Villegas, Jose Bernabe A.

GYNECOLOGY
Vinluan, Joseph David
Dr. Trinidad
Wong, Deo Adiel 3rd Year
–D
Yague, Glenn Sept. 6,
2007
Yang, Caprice

Case #16
56 year old G3P2 (2012), menopausic at age 51, consulted because
of on and off sero-sanguinous discharge for the past 6 months. She
took OCPs after her last pregnancy until age 45. Her eldest child is
40 y/o. VS stable. Heart and lungs essentially normal. Abdomen-
flat, soft, no mass or tenderness. Pelvic exam: Speculum: Cervix –
(+) friable nodular growth within the os which easily bleeds; IE:
cervix- barrel shaped, friable, nodular mass within the os; Uterus
slightly enlarged, anteverted, fixed; Adnexae- no mass or
tenderness. RVE: (+) induration noted on the right parametrium; (-)
fixation to the pelvic wall.

1. What additional data should be asked from the history?

Patients complaining of on and off sero-sanguinous discharge,

especially in the perimenopausal age group should be inquired for questions
mainly pointing to benign and neoplastic conditions initially.

One important thing to ask is the temporal association of the sero-

sanguinous discharge, whether it is continuous, only after coitus (post-coital
bleeding), or bleeding coming from a trauma to the vagina. As such, the
timing of which needs to be established.

Ask also for accompanying symptoms like vaginal soreness, postcoital

burning, and dyspareunia. Bloody fluid discharge in the patient may mean a
break in a thin vaginal mucosa of a patient with atrophic vaginitis. This is also
true for dyspareunia which may come from an ulceration of the vulvovaginal
epithelium.

Women who are taking hormone therapy during menopause may be

using a variety of hormonal regimens that can result in bleeding. Most
important is to ask what form of hormonal regimen was taken. Since
unopposed estrogen in OCPs or estrogen replacement therapy increases the
risk of hyperplasia and cancer and combination oral contraceptive pills and
combination hormone replacement therapy does not increase and may
decrease the risk of hyperplasia and cancer, as such, these will be very
helpful in establishing a cause for the bleeding in this patient especially when
considering endometrial hyperplasia and malignancies, particularly in the
case of the former medication. Although the patient mentioned she took oral
contraceptive pills after her last pregnancy up to age 45, ask if there had
been any recent intake, whether regular or irregular of such medications as
such may explain the etiology of withdrawal or breakthrough bleeding in the
patient.

Ask for pressure symptoms like urinary frequency, urgency, and/or

incontinence resulting from pressure on the bladder by a mass. Constipation,
difficult defecation, or rectal pain results from pressure on the colon and as
such, these needs inquiry as well. Abdominal cramping results from pressure
on the small bowel. Generalized pelvic and/or lower abdominal discomfort
may also be present. All of these are important things to ask whenever you
are considering pelvic masses presenting as perimenopausal bleeding.

Moreover, ask for cardiovascular symptoms like palpitations, chest pain

and the like especially when considering bleeding disorders in
hyperthyroidism of the elderly (toxic multinodular goiter, and less frequently
Graves disease.) The symptoms of hyperthyroidism are often atypical instead
of classic and may mimic other common diseases in this age group. Cardiac
complications are the most common manifestations of hyperthyroidism in
elderly and as such, needs asking. In line with this ask for any medications
taken at present time. Aside from directly causing bleeding, such as
antiplatelet, antithrombotic and/or fibrinolytic agents, medications like beta-
blockers taken for the underlying thyroid disorder may mask the typical
symptoms of thyroid disorders, and when considering this differential,
complicates the history. Because of this, intake of medications needs to be
considered heavily.

In parallel to this, ask for symptoms pertaining to hypothyroidism like

the classic cold intolerance, weight gain, dry skin, constipation, and mental
and physical slowing. In elderly patients this can easily be mistaken for
normal aging but nonetheless needs inquiry because this may also present as
abnormal bleeding.

Ask for noticeable pallor, easy bruising, easy fatigability, dizziness or

other signs of anemia as such may point to consequent iron-deficiency as a
result of continuous or massive sero-sanguinous bleeding. In addition to this,
inquire about hygienic practices like douching and a history of surgical
treatment, or diagnostic procedure that may result (directly or as a
complication) to traumatic bleeding.

Lastly whenever considering for a neoplastic cause of a bloody fluid

discharge, ask for fever, rapid weight loss, malodorous discharge, symptoms
that can evolve like constipation, hematuria, dysuria (ureteral obstruction) or
an accompanying discharge that may be different from the bleeding
character of this patient (from a fistula) coming out of the anus, vagina or
ureter. This may suggest local organ involvement. Ask for edema of the legs
as these may suggests lymphatic/vascular obstruction from a tumor. In line
with this, ask for symptoms of dyspnea or other symptoms pertaining to
pulmonary involvement in cases of metastasis. Some of the former symptoms
especially malodorous discharge and fever, in addition, burning may point to
 an inflammatory cause of bleeding, and this cannot be left out whenever
completing the history of the patient.

2. What is your clinical diagnosis and basis?

Considering the age of the patient which is in the menopausic period,

the friable, nodular growth within the cervical os found on speculum exam is
probably neoplastic. The clinical diagnosis that our group proposes for this
case is cervical cancer. From the history, we can deduce that the patient gave
birth to her eldest child at 16 years old. Early sexual intercourse predisposes
a woman to cervical cancer.

Below is a table of the FIGO Classification of Cervical Cancer. Cervical

Cancer is a clinically staged disease. In this patient, an induration was noted
at the right parametrium on rectovaginal exam. From the table, we can say
that the patient possibly has cervical carcinoma stage IIB in which the
carcinoma extends beyond the cervix but has not extended onto the pelvic
wall, involves the vagina but not as far as the lower third section and there is
obvious parametrial involvement but not onto the pelvic sidewall.

FIGO Staging of Cervical Carcinoma

Stage I
Stage I is carcinoma strictly confined to the cervix; extension to
the uterine corpus should be disregarded.
• Stage IA: Invasive cancer identified only microscopically.
All gross lesions even with superficial invasion are stage
IB cancers. Invasion is limited to measured stromal
invasion with a maximum depth of 5 mm* and no wider
than 7 mm. [Note: *The depth of invasion should be 5
mm or less taken from the base of the epithelium, either
surface or glandular, from which it originates. Vascular
space involvement, either venous or lymphatic, should
not alter the staging.]
o Stage IA1: Measured invasion of the stroma 3 mm
or less in depth and 7 mm or less in diameter.
o Stage IA2: Measured invasion of stroma more than
3 mm but 5 mm or less in depth and 7 mm or less
in diameter.
• Stage IB: Clinical lesions confined to the cervix or
preclinical lesions greater than stage IA.
o Stage IB1: Clinical lesions 4 cm or less in size.
o Stage IB2: Clinical lesions 4 cm or more in size.
Stage II
Stage II is carcinoma that extends beyond the cervix but has
not extended onto the pelvic wall. The carcinoma involves the
vagina but not as far as the lower third section.
• Stage IIA: No obvious parametrial involvement.
Involvement of as much as the upper two thirds of the
vagina.
• Stage IIB: Obvious parametrial involvement but not onto
the pelvic sidewall.
Stage III
 Stage III is carcinoma that has extended onto the pelvic
sidewall and/or involves the lower third of the vagina. On rectal
examination, there is no cancer-free space between the tumor
and the pelvic sidewall. All cases with a hydronephrosis or
nonfunctioning kidney should be included, unless they are
known to be due to other causes.
• Stage IIIA: No extension onto the pelvic sidewall but
involvement of the lower third of the vagina.
• Stage IIIB: Extension onto the pelvic sidewall or
hydronephrosis or nonfunctioning kidney.
Stage IV
Stage IV is carcinoma that has extended beyond the true pelvis
or has clinically involved the mucosa of the bladder and/or
rectum.
• Stage IVA: Spread of the tumor onto adjacent pelvic
organs.
• Stage IVB: Spread to distant organs.

Cervical cancer is the second most common malignancy in women

worldwide, and it remains a leading cause of cancer-related death for women
in developing countries.

Vaginal bleeding is the most common symptom occurring in patients

with cervical cancer. This is often post coital bleeding but may occur as
irregular or postmenopausal bleeding as what was seen in this patient.
Patients with advanced disease may present with malodorous vaginal
discharge, weight loss, or obstructive uropathy while in asymptomatic
women, cervical cancer is identified through evaluation of abnormal cytologic
screening.

The tumor grows by extending upward to the endometrial cavity,

downward to the vagina, and laterally to the pelvic wall. It can invade the
bladder and rectum directly. Symptoms that can evolve, such as constipation,
hematuria, fistula, and ureteral obstruction with or without hydroureter or
hydronephrosis, reflect local organ involvement.

The triad of leg edema, pain, and hydronephrosis suggests pelvic wall
involvement.

The common sites for distant metastasis include extrapelvic lymph

nodes, liver, lung, and bone.

3. Outline a diagnostic plan.

For the patient with a visible lesion, as what has been appreciated in
this patient, biopsy should be done to confirm the diagnosis. In cases wherein
gross disease is not present, a colposcopic examination with cervical biopsies
and endocervical curettage is warranted. Colposcopy of the vagina to exclude
associated vaginal intraepithelial neoplasia. (VAIN). Relevant clinical
symptoms should be investigated, and the bladder and rectum may be
evaluated by cystoscopy and sigmoidoscopy if symptomatic. Chest x-ray and
 renal evaluation (which may consist of renal ultrasound, IVP, CT or MRI) are
mandatory. CT and/or MRI and/or PET may provide some information on nodal
status or systemic spread. (Staging Classifications and Clinical Practice
Guidelines for Gynaecological Cancers FIGO Committee on Gynecologic
Oncology L Denny, NF Hacker, J Gori, HW Jones III, HYS Ngan, S Pecorelli
2000)

Lab Studies:

• A Papanicolaou test should be performed in every patient suggested to

have a diagnosis of cervical cancer.

• Colposcopy, direct biopsies, and endocervical curettage.

• After the diagnosis is established, a complete blood cell count and

serum chemistry for renal and hepatic functions should be ordered to
look for abnormalities from possible metastatic disease.

Imaging Studies:

• Once the diagnosis is established, imaging studies are performed for

staging purposes.

• A routine chest radiograph should be obtained to help rule out

pulmonary metastasis.

• CT scan of the abdomen and pelvis is performed to look for metastasis

in the liver, lymph nodes, or other organs and to help rule out
hydronephrosis/hydroureter.

• In patients with bulky primary tumor, barium enema studies can be

used to evaluate extrinsic rectal compression from the cervical mass.

Procedures:

• In patients with bulky primary tumor, cystoscopy and proctoscopy

should be performed to help rule out local invasion of the bladder and
the colon.

4. Outline a treatment plan if diagnosis is confirmed by the work-up.

As was presented in the history of the patient, she had parametrial

involvement but not onto the pelvic sidewall. Stage IIB cervical cancer is part
of the advanced cervical cancers which also include stages III and IVA.

Treatment options depend on the following:

• The stage of the cancer.
• The size of the tumor.
 • The patient's desire to have children.
• The patient’s age.

The staging of cervical cancer is very important especially when

choosing the appropriate therapy. The importance of good diagnostics (CT
scan) could not be more emphasized. Moreover, the size of the primary tumor
is an important prognostic factor and should be carefully evaluated in also
choosing optimal therapy. In our patient, there is only unilateral parametrial
involvement which indicates better survival and local control than bilateral
affectation.

The age of the patient is also crucial. Since she is postmenopausic,

conservative treatments must be taken into consideration. The desire of the
patient to have a baby must always be asked whenever complete resection of
the uterus is a possibility and an option.

Surgery is feasible only up to Stage IIA or for early stages of cancer.

Radical hysterectomy is the treatment to remove the uterus, cervix, and part
of the vagina. The ovaries, fallopian tubes, or nearby lymph nodes may also
be removed. Total Abdominal Hysterectomy is used for early stage cancer
and if the patient has completed her family. Cone biopsy is used for CIS and
Stage IA1 and if the patient still wants to get pregnant.

For our patient, radio and chemotherapy is the most feasible since she
is in the advanced stage of cervical cancer. Standard treatment is
irradiation combining external beam radiation and intracavitary
brachytherapy plus chemotherapy with cisplatin or
cisplatin/fluorouracil. Traditionally, low-dose rate (LDR) brachytherapy
(usually 137-Cs) is the main approach however, recently there has been a
rapid increase in the use of high-dose rate (HDR) brachytherapy (with 192-Ir).
HDR brachytherapy provides the advantage of eliminating radiation exposure
to medical personnel, a shorter treatment time, patient convenience, and
outpatient management. In three randomized trials, HDR brachytherapy was
comparable with LDR brachytherapy in terms of local-regional control and
complication rates.

REFERENCES:
• Berek & Novak’s Gynecology, 14th Edition.
• Robbins & Cotran’s Pathologic Basis of Disease, 7th Edition.
• “Staging Classifications and Clinical Practice Guidelines for Gynaecological
Cancers” www.figo.org
• “Cervical Cancer” www.emedicine.com
• “Stage IIB Cervical Cancer” www.cancer.gov
• “Cervical Cancer - Topic Overview” www.webmd.com