Case Conference January 24th 2018

24-Jan-2018, Divisi Ginekologi Onkologi RSCM

Case description

 

Mrs. S, 37 yo, 4262552

 

History Taking

Chief complaint: Post coital bleeding since 7 month BA (referred from Tanjung Pinang)

 

History:

Post coital bleeding since 7 month BA. Bleeding outside menstrual period. Abdominal mass (-), abdominal tenderness (-). Decreasing fetal body weight (-). Urinary and defecation within normal limit. Patient went to hospital and performed cervical biopsy. The result was squamous cell carcinoma cervix. Patient admitted

 

Married 2x, 2012 & 2017

P2, oldest 4 yo, youngest 2 yo

 

Physical exam

Fully alert

BP 120/70, Pulse 80, Temp 36.5, RR 18x/min                

BW 70 kg, BH 158 cm, BMI 28

 

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: erosion portio (+), flour (-), fluxus (-)

Bimanual exam: uterus size and shape within normal limit, no mass palpated on vaginal stump and adnexa, parametrium not rigid. Sphincter ani tonus is good, no mass palpable on rectal mucosa.

 

 

Cervical biopsy at Tanjung Pinang Hospital (5-10-17)

Squamous cell carcinoma cervix

 

USG FM (31/10-17)

Interna genitalia no anomaly

Not seen abnormal mass at cervix

 

Working diagnosis

Cervical cancer Ia

 

Plan

LBC

HPV DNA

 

LBC result (1-11-17)

Atypical squamous cell can’t exclude (ASCH)

 

HPV result (3-11-17)

High risk: negative

Low risk: negative

 

Review slide (27-11-17)

Chronic cervicitis

 

Clinical question

Population	Women ASC-H with negative HPV
Intervention	Observation
Comparison	Colposcopy
Outcome	CIN 2/3

 

SEARCH STRATEGY

We did database searching on pubmed, clinical key, and science direct with ASC-H AND cervical AND HPV AND colposcopy AND follow up 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 50 article match with the criteria above and we did further evaluation of the title and abstract and we got 2 full articles that appropriate answering our clinical questions. Our searching flow shown in figure 1.

 

CRITICAL APPRAISAL

From the 2 eligible articles, we did critical appraisal and can be seen in following table 1

 

DISCUSSION

 

The first study was done by Chen, et al in 2015 which observe HPV testing results and histologic follow-up in women with ASC-H cytology in different age groups. The result was patient with ASC-H and become CIN2 + only 14 (8.9%). Women with ASC-H had benign cervix with HPV negative approximately was 74%. It was stated women tih positive HPV and cytologic ASC-H were 6 times more likely to harbor high-grade dysplasia than those with ASC-H but negative HPV. Second study was done by David, et al in 2010 which title follow-up outcomes in large cohort of patients with human papillomavirus-negative ASC-H cervical screening test result. CIN 2+ were documented in 14 patients with negative HPV. The average interval from HPV-negative ASC-H to follow up CIN 2+ was 13 months.

 

CONCLUSION

 

HPV negative and ASC-H results a very low incidence of CIN 2/3 or HSIL findings and no cases of invasive cervical cancer. Repeat Pap and HPV testing after 1 year appears to be a safe option for follow up. 

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