumor mass as above

Conclusion: Non keratinizing epidermoid carcinoma A / r cervix

uteri

Resume Women 45 years P2A2

present with vaginal bleeding since 3 months SMRs. Bleeding as much as ± 10x replace the pads

in the day, fresh red bleeding, clots and

accompanied by abdominal pain. Bleeding

occurs outside the menstrual cycle

Patients also experience vaginal discharge,

yellowish, itching (+), smell (+). In addition to

the above complaints, the patient felt a weight loss

of 56 kg to 48 kg within 1 month, weak (+) and

dizziness (+)

general condition seemed ill being,

awareness compos mentis, blood pressure: 130 /

90mmHg, conjunctival pallor (+ / +),

+), inspection inspekulo portio: discharge smells (+),

bleeding (+), portio looks bumpy, fragile, checks in the lower portion: Palpable mass

bumpy, rough surface, iMobile, tenderness (+), ± 2-3

cm in size, fragile, easily bleeding, adnexal: pain (-),

left-right parametrium: infiltration (-) , RVT: CFS

100%

Working diagnosis Mrs A, 45 years P2A2 stage IB2 cervical

cancer with anemia

Planning Correct the patient's general condition Blood transfusion indication if Hb <11 g /

dL Refer patient to the Hasan Sadikin

Hospital Radical hysterectomy

Prognosis Quo ad vitam : dubia ad

bonam Quo ad functionam : dubia ad

bonam Quo ad sanationam : dubia ad

bonam

Follow Up

13th August 2015 14th August 2015 15th August 2015S :• Bleeding (+)• Abdominal pain (+)

S :• Itching in the whole body• Bleeding• Dizziness (+)

S :Itching in the whole body

O :-Moderate ill-ComposmentisVital signs :Blood pressure: 130/70 mmHgTemperature : 37,0 ℃Heart rate: 65 x/mRespiratory rate: 21 x/m

abdomen:Inspection: flatAuscultation: BU (+) normalPalpation: tenderness (+)Percussion: timpani 

 

O :- Moderate ill- Composmentis Vital Signs:Blood Pressure: 140/80 mmHgRespiratory rate : 20 x / mTemperature: 37.0 ℃Heart rate: 76 x / m

abdomen:Inspection: flatAuscultation: BU (+) normalPalpation: tenderness (+)Percussion: timpani 

O :- Moderate ill- Composmentis Vital signs :Blood Pressure: 140/90 mmHgRespiratory Rate: 20 x / mTemperature: 36.5 ℃Heart rate: 80 x / m

abdomen:Inspection: flatAuscultation: BU (+) normalPalpation: tenderness (+)Percussion: timpani

13th August 2015 14th August 2015 15th August 2015

Obstetrics status:Vaginal toucher:V / v: normalPortio: Palpable mass bumpy, rough surface, iMobile, tenderness (+), size 2-3 cm ±Bleeding: (+) rubra

Obstetrics status:Vaginal touche :V / v: normalPortio: Palpable mass bumpy, rough surface, iMobile, tenderness (+), size 2-3 cm ±Bleeding: (+) rubra

Obstetrics status:Vaginal touche :V / v: normalPortio: Palpable mass bumpy, rough surface, iMobile, tenderness (+), size 2-3 cm ±Bleeding: (+) rubra

A :P2A2 stage IB2 cervical cancer with anemia

A :P2A2 stage IB2 cervical cancer with anemia

A :P2A2 stage IB2 cervical cancer with anemia

P :Blood transfusion if Hb >11Asam mefenamat 3x1 p.oPlasminex 3x1 p.oAmoxiline 3x1 p.o

P :Blood transfusion if Hb >11Asam mefenamat 3x1 p.oPlasminex 3x1 p.oAmoxiline 3x1 p.o

P :Asam mefenamat 3x1 p.oPlasminex 3x1 p.oAmoxiline 3x1 p.o

Case analysis1. How to diagnosis of cervical cancer ?2. How management of the patient in this

case?3. What is prognosis of this patient in this

case?

1. The diagnosis steps from anamnesis to additional examinations compare to theoris was made into a table as follow :

Theory PatientAnamnesa

Vaginal bleeding after intercourseBleeding outside the menstrual cyclewhitishpelvic painBleeding after menopausespontaneous bleeding

Risk Factors :Age Marriage status and sexual activity in the younger ageAmount of parityHPV infectionSmoking Socio economic history

Patient complained of bleeding from her genital organ. Spontaneous bleeding, accompanied by abdominal pain. Patients also experienced a whitish, yellowish color, itch (+), smell (+),

patient were married for two times. Patient have given birth for two times.

Physical examinationExternal examinationDepends on staging, the mass could spread to 1/3 distal or proximal vagina.

Vulva and vagina : no abnormality.

Theory Patient

InspekuloPortio looks irregular with bleeding

Portio: smelling discharge (+), irregular portio

Vaginal touchePalpable mass depends on staging.

Portio: Palpable mass bumpy, rough surface, iMobile, tenderness (+), ± 2-3 cm in size, fragile, easily bleedParametrial left-right: infiltration (-)

Rectal toucheCancer free space

CFS 100%

Biopsy Non keratinizing epidermoid carcinoma A / r cervix uteri

Theory Case

Colposcopy Not performed on patient

Radiology Not performed on patient

2. Management patient in this case

Theory Case

Staging IB2

Radical Histerectomylymphadenectomy + neoadjuvan Radiation

Patients only received blood transfusion because Hb < 11 g/dl and simptomatic drugs such as: plasminex, asam mefenamat. Patient was referred to Hasan Sadikin Hospital to the further treatment

3. What is prognosis of this patient in this case ?

Theory Case Prognosis of cervical cancer depends on multi factors such as :

age, general state of physical,the level of clinical, histological characteristics of the tumor cells, the ability of experts who handleand the availability of adequate treatment.

According to the staging IB2, so prognosis for this patient : 88%Dubia ad bonam

5 years survival rate Stadium 5 years survival

I A

I B

100%

88%

II A

II B

68%

44%

III 18-39%

IV A 18-34%

Source: UICC / Clinical Oncology; Springer-Verlag, New York, Hiedelberg, Berlin; 1973, p: 218

TINGKAT AKH-5 tahun

T1S Hampir 100 %

T1 70-85%

T2 40-60%

T3 30-40%

T4 < 10 %

Conclusion In this case, it can be seen that in patients with

clinical manifestations and physical examination were found to support the diagnosis of cervical cancer grade IB2. In addition, this patients have anemia due to blood loss. Therefore the first management is The first management that can be done is to improve the patient's general condition

In its own cervical cancer prevention can be done for cervical cancer include primary prevention, secondary, and tertiary.

Thank You