CASE REPORT

CERVICAL CANCER
Supervised by:
dr. Ismu Setyo Djatmiko, Sp.OG
Presented by:
Bianca Pinky (2017 060 10115)
Introduction
Cervical cancer  4th most frequent cancer in women

• with an estimated 570,000 new cases in 2018 representing 6.6% of all female
cancers.

90% of deaths from cervical cancer occurred in low- and

middle-income countries
• The high mortality rate from cervical cancer could be reduced through a
comprehensive approach  prevention, early diagnosis, effective screening
and treatment programmes
High-risk subtypes of the human papilloma virus (HPV) are the
cause of the disease in most cases
• Which can be prevented with vaccination

Treatment depends on disease extent at diagnosis and locally

available resources
• Might involve radical hysterectomy or chemoradiation, or a combination of both

Cervical cancer and its treatment can contribute to psychological

distress
• It is important to educate women and their sex partners regarding the changes
that treatment will cause to their bodies
Case Report
History taking
Patient’s Identity

Kp. Tenjojaya
Mrs. E 42 years old Married
RT 02 RW 10

Junior high
Housewife Moslem
school

Date of examination: September 25th 2019)

Chief complain:
Lower abdominal pain that has worsened since 4 months ago

Vaginal discharge,
discomfort and pain during
Vaginal bleeding, decrease Constipation and lower
sexual intercourse, vaginal
appetite, weight loss abdominal pain
bleeding post sexual
intercourse
3 years 9 months 4 months
ago ago ago
 First sexual Never had HPV
intercourse Married for 3 vaccination
when she was times nor Pap-smear
19 years old nor HIV testing

Her second husband is

known to have multiple
sexual partners
History of • Cancer: denied
• Surgery: salphingectomy sinistra and dextra
past illness • PID, genital wart, other STD: denied

Family • Denied
history
Medication • Cephadroxil 2 x 500 mg PO
history • Mefenamic acid 3 x 500 mg PO
 • Smoking, alcohol, drugs and herbs
Habitual history consumption (-)

Menstruation • Menarche: 13 years old

• Menstrual cycle: regular, every 28 days, duration 4-5
history days, 3 total pads/day, dysmenorrhea (-)

Contraception • Combination oral contraception in 1998 –

history 2002 (4 years)
Marital History

Husband Year Duration Cause of divorce

I 1995 - 2004 7 years Deceased spouse

(bronchitis)
II 2006 - 2018 12 years Infidelity

III January 2019 - 9 months -

now
Gestational History
Pregnancy Husband Year Location/ Pregnancy result Delivery Condition
helper
I 1 1997 Midwife Term, no complication Spontaneous Male, alive, 22
years old
II 1 2003 Midwife Term, no complication Spontaneous Male, alive, 16
years old
III 2 2007 Hospital Ruptured ectopic Salphingectomy -
pregnancy dextra
IV 2 2009 Hospital Ruptured ectopic Salphingectomy -
pregnancy sinistra
Physical Examination
Physical Examination
• General condition : mildly ill
• Consciousness : compos mentis
• Blood pressure : 100/60 mmHg
• Heart rate : 84 bpm
• Respiratory rate : 18x/minute
• Temperature : 36,6oC
• Weight : 50 kg
• Height : 155 cm
• BMI : 20,8 kg/m2 (normal)
General Examination
• Eyes : anemic conjunctiva +/+, icteric sclera -/-
• Nose : deformity (-), discharge (-)
• Ears : deformity (-), discharge (-)
• Mouth : wet oral mucous membrane, cyanosis (-)
• Pharynx : hyperemic (-), T1/T1
• Neck : thyroid and lymph node enlargement (-), trachea at the
middle
Thorax
• Heart : regular 1st and 2nd heart sound, murmur (-), gallop (-)
• Lung : symmetric chest expansion, sonor both lungs, vesicular +/+,
rhonchi -/, wheezing -/-
Abdomen
• Inspection : flat, mass (-), lesion (-)
• Auscultation : bowel sound (+), 5x/minute
• Percussion : tympanic, shifting dullness (-)
• Palpation : lower abdominal tenderness (+), mass (-),
ballottement -/-, undulation (-), organomegaly (-)
Extremities
• Warm, CRT <2 seconds
• Edema -/-/-/-
• No enlargement of lymph node at axilla and inguinal
• Motoric 5/5/5/5, sensoric normal
• Physiologic reflex ++/++/++/++
Gynaecologic Examination
External examination
• Vulva edema (-), secrete (-), blood (-), mass (-)

Speculum examination
• Normal vulva
• Mass extension to the lower third of the vagina
• Portio: Irregular red exophytic lesion around portio, ±4
x 4 cm. Discharge from portio (+), yellowish mucoid
discharge (+) active bleeding from the lesion (+)
Vaginal toucher
• Vulva : Normal
• Vagina : Rugae (+), extension of exophytic mass can be
palpated
• Uterus : Enlarged 8 x 8 x 9 cm
• Bimanual : Right and left adnexa were rigid and fixed on
palpation, pain +/+

Rectovaginal toucher
• Cancer-free space 0% on the right side and 50% on the left side,
mass in rectum (-)
Laboratory Examination
September 17th, 2018 (before transfusion)
Examination Result Unit Normal Range

Hemoglobin 9,3 g/dL 12 – 14

Leucocyte 8.800 uL 4.000 – 10.000

Hematocrit 28 % 37 – 47

Erythrocyte 3.4 million/uL 3.8 – 5.2

MCV 80 fL 80 – 100

MCH 27 Pg 26 – 34

MCHC 34 g/dL 32 – 36

Thrombocyte 436.000 uL 150.000 – 450.000

September 19th, 2018 (after transfusion)
Examination Result Unit Normal Range
Hemoglobin 13,6 g/dL 12 – 14

Leucocyte 22.800 uL 4.000 – 10.000

Hematocrit 39 % 37 – 47

Erythrocyte 4.8 million/uL 3.8 – 5.2

MCV 83 fL 80 – 100

MCH 29 Pg 26 – 34

MCHC 36 g/dL 32 – 36

Thrombocyte 318.000 uL 150.000 – 450.000

Biopsy Result
Macroscopic Four pieces of thin and soft brownish white tissue: biggest 1 x 0,8 x 0,5 cm and
smallest 0,8 x 0,5 x 0,3 cm

Microscopic Biopsy sample of cervical tissue consists of tumor mass from hyperplastic
ovoid cell forming a gland structure. Pleomorphic, hyperchromatic, vesicular
nucleus, nucleolus is distinct, mitosis can be found. Massive inflammatory
lymphocyte and PMN can be found in between fibrotic connective tissue.

Conclusion Adenocarcinoma well differentiated a/r cervix

Working Diagnosis
Mrs. E, 42 years old, P2A2 with cervical
cancer stage IIIB and anemia

Management
Tranexamic acid 3 x 500 mg PO
Mefenamic acid 3 x 500 mg PO
Refer to RSUP Dr. Hasan Sadikin Bandung for more advance treatment

Prognosis
Quo ad vitam : dubia
Quo ad fuctionam : dubia ad malam
Quo ad sanationam : dubia ad malam
Case Analysis
Theory Case
Symptoms depends on the staging. Symptoms:
Precancerous lesion or cervical cancer • Foul-smelling, yellowish mucoid
in early stage are usually vaginal discharge
asymptomatic. • Vaginal bleeding
• Contact bleeding  postcoital
Some symptoms are not specific:
bleeding
Vaginal discharge (white mucoid to • Lower abdominal pain
brown and red, blood-tinged, fishy- • Difficulty in defecating 
smell), progressive vaginal bleeding, constipation
contact bleeding, pain, constipation, • Rapid weight loss  23% in 9
urination problem, rapid weight loss, months
decrease in appetite • Decrease appetite
Theory
Risk factors:
Average age of 35-45 years, coitus
before the age of 20 years, multiple
sexual partners, poor personal hygiene,
history of STDs, poor socioeconomic
status, smoking and drug abuse,
immunosuppressed individuals, pre-
invasive lesions, lack of regular health
check-ups and Pap tests, long term COC
usage
Case
• 42 years old
• Married three times, her second
husband has multiple sexual
partners
• Unknown history of STD, but she
had history of ruptured ectopic
pregnancy (suspicion for pelvic
inflammatory disease)
• Low education and socioeconomic
status
• Never had cervical cancer
screening
• Never had HPV vaccination
Theory
• May have normal general physical
examination findings, which
depends on the cancer staging.
• Speculum examination
• Cervix may appear grossly normal
if cancer is microinvasive, or
• Visible disease:
endophytic/exophytic growth;
cervical ulceration, granular mass,
necrotic tissue
• Watery, purulent, or bloody
discharge can also be seen
Case
General physical examination
• Anemic conjunctiva +/+
• No lymph node enlargement
• Lower abdominal tenderness (+)
Speculum examination
• Mass extension to the lower third
of the vagina
• Portio: irregular red exophytic
lesion around portio, yellowish
mucoid discharge (+) active
bleeding from the lesion (+)
Theory Case
Bimanual examination: • Extension of exophytic mass can
• May palpate enlarged uterus from be palpated on the lower third
tumor invasion and growth. vaginal wall
• Hematometra/pyometra may • Uterus is enlarged
expand the endometrial cavity • Right and left adnexa were rigid
following the obstruction of fluid and fixed on palpation
egress by primary cervical cancer.
• Extends to vagina, can be palpate
during anterior vaginal wall
palpation or rectovaginal
examination.
• Mass might be palpated if
parametria invaded (less mobile)
Theory Case
• Cervical biopsy • Biopsy: adenocarcinoma
• Imaging studies well differentiated a/r cervix
• Laboratory • CBC: hemoglobin 9,3 g/dL,
• CBC: anemia hematocrit 28%, erythrocyte
• Urinalysis: hematuria 3,4 million/uL
• Chemistry profile: electrolyte
abnormality
• Liver function: liver
metastasis
• Creatinine/BUN: renal
impairment or obstruction
Theory
• Firstly, determine staging
with biopsy and improve
patient general condition.
• IIB to IVA: chemoradiation
or rarely, pelvic exenteration
Case
• Tranexamic acid 3 x 500 mg
PO
• Mefenamic acid 3 x 500 mg
PO
• Refer to RSUP Dr. Hasan
Sadikin Bandung for more
advance treatment
Theory Case
5 Years Survival Rate: • Quo ad vitam : dubia
• IA : 100% • Quo ad fuctionam : dubia ad
• IB : 88% malam
• IIA : 68% • Quo ad sanationam : dubia
ad malam
• IIB : 44%
• III : 18-39%
• IVA : 18-34%
Staging of cervical cancer according to FIGO 2018
General treatment for primary invasive cervical carcinoma
Surgical treatment options for cervical cancer
Pap-smear
Squamous cell
• Atypical squamous cells (ASC) of
undetermined significance (ASC-US)
or atypical squamous cells that cannot
exclude HSIL (ASC-H)
• Low-grade squamous intraepithelial
lesions (LSIL), includes human
papillomavirus (HPV), mild dysplasia,
and CIN 1
• High-grade squamous intraepithelial
lesions (HSIL), includes moderate to
severe dysplasia, carcinoma in situ,
CIN 2, and CIN 3
• Squamous cell carcinoma
Glandular cell
• Atypical glandular cells (AGC),
specify endocervical,
endometrial, or not otherwise
specified (NOS)
• Atypical endocervical cells, favor
neoplastic, specify endocervical
or NOS
• Endocervical adenocarcinoma in
situ (AIS)
• Adenocarcinoma
Visual inspection with acetic acid (VIA) test
• VIA is a visual examination of the uterine cervix after application of 3-
5% acetic acid.
• If the cervical epithelium contains an abnormal load of cellular
proteins, the acetic acid coagulates the proteins conferring an
opaque and white aspect of the concerned area.
• A precancerous lesion has higher protein content when compared to
normal epithelium. As a consequence it becomes white (acetowhite)
and is considered to be “VIA positive”.
References
• Cervical cancer. World Health Organization. 2019 [cited 29 September
2019]. Available from:
https://www.who.int/cancer/prevention/diagnosis-
screening/cervical-cancer/en/
• Cohen P, Jhingran A, Oaknin A, Denny L. Cervical cancer. The Lancet.
2019;393(10167):169-182.
• Johnson C, James D, Marzan A, Armaos M. Cervical Cancer: An
Overview of Pathophysiology and Management. Seminars in
Oncology Nursing. 2019;35(2):166-174.
• Hoffman BL, Schorge JO, Bradshaw KD. Williams Gynecology. 3rd ed.
McGraw-Hill Education; 2016. 657–674 p.