Case Conference August 29th 2018

29-Aug-2018, Divisi Ginekologi Onkologi RSCM

Case description

 

Miss. ES, 59 yo, 4310301

 

Chief complain : Vaginal bleeding since 15 days on May 2018

History:

Initially patient had vaginal bleeding 15 days since on May 2018.  Patient had history recurent vaginal bleeding since 6 months, but patient doesn’t get medical treatment. The history of patient is as follows:

· May 2018 :

Patient had vaginal bleeding 15 days since on May 2018, untill 6 pads/days, patient tell that bleeding lot of clot when patient get urinating. Than patient came to RSUD. Siti Khadijah Pekalongan, and perform US exam (no data), said the OBGYN hyperplasia endometrium and underwent curretage on 30 May 2018, with PA result was endometrial cancer poor differentiated, then patient suggest referred to RSCM or RS.Kariadi Semarang.

· June 2018 :

Because the family event patient came to Jakarta, patient had vaginal bleeding as like when patient get treatment RSUD. Pekalongan, patient complain weakness, the patient came to RSUD. Tarakan , said that Hb 6, taking care with giving transfusion, diagnostic with CT Scan whole abdomen, and patient had PA result and perform HTSOB on July 2018 .

CT Scan Whole Abdomen RSUD. Tarakan

Uterus enlargement, visible intra uterine calcifications, no sign of infiltration in the surrounding tissue

~Myoma uteri dd Ca uteri, no infiltration or metastasis at intraabominal

Post Contrast: heterogenous heating appears on the peripher of the uterus

PA result from HTSOB: endometrioid adenocarcinoma grade III, with tumor cells infiltrate more than half the myometrium, both the tubes and ovaries do not contain tumor cells

PA operation results are said to be be malignant, patient referred to RSCM.

· July 2018 :

Patient came to RSCM with no complain, and bring PA results. In RCSM patient did perform review slide, US fetomaternal examination, roentgen thorax, and laboratorium.

And planning MRI Whole Abdomen with contrast with the aim to see enlargement of the KGB.

Review slide 10-08-2018:

Histology according to endometrioid carcinoma grade 3, invasion of the tumor more than half the thickness of the myometrium, cell tumor not found on the surface and cervical stroma

Fetomaternal US Examination (July 24^th 2018)

Non visual uterus and both of ovaries (post HTSOB)

Normal vaginal stump. No enlargement of the parailiac KGB. Liver and Renal wnl. No ascites

~ Endometrial cancer (Post HTSOB), no pelvicum abdominal mass is seen

Radiology Thorax (July 23^th 2018):

No radiological abnormalities in the heart and lungs, no metastatic nodules in both lungs.

Laboratory result :

Hb 12.9 Ht 40.3 leukosit 5230 trombosit 277.000 SGOT 21 SGPT 31 Ureum 22 Creatinine 0.6 Albumin 4.0 RBG 91 Electrolit: Na 139 K 4.0 Cl 104.5

 

Marital Status: Patient not married, P0A0

Physical exam

Fully alert

BP 134/76 Pulse 74, Temp 36, RR 20x/min

BW 49kg, BH 151 cm, BMI 21

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

RT; no abnormal mass, anal mucosa is smooth

Auxilliary examination

PA form curettage at RSUD. Siti Khadijah, May 30th, 2018 :

Adenocarcinoma poored differentiated

 

Working diagnosis

Carcinoma endometrium with Incomplete surgical staging( subtotal hysterectomy bilateral salphyngoophorectomy)  

 

Plan

MRI Whole Abdomen with contrast

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical question

Patients with carcinoma endometrium, intermediate risk, histopathology grade 3 perform hysterectomy bilateral salphingoovorectomy, What the Role of the General OBGYN in managing endometrial carcinoma? And what the next step management ?

 

Discussions

This patient with results PA from curretage at RSUD. Siti Khadijah Pekalongan, endometrial cancer poor differentiated, and patient came to RSUD. Tarakan due to vaginal bleeding, from CT Scan Whole Abdomen RSUD. Tarakan post contrast has result heterogenous heating appears on the perifer of the uterus. Patient perform by OBGYN subtotal hysterectomy bilateral salphingoovorectomy, PA result endometrioid adenocarcinoma grade III, with tumor cell infiltrate more than the myometrium, both the tubes and ovaries do not contain tumor cells.

This thing might be happen  due to :

1.  Missed diagnosis :  Improper diagnosis, in which diagnosed with PA from curretage endometrial cancer poor differentiated, CT Scan post contrast has look invasion to the perifer of the uterus. This case are actually must get risk determined; this risk including intermediate risk endometrial carcinoma, after obgyn determined risk of endometrial cancer, further management is in accordance with the risk of malignancy.

this can be happen because of :

· Missed interpretation from the examiner

2. Missed management, in which the management of intermediate risk of endometrial carcinoma should be surgical staging with lymphadenectomy.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Endometrial carcinoma stages I and Occult II: Patients requiring surgical staging

1. Patients with grade 3 lesions

2. Patients with grade 2 tumours > 2 cm in diameter

3. Patients with clear cell or serous carcinomas

4. Patients with greater than 50% of myometrial invasion

5. Patients with cervical extension

Berek and Hackers Gynaecology, 6^th, 2015.

 

 

CONCLUSSION

• Diagnosis in endometrial carcinoma from histopathology, before managing this problem, this case are actually must get risk determined; this risk including low, intermediate and high risk endometrial carcinoma, after obgyn determined risk of endometrial cancer, further management is in accordance with the risk of malignancy.

• If found that risk intermediate or high risk, we should referred to oncology division.

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