Case Conference December 13th 2017

13-Dec-2017, Divisi Ginekologi Onkologi RSCM

 

CASE CONFERENCE

 

December 13^th, 2017

 

Mrs. M, 64 yo, P1A0, 425-78-40

 

 

 

I.      Case Description

 

     A patient complained a lump in the vagina since 2 months ago with periodically lower abdominal pain. The patient can’t urinate since 2 months ago and must be installed catheter. She can defecate normally. At first, the patient went to Urology in Koja Hospital, and she was installed catheter and given medication to facilitate the passage of urine. The patient was then referred to Obgyn and told that she had a mass in the anterior of the vagina. The patient was then referred to Cipto Mangunkusumo Hospital on September 6^th 2017. Vaginal bleeding was negative. She had menopause since the age of 55. The patient was then performed an ultrasound examination on September 11^th, 2017 with the result was found a solid mass in the right periurethral (cranial) area of the vagina suspect for malignancy. The upper and lower abdominal MRI examinations were performed on September 14^th, 2017 with the result of cystic solid mass with malignant characteristic, suspiciously came from the anterior wall of the vagina and was expanding into the bladder, accompanied by inguinal and left para obturator lymphadenopathy sized <1cm, bladder diverticulum and multiple cystic lesions in the 6th and 8th segments of the liver. The patient was then performed biopsy on October 11^th, 2017 with histologic results showed a Mucinous Carcinoma features

 

 

 

II.    Physical Examination on November 20^th, 2017

 

a.      General status:

 

CM. BP: 130/80 mmHg, HR: 75 x/min, T: 36°C, RR: 18 x/min,

 

Head: Pale conjungtiva (-/-) icteric sclera (-/-)

 

Thorax: symmetry shape and movement of hemithorax

 

Lung: vesicular breath sound on both lungs, neither wheezing nor rhales

 

Cardia: no murmur, no gallop

 

Abdomen: flat, supple, intestine sound (+), ascites (-)

 

Extremity: warm, no edema

 

 

 

b.      Gynecology examination:

 

Inspection: vulva and urethra were normal, no bleeding

 

Speculum Examination: portio was smooth, no vaginal discharge was found and there was a visible mass in the anterior wall of the vagina

 

RVT: anteflexed uterus, a mass was palpable in the anterior wall of the vagina sized 3x3x6cm. The rectal mucosa was smooth. The tone of both sphincter ani were good.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III.   Work Up

 

a.        Laboratory Result on  September 8^th, 2017:

 

CBC: 9.3/29.1/9860/364000

 

PT 11.0 (10.9) APTT 35.6 (31.9)

 

SGOT/SGPT: 22/15 Albumin 4.38

 

Ur 27 Cr 0.90 eGFR 67.8

 

Blood Glucose 93

 

Na/K/Cl: 147/4.38/107.8

 

 

 

b.         Chest X-Ray Result on September 8^th, 2017

 

Description: The heart was not enlarged. Cardiothoracic ratio was <50%. The aorta and the superior mediastinum were not enlarged. Trachea was in midline. Both hila were not thickened. The bronchovascular markings at suprahilar of the right lung were increased. There was infiltrate in the right upper lung. The arch of the diaphragm and the costophrenicus angle were normal. The bones were still good.

 

Conclusion: The bronchovascular markings at suprahilar of the right lung were increased. No nodule was found. There was no radiological abnormality of the heart.

 

Suggestion: Top Lordotic

 

 

 

c.          US Result on September 11^th, 2017

 

Description: anteflexed uterus, normal shape and size. The myometrium was homogenous. The uterine cavity contained no abnormal mass. The basal layer of endometrium was regular, thin (<1mm). Endocervix and portio were normal. Both ovarian shape and size were normal. There was no abnormal mass in both adnexa. In the right periuretra area (cranial of the vagina) there wass a solid mass with irregular shape and edge, 32x30mm in size, derived from malignancy mass. There were no bilateral para aorta and para iliac lymph nodes enlargement.

 

Conclusion: there was a solid mass in the right periurethral (cranial) area of the vagina accordance to malignancy.

 

 

 

 

 

 

 

 

 

 

 

 

 

d.        Upper and Lower Abdominal MRI Result on September 14^th, 2017

 

Upper and Lower Abdominal MRI examination had been done, with and without giving intravenous Gadobutrol contrast 5cc, with the following results: Comparison: none

 

There was a solid mass with indistinct borders and irregular edges, hypointense on T1WI, hypo-hyperintense on T2WI, FS, inhomogeneous enhancement post contrast, diffusion restriction on DWI, suspiciously came from anterior wall of the vagina, sized +/- 4.4x5x7.4cm. To the superior side, the mass seemed to infiltrate the inferior wall of the bladder and into the bladder. The border of the mass with the uterus and cervix can still be identified. The wall of the bladder seemed irregular. Catheter balloon was inflated in the bladder. There was diverticulum on the right lateral wall of the bladder sized ± 1.4x1x1.2 cm. There were visible left paraobturator and left inguinal lymph nodes sized <1cm. Liver size and location were normal, smooth surface. Multiple cystic lesions appeared in the 6th and 8th segments of the liver with +/- 0.5cm in diameter. The intra and extra hepatic bile ducts were not dilated. The portal vein was normal. The gall bladder showed a smooth shape, size and edge, and homogeneous signal intensity. Spleen size was normal, regular edge and parenchymal signal intensity was homogenous. Pancreas size and location were normal. Caput, corpus and cauda were with homogeneous signal intensity. The pancreatic duct was not widened / narrowed. Both kidneys size and position were normal. The renal parenchyma showed a normal internal structure. The renal pelvis and calyxes were normal. The pelvicalyceal system and ureter were not dilated. Both adrenal size and position were normal. The aorta and paraaortic areas appeared to be normal, no lymphadenopathy. The minor pelvic vascular structure was good. No enlargement of the lymph nodes. The shape and articulation of caput femoris and acetabulum were normal. The bone marrow was normal. No soft tissue abnormality.

 

Conclusion: A cystic solid mass with malignant characteristic, suspiciously came from the anterior wall of the vagina and was expanding into the bladder, accompanied by inguinal and left para obturator lymphadenopathy sized <1cm. The border of the mass with the uterus and cervix can still be identified. Bladder diverticulum. There were multiple cystic lesions in the 6th and 8th segments of the liver. There was no visible feature of metastases in the liver and other intraabdominal organs.

 

 

 

 

 

 

 

 

 

 

 

 

 

e.        Pathology Anatomy Result on October 11^th, 2017

 

Macroscopic: Received 1 bag on behalf of Mulyanah without additional notes, filled with approximately 1.5cc volume of tattered tissue, brown, spongy, wrapped, all copied, 1 cassette.

 

Microscopic: Biopsy preparation with clinical description “suspek ca vagina” was limited in number, consisted of tissue pieces coated with squamous epithelium with connective tissue of the stromal contained irregular mucin pools, not coated by the epithelium. Around the pool of the mucin, there were small groups of cells with mild pleomorphic, hyperchromatic nucleus with eosinophilic cytoplasm. No mitosis was found.

 

Topography: C52.9                                             Morphology: M8480 / 3

 

Conclusion: histologic showed a Mucinous Carcinoma features

 

Note:

 

- Primary Mucinous Carcinoma in the vagina is very rare.

 

- The possibility of a secondary tumor can’t be ignored. Please consider clinical correlation, was there a tumor elsewhere?

 

 

 

CLINICAL QUESTION

 

 

 

Is radiotherapy better than surgery for patient with vaginal cancer stage IVA with histotype mucinous carcinoma?

 

 

 

What question did the study ask?	PICO Analysis
Population	Vaginal cancer stage IVA with histotype mucinous carcinoma
Intervention	Radiotherapy
Comparison	Surgery
Outcome	Overall survival

 

 

 

METHODS

 

Search strategy

 

 

 

In order to answer the question above, we conduct a searching in PubMed site by using keywords “mucinous carcinoma AND vaginal carcinoma”. The search was conducted with Pubmed search on December 12^th, 2017. We found 139 results. Then we filtered the journal, we found 35 journal. After reading the full text we found three useful journals.

 

Engine	Search Terms	Results
Pubmed	mucinous carcinoma AND vaginal carcinoma	139

 

 

 

mucinous carcinoma AND vaginal carcinoma

 

     

 

 

 

 

 

2 useful articles

 

 

 

Reading full text

 

 

 

Screening files

 

 

 

139

 

 

 

35

 

 

 

Filtering titles

 

 

 

Pubmed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Selection

 

1^st Article

 

Prognostic Factors in Primary Vaginal Cancer: A Single Institute Experience and Review of Literature

 

 Chelakkot G. Prameela1 • Rahul Ravind1 • Bharath C. Gurram1 • V. S. Sheejamol2 • Makuny Dinesh1

 

The Journal of Obstetrics and Gynecology of India (September–October 2016) 66(5):363–371

 

Are The Study Results Valid?

 

1.      Was there a representative and well-defined sample of patients at a similar point in the course of disease?	Yes
2.      Was follow-up sufficiently long and complete?	Yes
3.      Were objective and unbiased outcome criteria used?	Yes
4.      Was there adjustment for important prognostic factors?	Yes

 

What Were The Results?

 

1.      How large is the likelihood of the outcome events in a specific period of time?	Not measurred
2.      How precise are the estimates of likelihood? (Consider 95% CI)?	Not measured

 

Can The Results be applied to your patients?

 

1.      Were the study patients similar to my own?	Yes
2.      Are the results useful for reassuring or counseling patients?	Yes

 

CONCLUSIONS

 

3.      The results or recommendations are valid?	Yes
4.      The results clinically important?	Yes
5.      The results are relevant to my practice?	Yes

 

 

 

 

 

 

 

Form the table above, we can see that EBRT (external beam radiotherapy) combine with BT (brachytherapy) gives the best overall survival result compared to EBRT alone or surgery with or without radiotherapy. It might be not statistically significant, but clinically it is comparable. The overall survival in vaginal cancer patient treated with EBRT and BT, EBRT, and surgery with or without RT were 86,1, 32,1, 23,4 (respectively).

 

 

 

 

 

 

 

 

 

2^nd Article

 

Factors Affecting Risk of Mortality in Women With Vaginal Cancer

 

Chirag A. Shah, M.D., MPH1, Barbara A. Goff, M.D.1, Kimberly Lowe, Ph.D., MHS2, William A. Peters III, M.D.3, and Christopher I. Li, M.D., Ph.D.4


 

Obstet Gynecol. 2009 May ; 113(5): 1038–1045.

 

 Are The Study Results Valid?

 

1.      Was there a representative and well-defined sample of patients at a similar point in the course of disease?	Yes
2.      Was follow-up sufficiently long and complete?	Yes
3.      Were objective and unbiased outcome criteria used?	Yes
4.      Was there adjustment for important prognostic factors?	Yes

 

What Were The Results?

 

1.      How large is the likelihood of the outcome events in a specific period of time?	Not measurred
2.      How precise are the estimates of likelihood? (Consider 95% CI)?	Not measured

 

Can The Results be applied to your patients?

 

3.      Were the study patients similar to my own?	Yes
4.      Are the results useful for reassuring or counseling patients?	Yes

 

CONCLUSIONS

 

1.      The results or recommendations are valid?	Yes
2.      The results clinically important?	Yes
3.      The results are relevant to my practice?	Yes

 

 

 

 

 

 

 

From the table above, we can conclude that histology type is one factor that gives poor prognosis in vaginal cancer. Melanoma gives hazard ratio 1,51 compared to squamous, and the other histotype gives 1,33.

 

 

 

 

 

Treatment modalities didn’t give significant difference in hazard ratio after adjusted with the other variable.

 

 

 

The last table shows there is no difference between surgery, radiation, and combination of both modalities in cause of mortality in vaginal cancer.

 

 

 

Discussion

 

Carcinoma of the vagina is one of the rarest of malignancies comprising 1-2% of all gynecological malignancies. Squamous cell vaginal cancers account for approximately 85% and adenocarcinoma account for approximately 15% of the cases. There are subtypes of adenocarcinoma such as papillary, mucinous adenocarcinoma and clear cell adenocarcinoma. Primary mucinous adenocarcinoma of vagina is one of the rarest subtypes.

 

There are many prognostic factor for vaginal cancer. Histotype is one of the significant prognostic factor. Non squamous carcinoma has worse prognosis than squamous cell carcinoma. Stage of the disease also important for vaginal cancer. The more advance the staging, the worse prognosis of the disease.  

 

There is no single protocol in vaginal cancer management due to its rarity. The appropriate management for our patient with diagnosis vaginal cancer stage IVA with mucinous carcinoma histotype based on the first journal is EBRT (external beam radiotherapy) combine with BT (brachytherapy). The overall survival in vaginal cancer patient treated with EBRT and BT, EBRT, and surgery with or without RT were 86,1, 32,1, 23,4 (respectively). For the safety of radio therapy in vaginal cancer is explained in the second journal. There is no difference between surgery, radiation, and combination of both modalities in cause of mortality in vaginal cancer.

 

 

 

Kesimpulan:

 

-          Akan dilakukan cystoscopy dan rectoscopy untuk menentukan letak massa

 

-          Surgery

 

 

 

 

 

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