PRESENTATION CASE

ca cervix "

Rr Pramita Ines P

dr. Boy Busmar,

Sp.OG(K)
KEPANITERAAN KLINIK OBSTETRI DAN
GINEKOLOGI
RUMAH SAKIT UMUM PUSAT PERSAHABATAN
FAKULTAS KEDOKTERAN UPN VETERAN

CASE
IDENTITY OF PATIENT
Name
: Ny . A
Age
: 66 years
Religion
: Islam
Education : High School
Occupation : Housewife
Address
: Bekasi Timur
No. RM
: 01-31-87-63

ANAMNESIS (autoanamnesis July 9, 2015 at

11:00)

Main complaint : Bleeding from the pubic

since 2 days SMRs
Disease History : Patients present with
bleeding from the genitals since 2 days
SMRR . Patients complain of bleeding can
not be measured in number because the
patient was not wearing diapers .

 Bleeding is the first time felt the

patient . Patients complain of
appetite unusual but BB patients
fell as much as 5 kg which was
originally 55 kg to 50 kg in 4
months . Bowel and bladder no
complaints

 Formerly Disease history : HT ( + ) , Gastritis ( + ) ,

DM ( - ) , Asthma ( - ) , allergies ( - ) , Cardiac ( - ) ,
Pulmonary ( - ) .
Family Disease History : HT ( + ) , DM ( - ) , Asthma (
- ) , allergies ( - ) , Cardiac ( - ) , Pulmonary ( - )
Menstrual history : Menarche 12 years , the cycle of
28 days , on a regular , long menstrual 5-7 days ,
replace the bandage 2-3x / day , painful
menstruation ( - ) , menopause 15 years ago .
Obstetric history :
- P4A1 1.
1. Male , age 16 yr , spontaneous with paraji
2. Women , usia27 yr , spontaneous with paraji
3. Male , age 29 yr , spontaneous with paraji
4. Women , age 32 yr , spontaneous with paraji

 History of Marriage :
Married 1x , at the age of 16 years .
KB history :
pill for 10 years
Socio-economic history :
housewife , husband merchant

PHYSICAL EXAMINATION
-

General Situation : Well , Awareness CM

Vital Signs : TD : 170/100 mmHg , N : 84x / mnt , RR : 20x /
mnt , S : 36.9 C
Generalized status :
Head: normocephal
Eyes : conjunctival pallor - / - , sclera jaundice - / ENT : NCH - / - , otorhea - / - , rhinorrhea - / Neck : thyroid not palpable large , KGB ( N )
Chest : Symmetrical static - dynamic , retraction ( - ) Heart: BJ
I & II ( N ) regular , murmur ( - ) , gallops ( - ) Lungs : vesicular
+ / + , Rhonki - / - , wheezing - / Abdomen : in gynecology status
Extremities : akral warm , CRT < 2 " , edema ( - ) , varices ( - )

Status Gynecologic
Inspection : calm urethra Vulva
Inspekulo : Portio looks bumpy , atrophy ,
bleed easily , extending to the lateral
fornix , Fluxus ( + )
RVT : CUT AF , b / u 1 suprasimfisis
fingers , palpable lower portion with a
bumpy surface extending to the lateral
fornix . Right and left , up to 1/3 of the
vagina . No palpable masses adnexa . TSA
well . Mucous slippery , ampulla not
kollaps , mass ( - ) , blood ( - ) , stool ( + )

Nama Test

LAB

Hasil

Unit

Nilai Normal

10.02

Ribu/mm3

5 10

Netrofil

66.3

50 70

Limfosit

20.9

25 40

Monosit

6.1

28

Eosinofil

5.7

24

Basofil

1.1

01

Eritrosit

4.28

Juta/uL

3.6 5.8

Hemoglobin

13.0

g/dl

12.0 16.0

Hematokrit

13.0

35 47

MCV

83.0

fL

80 100

MCH

30.3

Pg

26 34

MCHC

36.5

32 36

RDW-CV

11.95

11.5 14.5

Trombosit

286

ribu/mm3

150 440

Darah Rutin
Lekosit
Hitung Jenis

Menit

<6

Menit

<11

*Menyusul

mg/dL

<180

Natrium (Na)

*Menyusul

mmol/L

135 145

Kalium (K)

*Menyusul

mmol/L

3.5 5.5

Hemostasis
Masa perdarahan/BT
Masa Pembekuan/CT

Kimia Klinik
Glukosa Darah Sewaktu
Elektrolit

pathology tissues
Macroscopic : COM network Cam 0.3 cc
brown chewy all print blocks
Microscopy: preparation cervical biopsy
contains malignant tumor mass keratinized
squamous cell carcinoma , poorly
differentiated , lightweight berserbukan
stromal cell lymphocytes. Not found
limfovaskuler invasion .
Impression : cervical squamous cell
carcinoma , poorly differentiated keratinized .

USG (7 Juli 2015)

Retroflexi uterus , shrink the size of normal .
Complex mass seemed to fill the cervix , with
defined, mass size 27 x 28 mm , with intramassa
increased blood flow , venous type , the mass
comes from the possibility of cervical
malignancies .
Endometrial thin , regular , less than 1 mm .
Both shrink ovarian normal shape and size . Do
not appear on both adnexal tumor mass .
Invisible ascites . Liver , gall bladder and a
second ginajl normal .
Impression : cervical malignancies

Work diagnose
Vaginal bleeding ec Ca Cerviks clinical stage
IIIA
+
Hypertension Grade II

Prognosis
Quo ad vitam
: dubia ad malam
Quo ad functionam : dubia ad malam

TREATMENT
Observation of vital signs and
bleeding ,
Asam Traneksamat 3x100 mg IV,
Asam Mefenamat 3x500 mg PO,
Captorpil 3x25 mg PO,
R/ CT scan with kontras.

Definition

CA CERVIX
Primary malignancy of the cervix uteri
( the cervical canal and or porsio )
Patients between 30-60 years of
age , Most are 45-50 years old.

Epidemiology

Ranks first in cancer incidence worldwide An estimated

493,000 new cases and 274 000 deaths per year in 2002 .
Basic Health Research in 2007 showed the prevalence of
cancer in Indonesia is 4.3 per 1,000 population. Every year
found 500,000 new cases of cervical cancer and three
quarters of them in developing countries .
Worldwide ratio of mortality to incidence is 55 % . RS dr .
Ciptomangunkusumo , cervical cancer is 76.2 % of 1,717
gynecological cancer from years 1989 to 1992 with an
overall survival rate at 5 years ranges from 56.7 % -72 %
anatara .
During the period of 5 years ( 1975-1979 ) at Dr Sardjito
there are 179 of the 263 cases ( 68.1 % ) .

Risk factor
MAYOR
HPV (Human
Papilloma Virus)
tipe 16, 18, 31, 33,
35,39,45, 51, 52, 56, 58,
59, 66, 68, dan 70

MINO
R

According daianda (2007 ) :

-Married young age ( < 16
years )
-Multiple sexual partners
- Exposure to STIs ( sexually
transmitted infections )
-smoke
-Deficiency of vitamin A / Vit C /
Vit E Old age ( > 35 years )
-A history of sexually
transmitted diseases such as
kutilgenital
-Parity or the number of births
that many
-Use of hormonal
contraceptives

Etiology
direct cause is not known with certainty.
The main causes of family papovirida
Human Papilloma Virus ( HPV ) cause
cervical cell .
Oncoprotein E6 and E7 derived from HPV
is the cause of the malignancy .

ANATOMY

Histology
nonkeratinizing ectocervix stratified
epithelium squamous epithelium ,
consisting of : basal layer Parabasal and
intermediate layers superficial layer
stroma mixture smooth muscle and
fibrous tissue ( fibromuskuler ) made of
collagen connective tissue ( smooth
muscle and elastic tissue ) and ground
substance ( mucopolysaccharides ) .
Stroma walking through the intake of
blood vessels , lymphatics and nerves

 Endocervical columnar epithelium is

covered by a layer of mucin
The border between layered squamous
epithelium of the ectocervix and
endocervical columnar epithelial layer
called the squamocolumnar junction
( SSK ) or squamocolumnar junction
( SCJ ) .

 squamous epithelium Relatively

opaque color and a pale pink due to
the multilayered histology and
presence of blood vessels under the
basement membrane .
squamocolumnar junction The
connection between squamous
epithelium and columnar epithelium .
Its location is influenced by age and
hormonal . During perimenarche ,
SSK is at or very close to the os
eksternum .

 Transformation zone It's

important to identify and
treatment of cervical
intraepithelial neoplasia . SSK
transformation zone lies
between original and new
SSK

 Age Related Changes in Transformation

Zone
- At 18-20 the first week of embryonic life
connects the vagina and cervix
- In the childhood until puberty , cells are
squamous meet with the rest of columnar cells in
squamocolumnarjuncntion ( SCJ ) , a thin line of
meeting existing on the surface of the cervix .
- With the arrival of puberty columnar cells in
SCJ gradually replaced by squamous cells of
emerging , this process is called squamous
metaplasia occur in the transformation zone .

 The importance of these changes in

Preventing Cervical Cancer
- In the early years of puberty , most of the
cells in the T - zone is columnar cells .
Substitution of these cells with cells of
the newly formed squamous is beginning.
- During this period the cells in the T zone, and especially the cells in SCJ is the
most vulnerable to changes associated
with cancer driven by certain types of
HPV and other supporting factors

Symptoms and Signs

Early diagnose

The spread of cervical cancer

(Diananda,2007)

LIMFOGE
N
HEMATOG
EN
parametrium , body
of the uterus ,
vagina , bladder and
rectum

immediate
deploymen
t

Examination
The standard examination is
recommended by FIGO clinical
examination which is the basis for
determining the stage of disease

investigations in patients with

cervical cancer (Aziz, 2006)
Pap smear

Colposcopes

Radiolog

Diagnosis
Histopathological examination of
tissue obtained through biopsy .
Location biopsy should be taken from
healthy tissue and avoid biopsy tissue
necrosis in large lesions . If the biopsy
is suspected mikroinvasi , followed by
conization , conization can be done
with a knife (cold knife ) or with
electrocautery .

 Diagnosis is based on symptoms and examination

results as follows : pap smear
Pap smear results are as follows :
- Normal .
- Mild dysplasia ( early changes that have not
malignant ) .
- Severe dysplasia ( further changes are not
malignant ) .
- Carcinoma in situ ( cancer confined to the
outermost layer of the cervix ) .
- Invasive cancer ( cancer has spread to deeper
layers of the cervix or other organs ) .

 biopsy Done if the pelvic exam

seemed a growth or lesion on the
cervix , or if the pap smear test
results showed an abnormality or
cancer .
Colposcopy ( examination of the
cervix with a magnifying lens )
Schiller test Cervical smeared with
iodine solution , healthy cell color will
change to brown , while abnormal
cells turn white or yellow color .

Stadium

Tingkat Kriteria
0
Karsinoma insitu (preinvasive carcinoma)
1
Karsinoma terbatas pada serviks
1A Karsinoma hanya bisa di diagnosis secara mikroskopis
1A1
Invasi stroma dalamnya 3 mm dan lebarnya < 7 mm
1A2 Invasi stroma dalamnya 3-5 mm dan lebarnya > 7 mm
1B Secara klinis tumor dapat diidentifikasi pada serviks atau massa tumor lebih
besar dari 1A2
1B1 Secara klinis lesi ukuran < 4 cm
1B2 Secara klinis lesi ukuran > 4 cm
II Tumor telah menginvasi uterus tapi tidak mencapai 1/3 distal vagina atau
dinding panggul
IIA Tanpa invasi ke parametrium
IIB Dengan invasi ke parametrium
III Tumor menginvasi sampai dinding pelvis dan atau menginfiltrasi sampai 1/3
distal vagina, dan atau menyebabkan hidronefrosis atau gagal ginjal
IIIA Tumor hanya menginfiltrasi 1/3 distal vagina
IIIB Tumor sudah menginfiltrasi dinding panggul
IVA Tumor menginvasi mukosa kandung kemih atau rectum dan atau menginvasi
keluar dari true pelvis
IVB Metastasis jauh

Clasification of cancer:

Grossly :
-preclinical stage
-stadium beginning
-Stadium half more
-advanced stage

Mikroskopis
Displasia
Stadium karsinoma insitu
Stadium karsinoma
mikroinvasif
Stadium karsinoma
invasive

Treatment
Setelah diagnosis kanker serviks ditegakkan
tentukan terapi yang tepat
Jenis terapi tergantung usia dan keadaaan
pasien, luasnya penyebaran dan komplikasi
yang menyertai.
Menurut Setyarini (2009) penatalaksanaan
yang dilakukan pada klien kanker serviks,
tergantung pada stadiumnya. penatalaksanaan
medis terbagi menjadi tiga cara yaitu:
histerektomi, radiasi dan kemoterapi.

Histerektomi
Suatu tindakan pembedahan yang
bertujuan untuk mengangkat uterus
dan serviks (total) ataupun salah
satunya (subtotal).
Biasanya dilakukan pada stadium
klinik IA sampai IIA (klasifikasi FIGO).
Umur pasien sebaiknya sebelum
menopause, atau bila keadaan
umum baik, dapat juga pada pasien
yang berumur kurang dari 65 tahun.

Radiasi
Bertujuan untuk merusak sel tumor pada serviks serta
mematikan parametrial dan nodus limpa pada pelvik.
Kanker serviks stadium II B, III, IV diobati dengan radiasi.
Pengobatan kuratif ialah mematikan sel kanker serta sel
yang telah menjalar ke sekitarnya dan atau
bermetastasis ke kelenjar getah bening panggul, dengan
tetap mempertahankan sebanyak mungkin kebutuhan
jaringan sehat di sekitar seperti rektum, vesika urinaria,
usus halus, ureter. Radioterapi dengan dosis kuratif
hanya akan diberikan pada stadium I sampai III B.
Bila sel kanker sudah keluar rongga panggul, maka
radioterapi hanya bersifat paliatif yang diberikan secara
selektif pada stadium IV A.

Kemoterapi
Pemberian obat melalui infus, tablet, atau
intramuskuler.
1. Utamanya untuk membunuh sel kanker dan
menghambat perkembangannya.
2. Untuk penyembuhan
3. Untuk mencegah kanker yang kambuh, ini
disebut pengobatan adjuvant.
4. Untuk mengontrol penyakit dalam periode waktu
yang lama walaupun tidak mungkin sembuh.
5. Sebagai paliatif untuk memberikan kualitas
hidup yang lebih baik.

Prognosis
Prognosis

tergantung dari

stadium
5-years survival rate :
1.stadium I lebih dari 90%,
2.stadium II 60-80%,
3.stadium III kira - kira 50%,
4.stadium IV kurang dari 30%.

Pencegahan (Menurut Dalimartha (2004) )

Menunda aktifitas seksual
sampai usia 20 tahun dan
berhubungan secara monogamy

Vaksinasi HPV proteksi > 90

%.

kontrasepsi
metode barier (kondom,

Pemakaian

diafragma, dan spermisida) yang

memiliki proteksi terhadap agen

DETEKSI DINI KARSINOMA SERVIKS

The American Cancer Society, the American College of
Obstetricians and Gynecologists, the American Society
for Colposcopy and Cervical Pathology, dan the US
Preventive Services Task Force menetapkan protokol
skrining bersama-sama, sebagai berikut :
Skrining awal
Thinprep atau sitologi serviks dengan liquid-base
method setiap 1-3 tahun untuk usia di bawah 30
tahun yang berisiko
Skrining untuk wanita di atas 30 tahun menggunakan
Paps smear dan pemeriksaan DNA HPV.
Skrining dihentikan bila usia mencapai 70 tahun atau
telah dilakukan 3 kali pemeriksaan berturut-turut
dengan hasil negatif.

Vaksin HPV
Vaksin HPV (telah disahkan oleh Food and Drug
Administration (FDA) dan Advisory Committee on
Immunization Practices (ACIP) dan di Indonesia
sudah diizinkan badan POM RI.) yang telah beredar
dibuat dengan teknologi rekombinan berpotensi
untuk mengurangi angka morbiditas dan mortalitas
Terdapat 2 jenis vaksin HPV yaitu :

vaksin bivalen (tipe 16 dan 18,

Cervarix)
vaksin quadrivalen (tipe 6, 11, 16 dan
18, Gardasil)
Vaksin ini mempunyai efikasi 96-100% untuk
mencegah kanker leher rahim yang disebabkan oleh

Vaksin HPV
Vaksin hpv diberikan pada perempuan usia 10-55 th
melalui suntikan sebanyak 3x yaitu :
Pemberian 1st saat kunjungan pertama ke pusat kesehatan
Pemberian 2nd 2 bulan setelah dosis pertama
Pemberian 3rd 6 bulan setelah dosis pertama

Imunisasi diberikan dengan dosis 0,5 mL secara

intramuskular pada M.deltoideus, untuk vaksin HPV
bivalen, imunisasi diberikan dengan jadwal 0, 1 dan 6
bulan. Sedangkan untuk vaksin HPV kuadrivalen,
dengan jadwal 0, 2 dan 6.
Dari penelitian yang dilakukan, terbukti bahwa respon
imun bekerja 2x lebih tinggi pada remaja berusia 10-14
th dibanding yang berusia 15-25 th

THANK YOU