Cervical Ca Case.docx

DEPARTMENT OF OBSTETRIC & GYNAECOLOGY KULLIYYAH OF MEDICINE INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

CASE WRITE UP GYNAECOLOGY YEAR 5 BLOCK 3 (2017/2018)

CERVICAL CARCINOMA

Name

: Mohammad Aiman bin Mohd Shah

Matric No

: 1314027

Supervisor

: Dr Raja Arif Shah

IDENTIFICATION DATA Name:

Mazenah binti Min

Identification Card No:

570408-11-5114

RN:

1047253

Age:

60 years old

Race:

Malay

Occupation:

Pensioner

Address :

Beserah, Kuantan

Marital Status:

Married

Para:

Para 5

Date and Time of Admission: 14th December 2017 Date and Time of Clerking: 15th December 2017

CHIEF COMPLAINT Mdm. Mazenah was electivley admitted for further management in view of post-coital bleeding for the past 5 months duration.

HISTORY OF PRESENTING ILLNESS She was apparently well until 5 months ago when she started to have per vaginal bleeding each time after inercourse. She describe the event when she bleeds minimal amount of fresh blood which soaked about one-third of the pad. The bleeding lasted about 15 minutes to an hour and she did not have to wear pad afterward. In January 2016- 3 months prior to presentation, the symptoms worsened as she claimed that the amount increased to soak half of the pad and was assciated with small 50 cents-sized clots. She claimed to usually have sexual intercourse once every two weeks and the last sexual activity was in Jnaury 2016, after the bleeding got worse. She did complain of mild vaginal dryness since having menopuase but claimed that it only minimally affect the citus. Otherwise, the post-coital

PHYSICAL EXAMINATION General examination She was lying comfortably on her bed on supine position. She was alert and conscious. She is a medium built lady. She was not cachexic. She is not pale or jaundice. There was a branula on the left dorsum of her hand. Hydration status and oral hygiene was good. There was no palpable lymph node. There was no bipedal oedema. Vital signs

Blood pressure: 110/60mmHg (normotensive) Respiratory rate: 20 breaths per minute (normal) Pulse rate: 90 beats per minute, good volume, regular rhythm Temperature: 37oC (afebrile) Anthropometric measurement Height: 155 cm Weight: 64 cm BMI: 26 Kg/m2 (pre- obese) Abdominal Examination On inspection, the abdomen was not distended with a caesarean scar measuring 15cm which was well healed with no keloid formation. No uterine scar tenderness. On palpation, the abdomen was soft and non-tender. There was no mass palpable. There was no hepatosplenomegaly and the kidneys were not ballotable. On percussion, the abdomen was resonance at all 9 quadrants. On auscultation, bowel sound was present. Neck Examination There were no obvious lumps or anterior neck swelling observed. There was no palpable mass and no cervical, axillary and inguinal lymph node palpable. The thyroid gland was not enlarged.

Involvement and it serves as baseline for future reference.



Renal Profile Urea Sodium Potassium Chloride Creatinine

3.0 mmol/L 141 mmol/L 3.5 mmol/L 106 mmol/L 67 umol/L

Reason  

Pre-operative assessment Advanced stage, renal involvement can cause impaired renal function This reading also serves as baseline for future reference





Comment 

No derangement

Coagulation Profile PT

12.5 sec

INR

1.0

APTT

35.2 sec

APTT ratio

0.9

Reason  



Comment 

Pre-operative assessment To rule out any coagulation disorders

None of the above was prolonged to suggest underlying coagulation disorder

Ultrasonography Reason 



To screen for any abdominal masses or changes in abdominopelvic region

Comment 

Not done

Electrocardiogram Reason 



Pre-operative assessment Chest X-Ray

Comment 

Normal

Reason  



Pre-operative assesment to rule out any active lung disease Look for any evidence of metastasis to the lungs

Comment 

CT scan (Thorax, Abdomen, Pelvis) Reason 



No abnormalities noted

To asses the involvement of lymph nodes at the thoracic region, abdomen and pelvic region and other possible organs metastasiswhich will aid in staging

Comment 

Not yet done, Planned after one week of discharge.

Examination Under Anaesthesia (EUA) & Hysteroscopy

There were no abnormalities noted at vulva, lower third and upper third of vagina. There was endophytic growth from 12 to 6 o’clock which measured less than 3 cm. Endocervix appeared fluffy and the whole length of endometrium was noted to be atrophic. Right and left parametrium were free. On bimanual examination, uterus was at 6 weeks of size. Perrectally, there was no mass palpable. 

Cystoscopy

There were no abnormalities noted at external meatus, bladder trigone, dome of bladder as well as other walls of bladder.

MANAGEMENT AND PROGRESSION IN WARD

The patient was referred from Klinik Al Farabi in view of post coital bleeding for the past 5 months and atypical endocervical cells which favours neoplasm on Pap Smear. Colposcopy on the first appointment at gynaecology clinic at HTAA revealed abnormal growth that suggest invasive cancer. Examination Under Euthanasia(EUA), hysteroscopy and dilatation and curettage (DD&C), also with cystoscopy was done for further evaluation. Intraoperative findings were as noted in the investigation section and she was diagnosed with cervical carcinoma stage 1b1 according to International Federation of Obstetricians and Gynaecologist (FIGO) staging in which clinical lesion are no greater than 4 cm in size. Histopathology examination result was still pending. Post-procedure, her vital signs were monitored in the ward and she was also put on pad chart. She was allowed orally as tolerated. Mefenamic acid 250 mg BD was also given for pain management. She was noted to be hemodynamically stable with only minimal discomfort over the suprapubic and perineal area but otherwise ambulating well, passing urine and flatus without problems. The pad chart was also nil. The patient was thoroughly explained about her current condition and she understood. She was then allowed discharge the next day and was given appointment for CT scan in the week to come and attend back at Gynaecology clinic one week after the CT scan.

DISCUSSION According to Malaysian National Cancer Registry Report (MCNR) 2007-2011, cervical cancer is the third most common cancer among women in Malaysia which constitutes about 7.7% of all female cancers in the country. The incidence rate is shown to increase after the age of 30years old and peak at the age of 65 to 69 years old. After the emergence of screening method and widespread use of it, namely Papanicolaou smear, the incidence of cervical cancer has dramatically reduced, especially in developed countries. This screening method provides an early recognition of abnormal cytologic changes and with appropriate intervention, this will prevent the progression of the disease from pre-invasive to invasive (Canavan & Doshi, 2000). Generally, malignant tumours can arise from the epithelium or from mesenchymal tissue. But the two major histologic types of cervical cancer are the squamous cell carcinoma and adenocarcinoma in which the former constitute the majority of cervical cancer. Identifying the woman at risk of developing cervical cancer is very crucial to make the screening programme more efficient and effective. One of the most important etiologist that has been implicated in the development of premalignant and malignant change in the cervix would be infection with human papilloma virus (HPV) which is a sexually transmitted infection spread by skin to skin contact during the intercourse, hence the use of condoms does not protect a woman from getting infected. It can also spread through oral, and anal sex. It is highly contagious with or without symptoms. The known HPV types that carry the oncogenic properties would be 16, 18, 31, and 33- particularly the first two in the list. The likelihood of the infection increase in certain types of sexual behaviour- and this include sexual intercourse at young age (< 18 years

say, need further evaluation and based on the American Society of Colposcopy and Cervical Pathology recommendation, in this pattern of case, colposcopy and endocervical curettage are needed (Kaferle & Malouin, 2001), which was done in this patient. Based on the colposcopy result, the abnormal growth favours invasive carcinoma on the basis of its bleeds on contact, its extension into the endocervix and negative iodine uptake. The latter is attribute to the fact that precancerous lesions and invasive cancer do not take up iodine as they lack of glycogen. Assessing the stage of the disease is crucial for prognostication and planning for treatment. The tumours are locally infiltrative in the pelvic area, but also spread via lymphatics and in the late stages via blood vessels. The tumour can grow through the cervix to reach the parametria, bladder, vagina, and rectum. Metastases can occur in pelvic (iliac and obturator nodes) according to the system introduced by the International Federation of Obstetricians and Gynaecologist (FIGO) staging system is largely based upon physical examination and a limited number of endoscopic diagnostic procedures and imaging studies as listed below.

1. Physical examination a. Pelvic examination-speculum, bimanual and rectovaginal examination for palpation and inspection of the primary tumour, uterus, vagina, and parametria b. Examination for distant metastasize- palpation of groin and supraclavicular lymph nodes, examination of the right upper quadrant. 2. Cervical biopsy a. Colposcopy b. Endocervical curettage c. Conization 3. Endoscopy a. Hysterectomy b. Cystoscopy c. Proctoscopy 4. Imaging a. Intravenous pyelogram-evaluate urinary tract b. Computed tomography (CT scan) or MRI c. Chest X-ray