Case Conference April 11th 2018

11-Apr-2018, Divisi Ginekologi Onkologi RSCM

 

CASE CONFERENCE

 

Mrs S, 80 yo, P6A0, 427-21-51

 

 

 

I.     Case Description

 

The patient complained for bleeding from the birth canal since 4 months ago. Complain was felt become worse since a month ago. The patient also complain about uterus descending into her vagina since 20 years ago. She refused any medication before. She could defecate and urinate while standing up because she was not able to squat. Patient came to Fatmawati Hospital, then performed biopsy with pathology anatomy examination at January 11^th 2018. The result was cervical carcinoma squamous cell type keratin, well differentiated. Patient was reffered to RSCM. The lower abdominal MRI examination was performed on March 1^st, 2018 with the result was uterine prolapse. There was mass in the proplase area (uterus cervix) that homogeneous and strong with restriction diffusion à dd/ suggestif maligna. There was also right parailiacs lymphadenopathy with size 1,5 x 1,6 cm.

 

 

 

     Physical Examination on February 22^th, 2018

 

a.      General status:

 

CM. BP: 110/70 mmHg, HR: 94 x/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 (-)

 

Extremity: warm, no oedema

 

Gynecology examination:

 

Inspection: vulva and urethra was normal, there was a mass on introitus vagina  sized  10 x 10 x 8 cm (uterine prolapse grade IV) and an eksofitik mass on cervix, easily to bleed Ø 8x 6 x 4 cm, right and left parametrium without nodule.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.     Laboratory Result on  February 19^th, 2018:

 

CBC : 9,3/28,6/18230/439000

 

Diff:  0.2/1.6/82.0/9.3/6.9

 

LED: 80

 

PT 10.5 (11.1) APTT 33.5 (30.6)

 

SGOT/SGPT: 10/7

 

Ur 30 CR 1.2 eFGR 42.8

 

Na/K/Cl : 139/4.35/100.2

 

Albumin 3.07

 

 

 

c.      Pathology Anatomy Result from Fatmawati Hospital on January 11^th 2018

 

Makroskopik: Diterima jaringan tidak teratur sebanyak 0,2 cc, putih, kenyal. Semua cetak: 1 kup 1 blok.

 

Mikroskopik: Sediaan jaringan biopsy dengan keterangan asal serviks berupa keping keping jaringan sebagian dilapisi epitel skuamous berlapis. Epitel hiperplastik dan proliferasi membentuk sarang sarang infiltrative ke dalam stroma jaringan ikat disertai pembentukan mutiara mutiara keratin. Stroma berserbukan padat sel radang mononuclear.

 

Kesimpulan: karsinoma serviks jenis sel skuamous berkeratin, berdifferensiasi baik

 

 

 

        d. Chest X-Ray Result on February 19^th, 2018:

 

Description: asimetric position. The heart was enlarged. Cardiothoracic ratio was 60%. The aorta was elongated and calcification. 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 right costophrenicus angle was normal, the left was blunt. The bones were still good.

 

Conclusion:  cardiomegaly with elongation and calcification. Suspecious pleural effusion of the left lung. No metastase nodule in the lungs

 

 

 

 

 

       

 

        e. Lower Abdominal MRI on March 1^st, 2018

 

Description: it appears that total uterine prolapse through the vagina and part of structure of the bladder was attracted to the inferior through the vagina. The surface of the prolapsed uterus appears irregular and thickened, accompanied by restriction on diffusion and strong and homogeneous post-contrast exposure. Structure of the cervix and the uterine corpus were difficult to differentiated. The lymph nodes of the right parailiacs region were enlarge, size 1,5 x 1,6 cm.  The shape and articulation of the femoral caput and acetabulum were normal. The bone marrow was normal. No soft tissue abnormality. the wing of ilium and both iliopsoas muscles were symmetrically good. The intestinal bowel structure in the pelvic area didn’t appear to be attracted to the prolapse area.

 

Conclusion : uterine prolapse. There was mass in the proplase area ( uterus cervix) that homogeneous and strong with restriction diffusion à dd/ suggestif maligna. Right parailiacs lymphadenopathy with size 1,5 x 1,6 cm.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Problems to be discussed

 

Is radiotherapy based better than surgery based for patient with cervical cancer complicated  by complete uterine prolapse?

 

 

 

Clinical question in this case will be developed by PICO approach

 

Patient	Cervical cancer complicated by complete uterine prolapse
Intervention	Radiotherapy based
Comparison	Surgery based
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 OR cervix carcinoma AND uterine prolapse. The search was conducted on PubMed on April, 9^th 2017

 

 

 

Search strategy in PubMed conducted on

 

 

 

Engine	Search terms	Results
PubMed	Cervix cancer OR cervix carcinoma AND uterine prolapse	3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIgure 1. Flowchart of search strategy

 

Critical Appraisal

 

 

Cervix cancer OR cervix carcinoma AND uterine prolapse

 

 

 

 

 

224 articles

 

 

 

 

 

 

Filtering titles and abstract

 

 

 

 

 

 

Reading fulltexts

 

 

 

 

 

 

3 useful articles

 

 

 

 

 

 

Screening files

 

 

 

 

 

 

PubMed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Article 1

 

Matsuo, K et al. Treatment patterns and survival outcomes in patients with cervical cancer complicated by complete uterine prolapse: a systematic review of literature. Int Urogynecol J. 2015. DOI 10.1007/s00192-015-2731-8.

 

 

 

Article 2

 

 

 

Pardal, C et al. Carcinoma of the cervix complicating a genital prolapse. BMJ Case. 2015. DOI 10.1136/bcr-2015-209580.

 

Article 3

 

Loizzi, V et al. Locally advanced cervical cancer associated with complete uterine prolapse. European Journal of Cancer Care. 2008;19:548-550.

 

 

 

 

 

	1st art	2nd art	3rd art
A. Are the study results valid
1.  Was there a representative and well-defined sample patients at a similar point in the course of disease?	yes	Yes	Yes
2. Was follow-up sufficiently long and complete?	yes	yes	yes
3. Were objective and unbiased outcome criteria used?	yes	yes	yes
4. Was there adjustment for important prognostic factors?	yes	yes	yes
B. What were the results?
1. How large is the likelihood of the otcome events in a specific period of time?	N/A	N/A	N/A
2. How precise are the estimates of likelihood? (consider 95% CI)	N/A	N/A	N/A
C. Can the results be applied to your patients?
1. Were the study patients similar to my own?	yes	yes	yes
2. Are the results useful for reassuring or counseling patients?	yes	yes	yes
3. Is the treatment feasible in my setting?	yes	yes	yes
D. Conclusions
1. The results or recommendation are valid?	yes	yes	yes
2. The results clinically important?	yes	yes	yes
3. The results are relevant to my practice?	yes	yes	yes

 

 

 

 

 

Introduction

 

 

 

Patient with cervical cancer complicated by uterine prolapse is an uncommon condition despite of cervical cancer as the most common gynecologic malignancy in the world and uterine prolapse is not a rare condition in elderly women. There is no reported incidence, but the available information suggests that the incidence of cervical cancer among those with procidentia is between 0.14 % and 1 %. Some literatures have postulated that prolapse might be protective against cervical cancer while others have considered that the irritation of the cervix by being outside the body might increase the propensity for neoplastic changes. However, no clear explanation has been validated. Currently, no standard recommendations for treatment of this combined entity have been elucidated. Some speculate that surgical resection holds more benefit than RT and others argue the reverse; however, no data have been collected to show that one modality improves outcome more than the other. With a growing elderly population, one can assume that both procidentia and cervical cancer may become more prevalent and force physicians to develop optimal treatment plans.

 

Discussion

 

Based on publication searching for patient with cervical cancer complicated by complete uterine prolapse, we find three useful journals. One systematic review and two case reports related to the management for this patient.

 

Matsuo et al. (2015) conducted systematic review of the literature using three public search engine, included case reports with detailed descriptions. Treatment patterns and tumor characteristics were correlated to survival outcomes. There were 78 patients with cervical cancer with complete uterine prolapse. Their mean age was 63.7 years. The median duration of prolapse was 147.9 months and 22.2 % of the patients experienced persistent/recurrent prolapse after cancer treatment. The mean tumor size was 8.9 cm and squamous cell carcinoma (83.9 %) was the most common histologic type. The majority of patients (56.2 %) had stage I cancer. Tumor characteristics were similar across the treatment patterns. Survival outcomes were more favorable with surgery-based treatment (48 patients) than with radiation- based treatment (30 patients): 5-year recurrence-free survival rate 72.0 % vs. 62.9 % (p = 0.057), and 5-year disease-specific overall survival rate 77.0 % vs. 68.2 % (p = 0.017). After con- trolling for age and stage, surgery-based therapy remained an independent prognostic factor for better disease-specific over- all survival outcome (hazard ratio 0.32, 95 % confidence interval 0.11 – 0.94, adjusted p = 0.039).  It was concluded that surgery-based treatment may have a positive effect on survival outcome in cervical cancer patients with complete uterine prolapse.

 

Pardal et al. (2015) reported a 74-year-old patient gravida 10, para 9 with an ulcerated lesion in a prolapsed uterus of 20 years duration. The patient reported of local pain, fever and anorexia. Physical examination revealed procidentia with a 4.5 cm ulcerated lesion on the posterior lip of the cervix and a low-grade cystocele-rectocele. Rectovaginal examination gave no evidence of vaginal, rectal or parame- trial involvement. Biopsy of the ulcerated cervical lesion confirmed a squamous-cell carcinoma (SCC) and a pelvic MRI suggested a disease limited to the cervix. The patient underwent a vaginal hysterectomy plus open bilateral iliopelvic lymphadenectomy, and based on the pathological stage (IIIB) proceeded with coadjuvant treatment with radiotherapy (pelvic external beam radiotherapy 50Gy/25F plus vaginal brachytherapy 3×7Gy) and chemotherapy with cisplatin (40mg/m²/weekly). Overall, the treatment was well tolerated. Despite the initial aggressive treatment approach, the patient showed disease progression and initiated pal- liative therapy with paclitaxel (175 mg/m²) plus carboplatin (AUC5) every 3weeks. After completing four cycles of the protocol, this approach was also ineffective in halting the disease progression, as shown by progression of the regional disease. Palliative radiotherapy was considered but the patient underwent rapid deterioration of her general condition manifested by increasing asthenia, anorexia and cachexia, as well as severe oncological lumbar pain and refractory nausea and vomiting episodes, postponing several times the treatment. Twelve months after the diagnosis the patient was admitted in the hospital due to an insidious onset of altered mental status and end life care measures, regarding her comfort, were performed.

 

Loizzi et al. (2010) reported an 86 yo patient gravida 8, para 5 with as a complete third degree uterine prolapse and an ulcerated lesion of 12 cm in diameter involving the cervix was observed. A low grade of cystocele-rectocele was evident and an invasion of the vagina was also present (FIGO stage IIA). Rectal examination revealed no infiltration of the parametria. Biopsy of the lesion was performed revealing a poor differentiation (G3) squamous cell cervical carcinoma. Laboratory tests showed severe anemia for which the patient received transfusion for her severe anemia. No infection was present and a chest x-ray revealed a chronic obstructive pulmonary disease. A prophylactic low molecular weight heparin was performed. Because of the poor performance status and the American Society of Anesthesiology score class 3, the patient was admitted for a less radical surgical procedure such as vaginal simple hysterectomy with upper vaginectomy in spinal anesthesia. Histological report confirmed her diagnosis showing stroma and lym- phatic vascular space invasion. All resection margins of the surgical specimen were clear. She was started with low molecular weight heparin after surgery. Some days later, the patient showed yellow sclera, and an increased level of bilirubina and low proteins was observed. Because of dyspnoea, the patient received a chest x-ray that showed pleural effusions on both sides. Then, she was admitted to computerized tomography scan of the chest, which showed a thrombosis of the pulmonary artery and she was admitted to the Department of Internal Medicine where she died 20 days later.

 

 

 

 

 

Conclusions

 

In our patient, surgery based therapy is the best choice for management. Radiotherapy or chemotherapy may be considered as an adjuvant therapy based on the pathology anatomic result after the surgery. There is no standard recommendation of the surgery method related to the lack of evidence and rarity of the case. But we can see from the systematic review that the surgery method mostly done by vaginal approach (38 patients from total 48 patients (79%). And from the two cases report also done with vaginal approach. This finding is unique to cervical cancer patients with complete uterine prolapse because the common surgical modality for cervical cancer without prolapse is the abdominal approach. It is speculated that the presence of complete uterine prolapse enable surgeons to access the surgical site more easily with a vaginal approach. In the studies highlighting vaginal hysterectomy as the treatment of choice, older patients were spared the morbidity of an open abdominal procedure. The last consideration is about radicality, it is tailored based on patient condition. The first case report using vaginal hysterectomy plus open bilateral iliopelvic lymphadenectomy, and the second case report using vaginal simple hysterectomy with upper vaginectomy only. The conclusion for our patient management based on three journals is surgery with vaginal hysterectomy and open bilateral pelvic lymphadenectomy continued with adjuvant therapy based on pathology anatomic result.

 

 

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