Name : Puan R

R/N : AM 00456972
Age : 58 years old
Sex : Female
Race : Malay
Occupation : Housewife
Date of admission : 2nd August 2015
Date of clerking : 3rd August 2015
Gravida :3
Para :3
Last Normal Menstrual Period (LNMP) : unsure

CHIEF COMPLAINT

Electively admitted to Hospital Ampang for extrafascia hysterectomy bilateral salphingo-

oophorectomy + pelvic lymph node dissection kiv appendicectomy with complaint of heavy per
vaginal bleeding since 3 month ago.

HISTORY OF PRESENTING ILLNESS

She was apparently well until on May which is 3 month ago, she experienced painless
per vaginal bleeding which is fresh blood with clots . She said about 10 pampers per day and
associated with fatigue. She dont seek the treatment at that time because she thought of been
menstruation again. She present herself to Hospital Ipoh after receiving suggestion from her
friend. Otherwise, she has no hypothyroid symptoms such as cold intolerance, constipation and
dry skin , no post coital bleeding no pelvic pain and dyspareunia.

In Hospital Ipoh, she was undergone ultra sound and hysteroscopy and dilatation and
curettage (D & C). The sampling was taken and she was discharged with tablet Provera 10mg
three time a day. After been discharged, her bleeding reduce from to time and able to do daily
routine. The result of endometrial sampling revealed adenocarcinoma grade 2 with features in
keeping with endometriod adenocarcinoma, villoglandular type.

On 24th July 2015, she undergone chest radiograph and CT thorax abdominal pelvis to
rule out metastasise. The result reveal there was no metastasise to other organ. She was refer to
Hospital Ampang for further management. She was planned for extrafascial hysterectomy
bilateral salphingo-oophorectomy + pelvic lymph node dissection and kiv appendicectomy.

SYSTEMIC REVIEW
Unremarkable

PAST OBSTETRIC HISTORY

She delivered three children, all of them delivered by lower segment caesarean section. All of her
children alive except the 1st children die after birth. She unable to recall the weight of her
children and both of them was breastfed.

PAST GYNAECOLOGY HISTORY

She attained her menarche at 12 years old with 7 day flows and 30 days cycle. No history of
intermenstrual bleeding, no history of menorrhagia and dysmenorrhea. She has menopause about
18 years ago.

PAST MEDICAL AND SURGICAL

She was diagnosed having diabetes mellitus and hypertension since 5 years ago. It occurs when
she has fever and seek treatment at private clinic incidentally revealed she has hypertension and
diabetes mellitus. Regarding the diabetes mellitus, initially she was treated with metformin for 3
years and the last year was on insulin due to uncontrolled blood glucose. She undergone follow
up once monthly at Klinik Kesihatan Jelapang. Regarding the hypertension, the average blood
pressure every visits was 120-130/80 mm Hg.
DRUG AND ALLERGY HISTORY
She currently was on subcutaneous Actrapid 20/20/20, subcutaneous Insulatard 28 units on night,
tablet amlodipine 10mg once daily, tablet Micardis plus 80/12.5 mg once daily, tablet Cardipirin
100 mg once daily, tablet metformin 1g twice daily and tablet Simvastatin 20 mg on night. She
has no history drug allergy.

FAMILY HISTORY

Her younger brother was recently been diagnosed to have colon carcinoma.
SOCIAL HISTORY

She is housewife married with ex- military army currently work as taxi driver. They live in
terrace house in Ipoh with two rooms and with two children. The second children was already
working at Ipoh and still unmarried.The last children is disable person since birth and receive
budget from welfare about RM 300 monthly. She was non-alcoholic and non smoker. Their total
income was less than RM 2000 monthly.

PHYSICAL EXAMINATION

General inspection
Patient was alert and conscious lying comfortably on flat bed. She was clinically pink.
Vital signs
Pulse rate : 80 bpm, regular rhythm, good volume
Blood pressure : 139/79 mmHg
Respiratory rate : 20 breaths per minute
Temperature : 37 C, afebrile
Pain score :0
Height : 144 cm
Weight : 96 kg
BMI : 46.30
General examination
Hand : Both hands are warm and dry. There are no palmar erythema, peripheral cyanosis and
koilonychia.
Head : No conjunctiva pallor and jaundice. The hydration status is good and no central
cyanosis
Neck : No thyroid enlargement noted. JVP is not raised and no palpable cervical lymph
nodes.
Leg : No pedal edema.

Cardiovascular examination
The apex beat located at 5th intercostal space, 1.5 cm lateral to mid-clavicle .First and second
heart sounds can be heard. Dual rhythm and nor murmur

Respiratory examination
Air entry equal bilaterally with vesicular breath sound and no added sound.

Breast examination
Both breasts are a symmetrical. The nipples are in the same line. No palpable mass and peau de
orange appearance. The axillary lymph nodes are not palpable.

Abdominal examination
Inspection :
The abdomen is flabby and there is midline incision post extrafascial TAHBSO (total abdominal
hysterectomy bilateral salphingo-oophorectomy) operation + pelvic lymh node dissection +
appendicectomy and LSCS scar noted measuring approximately 15 cm and well healed.
No organomegaly noted and kidney was unballotable.
Shifting dullness was negative.
On auscultation, the bowel sound was present and no bruit

Central Nervous System

Normal

CASE SUMMARY

A 58 year old malay lady known case of diabetes mellitus and hypertension, low parity
and post menopauseal since 18 years ago was electively admitted to Hospital Ampang for
extrafascia hysterectomy bilateral salphingo-oophorectomy + pelvic lymph node dissection kiv
appendicectomy with complaint of heavy pervaginal bleeding since 3 month ago. The operation
was successful done with the patient was able to pass urine, bowel motion was good, able to
ambulate well and estimated blood loss was 300 ml.

PROVOSIONAL & DIFFERENTIAL DIAGNOSIS

-Endometriod adenocarcinoma
Point for : suggested by histopathology result. It was supported by the
presence of risk factor of diabetes mellitus, low parity and obesity
-endometrial hyperplasia
Point for : the thickness of endometrium lining more than 4mm by transvaginal
scan and menorrhagia
Point against : histopathology revealed the endometriod carcinoma.

INVESTIGATION

Relevant Investigation
Blood investigation
Full blood count
Haemoglobin : to detect anaemia
White blood cells : to rule out infection by presence of leucocytosis
Platelets : to rule out thrombocytopenia, prevent the case of disseminated
intravascular coagulation (DIVC)
Liver function test : to rule out liver failure
Renal profile : to know the status of renal condition and to rule out renal
failure, such as in case of hypokalaemia that can cause cardiac
arrythmia
Random blood sugar : to know glucose level in blood for preparation patient going to
operation and diabetic control.
Group screen and Hold (GSH): preparation for operation if massive bleeding occur
Coagulation profile : to know the parameter of clotting factors and hypercoagulable
state

Imaging

Chest X-ray : to rule pleural effusion and metastases of tumours

Result of Investigation ( at the day of admission):-

Full blood count

Contents Reading Normal range
Haemoglobin 12.3 12-18 g/dL
White cells counts 7.0 4-11 K/uL
Platelets 300 140-440 K/uL
Haematocrit 37.4 % 37-50 %
Mean cell volume 83.7 76-96.0 fL
Mean cell haemoglobin 27.4 27-32 pg
Mean cell haemoglobin 32.7 30-35 g/dL
concentration

Liver function test

Contents Reading Normal
Total Bilirubin 6.1 0.00-17.00 umol/L
Total protein 86 66-87 g/L
Alkaline phosphatase 117 35-104
Albumin 43 34-48
Globulin 43 20-35
Albumin: Globulin 1.00
Alanine transaminase 17 7-35 U/L

Renal profile
Contents Reading Normal
Urea 3.6 1.7-8.30 mmol/L
Sodium 136 136-146 mmol/L
Potassium 4.2 3.3-5.1 mmol/L
Chloride 100 98-106 mmol/L
Creatinine 83 44-80 mmol/L

Coagulation Profile
Contents Reading Normal
Prothrombin Time 12.0 11.7-14
International normalise ratio 0.88
(INR)

Random Blood sugar

RBS 8.9 3.9-7.8 mmol/L

Chest X-ray
-normal finding and no abnormalities.

MANAGEMENT

1. Admit patient to the ward.

2. Prepare the patient for preoperative management
3. Her hemodynamic status should be monitored 4 hourly.
4. After she is kept nil by mouth, fluid therapy with monitoring can be started.
5. An informed consent regarding total abdominal hysterectomy should be taken prior to
surgery. The risks and complications of the surgery should be explained to her.
a. Complication of surgery are bowel injury, bladder injury, hemorrhage and infection
6. She will need to fast at least 6 hours before the surgery.
7. She was planned for TAHBSO + PLND +kiv appendicectomy on 4/08/2015
8. She needed to stay at ward for monitoring post operation of extrafasical hysterectomy
bilateral salphingo-oophorectomy + pelvic lymph node dissection + appendicectomy
a. Blood pressure and pulse rate monitoring every 15 minutes to hours to hourly and
then 4 hourly when patient was stable
b. Pad chart and input output chart, keep urine output at least 40 ml/ hour
c. Intravenous drip 5 pints in 24 hour- 3 pints ofnormal saline and 2 pints of dextrose
 d. Give antibiotic sulperazone 1g bd for 5 days, ranitidine 50mg tds for 3 days,
intravenous maxolon 10mg tds for 3 days
e. Chest and limb physio, do incentive spirometry
f. Put patient on ted stocking
g. Subcutaneous clexane if blood investigation are normal
9. Follow up
a. Physical examination every 3-6 month for 2 years, then review for annually
b. Check for CA 125 to check for recurrence
c. Vaginal cytology every six months for 2 years, then annually

DISCUSSION

Endometrial carcinoma is a cancer that arise from uterine lining. This abnormal growth of
cell have an ability to invade other structures and spreading to other parts of body. In US, it was
the fourth common cancer among women in 2012 1. The etiology of endometrial carcinoma due
to the presence of unopposed estrogen either exogenous or endogenous. The risk factors are
postmenopausal, nulliparous and low parity, obesity, endometrial hyperplasia and breast cancer.
Generally, about 75% of women have endometrial carcinoma are postmenopausal and 25 % are
perimenopausal and premenopausal. In addition to full history taking such as the patient usually
presented as irregular menses, heavy bleeding, intermenstrual period and vaginal discharge, the
physical examination are needed to rule out the causes. The vulva, vaginal, cervical with pelvic
examination and speculum are done. The manual examination also been done however the uterus
usually normal. In endometrial carcinoma, there are 4 type, such as endometriod
adenocarcinoma, adenosquamous carcinoma, clear cell carcinoma and mixed mesodermal
Mullerian tumours. The most commonest endometrial carcinoma is endometriod
adenocarcinoma, about 87 %.

Obesity are the risk factor for endometrial carcinoma. About 40% cases of obesity related
to endometrial carcinoma. In women, the estrogen was produced by ovary however, in obese
person, they have more fat and adipose tissues, these tissues will convert into estrogen Thus, the
women have high amount of estrogen and high exposure to estrogen. As the result, the risk to
endometrial carcinoma is about 2-3 times than normal person of women 2. In this case, the BMI
of patient was 35 kg/m2. Diabetes mellitus is a systemic disease, it can contribute most of the
diseases. In endometrial carcinoma, insulin resistance in case of diabetes mellitus type II, it will
cause the accumulation of fat and adipose tissue, subsequently lead to convertion into estrogen 2.
As conclusion, excessive estrogens and obesity have been associated with endometrial cancer3,4.

In investigation, the full blood count was ordered. It was necessary for pre-operative
assessment as baseline and it affect the surgical management 5.In addition, the haemoglobin value
can predict the risk of patient to have postoperative transfusion 6. In this case, the patient was not
done the mammogram, in my opinion, although there was no complaint and normal finding in
physical examination, the mammogram should be done as the patient was more than 50 years
old. Besides, the tumour marker also important in case of endometrial cancer as it had been
shown that the elevation of Ca-125 levels have been noted in women with endometrial cancer7.

The complication of surgery itself also to be noted. In hysterectomy, there is the risk of
bowel injury8 . Besides, the main problem with this surgery is the haemorrhage 9 . However, the
most common complication is post surgery infection10,11. That why after the operation we should
monitor whether patient febrile or not before to be discharged. In addition, the patient may
experience feeling of depression, decreased libido and social lacking due to post surgery
recovery but the psychological problems or effect are different from women to women.

In management, the prophylactic surgery is required before the major surgery been done.
It can prevent the risk of having deep vein thrombosis( DVT) . The DVT may occur in up to 40%
of women after major gynaecologic surgery without any prophylaxis12.

Conclusion

In conclusion, there was association between excessive estrogen exposure such as low
parity or nulliparous and obesity to develop endometrial carcinoma.
REFERENCE

1. Surveillance, Epidemiology, and End Results (SEER) Program. SEER Database: Incidence -
SEER 9 Regs Public-Use. National Cancer Institute, DCCPS, Surveillance Research Program.
Available at http://seer.cancer.gov/.
2. Rudolf Kaaks, Annekatrin Lukanova, and Mindy S. Kurzer.Obesity, Endogenous Hormones,
and Endometrial Cancer Risk. Available at http://cebp.aacrjournals.org/content/11/12/1531.full
3. Gusberg SB. Precursors of corpus carcinoma: estrogens and adenomatous hyperplasia. Am J
Obstet Gynecol 1947; 54:905.
4. Way S. The aetiology of carcinoma of the body of the uterus. J Obstet Gynaecol Brit Emp
1954;1:4658.
5. Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med
Clin North Am 2003; 87:740.
6. Faris PM, Spence RK, Larholt KM, et al. The predictive power of baseline hemoglobin for
transfusion risk in surgery patients. Orthopedics 1999;22:s135s140
7. Niloff JM, Klug TL, Schaetzl E, et al. Elevation of serum CA125 in carcinomas of the
fallopian tube, endometrium, and endocervix. Am J Obstet Gynecol 1984;148:10571058
8.Stovall TG, Mann WJ. Vaginal hysterectomy. UpToDate Online 16.2.
http://utdol.com/online/content/topic.do?
topicKey=gyn_surg/6246&selectedTitle=6~150&source=search_result. Accessed June 22, 2008.
9. Maresh MJ, Metcalfe MA, McPherson K, et al. The VALUE national hysterectomy study:
description of the patients and their surgery. BJOG. 2002; 109:302-312.
10. Rice CN, Howard CH. Complications of hysterectomy. US Pharm. 2006; 31(9):HS-16-HS-
24.
11.National Women's Health Network. Hysterectomy. www.nwhn.org/ healthinfo/detail.cfm?
info_id=8&topic=Fact%20Sheets. Accessed August 7, 2008.

8.Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh
ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:338S400S.
 OBSTETRICS & GYNAECOLOGY POSTING

PAG 6018

CASE WRITE-UP

ENDOMETRIAL CARCINOMA

NAME :MUHAMAD AMIN MUKHTAR

MATRIC NUMBER :1090255
COORDINATOR :DR ZAIREENA BT ZAINAL