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CASE REPORT

CERVICAL CANCER STAGE IIIB WITH


ANEMIA ON CHEMOTHERAPY

Supervisor:
dr. Putu Agus Suarta, Sp.OG (K) Onk
Presentation By:
Gabriela L. Y. Watilay

Introduction

Cervical cancer is the most


common gynecologic cancer
that can happened in women.

Cervical cancer still on the


second place behind breast
cancer for the most common
cancer in women. In the
developing countries, cervical
cancer is still ranks first as the
cause of deaths (because of
cancer) on reproductive ages
women.

In 2013, the highest prevalence


cancer in Indonesia is cervical
cancer. Riau islands province, North
Maluku province, and Yogyakarta
province has the highest prevalence
of cervical cancer, while Papua
occupies the third position.

The current therapeutic options are still limited to surgery, radiation and chemotherapy,
or a combination of these treatment modalities. However, this therapy is still a
"symptomatic therapy" because they have not touched the cause of cancer, that is a
change in cell behavior.

Determining the choice of therapy and prediction of prognosis or to compare the success
rate of a new therapy should be based on the extent of disease. Universally scientist
approved that determination of the extent of the spread of disease are through the
staging system.

Cervical Cancer

Definition
Cervical cancer is a primary cancer of the cervix
(cervical canal and or porsio). Cancer in pregnancy is
rare and cervical cancer is the most frequent
malignancy in pregnancy.
Etiology
The one reason is due to infection with human
papilloma virus (HPV) that stimulate behavioral changes
of cervical epithelial cells. Cervical cancer is caused by
infection with HPV types 16 and 18.

Clinical symptoms :
Bleeding after sex (contact bleeding)
Vaginal discharge (watery fluids) / Fluor Albus
Bleeding even after menopause phase
At a later stage will come out a smelly-yellowish liquid,
and sometimes mixed with blood.

Diagnose

Stage of cervical cancer (FIGO 2015)

Treatment of cervical cancer


Surgery

Usually performed on clinical stage IA to IIA


Cancer can be recurrent, the patient is advised to
undergo re-examination and Pap smear every 3
months for 1 year first and then every 6 months.

Radiotherapy

Cervical cancer on stage IIB, III, and IV should be


treated with radiation.
Radiotherapy with curative doses will only be given to
patients with stage I sampi IIIB. If the cancer cells has
spread into the pelvic cavity, there will be only
palliative radiotherapy and must given selectively only
for stage IVA.

Kemotherapy

Chemotherapy is given to control the disease in a long


period of time even though it is impossible to recover
If the cancer has spread and in the final phase,
chemotherapy is used as a palliative to provide a
better quality of life.

Chemotherapy Agents and Assessment of Response in Cervical


Cancer

Basic Methods of Chemotherapy


Adjuvant therapy
This therapy is usually
given after other
treatments such as surgery
or radiation.

Combination therapy
Combination of two or
more chemotherapy
agents in cancer therapy

Induction therapy
Therapies that aim to
shrink the tumor mass
as quickly as possible
or the number of
cancer cells

Neoadjuvant therapy
Usually given before
treatment such as surgery or
radiation.

Primary therapy
as a primary treatment
in malignant tumors
that were given only
for chemosensitive
cancer

The Prognosis Of Patients With Chemotherapy


From the research results can be made the same conclusion, that
giving
neoajuvan chemotherapy for an advanced cervical
cancer, especially stage IIB cervical cancer, obtained a low
success rate of therapy.
Giving neoajuvan chemotherapy with a lower result clinical
complete response still should be considered whether the
administration of neoajuvan chemotherapy have more beneficial
than the losses at IIB cervical cancer patients because the tumor
cells that have been exposed to neoajuvan chemotherapy will be
have a cross resistance to radiation.

Case Report

IDENTITAS PASIEN
Name
: Mm. E.K
Gender
:
Address
: Doyo, Sentani
Age
: 29 yo
Religion
: Christian
Occupation
: Housewife
Med Rec Number : 38 91 16
Hospital admission date: October 26, 2016

Main complaint
She was admitted to the hospital with complaints of dizziness and a feeling
of weakness in the body.

Present Disease History


Patients came from obstetricss poly with the diagnosis of cervical cancer stage III B, the patient had
received chemotherapy (4 times), admission to hospital with the complaint her head feels dizzy and
feeling weak at the body since 3 days Meanwhile, before hospital admission, bleeding from the
vagina ( -), eating and drinking well, defecate and urinate smoothly. Earlier in May patients admitted
have some frequent bleeding from the vagina, but after that bleedings are more and more so the
patients then went to a gynecologist. In July she know that she suffering from cervical cancer and
shebegan to undergo his first chemotherapy.

Past Disease History


Patient admitted even do surgery for Lifting cyst in 2015. History of Asthma (-), Allergy (-),
Diabetes Mellitus (-), Hypertension (-) and Heart Disease history denied.
Family Disease History
A history of Asthma denied, Allergic history denied, Diabetes Mellitus history denied,
Hypertension and Heart Disease history denied

Social Disease
History
The patient had been
married twice, first
marriage was in
1998, and the
patients husband
has passed away. And
re-married in 2003
but until now the
patient himself
claimed not to have
children from both
the first and second
husbands.

Obstetrics History
G0P0A0

Menstruation
History
First menstruation: 12
years old, a regular
cycle,
menstruation
periode:
1
week,
patients
admitted
Menstrual
blood
increases. Menstrual
pain is undeniable.

Pemeriksaan Fisik
Consciousness

Compos mentis

Gynecology

External examination: Abdomen; flat,

Height

155 cm

Status

supple,

Berat Badan

63 kg

Blood Pressure

100/70 mmHg

Heart Rate

symmetrical

fundus

impalpable, mass (-), tenderness (-), free


fluid signs (-).
I : v/u : active bleeding (-).
Io : Portio soft, easy to bleed, flour

84 kali/ menit

(+), fluksus (-), active bleeding(-)

Respiration Rate 20 kali/ menit

VT : portio covering OUE, Uterus looking

Temperature

37,2C

normal, adnexalmass -/-, stiffness of

Generalist

Conjungtiva

status

(+/+)

anemis

parametrium +/+, vaginal wall smooth,


bleeding(-), fluor (-).
RT: Good anal sphincter reflex, ampula
collapse, smooth mukosal., blood(-).

Complete blood test (25/10/2016)


Blood

Result

examination

Examination

Result

Blood sugar level

212 mg/dl

Hb

8,1 g/dl

BUN

7,0 mg/dl

WBC

2.310

Kreatinin

0,76 mg/dl

Hematokrit

23,7 %

SGOT

39mg/dl

Trombosit

170.000

SGPT

23 mg/dl

Albumin

4,5 mg/dl

Cholesterol

194 mg/dl

Trigliserida

162 mg/dl

Histopatology Examination (22/06/2016)

Final diagnosis
Cervical cancer St. III B (5th Chemo) with
Anemia and Leukopenia

Prognosis
Quo Ad Vitam
:
Dubia ad
malam
Quo Ad Fungtionam : Dubia ad malam
Quo Ad Sanationam: Dubia ad malam

Does the management of patients is appropriate?

Anamnesis
Bleeding from the genitals
that
occurs
after
intercourse
Bleeding even after
intercourse, typical on
servical cancer at an
advanced stage.

physical examination
Status ginekologis :
Pemeriksaan luar : Abdomen; flat,
supple, symmetrical , fundus
impalpable, mass (-), tenderness
(-), free fluid signs (-).
I : v/u : active bleeding (-).
Io : Portio soft, easy to bleed, flour
(+), fluksus (-), active bleeding(-)
VT : portio covering OUE, Uterus
looking normal, adnexalmass -/-,
stiffness of parametrium +/+,
vaginal wall smooth, bleeding(-),
fluor (-).
RT: Good anal sphincter reflex,
ampula collapse, smooth
mukosal., blood(-).

Supporting examination

Hb: 8,1 g/dl


Wbc: 2.310
Plt: 170.000
Ht: 23,7%
MCV: 85,3
MCH: 29,1
MCHC: 34,2
The results from Cervical
biopsy examination (June
20, 2016) are poorly
differentiated Squamous
Cell Carcinoma to
moderate.

From the results of anamnesis, physical examination and


supporting examination, the final diagnosis of patients is
Cervical Carcinoma Stage IIIB with Anemia and
Leukopenia.

Does the management of patients is appropriate?

Treatment of Cervical Cancer at


an advanced stage (IIB, III, IVA)
is complete radiotherapy is
external
radiation
followed
intracavitary radiotherapy.
Therapeutic
variation
like
khemoradiasi are often given,
chemotherapy agent that given
fore
th
this
patient:
Cisplatinum,
pachitaxel,
docetaxel,
fluorouracil,
gemcitabine.

The best treatman on this case


(Cervical Carcinoma Stage IIIb)
should be the by radiotherapy but
because of limited facilities and
infrastructure in hospitals, so that
patients do chemotherapy with
chemotherapy regimen paclitaxel
and Carboplastin which is a firstline combination therapy in
patients with cervical cancer
stage IIIb, patient therapy
obtained in accordance with the
procedure of which have been
approved. However, in these
patients before do chemotherapy
treatment, first must have blood
transfition due to anemia (until
the HB level raise up 10 g / dl.)

what is the predisposing factors of cervical carcinoma in this


patient?

Predisposing factors that may include:


Contraceptives.
Cigarette smoke as a source of free radicals can dropping some
of available of anti-oxidants in the body that can help recover
some abnormalities in the body;
Low socioeconomic (patient and her family are work as farmers)
usually have some effect on the knowledge about sexually
transmitted diseases and hygiene pubic area.

\
The Patients had a predisposing factors that patients had
been married at the age of 13 years (young age),
patients have also been married twice as extrinsic factors
that cause the patient is infected with HPV. Multiparity
history and contraceptive use was not found in this case.

How the prognosis in this patient?


The factors that determine prognosis are: age, general condition,
degree of malignancy clinical, histological characteristics of the
tumor cells, the ability of rescue teams and medical facilities.
Resilience Score Life (AKH) 5 years according to international
data are as follows:
level

AKH-5 year

T1S

Almost 100 %

T1

70 85 %

T2

40 60 %

T3

30 40 %

T4

< 10 %

On this patients prognosis of patients according to


Resilience Score Life 5 years is 30-40%, because the
patient life are dependent on the ability of paramedics,
medical facilities, and the availability of medicines for
the chemotherapy.

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