Group 24

Clarissa Fiolly Refieska

Diana Ardila
Dwi Rizki Fadhilah
Ervin Maulana
Ivo Mahalia
Muhammad Al Fath
Nurhayani Fatimah
Rani Apriani

Scenario
Mrs. Daras Secret
Mrs. Dara 52 years old, come to Seberang Padang Clinics with the lump
on her breast. The swelling has been perceived since 2 months ago,
but since 3 days ago felt bothering because of the pain. Then the
doctor did the physical examination and suspecting that the swlling on
her breast are malignancy. Mrs. Dara conceal this to her husband.
When she was 20 years old, mrs. Dara had the ovarium tumor
operation and done with pathology anatomy exam, with the result
dermoid cyst (mature teratoma), and according to the doctor this was
benign tumor, and right now mrs. Dara has 4 childrens. Her sister ever
had servical cancer, and died 5 years ago.
On gynecological examination with the result: on abdomen no palpable
masses. Inspekulo : vaginal wall are smooth, no tumor and fluid, portio
multipara, smooth and there is no fluid out of the canal sevicalis.
VT/BM : the uterus as big as chicken eggs, with springy consistency,
Adneksa parametrium palpable weakness. Laboratorium inspection :
Hb 9,3. The doctor on the clinics refer the patient to Dr. M. Djamil
Padang hospital.
How do you explain what mrs. Dara experienced with ?

Step 1 Terminology

Dermoid cyst : benign tumor that

came from germinativum cell
Mature teratoma : come from
ektoderm, mesoderm, and endoderm
that already mature.
Gynecology ; the study of woman
genitalia.
Portio multipara : part of the uterus
that protruding into the vagina that
often gave birth.

Step 2 Problem Identification

1. Why mrs. Dara complain about lump on her rigth breast

since 2 months ago and felt pain since 3 days ago?
2. How the relation between the swelling on her breast
with her age?
3. Why doctor suspecting that is malignancy?
4. Why mrs dara concealing to her husband?
5. What the purpose of patholgy anatomy examination?
6. How the relation between the lump on her breast with
ovarium tumor?
7. How the relation of genetic between mrs dara and her
sister experienced?
8. Why mrs dara with the ovarium tumor still alive but her
sister with breast cancer could died?
9. How the interpretation of doctor examination?

Step 3 Brainstorming
1.

2.
3.
4.
5.
6.
7.
8.

9.

The lump on her breast could be benign or malignant

tumor. Malignant because of the fast growth of tumor and
the pain. The pain that mrs dara felt because of the tumor
already invasion the other tissue.
On her age are increased the risk of cancer, hormonal
production decrease, often exposed with carsinogen.
Maybe on examination docter found like imobile, peau de
orange, dimpling, hard, restriction etc.
Mrs. Dara worry that her husband will left her alone
because of what she experienced now.
To ensure that the lump are benign or malignant.
It has the same cause of tumor, it is because the mutaion
of gene BRCA1
The familial genetic are one of risk factor
Mrs dara tumor are still benign and get the resolve, her
sister cancer maybe already invasion the other tissue and
undermine it and metastatic to vital organs.
The exam on abdomen, inspekulo, vt/bm are normal. The

Step 4 Scheme
BREAST TUMOR

MALIGNANCY

P. ANATOMY
EXAM
SERVICAL
CANCER

GYNECOLOGICA
L EXAM

DERMOID CYST

Step 5 Learning Objectives

1. Benign tumor of woman
reproduction system
2. Malignancy of woman reproduction
system
3. Benign tumor of mammae
4. Malignancy of mammae
5. Gynecological exam

LO 1 Benign tumor of woman reproduction system

LO 2 Malignancy of woman
reproduction system

Cervical cancer
Etiology
- HPV
- Socio-economic status

Risk factors

HPV infection
Cigarette smoking
Multiparity
Oral contraceptivs
Other STD (Chlamydia trachomatis)
Poor nutritional status

symptoms
Bleeding from the vagina that is not
normal, or a change in your
menstrual cycle that you can't
explain.
Bleeding when something comes in
contact with your cervix, such as
during sex or when you put in a
diaphragm.
Pain during sex.
Vaginal discharge that is tinged with

Cancer diagnosed
Pap smear
Biopsy
Treatment
Surgery, such as a hysterectomy and removal
of pelvic lymph nodes with or without
removal of both ovaries and fallopian tubes.
Chemotherapy.
Radiation therapy.

vulval cancer
It accounts for about three per cent
of all gynaecological cancers and is
most commonly diagnosed in older
women aged around 70 years or
over.

Symptoms of vulval
cancer

In its early stages, vulval cancer often has no symptoms. This is

because the cancer is so tiny. The progression of symptoms can
include:
An unusual lump or bump can be felt somewhere on the vulva.
The lump becomes itchy and painful.
The lump progresses to an ulcerated sore that refuses to heal.
The raw-looking sore can be white, red or pink. The sore gets
bigger with time.
There could be unusual bleeding or discharge from the vagina.
The lymph glands in the groin may swell.
Problems with bowel motions and passing urine may indicate
the cancer has spread into the bowel or bladder.
Secondary cancers may cause a range of symptoms, such as
aching bones.

Risk factors for vulval cancer

Some of the risk factors for vulval cancer include:
Age vulval cancer usually occurs in postmenopausal women, but
there appears to be an increasing number of young women being
diagnosed
Sexually transmitted infections
Multiple sex partners
Never having children (nulliparity)
Chronic vulval itching (pruritis)
Genital warts (human papilloma virus infection)
Vulval intraepithelial neoplasia (a pre-cancerous condition)
Prior incidence of squamous cell cancer of the cervix
Prior incidence of squamous cell cancer of the vagina
Smoking
Lichen sclerosus (a rare skin condition that usually occurs around the
vulva and anus).

Types of vulval cancer

Vulval cancer is classified according to its cell of origin. This can

include:
Squamous cell carcinoma originating in the skin cells. This
type accounts for about 90 per cent of cases
Melanoma originating in the pigment cells deeper in the skin.
This type accounts for about five per cent of cases (in the vulva
it is not related to sun exposure)
Adenocarcinoma originating from the Bartholins glands, the
structures that supply lubricant to the genitals. This type
accounts for less than one per cent of cases
Sarcoma originating from fat cells. This type is quite rare
Lymphoma originating from the immune cells. This type is
quite rare
Basal carcinoma a form of skin cancer. This type is quite rare.

Diagnosis of vulval cancer

Some of the methods for diagnosing vulval cancer

include:
Taking a medical history
A physical examination
Examination of the vulva with a colposcope, which
makes it easier to see the lesions of certain diseases
(including VIN and vulval cancer)
Taking a biopsy of the sore or lump using a scalpel
(with local anaesthesia), or performing a punch
biopsy (this instrument extracts a little core sample)
Excising (removing) some tissue under general
anaesthetic.

Treatment for vulval cancer

Treatment for vulval cancer can include:
Vulvectomy the first line of treatment is to surgically remove
the tumour. Depending on factors including the location, type,
stage and severity of the cancer, surgery may include radical
vulvectomy (removal of the vulva), with or without removal of the
groin lymph nodes from one or both sides. The clitoris may or
may not need to be removed
Radiation therapy the use of precisely targeted x-rays to kill
cancer cells. This may be used as the primary treatment to avoid
removal of the clitoris
Chemotherapy the use of cancer-killing drugs, often in
combination. Chemotherapy can be helpful in controlling
secondary cancers because it treats the whole body. It may also
be used with radiation to increase the effectiveness of
radiotherapy.

ovarian cancer
About 90 per cent of ovarian cancers occur in women over the age of 40.
Like most cancers, the risk of ovarian cancer increases with age.
Risk factors of ovarian cancer
The exact causes of ovarian cancer arent known, but some of the risk
factors include: an increase in age. In Victoria, the median age at
diagnosis has risen over the past 20 years from 63 to 65 years
inheriting a faulty gene (called a gene mutation) that increases the risk of
ovarian cancer
being Caucasian (white) and living in a Western country with a high
standard of living
having few or no full-term pregnancies
starting your menstrual cycle early (before the age of 12) and beginning
menopause after the age of 50

 taking hormone therapy (HT) after menopause. Some

studies suggest this may increase your risk of developing
ovarian cancer, but others dont make this connection
never having taken the contraceptive pill the pill has been
found to reduce the risk of cancer of the ovaries and uterus
only five to 10 per cent of all ovarian cancers are associated
with a family history. The risk of developing ovarian cancer
increases with the number of affected first degree relatives
(parents, siblings, children)
for an Ashkenazi Jewish woman with a family history of
breast or ovarian cancer, background should be considered
as an additional risk factor.
Other risk factors are still being researched.

Symptoms of ovarian cancer

Ovarian cancer can be difficult to diagnose at an early stage,
largely because symptoms can be vague and similar to those of
other common illnesses.
The symptoms of ovarian cancer will vary depending on the stage
of the cancer. Many women with early stage ovarian cancer may
not have any symptoms. If they do, it may be some pain in the
lower abdomen or side and a bloated or full feeling in the tummy.

Some of the symptoms of later stage ovarian cancer include:

discomfort in the abdomen, such as bloating or a feeling of
pressure
a change in bowel habits
indigestion
vaginal bleeding that isnt due to normal menstrual periods
pain, especially during sex
swollen abdomen as the cancer grows.

If the cancer is very advanced and spreads to

other parts of the body, it can cause:
loss of appetite
sickness (nausea and vomiting)
constipation
tiredness
breathlessness
severe pain
more extensive abdominal swelling that may
need draining.

Types of ovarian cancer

The four main types of ovarian cancer are:

epithelial cancer of the epithelium, which consists of
the outer cells covering the ovary. This is the most
common type nine out of 10 ovarian cancers are
epithelial cancers
germ cell cancer of the cells inside the ovary that
mature into eggs. This uncommon form of ovarian cancer
usually affects women less than 30 years of age
sex-cord stromal cell cancer of the cells that release
female hormones. This uncommon form of ovarian
cancer can affect women of any age
borderline tumours types of epithelial tumours that are
not as aggressive as other forms.

Diagnosis of ovarian cancer

There are a range of tests to diagnose ovarian cancer, including:
physical examination the doctor checks for lumps in the lower
abdomen or pelvis
blood tests to search for tumour markers (for example, CA 125). These
are proteins that are often higher than normal in women with ovarian
cancer
imaging tests such as a computed tomography (CT) scan, magnetic
resonance imaging (MRI), a positron emission tomography (PET) scan or
abdominal and trans-vaginal ultrasounds
colonoscopy to make sure that your symptoms are not caused by a
bowel problem
surgery this is the only definitive way to find out if you have ovarian
cancer.
The pap test is only effective for the early detection of cancer of the
cervix, not ovarian cancer.

uterine cancer
Risks and causes of uterine cancer
The exact cause of uterine cancer is not known. Some things
seem to put women at more risk including:
endometrial hyperplasia (an abnormal increase in the
number of cells in the endometrium)
menopause, never having children or being infertile
being overweight
high blood pressure and diabetes
a family history of endometrial, breast or bowel cancer
being on oestrogen hormone therapy without progesterone
being on tamoxifen or anastrozole for treatment of breast
cancer. if you are on either of these medications, you should
discuss this risk with your doctor.

Symptoms of uterine cancer

The most common symptoms of uterine cancer are:
unusual bleeding
watery, bloody discharge from the vagina, which can
sometimes be smelly.
Less common symptoms include bloating and discomfort
in the abdomen and pain during sex. If the cancer is very
advanced, other symptoms may be present such as
tiredness, loss of weight and constipation.
Unusual bleeding or discharge can happen before and
after menopause. It is usually not due to cancer of the
uterus. However, all women with unusual bleeding or
discharge should see their doctor for a check-up.

Types of uterine cancer

Most cases of cancer of the uterus are cancers of the uterus lining
(endometrium), though some cancers grow in the muscle layers
of the uterus.
The different types of uterine cancer include:
Adenocarcinoma of the endometrium around 85 per cent
of women diagnosed with cancer of the uterus have this form. An
adenocarcinoma is a cancer that starts in the glandular tissue.
High-risk cancers less common types of cancer (such as
adenosquamous carcinoma, papillary serous carcinoma and clear
cell carcinoma) are more likely than others to spread around the
body.
Endometrial hyperplasia sometimes women develop a thick
uterus lining that can cause heavy periods. Some types of
endometrial hyperplasia may later become precancerous.

Diagnosis of uterine cancer

The tests used to diagnose cancer of the uterus include:

physical examination to check the abdomen for swelling
transvaginal ultrasound to look at the size of the ovaries,
uterus and thickness of the endometrium
biopsy removing some tissue so it can be looked at under
a microscope. This can be done in several ways including
having a dilatation and curettage (D&C)
x-rays and other scans such as computed tomography
(CT) scan or magnetic resonance imaging (MRI)
blood tests to check your general health and help make
decisions about your treatment.

Treatment of uterine cancer

Most cancers of the uterus are diagnosed early and treated before the cancer
has spread. Treatment options include:
Surgery this is the first and most important treatment for almost all women
with uterine cancer. This means removing the uterus (hysterectomy), the
fallopian tubes or the ovaries (or both). If cancer has invaded the muscle walls
of the uterus, the lymph nodes inside the pelvis and abdomen will also be
removed. If cancer has spread to the cervix (neck of the womb), a small part of
the upper vagina and the cervix must be taken out as well
Radiotherapy this might be external (using a machine to direct x-rays at the
part of the body needing treatment) or internal (a radioactive implant is put
inside the body close to the cancer). Radiotherapy may be given alone, or
before or after surgery.
Hormone therapy since cancer of the uterus is sensitive to hormones,
oestrogen-blocking drugs might be used as a treatment if the cancer comes
back or has spread.
Chemotherapy involves anti-cancer drugs being injected into the veins,
which kill cancer cells by stopping them from multiplying. This is sometimes
given to help control advanced-stage uterine cancers.

vaginal cancer
Symptoms of vaginal cancer
Some vaginal cancers have no symptoms in their early
stages, and only cause symptoms once they have invaded
other parts of the body. They may be found through an
abnormal pap smear.

Some of the symptoms of vaginal cancer can include:

Painless vaginal bleeding thats not associated with
menstruation
Bleeding after sexual intercourse
Smelly vaginal discharge
Pain when urinating or passing bowel motions
Constant pelvic pain.

Risk factors for vaginal cancer

The risk factors for vaginal cancer include:

Advancing age most women with vaginal cancer are
aged over 50 years
Prior history of gynaecological cancer, such as cancer
of the cervix or vulva
Previous treatment for dysplasia (abnormal cells on
the cervix, vagina and vulva)
Genital warts (human papilloma virus infection)
Cigarette smoking (women with vaginal cancer are at
increased risk of lung cancer, which is strongly
associated with tobacco use)
Prenatal exposure to the synthetic hormone DES. (This
has not been prescribed since 1971.)
Vaginal adenosis, whereby cells that should be
confined to the internal cervix lining (endocervix) are
also found on the vaginal walls (almost all DES

Diagnosis of vaginal cancer

Vaginal cancer is diagnosed using a
number of investigations, including:
Medical history
Physical examination, including a
pelvic examination using an
instrument called a colposcope
Biopsy of the affected tissue, which
may need to be performed under
anaesthetic.

Treatment for vaginal cancer

Treatment options can include surgery, if the cancer is
small, radiation therapy or extensive surgery after
radiation therapy when the cancer is very large or has
recurred. These involve:
Surgery the vagina and surrounding tissues may
need to be removed. The surgeons can create an
artificial vagina using tissue from elsewhere in the
body, such as the thigh, so that you can still have
sexual intercourse. A radical hysterectomy may also
be needed (the uterus, cervix, ovaries and fallopian
tubes are removed, along with associated lymph
nodes and the top end of the vagina). If the cancer
has spread to other pelvic organs, such as the bladder
or rectum, surgery will be required to remove the
diseased tissues or organs.
Radiation therapy is the use of precisely targeted x-

LO 3 Benign tumor of
Mammae

Mammary fibroadenomas
Fibroadenoma palpable as lumps or bumpy
round and chewy consistency. These
tumors are not attached to the surrounding
tissue and very easily moved to and fro.
Sometimes multiple fibroadenomas grow
(in many places).
The growth of these tumors can rapidly
during pregnancy and lactation or
approaching menopause, when estrogen
stimulation rises.

Sistosarkoma Filoides
Benign tumors that are infiltrative
(infiltrate) locally
Abatement is wide excision (discard
the entire mass of the tumor and the
surrounding healthy tissue). If a large
tumor is usually needed for a simple
mastectomy (removal of the affected
breast tissue)

Intraductal Papilloma
This benign tumor derived from the
lactiferous ducts and 75% growth
under the nipple.
Symptoms:
Symptoms typically are out
secretions / bloody fluid from the
nipple.
Subareola small tumor with a
diameter of a few millimeters that is
too small to be palpated

LO 4 Malignancy of
Mammae

Breast Cancer
Breast cancer is second only to lung cancer

as a cause of cancer deaths in American

women

One out of every seven women

will be diagnosed with breast
cancer in 2007

Fortunately, radical mastectomy

(surgical removal) is rarely
needed today with better
treatment options

Signs and Symptoms

Most
common:
lump or
thickening in
breast.
Often
painless

Dischar
ge or
bleedin
g
Change in
size or
contours of
breast

Redness or
pitting of skin
over the
breast, like the
skin of an
Changeorange
in
color or
appearance
of areola

Noncancerous Conditions
(1)
Fibrocystic changes: Lumpiness, thickening
and swelling, often associated with a womans
period
Cysts: Fluid-filled lumps can range from very
tiny to about the size of an egg
Fibroadenomas: A solid, round, rubbery lump
that moves under skin when touched, occuring
most in young women
Infections: The breast will likely be red, warm,
tender and lumpy
Trauma: a blow to the breast or a bruise can
cause a lump

Causes
Some of the cells begin growing
abnormally
These cells divide more rapidly than
healthy cells do and may spread through
the breast, to the lymph or to other parts
of the body (metastasize)
The most common type of breast cancer
begins in the milk-production ducts, but
cancer may also occur in the lobules or in
other breast tissue

Ductal Carcinoma in situ

(DCIS)
Ductal
cancer
cells

45

Illustration Mary K. Bryson

Carcinoma refers to
any cancer that begins
in the skin or other
tissues that cover
internal organs

Normal
ductal
cell

Invasive Ductal Carcinoma (IDC

80% of breast cancer)

Ductal cancer
cells breaking
through the
wall

The cancer has spread to the

surrounding tissues
46 Mary K. Bryson
Illustration

Mammography
Use a low-dose x-ray system to examine
breasts
Digital mammography replaces x-ray
film by solid-state detectors that
convert x-rays into electrical signals.
These signals are used to produce images
that can be displayed on a computer
screen (similar to digital cameras)
Mammography can show changes in the
breast up to two years before a
physician can feel them

What Mammograms Show

Two of the most important
mammographic indicators of breat
cancers
Masses
Microcalcifications: Tiny flecks of calcium
like grains of salt in the soft tissue of the
breast that can sometimes indicate an early
cancer.

LO 5 Gynecological exam

GYNAECOLOGICAL HISTORY
Age
Past medical, surgical,
gynaecological history
Medications
Allergies
Family History
Social History

GYNAECOLOGICAL HISTORY
Past Obstetric History
ever been pregnant before
Spontaneous abortions, terminations of
pregnancy, ongoing pregnancies, living
children

What happened in those pregnancies

Spontaneous, duration of pregnancy, type of
labour and delivery, outcome, complications

GYNAECOLOGICAL HISTORY
Gynaecological History
Abdominal pelvic pain
Bleeding
Contraception
Discharge (itch)
Incontinence and prolapse
Fertility
Screening history

GNAECOLOGICAL
EXAMINATION
General examination
H&N, breasts, cardiorespiratory,
abdominal, periphery

Abdominal palpation
Inspection external genitalia
Speculum examination vagina/cervix
Bimanual palpation of uterus and
adnexae

Pelvic Examination
Empty bladder
Wash hands, gloves, warm vaginal speculum with
warm water, obtain specimens as needed (Pap
smear, cultures)

Vaginal
Lesions, discharge

Cervix
Cervical excitation, os open/closed,
Polyps, erosions, etc...

Uterus
Size, shape, regularity, tenderness, position,
mobility

Adnexa
Masses, tenderness, ovaries

Rectal
Mass, tenderness, blood

Thank you