Case Conference January 17th 2018

17-Jan-2018, Divisi Ginekologi Onkologi RSCM

Case description

 

Mrs. D, 44 yo, 4262602

 

Chief complaint: vaginal bleeding since 1 month BA

 

History:

Initially had vaginal bleeding in 2015, mostly post coital bleeding. Then she did hysterectomy in Makassar due to hyperplasia endometrium, CIN I. PA result was hyperplasia simplex atypical, invasive squamous cell carcinoma, large non keratinizing, moderately differentiated, LVSI (+). The PA result was already read by the doctor and told that there was no another treatment necessary and patient was discharged.

Few months after surgery, vaginal bleeding recurs for around 2 years, she went to several doctors and get some medication to stop the bleeding.

On September 2017, she went to OBGYN and told she had vaginal tumor then patient went to Jakarta.

RS pelni did MRI and lab, diagnosed with cervical canceràrefer to RSCM for biopsy.

She came initially to RSCM with acute kidney injury, consult to internal medicine, there was no indication for emergency hemodialysis dan suggest to consult to urology nephostromy.

Did cystoscopy and rectoscopy, the result was normal

On November 2017 did nephrostomy (repair in December 2017)

 

Married 1x, 2003

P3, oldest 24 yo, youngest 14 yo

 

Physical exam

 

Fully alert

BP 100/70, Pulse 100, Temp 36.5, RR 18x/min              

BW 75kg, BH164 cm, BMI

General condition

Eyes                - no pale conjungtiva, no icteric sclera

Lung                - Vesicular, no rhales, wheezing

Heart               - normal S1S2, no murmur, gallop

Abdomen        - Supel, no mass palpable, normal intestinal sound

Extrimity         - warm, no edema

 

Gynecological status

Inspection: normal vulva and urethra

Inspeculo: seen mass on vaginal stump 2x2 cm, cauliflower like, easily bleed

Bimanual exam: mass palpated on vaginal stump, left parametrium was rigid. Sphincter ani tonus is good, no mass palpable on rectal mucosa.

 

Auxilliary examination

Pathology 13/10-15 RS Siti Khadijah

Simplex atypical endometrial hyperplasia

Invasive squamous cell carcinoma, large non keratinizing type, moderately grade differentiation, LVSI positive

 

Pathology RSCM no 1709724 (2/11-17)

Squamous cell carcinoma without keratin, moderate differentiation dd/ neuroendocrine carcinoma

Suggest to do immonuhistochemistry for confirmation

 

USG (1/11-17)

No uterus and ovary visualized

Seen mass with active vascularization on vaginal stump with inhomogen solid part ~ malignant cervical mass

No parailiaca lymph node enlargement

Bilateral hidronephrosis

~malignancy on vaginal stump

 

 

 

Chest Xray (31/10-17)

Situs inversus, cardiomegaly, no abnormalities on lung and heart

 

Renal ultrasound

Solid mass on posterior part of bladder susp malignant dd/ residual mass.

Hidronephrosis, hidroureter with fluid retention in left perirenal part dd/ urinoma

LAB 8/1-17

CBC 10.9/32.6/9480/350000//84/28/33

Ureum 25, creatinine 1.6, eGFR 38.9

 

Working diagnosis

Occult invasive cervical cancer

 

Plan

Radiotherapy

 

 

Clinical question

What is the best management for patient with occult invasive cervical cancer found after hysterectomy for benign condition.

Population	Women with occult invasive cervical cancer diagnosed after hysterectomy for benign condition
Intervention	Surgical
Comparison	Radiation
Outcome	Disease free survival Overall survival

 

SEARCH STRATEGY

We did database searching on pubmed, biomed central and science direct with keywords Occult invasive cervical cancer  AND radiation AND surgery AND/OR parametrectomy looking for a match in title or abstract. Search result were filtere by the engine by the following criteria: articles published in the last 5 years, English language, human species and availability of full access to the article. We found 66 article match with the criteria above and we did further evaluation of the title and abstract and we got 3 full articles that appropriate answering our clinical questions. Our searching flow shown in figure 1.

 

 

CRITICAL APPRAISAL

From the 3 eligible articles, we did critical appraisal and can be seen in following table 1

	Study	Type of study	Sample	Validity				Result		Applicability	Total Score
				1	2	3	4	5	6	7
1.	Park, et al (2010)	Retrospective	147	+	+	-	+	+	+	?	5/7
2.	Narducci, et al (2015)	Retrospective	29	+	+	-	+	+	+	?	5/7
3.	Bai, et al (2016)	Retrospective	89	+	+	-	+	+	+	?	5/7

 

DISCUSSION

Initial study comparing surgical and non surgical approach to patient with occult invasive cervical cancer was done by park et al in 2010 that found surgical approach was more superior than non surgical (observation, radiation and or concomitant chemoradiation). The 10 year disease free survival and overall survival was 100% for the surgical groups and 93% and 94% in non surgical group, even lower in observation group of 63% and 84%. This finding was supported by another study from narducci et all in 2015 that found 5 year disease free survival and overall survival in surgical group was 100% and 86% comparing with 77% and 37% in radiation group. Latest study by bai et al in 2016 looking more specific to the pathologic findings and found that in patient with tumor with <20mm, superficial stromal invasion, no lymph node metastatis and negative section on specimen as good prognostic factors and radiation, chemoradiaton or surgical management can be omitted in this group of patient with comparable disease free survival and overall survival. (97.8% and 97.4% in observation group compared with 87.7% and 90.3% in radiation group and 83.8% and 87.9% in chemo group). All this study was statistically relevant but the albeit was the small number of sample. Guidelines from national comprehensive cancer network in 2016 stating that in patient with stage IA1 and no LVSI, scheduled survival was sufficient. But in patient with more than stage IA1 with LVSI, the management choice was surgical, chemoradiation or radiation depends on the clinical status and pathologic findings and imaging, further evaluation of the lymph node also needs to be done.

 

CONCLUSION

Radical parametrectomy should be performed in patient with occult cervical cancer found after hysterectomy if surgically feasible. Good prognostic factor such as small volume tumors (a largest tumor diameter ≤ 2 cm), superficial stromal invasion (≤10 mm or 5 mm), negative lymphovascular space involvement (LVSI) , no lymph node metastasis, negative section margin in a hysterectomy specimen.

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