CASE PRESENTATION of Cancer cervix diagnosis management

Cancer Cervix

1. CASE PRESENTATION Dr. Aparna Sasane

2. HISTORY 55 year old P4L4 tubectomised postmenopausal homemaker resident of manik baug , Pune came to the OPD with complaints of PV discharge since 11 months and patient came with histopathology invasive squamous cell carcinoma (large cell non keratinizing type) reports of cervical biopsy done in an outside hospital suggestive of Discharge PV was gradual in onset , increased and not associated with foul smell or bleeding PV No H/O of pain in abdomen No H/O of bleeding per vagina No H/O of bowel irregularities No H/O of any bladder complaints No H/O fever , loss of appetite , weight loss No H/O of cough ,cold.

3. MENSTRUAL HISTORY Patient is post menopausal since 10 years . Past menstrual history : Regular cycles / 28-30 days / lasting for 3-4 days/moderate flow / not associated with dysmenorrhea or passage of clots

4. MARITAL HISTORY Married since 40 years Non - consangineus marriage

5. OBSTETRIC HISTORY P4l4 P1L1/ male child / 37year old / FTVD / A&W P2L2/ male child / 35 year old/FTVD/A&W P3L3 /female child/32 year old/FTVD/ a&W p4L4/ female child/30 year old/ FTVD/A&W Puerperal tubal ligation done 30 years ago

6. Patient had no significant history of any 1 st degree relative having cancer. No other significant family history Patient has a mixed diet With total calorie intake of 2600kCal Total protein intake 80gms FAMILY HISTORY DIET HISTORY

7. Medical & Surgical history Patient had underwent D&C hysteroscopy with cervical biopsy on 20/3/25 in an outside hospital PTL done 30 years ago No other major medical or Surgical history

8. General examination Patient is moderately built Height -157cm Weight – 58kg BMI: 23.5 No pallor/icterus/clubbing/edema/lymphadenopathy Pulse : 98/min ,regular equal on both sides BP:110/76mmhg right arm sitting position Breast examination – normal , no abnormal discharge , lump,or secretions Thyroid examination – normal , no abnormal lump noted

9. SYSTEMIC EXAMINATION Cardiovascular examination : S1S2 heard , no murmurs heard Respiratory system : air entry bilaterally equal , clear CNS : conscious & oriented

10. PER ABDOMINAL EXAMINATION Inspection : soft ,umbilicus inverted, small scar infraumbilical 2-2.5cm transverse No prominent veins or sinuses seen PALPATION : Abdomen was soft , no guarding ,rigidity, tenderness. No palpable mass felt No other organomegaly PERCUSSION : resonant note heard on percussion AUSCULATATION : bowel sounds heard in all quadrants

11. PER SPECULUM Cervical erosion present on anterior lip Anterior lip was showing irregularity probably due to biopsy taken Vagina healthy Bleeds on touch

12. PER VAGINAL EXAMINATION Anterior & posterior lip of cervix flushed to the vaginal wall . Uterus normal size B/L Fornices free non tender No induration , no mass felt Parametrium free PER RECTAL EXAMINATION : No nodules ,metastatic deposits felt Rectal mucosa was free

13. PROVISIONAL DIAGNOSIS 55 year old P4L4 post menopausal tubectomised most probably a case of Ca cervix clinically stage 1B, invasive squamous cell carcinoma large cell non keratinzing type confirmed on histopathology

14. INVESTIGATIONS Pap smear was done suggestive of (ASCUS). (done outside before admission to SKNMC ) Histopathlogy report of D&C hysteroscopy conducted In outside hospital was suggestive of invasive squamous cell carcinoma (large cell non keratinizing type) CBC 11.8/4660/3.04 Urine routie microscopy : urine protein + rest NAD TSH : 0.99 BSL: 80 mg/dl HbA1C: 5.15 Blood group: A positive LFT : 30/0.6/141/4.5/107 RFT : 0.2/0.2/41/54/98

15. Investigations USG (A+P) - E/o 9*7mm echogenic lesion seen within endometrial cavity mostly endometrial polyp with surrounding endometrial collection 16*6mm rest abdomen pelvis study NAD MRI PELVIS done : An ill defined heterogeneously enhancing lesion involving the anterior lip of the cervix measures 9 * 9mm no evidence of extension to vagina or lateral pelvic walls CT (abdomen pelvis): ill defined and soft density lesion involving the cervix , lower part of the uterus and upper part of vagina , no loss of fat planes noted Rest CT abdomen – NAD

16. TREATMENT With due fitness for surgery and written consent patient was posted for modified radical hysterectomy Operative notes : After written informed consent and under general anesthesia painting draping done Midline incision taken 2cm above the umbilicus and towards the pubic symphysis Bowels packed and abdominal cavity exposed with the help of self retaining Balfour’s retractor. Uterus specimen held with straight clamps and round ligament clamped , cut & ligated with vicryl RB no 1

17. Anterior leaf of broad ligament dissected bluntly and paravesical space identified , ureter dissected on medial leaf of broad ligament . Pararectal space identified and bilateral anterior division of internal iliac artery identified and ligated 2cm below the bifurcation of common iliac artery Bilateral infundibulopelvic ligaments clamped cut & ligated with vicryl Rb no 1 Bilateral uterine pedicle clamped cut & ligated . Anterior peritoneum of the bladder dissected Ureteric tunnel dissected Base of the broad ligament is excised from its attachment to the lateral pelvic wall The uterosacral ligaments are divided avoiding hypogastric nerve plexus Colpotomy is done and 2cm vaginal wall removed and specimen sent for HPE Vault sutured followed by B/l pelvic lymphadenectomy Hemostasis confirmed and abdomen closed in layers .

18. Post operative management Patient kept on 5 days I.V antibiotics Patient shifted to surgical ICU for 48 hours and shifted to ward on post operative day 3 DVT prophylaxis given Early ambulation done Foleys catheter kept for 12days Abdominal Drain removed on day 10 after collected <25cc Tumour board reference done and advised by oncophysician for radiotherapy and hence referred to higher centre for the same.

19. HISTOPATHOLOGY REPORT Cervix pathological staging : T1b2 N0 MX- STAGE 1B2 DEPTH OF INVASION 7mm Endometrium and inner half of myometrium involved by tumor Isthmus involved by tumor Right anterior and right lateral vaginal cuff margins - free of tumor Right posterior vaginal cuff margin – moderate to focal marked dysplasia Left lateral vaginal cuff margins – moderate dysplasia Right and left parametrium free of tumor B/L fallopian tubes and ovaries - unremarkable All dissected lymph nodes are free of tumor

20. FINAL DIAGNOSIS 55 year old P4L4 post menopausal tubectomised a case of Ca cervix stage 1B2.