TRIGGER 5
HEMATOLOGY ONCOLOGY
Group C
Trigger:
A 37 years-old female, came to gynecolog due to
per vaginam bleeding since 1 week ago. She told
that there was smelly discharge since 1 year ago
and she got a medicine from a primary health
care but no improvement. She also complain
that there was a post coital bleeding since 1 year
ago and she got heavy menstrual bleeding in the
past 6 months.
She told that she married twice, is an active
smoker, has three children, a contraceptive user.
Her husband is an long track bus driver.
On physical examination her blood pressure was
110/g70 mmHg, pulse rate 100/min, respiratory
rate 22/min, temperature 37 0 C. Cor and pulmo
were no alteration. Abdomen normal.
Extremities: slightly edema.
Laboratory findings
Hb 7.6 g/dL, hematocrit 22 %, leukocyte
7800/uL, platelet 400.000/uL
Identification of keywords:
•37 yo female
•Per vaginam bleeding since 1 week
•Smelly discharge since 1 year
•Consumed medicine from primary health
care  no improvement
•Post coital bleeding since 1 year ago
•Heavy menstrual bleeding (past 6 months)
•Risk factors:
•Married twice
•Active smoker
•Three children
•Contraceptive user
•Husband occupation: long track bus
driver
•PE: slightly edematous extremities
•Lab findings: anemia (Hb 7.6 g/dL, Ht 22%)
Identification of problem:
The woman is suffering from
per vaginam and post coital
bleeding
Analysis of problem
Female, 37 years old
-Married 2x
-Contraceptive use
- Active Smoker
- 3 children
- Husband: long track bus driver.
Smelly discharge
Post coital bleeding
(since 1 year ago)
Infection (HPV?)
Differential
Diagnosis
Heavy menstrual
bleeding (since 6
months ago)
Trauma
Bleeding disorder
Malignancy Infection
Per vaginam bleeding
(since 1 week ago)
Malignancy
(Uterus, cervical, ovaries?)
Definitive diagnosis:
CERVICAL CANCER
Current condition
-Slight edema
- Anemia
Age, post-coital
bleeding
Complication
Hypothesis
The woman suffers
from cervical cancer
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Identification of knowledge needed
Normal anatomy & histology woman’s reproductive
organs  Christy
Cervical cancer
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ADENOCARCINOMA  Nissha, Didit
SQUAMOUS CELL CARCINOMA  Astari Raisa
Symptomatology  Michelle, Fidi
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Definition
Classification
Etiology (HPV)
Epidemiology & Risk factors
Pathogenesis & Pathophysiology
Clinical Manifestations & Diagnosis (including
examination)
Management & treatment
Prognosis & complications
Prevention and education
Smelly discharge
Post coital bleeding
Edema
Per vaginal bleeding
Heavy menstrual bleeding
Anemia
DD (Definition, pathophysiology – pathogenesis,
clinical manifestations)  Mariska, Bhanu
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Uterine cancer
Ovarian cancer
Trauma  what kind of trauma?
Infection  mention types of infection
Bleeding disorder  known
•Identification of knowledge known
1.Anemia
2.Bleeding disorder
3.Edema
•Identification of appropriate learning
resources
•Textbooks:
Anatomy
Histology
Oncology
Hematology
Pathology
Pharmacology
Internal Medicine
Epidemiology / community medicine
Gynecology
•Reliable internet sources
•Medical journals
Resource person
Anatomy of Female’s
Reproductive System
Christy Magdalena
1206289312
Trigger 5/Group C
Introduction
• The female’s reproductive system includes
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ovaries (female gonads),
uterine/fallopian tubes/oviducts,
uterus,
vagina, and
External genitalia.
• The ovaries, fallopian tubes, and uterus are surrounded by broad
ligament.
• The fallopian tubes run along the superior border of broad ligament
and open into the pelvic cavity lateral to the ovaries.
• The free border of the broad ligament that attaches to each
fallopian tube is known as the mesosalpinx, while the mesovarium
stabilizes the position of each ovary
Ovaries
• It is responsible for the production of ova and
hormones
• Each ovary is supported by the mesovarium and
also by a pair of supporting ligaments:
– ovarian ligament: lateral wall of the uterus  to the
medial side of the ovary
– suspensory ligament: lateral side of the ovary past the
open end of the fallopian tube to the pelvic wall
(inside: ovarian artery and ovarian vein. These vessels
run through the mesovarium along with nerves and
lymph vessels  linked to the ovary at the ovarian
hilum)
Uterine/Fallopian Tubes/Oviducts
1. Infundibulum.
– Fimbriae.
2. Ampulla
– longest and widest part.
– As it approaches the uterus, the thickness of smooth
muscle layers in the wall of the ampulla substantially
increases
3. Isthmus.
– A short part, which is located near the uterine wall
– This part joins the oviducts with the uterus
Uterus
• Located between the urinary bladder and rectum.
• It is a small, pear-shaped organ about 7.5 cm long
with a maximum diameter of 5 cm. The weight
ranges from 30–40 gram.
• Position of uterus:
– Anteflexion: uterus bends anteriorly near its base. The
body of the uterus lies across the superior and
posterior surfaces of the urinary bladder
– Retroflexion: uterus bends backward toward the
sacrum
Internal Anatomy of Uterus
Anatomically, uterus is divided into three regions:
1. Fundus: a dome-shaped portion superior to
the attachment of the fallopian tubes
2. Body or corpus: narrowing central portion 
largest portion of the uterus. This part ends at
cervix.
3. Cervix: An inferior narrow portion, which
opens into the vagina
• Isthmus: Connecting the corpus and the cervix.
– Length is 1 cm
– The internal part of the corpus  uterine cavity
– The internal part of cervix  cervical canal
– The cervical canal opens into the uterine cavity at
the internal os (internal orifice) and into the vagina
at the external os (external orifice).
Suspensory ligaments of uterus
In addition to mesenteric sheet of broad ligament, there are
three pairs of suspensory ligaments.
• Uterosacral ligaments
• Round ligaments
• Cardinal ligaments
Uterosacral ligaments. These ligaments run from the lateral sides of the uterus to the
anterior part of the sacrum. The function is to keep the corpus of the uterus from moving
anteriorly and inferiorly
Round ligaments arise on the lateral margins of the uterus just inferior to
the bases of the uterine tubes. They extend anteriorly, passing through the
inguinal canal before ending in the connective tissues of the external
genitalia. These ligaments mainly limit posterior movement of the uterus.
Cardinal ligaments extend from the base of the uterus and vagina to the lateral walls of the
pelvis. These ligaments prevent the inferior movement of the uterus
Uterine Wall
• Outer: muscular myometrium
– The thickest segment of the uterine wall
– The smooth muscle tissue functions to push fetus
out of the uterus and into the vagina
• Inner: glandular endometrium or mucosa
- Many uterine glands open onto the endometrial
surface.
- The fundus and the anterior and posterior surfaces of
the uterine body are lined by a serous membrane
continuous with the peritoneal lining  perimetrium.
Vagina
• Vagina is an elastic,
muscular tube
extending from the
cervix to the vestibule.
• At the proximal end of
the vagina, the cervix
extends into the vaginal
canal. The recess
surrounding the cervical
protrusion is termed the
fornix.
External Genitalia
• It is covered by vulva or pudendum
• The following elements constitute vulva:
– Mons pubis  consisting of adipose tissue. Layered by skin
and coarse pubic hair  cushion the pubic symphysis
– Labia majora (singular: labium majus)  covered by pubic
hair and contains adipose tissue, sebaceous glands, and
sweat glands
– Labia minora (singular: labium minus) located medially to
the labia majora. Has no pubic hair and fat and has only a
small amount of sudoriferous glands, but they contain
many sebaceous glands.
– Clitoris is made up of two small erectile bodies, the
corpora cavernosa, and an abundance of nerves
and blood vessels. Located at the anterior junction
of the labia minora.
• Prepuce of the clitoris: a point where the labia minora
join and enclose the body of the clitoris. The exposed
portion of the clitoris is the glans clitoris.
• Analogous to penis in male
• Vestibule
– area located between the labia minora.
– Enclosing: hymen (if still present), the vaginal orifice,
the external urethral orifice, and the openings of the
ducts of several glands.
• The vaginal orifice is the opening of the vagina to
the external environment. It is bordered by the
hymen.
• Anterior to the vaginal orifice and posterior to the
clitoris is the external urethral orifice
• Bartholin’s glands (greater vestibular glands):
located on either side of the vaginal orifice.
– produce a small amount of mucus during sexual
arousal and intercourse  as lubrication in addition to
cervical mucous.
• Bulb of the vestibule is composed of two
elongated masses of erectile tissue. 
becomes swollen with blood during sexual
arousal  narrowing of vaginal orifice
Clitoris, External Urethral Orifice, Vaginal Orifice, Bartholiln’s glands, Bulb of the vestibule
Histology of Female Reproductive
System
Female reproductive system
• Internal reproductive organs
– Ovaries & oviducts
– Uterus
– Vagina
• External genitalia
– Labia majora
– Labia minora
– Vestibule
– Clitoris
Ovaries
• Covered by
germinal
epithelium
(simple
squamous or
cuboidal)
• Regions:
medullary
and cortical
Ovarian follicles
• Corpus luteum formed of the
remnants of Graafian follicle
after ovulation
– Granulosa-lutein cells
• Produce progesterone
• Convert androgen  esterogen
– Theca-lutein cells
• Corpus albicans formed by
degeneration of corpus luteum
• Atretic follicles  degeneration
of Graafian follicles
Oviducts
• The wall:
– Mucosa
• Simple columnar epithelium
– Peg cells  secretion
– Ciliated cells  movement
• Lamina propria
– Muscularis
• Inner circular
• Outer longitudinal
– Serosa
• Simple squamous
epithelium
CERVICAL CANCER
Molecular pathogenesis and etiology
(1)
HPV is thought to occur through microabrasions in the epithelium that expose the
cells in the basal layer to viral entry
Cells in the basal layer consist of stem cells, called reserve cells that are
continuously dividing and provide a reservoir of cells for the suprabasal regions.
Cells at early reserve cell hyperplasia are preferred targets for HPV viruses
HPV infections are likely to occur in the transformation zone, due to the
appearance of reserve cells in this zone.
Viruses will establish their genomes as multicopy nuclear episomes in reserve cells
cells, ultimately forming koilocytes
The infected basal cell undergoes cell division, and the daughter cell migrates
away from the basal cell layer and undergoes differentiation.
In these differentiated suprabasal cells, production of mature virions occur.
Viruses will then be shed off via desquamation, allowing transmission to other
cells.
Viral DNA episome
Early Open Reading Frames (ORFs) of the HPV virus encode for E1, E2, E4, E5,
E6 and E7 HPV proteins.
E1 and E2
E1 and E2 are responsible
for the maintenance of
viral DNA as an episome
during initial HPV
infection
Involved in the packaging
of HPV DNA and in the
promotion of virion
assembly
E2 facilitates the
separation of the HPV
genome
 distribution of HPV
DNA into daughter cells
E2 has the capacity to
repress the activity of E6/
E7 promoter
E6 and E7
E6  p53 (tumour
suppressor gene)
E7  Rb family
E6 binds to the p53 tumour
suppressor protein as part
of a trimeric complex with
the cellular ubiquitin
complex E6AP
Leading to the rapid
proteasomal degradation of
p53, and thus loss of
tumour suppressor
function in cells.
E7 binds to the retinoblastoma (Rb) family
of tumor suppressors
In normal uninfected epithelia, cells exit
the cell cycle as they leave the basal layer
However, in the case of infected cells, as
infected cells leave the basal cell layer and
undergo differentiation, they remain
active in the cell cycle due to the action of
the E7 protein on Rb.
• Rb helps stimulate cells to reenter the S phase thus,
restarting the cell cycle and allowing for proliferation.
• The presence of E7 leads to a characteristic retention
of nuclei throughout all layers of infected epithelia.
HPV types
• HPV types may be grouped into low-risk HPV
type and high-risk HPV type
– Low risk HPV  HPV 6, HPV 11 (causes low grade
CIN,  CIN 1)
– High risk HPV  HPV 16, HPV 18 (causes high
grade CIN  CIN2 and CIN3)
Low-grade CIN
• Low-grade CIN occurs due to infections caused by low-risk HPV 6 and 11.
• HPV6 and 11 can cause:
– 90% of the time  Genital warts (condylomata acuminata)
– 10% of the time  low grade CIN, which may be cleared by the immune
system in less than a year.
• Low grade HPV infection can also be caused by high-risk HPV types, e.g.
HPV 16 and HPV 18, which can then lead to progression to cervical cancer.
• Viruses will establish their genomes as multicopy nuclear episomes in lowgrade CIN.
• In differentiated suprabasal cells, viral replication and assembly can
proceed.
• Differentiated squamous cells then undergo desquamation, releasing virus
particles and allowing transmission of the virus.
High-grade CIN
• Persistent infections through increasing number of sexual partners
with high-risk HPV types can lead to squamous carcinoma or less
commonly adenocarcinoma of the cervix.
• Cells in high-grade CIN usually contain HPV types 16, 18, 31, 33, 35,
39, 45, 51, 52, 56, 58, 59 and 68,
– 16 and 18 being the most common, accounting for 70% of invasive
cancers.
• In high grade CIN, viral DNA integrates into the cell genome.
• After HPV integrates into host DNA, copies of episomal viral DNA are
no longer seen and do not accumulate in the cell cytoplasm.
• Koilocytes are not seen, and this is the case in high-grade dysplasia
and all invasive cancers.
Low risk and high risk HPV both express the same
proteins. Why is one malignant and not the other?
• Recall  E2 has the capacity to repress the
activity of E6/ E7 promoter.
– The integration of HPV DNA within the cellular genome
disrupts the E2 ORF
– Loss of normal E2 repressing function on E6 and E7
– Permitting free transactivation of E6/E7 promoter by:
• Cellular transcription factors, nutritional agents  random
activation
• Increased expression of E6 and E7 oncoproteins, leading to
malignancy.
Role of HPV in the pathogenesis of
cervical neoplasia
(Persistent infection with high-grade HPV
types)
Screening, Examinations, Prognosis,
Complication, Prevention, Education
of Cervical Cancer
Raisa Cecilia Sarita
Group C
Papanicolau Smear (Pap Smear)
1. Places the speculum
inside the vagina
2. A small brush or a
cotton-tipped swab is
then inserted into the
cervical opening to
take a sample from
the endocervix
3. The cell samples are
then prepared so that
they can be examined
under a microscope in
the laboratory
Then, it will proceed to laboratory using 2 ways :
- Conventional Cytology
- Liquid-based cytology
Papanicolau Smear (Pap Smear)
• RESULT :
– Negative for
intrapeithelial
lesion or
malignancy
– Epithelial cells
abnormalities
– other malignant
neoplasms
HPV Typing / HPV Tests
Tests for the types of HPV that are most likely to cause
cervical cancer (high-risk types) by looking for pieces of their
DNA in cervical cells.
The test is done similarly to the Pap test in terms of how the
sample is collected, and in some cases can even be done on
the same sample.
Cervicography
Cervicography is a photographic screening technique in which a 35-mm
photo is taken of the cervix after staining with acetic acid.
VIA (Visual Inspection with Acetic Acid)
- A comprehensive screening that
is applicable in low resource
settings area
- using some simple instruments
include cotton swabs,
examination table, speculum,
adequate light source, speculum,
gloves, and 3% to 5% acetic acid.
Treating the positive pre-cancer :
- Cryotheraphy
- Loop Electrical Excision
Procedure
procedure
• starts similarly in a way of pap smear in
order to open the vagina using speculum.
• After the inspection of cervix, soak a clean
swab in 3% to 5% acetic acid and apply to
the cervix liberally.
• Wait at least 1 full minute for the acetic acid
to be absorbed, after that, observe the
transformation zone carefully, especially
near the squamocolumnar junction .
• POSITIVE  sharp, distinct, well-defined,
dense (opaque/dull or oyster white)
acetowhite areas, with or without raised
margins, close to the squamocolumnar
junction near the transformation zone.
Medical History and Physical
Examinations
Ask the patient about his/her complete personal
and family medical history.
Include any information related to the risk factors
and symptoms of cervical cancer.
An integrated and complete physical examination
 evaluate patient’s general state of health.
A pelvic exam and a pap test may be done if one
has not already been done.
Patient’s lymph nodes will be checked closely for
evidence the spreading of cancer.
Physical Examinations
Bates
Colposcopy
The colposcope is an instrument used to
magnify and examine the transformation zone
of the cervix to identify abnormal areas
It lets the doctor see the surface of the cervix
closely and clearly
The doctor will apply a weak solution of acetic
acid to your cervix to make any abnormal areas
easier to see
If an abnormal area is seen on the cervix, a biopsy will
be done. For a biopsy, a small piece of tissue is removed
from the area that looks abnormal. The sample is sent
to a pathologist to look at under a microscope.
Other Cervical Examinations
Cervical Biopsies
• Colporoscopy biospy
• Endocervical biospy
• Cone biospy
Imaging Studies
 Chest x-ray  lung metastasis
 Computed Tomography (CT)  on
abdomen and pelvis, detect any
lymph node and organ metastasis
 Magnetic Resonance Imaging (MRI)
 local extracervical invasion
 Intravenous Urography 
hydronephrosis
 Positron Emission Tomography
(PET)  lymph node metastasis
Prognosis and Complication
The prognosis of patient depends on the
stage of cervical cancer
The complications can occur as side effect of
treatment or as result of advanced cervical
cancer. For instance :
- Early Menopause
- Narrowing of Vagina
- Lymphoedema
- Emotional Impact
- Pain
- Kidney failure
- Bleeding
- Vaginal discharge
Prevention and Education
• Avoid being exposed to HPV
– HPV is passed from one person to another during skin-toskin contact with an infected area of the body
– Wait for sex in appropriate age
– Use condom, men circumcision
• Do not smoke
• Maintain good diet
• Vaccination
– Gardasil  HPV 6,11,16,18
– Cervarix  HPV 16,18
– Series of 3 injections over 6 month period
References
•
•
•
•
•
•
•
•
Aziz K, Wu G. Cancer screening. 1st ed. Totowa, N.J.: Humana Press; 2002.
Longo D, Harrison T. Harrison's hematology and oncology. 1st ed. New York: McGraw-Hill Medical;
2010.
12. F. Boggess J, Lin Bae-Jump V. Cervical Neoplasia [Internet]. 1st ed. Philadelphia: Centers for
Disease Control and Prevention; [cited 30 September 2014]. Available from: http://www.
cdc.gov/cancer/cervical
American Cancer Society. Cervical Cancer. [Internet]. [cited 30 September 2014]. Available from :
http://www.cancer.org/acs/groups/cid/documents/webcontent/003094-pdf.pdf
Camacho Carr K, W. Sellors J. Cervical Cancer Screening in Low Resource Settings: Using Visual
Inspection With Acetic Acid. Journal of Midwifery & Women's Health [Internet]. 2010 [cited 30
September 2014];49(4). Available from: http://www.medscape.com/viewarticle/484034_8
National Health Services. Cervical Cancer Complications. [Internet]. [cited 30 September 2014].
Available from : http://www.nhs.uk/Conditions/Cancer-of-the-cervix/Pages/Complications.aspx
Women's Health.gov. Pap Tests [Internet]. 2014 [cited 30 September 2014]. Available from:
http://www.womenshealth.gov/publications/our-publications/fact-sheet/images/PapTest-large.jpg
Cleveland Clinic. Cervical Cancer Screening [Internet]. [cited 30 September 2014]. Available from:
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/womens-health/cervicalcancer/images/cervical-cancer-fig2_large.jpg
Diagnosis, Clinical Manifestation,
Management & Treatment in
Cervical Cancer
Dhitya Prasetya
Group C
Physical Findings
• The first step of evaluation, and to provide
good information regarding the condition of
the disease
• Physical appearance:
- Exophytic  Proliferating outside the organ
- Endophytic  Tumor is invading the tissue
- Ulcerative
Barrel-Shaped Cervical Cancer
Diagnosis
• One of the gold standard is to provide routine
Pap smear screening if there is suspicion of
malignancy
• If there is an invasive malignancy, cytologic
evaluation may be needed to confirm the
diagnosis by cervical punch biopsy, because
cytologic evaluation sometimes can give false
negative result.
Colposcopy
• Colposcope are used to examine the cervix
with the help of speculum, and the instrument
is actually in outside of the body leaving just
the magnifying lenses inside the cervix
Cervical Biopsies
Colposcopic
Biopsy
Endocervical
Scraping
Cone Biopsy
Colposcopic Biopsy
• In this type of biopsy the cervix is examined
with the colposcope to find the abnormal
areas, and use biopsy forceps section of the
abnormal area on the surface of the cervix.
Endocervical Scraping
• Cervical cancer usually occur in the
transformation zone, in which the area are
usually filled with HPV, but using colposcope
alone cannot determine whether the cervix is
caused by infection
Cone Biopsy
• In this procedure, the physician removes a
cone-shaped piece of tissue from the cervix
• In cone biopsy the base of the cone is formed
by exocervix and the apex is from endcervix.
While the transformation zone is contained
within the cone specimen
Imaging Studies
• Imaging studies can also be one of the
alternative method to detect cervical cancer.
The most common type of imaging are MRI
and CT scan
• However there are other alternative method
that can be used to diagnose the cervical
cancer
CT Scan & MRI
• CT Scan  The CT scan in cervical cancer can
be one of the guiding method for biopsy to
locate the area which has already been
invaded by the cancer.
• MRI  The most common use of MRI in
cervical cancer is to examine pelvic tumors.
Intravenous Urography
• This test usually find abnormalities in the
urinary tract, however changes in the pelvic
lymph nodes will make a compression or
even block the ureter. The use of IVP is
usually rare for cervical cancer.
Positron Emission Tomography (PET)
• The use of PET is actually to find large glucose
activity by the radioactive atom.
• In cervical cancer we know that there is a lot of
angiogenesis from the tumor and because of
this many glucose activity will be high in that
particular area.
Clinical Staging
• In cervical cancer there are 4 stages and each of
the stage has their own characteristic
• Stage 1  stage 1 it has been group into stage 1A
and 1B. Stage 1A is the condition where the
cancer has invade the superficial region with a
depth of 5.0 mm and wide 7.0 mm, while for
stage 1B the cancer is still confined in the cervix,
however the depth has reached greater than 4.0
cm in size
• Stage 2  In stage 2 the cancer extends
beyond the cervix but has not extended to the
pelvic wall, although the cancer may involve
the vagina but not that deep.
• It also have two groups which are stage 2A and
2B while for stage 2A there are no parametrial
involvement, while stage 2B there are
parametrial involvement
• Stage 3  Stage 3 involves the cancer that has
extended to the pelvic wall, and the tumor are
involve in the lower third of the vagina.
• Stage 4  The cancer has extended beyond the
pelvis and involve the mucosa of the bladder or
rectum. While the group has been divided into 4A
and 4B the difference is that stage 4A is that the
cancer has spread to the adjacent organs while 4B
the cancer has spread to distant organs
Clinical Manifestation
• In pre-invasive the tumor show no sign of
symptoms, however that as the tumor
progress to become invasive sometimes
women will complain of abnormal vaginal
discharge and intermenstrual bleeding after
coitus
• Other clinical manifestation such as pain, loss
of appetite, and weight loss are late
manifestation
Treatment
• In treating cervical cancer, it is important to
treat the cancer according to the stages. Most
common physical findings that needs to know
are the size, depth of invasion, and how far the
spreading of the cancer
• Most common treatment
- Surgery
- Radiotherapy
- Chemotherapy
Surgery
• 1. Cryosurgery
- Surgical method that uses metal probed with
liquid nitrogen that will freeze the abnormal
cells. The use of this surgery is actually a precancer surgery, which there cannot be any
invasive cancer
• 2. Laser Surgery
- Laser surgery is actually a focused laser beam
that aims directly to the vagina, and it is often
use to burn the abnormal cells or remove tissue
for other evaluation
• 3. Conization
- The cone biopsy is used to diagnose the cancer
before additional treatment can be given such
as surgery or radiation
- This type of surgery is actually one of the
surgical method that is used to treat stage 1A
cancer, in which the women still wants to
preserve to have a children.
• 4. Hysterectomy
- This type of surgery that actually remove the
uterus and the cervix, while the vagina and
pelvic lymph nodes are not removed
- 3 Types of Hysterectomy:
• When the uterus has been removed with
surgical incision in front of the abdomen it is
known as abdominal hysterectomy
• If the uterus is removed through the vagina it is
known as vaginal hysterectomy
• if the uterus is removed by laparoscopy it is
known as laparoscopic hysterectomy
- This surgery is used to treat stage 1A cervical
cancers but sometimes it can also be used in
stage 0
Radical Hysterectomy
• This surgery remove the uterus along with the
parametria and uterosacral ligaments, and also
the upper part of the vagina
• The ovaries and fallopian tubes are not
removed unless there is some medical concern
Pelvic Lymph Node Dissection
• This type of surgical approach usually remove
some of the lymph nodes or lymph node
sampling
• The consequence of removing the lymph
nodes will caused fluid drainage in the leg,
which can caused swelling in the leg or known
as lymphedema
Radiation Therapy
• The use of radiotherapy must be carefully
calculated the number of dose
• The use of radiotherapy usually takes 6-7
weeks to complete, moreover in cervical
cancer the type of the radiation therapy is
often given along with low doses of
chemotherapy with a drug called cisplatin
Brachytherapy
• This is an internal radiation to treat cervical
cancer in women who already had
hysterectomy.
• The radioactive material will be placed in a
cylinder shape in the vagina
Chemotherapy
• The use of chemotherapy is to give anti-cancer
drugs which are injected or given orally and
the drugs will enter the bloodstream and kill all
cancer in the body
• In some stages of cervical cancer both
radiation and chemotherapy are used together
to work better which is called concurrent
chemoradiation
Targeted Therapy
• The drugs are used to respond to the changes
of the cancer cells such as by blocking the
forming of blood vessels to the cancer cells
which the most common drugs is bevacizumab
References
• Steven. M. Manual of Gynecologic Oncology and
Gynecology. 1st ed. Boston: A Little Brown; 1989.
• John. F. Abeloff’s Clinical Oncology. 5th ed. Virginia:
Elsevier Saunders; 2014.
• American Cancer Society [Internet]. [Cited: 1 OCT
2014] [Last Updated: 8 AUG 2014]. Available
from:
http://www.cancer.org/cancer/cervicalcancer/det
ailedguide/cervical-cancer-diagnosis
Symptomatology: POSTCOITAL BLEEDING,
VAGINAL DISCHARGE, EDEMA
Trigger 5
Fidinny Izzaturrahmi Hamid
1206225542
Cervical cancer
Anemia
Post coital
bleeding
Per vaginal
bleeding
Heavy
menstrual
bleeding
Smelly
discharge
Edema
Abnormal vaginal bleeding
abnormal or unscheduled bleeding from the lower
genital tract
– intermenstrual bleeding ( a non menstrual bleeding that occurs at any time
during the menstrual cycle other than during normal menstruation)
– postcoital bleeding
– menorrhea (post menopause bleeding)
Post-coital bleeding
non-menstrual bleeding that occurs after sexual
intercourse
• first manifestations of cervical cancer.
Post-coital bleeding
Post-coital bleeding
most concerning causes of post coital bleeding are
cervical cancer and cervical intraepithelial
neoplasia
• malignancies would most likely to cause damage to
their surrounding tissues would result in bleeding.
• 6% of women per year
• in 1-39% of women with cervivcal cancer.
• 2/3 in post coital bleeding patients  idiopathic
– If certain bleeding only occur during/after sex :
consider the etiologies
Smelly Discharge
Vaginal discharge– leucorrhea
• Common.. Normal: clear and white discharge
• mucus naturally produced from the cervix.
• Abnormal when:
•a change in color or consistency
•a sudden bad smell
•an unusually large amount of discharge
•another symptom alongside the discharge, such as itching outside your vagina or pain
in your pelvis or tummy
•unexpected bleeding from the vagina
•Most cases due to infection!
Infection
Breakdown of
tissue
Cancer of cervix
Leakage of
bladder or bowel
contents
Smelly discharge
Edema
A late clinical onset of cervical cancer.
•
malignancy
Press ureters
Blocked urine
flow
Hydronephrosi
s
Scarred kidney
Kidney failure
Lower extremities
Persistent
Unilateral
bilateral
result
from
lymphatic
and
venous
blockage
a
characteri
stic of
advanced
stage
disease
(IIIB)
Water
retention
Edema, Hematuria. Shortness
of breath , tiredness
Michelle Audrey Darmadi
1206289193
Group C
DISORDERS OF MENSTRUAL CYCLE
• Amenorrhea: lack of menstrual bleeding, may be
– primary  failure of onset of menstrual periods by age
16
– secondary  lack of menstrual periods for 6 months in
a previously menstruating woman
• Dysmenorrhea: pain and other symptoms
accompanying menstruation
• Menorrhagia: excessive vaginal bleeding
• Metrorrhagia: irregular or abnormally protracted
vaginal bleeding
ABNORMAL VAGINAL BLEEDING
• Pre-pubertally
• At the time of usual menses but unusually
longer than normal duration
• At the time of usual menses but unusually
heavier
• Between menstrual periods
• After menopause in the absence of
pharmacologic treatment with estrogen and
progesterone (post-menopausal bleeding)
VARIOUS ETIOLOGIES OF VAGINAL
BLEEDING
• Infection: vaginitis
• Dysfunctional uterine bleeding: estrogen breakthrough,
estrogen withdrawal
• Benign lesions: uterine leiomyoma, cervical / endometrial
polyp, adenomyosis
• Trauma: intrauterine devices (IUD), genital laceration
• Pregnancy: ectopic pregnancy, miscarriage, threatened
abortion
• Malignancy: endometrial cancer, cervical cancer, vaginal
cancer
• Other diseases: autoimmune (lupus), thyroid disease,
hemostatic disturbances (von Willebrand’s disease,
thrombocytopenia)
Funtional
Disorder
• most common cause of abnormal vaginal bleeding
• Endocrine  ovulation disrupted  no corpus
luteum  no progesterone  continuous
proliferation of endothelium  sloughs off 
incomplete, irregular bleeding, may be for long time
Structural
Lesions
• often results in dysfunctional uterine bleeding.
• Benign tumors within endometrial cavity / uterine
wall  Disrupted normal endometrial vasculature
regulation  very heavy prolonged / sporadic
bleeding
Systemic
Condition with
Altered
Coagulation
• Any disorders affecting the production, quality, and
survival of either clotting factors or platelets can
cause abnormal vaginal bleeding.
• the rarest cause of abnormal vaginal bleeding
CERVICAL CANCER AND BLEEDING
• Cervical cancer  asymptomatic in precancerous
stage, detect by VIA / PAP
• Symptoms  lesion turned cancerous and starts
invading the underlying cervical stroma
• Erosion of cervical surface  tissue necrosis &
hemorrhage
• One of the first symptoms of the disease 
include post-coital vaginal spotting
• Later on, the highly vascular tumor mass may
enlarge and become ulcerated, resulting frank
vaginal bleeding, heavy vaginal discharge, or both
Cancer cells
increased
vascularity of
cervical
microcirculation
angiogenesis
sustained cell
growth
new branching
vessels in cervical
stroma pushed to
surface
more invasion of
cervical tissue
hit nearby blood
vessels
infiltration &
expansion of
tumor mass
irregular and
friable contour of
cervix
loss of surface
epithelium
increased vascular capillary supply &
increased friable and erosive cervical
surfaces with large collateral branches
 hemorrhage
increased risk of
hemorrhage
ulceration,
exophylic,
endophylic
lesions
bulky tumor and
increased
neovascularization
ANEMIA
• Severe chronic bleeding in cervical cancer may
ultimately lead to anemia (hemorrhagic anemia),
accompanied by weight loss and extreme fatigue
• Other than tumor bleeding , iron deficiency is also a
common cause of anemia in cervical cancer.
• Increases hypoxia of cervical carcinomas, worsening
iron deprivation, inflammatory reactions, infections 
correction  improve prognosis.
• Treated with either transfusion and/or erythropoietin
• Parenteral iron also was found to be perhaps effective
to increase hemoglobin in cervical cancer patients
REFERENCES
•
•
•
•
•
•
Loscalzo J, Fauci AS, Kasper DL, Longo DL, Braunwald E, Hauser SL, et al. Harrison’s
internal medicine. Philadelphia: Tim-McGraw Hill Companies; 2012
Kumar V, Abbas AK, Fausto N, Aster JC. Robbins and Cotran pathologic basis of
disease. 8th ed. International edition. Philadelphia: Elsevier Saunders; 2010
McPhee SJ and Hammer GD. Pathophysiology of disease: an introduction to clinical
medicine. 6th ed. San Fransisco: The McGraw-Hill Companies, Inc.; 2010
Zanotti K of The Cleveland Clinic Disease Management Project. Endometrial,
ovarian, and cervical cancer [internet]. 2010 Aug 1 [cited 2014 Sept 30]. Available
from:
http://www.clevelandclinicmeded.org/medicalpubs/diseasemanagement/womenshealth/gynecologic-malignancies/
Chernecky CC and Murphy-Ende K. Acute Care Oncology Nursing. 2nd ed. Missouri:
Elseier Saunders; 2009
Candelaria M, Cetina L, Dueñas-Gonzáles A. Anemia in cervical cancer patients:
implications for iron supplementation therapy. Med Oncol. 2005;22(2):161-8.
Differential Diagnosis: Infection &
Uterine Cancer
Mariska Anindhita
Pelvic Inflammatory Disease
• Polymicrobial infections most common 
• N. gonorrhoeae and C. trachomatis
– Gonorrhea and chlamydia infections
• Affected pelvic organs
– Ascend from cervix or vagina through the fallopian
tubes and ovaries
• Clinical manifestation
– Endometritis  abnormal bleeding, lower abdominal
pain
– Salpingitis malodorous vaginal discharge, nausea,
vomiting
Pelvic Inflammatory Disease
Porth CM & Matfin G. Pathophysiology: concepts of altered health states. 8th Ed.
Philadelphia: Lippincott Williams and Wilkins; 2009.
Pelvic Inflammatory Disease
• Other clinical manifestation
– Elevated C-reactive protein
– Back pain
– Fever
– Dyspaerunia
– Painful cervix  bimanual pelvic examination
– Increase sedimentation rate
– Elevated WBC count
Gonorrhea
• N. gonorrhoeae
infections
– Gram negative
diplococcus
• Vaginal discharge/heavy
bleeding
– Endocervitis
• Dysuria
• Abdominal pain
– Fallopian tube swell with
pus
• Asymptomatic
– Few cases
Gonorrhea
Rubin R & Strayer DS. Rubin’s pathology: clinicopathologic foundations of medicine.
6th Ed. Philadelphia: Lippincott Williams and Wilkins; 2012.
Chlamydia Infection
• Chlamydia trachomatis
– Gram negative bacteria
– 15 serotypes  D
through K
• Sign and symptoms
similar to gonorrhea
• Infected  cervical
mucosa severely
inflamed
• Inclusion bodies 
– metaplastic squamous
cell and endocervical
• Cytologic examination
– Coccoid bodies in
cytoplasm of cell
• Infiltration of
neutrophils and
lymphoid
Uterine Cancer
• Several types according to the location
– Endometrial adenocarcinoma  glandular lining
– Uterine leimyemoma  smooth muscle (benign)
• Most common uterine cancer  endometrial
cancer
• Hereditary cancer
– Family history  colorectal cancer  DNA
mistmatch repair genes inherited
Endometrial Cancer
• Frequent in older women (peak ages 55 to 65)
• Two types of endometrial cancer
– Type 1  prolonged estrogen exposure and
endometrial hyperplasia
– Type 2  not associated with condition in type 1
• Frequency  type 1 > type 2
• Malignancy  type 1 < type 2
Endometrial Cancer
• Exposure of estrogen
and progesterone to
endometrium
– Structural modification
and cellular changes
• Prolonged stimulation of
unopposed estrogen
– Endometrial hyperplasia
 atypical hyperplasia
 type 1 endometrial
cancer
• Conditions related to
type 1 endometrial
cancer
– Anovulatory cycles
– Disorders of estrogen
metabolism
– unopposed estrogen
therapy
– estrogen-secreting
granulosa tumour
– obesity
Endometrial Cancer
Main cause 
administration of
unopposed estrogen
without progesterone
Progesterone 
maturation of
endometrium
No progesterone 
sloughing of
endometrium 
continue growth 
hyperplasia
Endometrial Cancer
• Type-2-endometrial
cancer
– High-grade tumors
– Tend to recur in early
stages
– Result from underlying
disease in women with
elder age
• Signs and symptoms
– Painless bleeding 
prolonged menstruation or
sudden bleeding
(postmenopausal)
– Endometrium hyperplasia
– Cramping
– Pelvic discomfort
– Postcoital bleeding
– Lower abdominal pressure
– Enlarge lymph node
References
• Better Health Channel. Menstruation - abnormal bleeding.
[homepage on the Internet]. 2012 [cited 2014 Oct 1]. Available
from: Better Health Channel, Web site:
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Me
nstruation_ abnormal_bleeding
• Porth CM & Matfin G. Pathophysiology: concepts of altered health
states. 8th Ed. Philadelphia: Lippincott Williams and Wilkins; 2009.
• Longo DL, Kasper DL, & Jameson JL. Harrison's: principles of internal
medicine. 18th Ed. Ohio: The McGraw-Hill Companies; 2012.
• Rubin R & Strayer DS. Rubin’s pathology: clinicopathologic
foundations of medicine. 6th Ed. Philadelphia: Lippincott Williams
and Wilkins; 2012.
Gynecologic examination:
• Inspection: normal vulva and urethra
• Speculoscopy: Exophytic growth, fragile, easily bleed, size
4x4x3 cm
• Vaginal touché and rectal touché: enlarged portio, corpus uteri
size was normal, left and right parametrium rigid, nodular,
reaching pelvic wall
CONCLUSION
Hypothesis accepted, the woman is suffering from cervical
cancer most likely squamous cell carcinoma type. According to
the symptoms, the cancer is at least stage IIIb. We can do
coloposcopic biopsy for confirmation of the diagnosis and MRI
to detect metastasis. The therapy would probably be radical
hysterectomy and combined radio-/chemo- therapy
DISCUSSIONS
• Group A: how smoking can be a risk factor for cervical cancer?
– Smoking  exposure to benzyrene  damage Langerhans cell which is
supposed to be protective  epithelial damage on the mucus of the
cervix  carcinogenesis
– Smoking have thousands of carcinogens  enter the body 
metabolized and activated  binds to receptors  angiogenesis,
apoptosis, interfere with DNA repair  mutation  cancer (specifically
in cervical cancer p53 & Rb)
• Is there any relation between cervical care and her husband being a
long track bus driver?
– Possibility of unfaithful from either side  multiple sexual partners
• Group B: VIA  when you have positive result do you
go directly for treatment or other examination?
– Examine the size of the lesion, if it’s small we can do
cryotherapy (freeze the cells  lysis) after that referred to
hospital  screening for 1 year. Bigger lesion  LEEP 
electrosurgical procedure  refer to ob/gyn after.
• Colposcopy biopsy  why not endocervical currate /
cone biopsy?
– Do least harm to the patient. Colposcopic biopsy itself
actually help removes not only the cell but also the tissue.
Colposcope  illuminate the cervix and take out the tissue
for further examination
• Group E: HPV screening for male? Because
HPV can be transmitted through sexual
intercourse
– We don’t know yet about screening for male but
then HPV typing may be used because it directly
detects the type of the virus