Small Group Discussion Case Protocol: Cervical Cancer

OLIVERAS Rommel, ORAYA Denisa, ORTEZA Melissa, PASAMBA Koleen, PASCUAL

Julianne, PASCUAL Miguel, PEREZ Joy, PIAMONTE Bernadeth

Learning Objectives:
1. To be able to diagnose patients with cervical cancer.
2. To be able to list the necessary diagnostic/laboratory examinations necessary for the
diagnosis of cervical cancer.
3. To be able to discuss an appropriate plan of management for cervical cancer.

General Data: The patient is D.L., 34 years old, college undergraduate, right-handed
Roman Catholic, married, housewife from Mandaluyong City.

Chief Complaint: abdominal pain

Past Medical History: She has no history of hypertension, diabetes mellitus, cancer,
tuberculosis, bronchial asthma, or allergies. She has no history of hospitalizations, surgeries,
or trauma.

Family Medical History: Her father had cancer. She has no family history of no
hypertension, diabetes mellitus, tuberculosis, bronchial asthma, cardiovascular disease, liver
disease.

Personal/Social/Sexual History: D.L. is a college undergraduate and is currently

unemployed. She is an occasional alcoholic beverage drinker and denies smoking or illicit
drug use. She had her first coitus at the age of 16 and she had a total of 5 sexual partners
with unknown promiscuity. She used oral contraceptive pills from January - November 2013,
but she denies the use of condom and having intrauterine (IUD). She does not have a
history of having sexually transmitted infections and she was also unaware if her sexual
partners had such kinds of infection. She had her first pap smear this year and has no HPV
vaccination.

Menstrual History: D.L. had her menarche at 16 years old. Her menses occur at regular
monthly intervals usually lasting for 4 days soaking up to 3 pads per day. She does not
experience dysmenorrhea with her menses. Her last menstrual period was on February 18,
2015. Her past menstrual period was on January 18, 2015.

Obstetric History: G5P4 (4014)

Pregnancy Date AOG Form of Delivery Place Weight FMC

G1 2000 FT SVD Hospital AGA None

G2 2002 FT SVD Hospital AGA None

G3 2003 FT SVD LHC ℅ midwife AGA None

G4 2007 FT SVD LHC ℅ midwife AGA None

G5 2014 Abortion - 10 weeks AOG

History of Present Illness:

5 months PTC, patient experienced left hypogastric pain described as having pins and
needles sensation, associated with vaginal bleeding soaking 2 pads per day.

4 months PTC, ultrasound was done and she was advised biopsy. Biopsy of the cervix
revealed adenocarcinoma. Patient was advised to undergo CT scan but was canceled due
to high creatinine level.

In the interim, there is persistence of the abdominal pain with associated vaginal bleeding.

5 days PTC, CT scan was done but no still awaiting for the results.

3 hours PTC, persistence and worsening left hypogastric pain (NRS 9/10 described as
“humihilab”) prompted consult. There is no associated vaginal bleeding or discharge.

Review of Systems
There was no blurring of vision, nausea, vomiting, bowel disturbances, or urinary changes.

Physical Exam
General: awake, coherent, tachycardic, tachypneic
Vital signs: BP 90/60 PR 110 RR 25 T 36.7 C Height 157 cm Weight 57 kg BMI 23.12
kg/m2
HEENT: anicteric sclerae, pale palpebral conjunctivae, no cervical lymphadenopathies,
anterior neck mass or tonsillopharyngeal congestion
Heart: adynamic precordium, distinct heart sounds, normal rate and regular rhythm, no
murmurs
Lungs: equal chest expansion, clear breath sounds, no adventitious sounds
Breast: No asymmetry, no palpable masses or tenderness, no lesions or discharge
Extremities: full and equal pulses, pink nail beds, capillary refill time < 2 seconds, cold
clammy extremities, no edema
Abdomen: Soft abdomen.Diffuse tenderness, right> left. There is noted tenderness on deep
palpation of the right hemiabdomen and tenderness on light palpation of left hypogastric
area. There is also noted rebound tenderness. Hypoactive bowel sounds.
Speculum exam: On speculum exam, there is a foul-smelling, nodular fungating mass
extending to the middle third of the anterior vaginal wall.
Internal exam: Normal external genitalia, cervix converted to a 7x 5 cm nodular fungating
mass extending to the middle third of the anterior vaginal wall. Corpus is small. The adnexae
could not be assessed due to guarding.
Rectovaginal exam: Good sphincter tone. Collapsed rectal vault. Noted palpable mass 3
cm from the anal verge at the anterior rectal wall. Bilateral parametria are fixed. No blood but
there is stool per examining finger.

Admitting Diagnosis:
Adenocarcinoma of the cervix, Stage IIIB
T/c Ovarian New Growth
Pertinent Labs on Admission

CBC
Results Reference

WBC 19.27 (high) 4.5-11 x10^9/L

RBC 3.30 (low) 4.2-5.4 x 10^12/L

Hemoglobin 70 (low) 120-160 g/L

Hematocrit 0.22 (low) 0.38-0.47

MCV 67.1 (low) 80-96 fL

MCH 21.1 (low) 27.0-31.0 pg

MCHC 314 (low) 320-360 g/L

RDW 17.1 (high) 11.0-16.0

Platelet count 515 (high) 150-450 x 10^9/L

Neutrophil 0.85 (high) 0.50-0.70

Lymphocyte 0.11 (low) 0.20-0.50

Monocyte 0.03 0.02-0.09

Eosinophil 0.01 0.00-0.06

Basophil 0.00 0-0.02

Serum Studies
Results Reference Range

Na 135 (low) 137-145 mmol/L

K 4.3 3.5-5.1 mmol/L

Cl 98-107 mmol/L

RBS 74-118 mg/dL

BUN 2.5 2.5-6.1 mmol/L (7-17mg/dL)

Crea 81 39-91umol/L (0.44-1.03 mg/dL)

AST 20 14-36 U/L

ALT 18 9-52 IU/L

Alk Phos 85 38-126 IU/L

Albumin 34 (low) 35-50 g/L

LDH 266-500 IU/L

Ca 2.2 2.10-2.55 mmol/L

Mg 0.84 0.70-1.00 mmol/L

Protime (Reference: 13.2/Patient: 13.8/Pt% 91/Pt-INR 1.06)

APTT (Reference 30.6/ APTT-time 28.6)

Blood typing: A-

Urinalysis
Result Reference Range

Color yellow

Transparency turbid

Bilirubin negative <17 umol/L

Urobilinogen normal <35 umol/L

Ketone negative <1.5 mmol/L

Glucose normal <2.8 mmol/L

Albumin negative <0.3 g/L

Blood +1

pH 5.5 (acidic)

Nitrite negative Negative

Leucocytes +3 <25 leuco/uL

Specific Gravity 1.010

RBC 4 0-9

WBC 70 0-22

Epithelial Cells 26 0-13

Bacteria 1285 0-220

Mucus Thread 75 0-13

Urine GS/CS
Microscopy: PMN 0-1/OIF, no organism seen
Culture/Result: No growth after 2 days of incubation

Biopsy and Histopathology of the Cervix

Impression: Adenocarcinoma, favors serous carcinoma

Tumor Markers
Results Reference Range

CEA 7.940 (high) less than 5.0 ng/ml

CA 125 II 238.6 (high) less than 35.0 U/ml

Transvaginal/Transabdominal UTZ (October 1, 2015)

The urethra, urinary bladder mucosa and rectum are intact.
The cervix is converted into an irregular heterogeneous mass measuring 8.0 x 5.4 x 6.7 cm
with extension to the middle ⅓ of the vagina and uterine midcorpus. The bilateral parametria
are obliterated.
The corpus is anteverted with smooth contour and heterogeneous echopattern measuring
6.1 x 5.6 x 5.4 cm.
The endometrium is hyperechoic measuring 0.1 cm each anteriorly and posteriorly with low
level echo fluid interface measuring 0.3 cm. The subendometrial halo is distinct.
Both ovaries are not visualized.
Occupying the culdesac area is an irregular hypoechoic fluid collection measuring 3.5 x 6.6 x
5.9 cm (volume = 71.6 cc), bounded by the posterior uterine wall and pelvic sidewall.
Anterior and adherent to the uterus is an irregular predominantly solid mass measuring 6.1 x
4.2 x 3.6 cm.
The pelvic and paraaortic vessels cannot be fully assessed due to obscuring bowel loops.
The liver parenchyma is homogenous.
The right renal calyces are dilated while the left renal calyces are not dilated.

Doppler Studies
Color flow mapping of the cervical mass shows moderate central vascularity which on
Doppler interrogation reveals low resistance indices (PI=0.62, RI=0.55).

Impression:
Cervical mass, consistent with malignancy with extension to middle ⅓ of vagina, uterine
midcorpus and bilateral parametria
Anterior wall mass consider ovarian new growth, probably malignant by Sassone = 14 and
by Lerner = 7; IOTA: unilocular-solid; color score of 3; probably tumor extension
Thin endometrium with hematometra
Pseudocyst formation
* Please correlate clinically

Assessment
Adenocarcinoma of the cervix, Stage IIIB
Ovarian New Growth, probably malignant
Partial gut obstruction, resolved
Plan
1. Manage complication:
● Anemia - transfuse packed RBCs
2. The standard management for the cervical cancer in this patient is concurrent
chemotherapy and radiotherapy.
3. Diagnostics: We are still awaiting for the CT scan (abdominopelvic CT with triple contrast),
holoabdominal ultrasound, and plain abdominal x-ray results to guide radiotherapy and
further management.
4. Medications: Ceftriaxone, Metronidazole, Omeprazole, Paracetamol and Tramadol (for
abdominal pain).
5. Referrals
- General Surgery II - for possible exploration and staging
- Pain service
- Hospice
6. Diet as tolerated. Full body bath daily with perineal hygiene.