Case Conference December 20th 2017

20-Dec-2017, Divisi Ginekologi Onkologi RSCM

 

CASE CONFERENCE

 

December 20^th, 2017

 

Mrs. N, 34 yo, P3A0, 425-84-30

 

 

 

I.      Case Description

 

        A patient complained of vaginal bleeding in August 2017 with no abdominal pain. She had a history of vaginal discharge that clear-brownish, fishy but sometimes stinks since ± 1 year ago. A history of post coital bleeding was positive 1 year ago. No significant weight loss. The patient still menstruates regularly every month. The patient went to dr. Murjani Sampit Hospital and was told that she had Cervical Cancer stage IIA. The patient was biopsied on August 11^th, 2017 with the result was Invasive Non Keratinizing Squamous Cell Carcinoma. The patient was then referred to the Cipto Mangunkusumo Hospital on September 12^th, 2017. An anatomical pathology examination was performed on September 19^th, 2017 with the result was non-keratinizing squamous cell carcinoma, moderately differentiated. The patient was then had an ultrasound examination on September 27^th, 2017 with a result of cervical malignancy mass with both parametria were invasion-free (the mass confined to the cervix). Then the patient underwent a Laparoscopic Radical Hysterectomy, Pelvic Lymphadenectomy and Bilateral Salpingo-Oophorectomy on October 16^th, 2017 and anatomical pathology examination was performed on October 17^th, 2017 with the result was histologically accordance to non-keratinizing squamous cell carcinoma of the cervix, moderately differentiated. The deepest invasion of tumor mass reached 9mm from 15mm of cervical wall thickness. At the margin of vaginal incision was found in situ carcinoma foci.

 

 

 

I.      Physical Examination on September 27^th, 2017

 

a.      General status:

 

CM. BP: 110/75 mmHg, HR: 84x/min, T: 36°C, RR: 20 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 (-), tenderness (-), tumor mass (-)

 

Extremity: warm, no edema

 

 

 

b.      Gynecology examination:

 

Inspection: vulva and urethra were normal, no bleeding

 

RVT: there was an ulcerative exophytic mass sized 3.5 x 3.5 x 2 cm that invaded the left fornix. The left and right parametria were loose. There was no infiltration in the uterine cavity. The rectal mucosa was smooth. The tone of both sphincter ani were good.

 

II.     Work Up

 

a.        Laboratory Result on  September 15^th, 2017:

 

CBC: 13.7/41.5/15670/413000

 

Diff: 0.3/1.0/77.5/16.7/4.5

 

SGOT/SGPT: 20/16

 

Ur 28 Cr 0.90 eGFR 84.3

 

Random Blood Glucose 99

 

Na/K/Cl: 149/3.99/104.1

 

 

 

b.        Laboratory Result on  December 07^th, 2017:

 

Na/K/Cl: 141/4.42/101.9

 

 

 

c.          Chest X-Ray Result on September 15^th, 2017:

 

Description: The heart was not enlarged. Cardiothoracic ratio was <50%. The aorta was elongated. The superior mediastinum was not dilated. Trachea was in midline. Both hila were not thickened. The vascularization of the lung was not increased. No infiltrate/nodule. The arch of diaphragm and the costophrenicus angle were normal. The bones were still good.

 

Conclusion: No radiological abnormalities appeared in the heart and lungs.

 

 

 

d.         The Anatomic Pathology Result From Prof. Roem Soedoko & dr. Etty Ananto On August 11^th, 2017:

 

Macroscopic: Received 1 container that contained pieces of tissues. The shape was irregular. Sized 1.2 x 0.7 x 0.3 cm. The color was brown-gray. The tissues were all processed in 1 cassette. 

 

Microscopic: The tissue’s cut consisted of the proliferation of anaplastic squamous epithelial cells. The nucleolus was pleomorphic, hyperchromatic. The cytoplasm was eosinophilic. The cells were infiltrated on the stromal

 

Conclusion: Cervix, Biopsy: Invasive Non Keratinizing Squamous Cell Carcinoma

 

 

 

e.         The Anatomic Pathology Result On September 19^th, 2017:

 

Macroscopic: Received 1 slide PA no. REH 348/17

 

Microscopic: 1 slide of the review preparation number REH 348/17 showed pieces of cervical tissue were containing an epithelial malignant tumor mass that arranged trabecular and solid, infiltrating among the connective tissues. The nucleus of the tumor cell was pleomorphic, hyperchromatic, vesicular, some of it with the nucleolus, the cytoplasm was eosinophilic. The cell boundary was not clear. The lymphocyte reaction was mild. Lymphovascular invasion was not found.

 

Topography: C53.9                                 Morphology: M8072/3

 

Conclusion: Non-keratinizing Squamous Cell Carcinoma, moderately differentiated. Lymphovascular invasion was not found.

 

 

 

f.          US Result On September 27^th, 2017:

 

Description: Fundus and corpus of the uterine were normal. The uterine cavity contained no abnormal mass. The basal layer of endometrium was regular, 5mm thick. Cervix: contained inhomogeneous solid mass with irregular shape and edge, sized 31 x 14mm, derived from cervical malignancy. Both parametria were invasion-free. (The mass was limited to the cervix). Both ovaries had normal shape and size. There was no abnormal mass in both adnexa. There was no enlargement of paraaorta and bilateral parailiac lymph nodes. The liver and both kidneys were normal. No ascites.

 

Conclusion: Cervical malignancy mass. Both parametria were invasion-free (the mass confined to the cervix).

 

 

 

 

 

 

 

 

 

 

g.         The Anatomic Pathology Result On October 17^th, 2017:

 

Macroscopic: Received 3 bags on behalf of Novilla Mertha

 

I. Bag with a note "1. uterus "contained 1 uterine tissue sized 8.5 x 4 x 3.5 cm, already split, brown, spongy, there were portio, vagina, both tubes, no bilateral ovaries. On cleavage, the cervical canal was dilated; there was no cyst on the cervical wall. There was a tumor mass on the cervical wall, the margin was not firm, invading 1.5 cm and apparently not yet infiltrate the lower uterine segment, approximately 0.8 cm below the lower uterine segment. The uterine cavity was empty, the wall was 0.8 cm thick. No visible mass or myoma. The right tube was 7 cm long, 0.5 cm in diameter, there were fimbriae. The left tube was 5 cm long, 0.5 cm in diameter. There were fimbriae. Partially copied.

 

IA. The margin of vaginal incision (inked) 6 kup 3 cassettes. (IA1-IA3)

 

IB. The tumor mass on the cervical wall (the deepest invasion) inked, 1 kup 1 cassette

 

IC. The tumor mass on the cervical wall (invasion seemed to be below the lower uterine segment 0.8 cm), 2 kup 2 cassettes

 

ID. Endometrium, 1 kup 1 cassette

 

IE. The right tube and fimbriae, 5 kup 1 cassette

 

IF. The right tube and fimbriae, 3 kup 1 cassette

 

IG. The right side of parametrium, 4 kup 4 cassettes (IG1-IG4)

 

IH. The left side of parametrium, 4 kup 4 cassettes (IH1-IH4)

 

II. Bag with a note "2. KGB Pelvik kanan" contained 1 piece of tissue sized 8.5 x 6 x 1.2 cm, yellowish brown, spongy. Found 7 lymph nodes sized ranging from 0.5 cm in diameter up to 2.5 x 1 x 0.8 cm, brown, spongy, all copied.

 

IIA. 4 lymph nodes, were not split, 4 kup 1 cassette

 

IIB. 1 lymph node, halved, 2 kup 1 cassette

 

IIC. 2 lymph nodes, were not split, 2 kup 1 cassette

 

IID. The remaining fat tissue, 3 cassettes (IID1-IID3)

 

III. Bag with a note "3. KGB Pelvik kiri "contained 1 piece of tissue sized 5 x 4 x 1.5 cm, yellowish brown, spongy. Found 6 lymph nodes sized ranging from 0.5 cm in diameter up to 2 x 0.8 x 0.4 cm, brown, spongy, all copied.

 

IIIA. 3 lymph nodes, were not split, 3 kup 1 cassette

 

IIIB. 2 lymph nodes, were not split, 2 kup 1 cassette

 

IIIC. 1 lymph node, was not split, 1 kup 1 cassette

 

IIID. The remaining fat tissue, 3 cassettes (IIID1-IIID3)

 

Microscopic: I. Hysterectomy preparation consisted of uterine tissue, bilateral adnexa and vagina. The cervical preparation showed cervix and some vaginal tissues contained epithelial malignant tumor mass arranged trabecular, irregular and solid islands. The size of the tumor cells were medium to large with pleomorphic, hyperchromatic, vesicular, rough chromatin nucleus, some of it with clear nucleolus and accompanied by mitosis. The cytoplasm was eosinophylic. Individual keratosis was found. No keratin pearls. The deepest invasion of the tumor reached 9mm from 15mm of cervical wall thickness. Some of the ectocervical surface epithelium and sampling of the margin of vaginal incision locally showed a maturation and cellular polarity disorder throughout squamous epithelial thickness with clear atypical cells. No tumor cell was found in the lymph vessels. Endocervical tissue was coated by a layer of columnar epithelium. Partially dilated endocervical glands, coated by high columnar epithelium with uniform nucleus. Endometrial preparation showed endometrial tissue with glands that spread among them, partially dented, coated with a layer of columnar epithelial with uniform nucleus. The stromal was cellular. The myometrial layer consisted of smooth muscle tissues arranged interlacing. The right and left tube - fimbriae preparations showed the tube - fimbriae tissues with good plica structure, coated by a layer of ciliated columnar epithelial. The muscle was intact. There was a paratubal cyst in the right tube preparation, coated by a layer of cuboid epithelial. The right and left parametria sampling preparations consisted of connective tissue and mature fat.

 

II. The preparation with a note "KGB Pelvik kanan" consisted of connective tissue and mature fat. Found 12 lymph nodes with a dilated sinus containing lymphocytes and histiocytes.

 

III. The preparation with a note "KGB Pelvik kiri " consisted of connective tissue and mature fat. Found 10 lymph nodes, all with a dilated sinus containing lymphocytes and histiocytes.

 

Topography: C53.9                                             Morphology: M8072 / 3

 

Conclusion: histologically accordance to non-keratinizing squamous cell carcinoma of the cervix, moderately differentiated. The deepest invasion of tumor mass reached 9mm from 15mm of cervical wall thickness. At the margin of vaginal incision was found in situ carcinoma foci. No lymphovascular invasion was found. No metastasis was found in the right and left parametria. From “KGB Pelvik kanan” preparation was found 12 lymph nodes, all of it were found no metastasis. From “KGB Pelvik kiri” preparation was found 10 lymph nodes, all of it were found no metastasis. 

 

 

 

CLINICAL QUESTION

 

 

 

Is EBRT combine brachytherapy is better than EBRT only in patient with cervix cancer IIA1 post hysterectomy radical and bilateral pelvic lymphadenectomy with carcinoma in situ focus in vaginal margin?

 

 

 

What question did the study ask?	PICO Analysis
Population	cervix cancer IIA1 post hysterectomy radical and bilateral pelvic lymphadenectomy with carcinoma in situ focus in vaginal margin
Intervention	EBRT combine brachytherapy
Comparison	EBRT
Outcome	Overall survival

 

 

 

METHODS

 

Search strategy

 

 

 

In order to answer the question above, we conduct a searching in PubMed site by using keywords “cervix cancer IIA1 post hysterectomy radical and bilateral pelvic lymphadenectomy with carcinoma in situ focus in vaginal margin AND EBRT AND brachytherapy”. The search was conducted with Pubmed search on December 19^th, 2017. No result was found. We changed the keyword in to “cervix cancer with positive vaginal margin AND radiotherapy”. We found 15 results. After reading the full text we found one useful journal.

 

Engine	Search Terms	Results
Pubmed	cervix cancer with positive vaginal margin AND radiotherapy	15

 

 

cervix cancer with positive vaginal margin AND radiotherapy

     

 

 

 

 

 

5

1 useful articles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Selection

 

1^st Article

 

Postoperative Radiotherapy in Carcinoma of the Cervix with Microscopically Positive Resection Margin

 

SeungJae Huh, 1. Won Dong Kim, 2 Sung Whan Ha, 3 Hong Gyun Wu, 1 Yong Chan Ahn, 1 Dae Yong Kim,1II Han Kim,3and Charn II Park3

 

 IntJ Clin Onco11997;2:147-151

 

 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

 

 

 

 

 

 

 

This table shows that positive vaginal margin gives recurrence rate in 40 percent in patient treated with EBRT alone. The other way, the recurrence rate is 21 percent in patient treated with combination EBRT and VOI/brachytherapy. It shows significant difference between two methods in patient with positive vaginal margin. It is recommended to give combination external beam radiotherapy and brachytherapy to produce excellent pelvic control rate with tolerable complication.

 

 

 

Discussion

 

Management after hysterectomy radical pelvic lymphadenectomy in early stage cervix cancer depends on some variables. One of the variable should be considered is radicality of the surgery. Once it’s not achieved, we must continue with the other modality such as radiotherapy. One of the parameter used in assess in radicality is surgical margin. Carcinoma in situ in vaginal margin means that there is positive tumor cell in vaginal margin. Radiotherapy is the next appropriate management after surgery in such condition. External beam radiotherapy boost with brachytherapy in positive vaginal margin is recommended to prevent the recurrence.

 

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