Case Conference Dec 14th 2011

14-Dec-2011, Divisi Ginekologi Onkologi RSCM

Case conference December 14 ^th 2011,

Mrs S/54 yo/P5A0/MR 3307023/jamkesmas

 

8/4/2009 : os was referred from Jambi with ovarian cancer IIIB

History :

Patient was performed laparotomy hystrectomy, Salpingoooforectomy, omentectomy and appendectomy in Asia medica Hospital Jambi, with PA result : Cystadenocarcinoma musinosum papiliferum ovarium infilttrated to uterus, appendix and omentum. No bodyweight decreasing, Normal defecation and micturition.

Marriage 2x, P5

Physical examination (on admission):

St gen :

·        Still within normal limit

·       No enlargement of supraklavicular or inguinal lymph node

·       Abdomen : palpated mass until 2 finger under navel, limited mobile, smooth surface

St gyn:

I: vulva /urethra wnl

Io: Smooth portio, vagina wnl

RVT:palpated mass until 2 finger under navel.

 

USG oncology april 8th 2009:

Cystic mass size 6,3x6,2 x 5,1 cm at posterior vagina stam, no vascularitation intra mass. No ascites. No metastatic in Hepar, Lien and no lymphnode enlargement. Ren dx wnl, Ren sinistra with 7 mm dilated pevis renis

Conclution: NOP progresif and hidronefrosis sinistra gr 1.

Laboratory finding April 13th 2009:

Ca 125 : 1151 U/ml

Review slide PA (0902584):

Adenocarcinoma ppiliferum ovarii tipe endometrioid well differentiated with spreading at omentum and periappendix. Whether there is lesion in uterus can not be sure.

Assesment: Ovarian cancer advanced stage suboptimal debulking

Discussion with consultant : chemotherapy with CP.

CP  I :

Cycle 1: 13/05/09

Cycle 2; 17/6/09

Cycle 3: 15/7/09

Cycle 4: 4/08/09

Cycle 5: 1/09/09

Cycle 6: 28/09/09

Lab finding: Ca 125 : 55,3 U/ml

USG oncology oct 7th 2009:

No mass visible. Compare with usg result april 4th 2009 à complete remission.

Minimla free peritoneal fluid normal in cavum pelvis. Efusi pleura dx.

Pulmonology consult oct 2009:

Suspected TB paru and pleura effusion on OAT. Cytology pleura efusion : negative tumor cell.

Assesment : complete remission à she went back to Jambi and did regularly controls in Jambi  at Obgyn.

August 23th 2010 :  control after 1 year with chief complain : abdominal enlargement since 1 months before admission.

Physical examination:

St gen : abdomen : massive acites with cystic mass with solid part size 6x5x5 cm, limited mobile.

 

St gyn : I: V/U wnl

Io : vagina stam smooth

RVT : palpated cystic mass with solid part in pelvic cavity and acites

USG gynecology august 23th 2010:

Posterior V. Urinaria there was hipoekoik mass, clear border size 3,03x1,37,3,37 cm (vol 7,32 cm 3). And also acites. No metastasis in hepar, lien or lymph node.

Lab finding : ca 125 : 2599 U/ml

Cytology acites August 2008: positive  adenocarcinoma.

Assesment: Ovarian cancer advanced stage residive platin sensitive.

Discussion with consultant : plan to give chemotherapy with CP

CP II: cycle 1: september 4th 2010

          Cycle 2: september 23rd 2010

          Cycle 3: October 19th 2010

          Cycle 4: November 9th 2010

          Cycle 5: November 30th 2010

          Cycle 6: December 21th 2010

USG February 22th 2011 : No mass were seen, no acites à complete remission.

Lab ca 125 : 32,9 U/ml

Discussion with consultant (Prof Dr Andrijono SpOG (k)) : assesment as complete remission,  she could go to Obgyn in Jambi to do the post therapy controls every 3 months  and in 1 year control in Jakarta.

September 21st 2011:

Control after 1 year with abdominal enlargement.

 

Physical examination :

St gen:Abdomen no palpable mass, shifting dullness (+)

St gyn: I: V/U wnl

            Io: vagina stam  smooth

RVT : no palpable mass in pelvic cavity.

USG FM sept 22th 2011 : acites with suspected secretion process from the tiny implantations. Pseudocyst intraabdomen.

Lab finding : ca 125 : 4781 U/ml

Cytology acites: serohemorrhagic.

Assesment: Ovarian cancer advanced stage residive platin sensitive.

Discussion with consultant (Dr dr Laila SpOG (k)):

-         No need to do cytology

-         Considering acites serohemoragic (+), and ca 125 raised à alternative palliative or chemotherapy other regimen.

Discussion with Prof Dr dr Andrijono SpOG(k): whether giving second line or CP again à decided to give carboplatin paclitaxel.

Carbo Pacli I: October 4th 2011

                    II: October 25th 2011

                   II: November 15th 2011

After 3 cycles chemotherapy, she felt better, the abdomen is getting smaller.

 Lab ca 125 : 1213 U/ml

USG FM : Vagina stam wnl. Around posterior peritoneum there is hipoekoik mass with form and border irreguler, size 16 x 12 x 13 mm  with acites. There are Fibrin – fibrin adhesion  suspected spesific process.  How is pulmo?

Foto thorax 13/12/2011 : Pneumonia, no sign TB or metastasis.

 

Discussion with consultan ( dr Sigit P SpOG (k):

Discuss in case conference.

Problem:

Considering :

-         Ultrasound : new mass

-         Ca 125 : : 4781 U/ml à1213 U/ml

-         Complain : felt better.

 Progressive disease  after 3 cycles  in recurrent advanced stage ovarian cancer.

Plan :

Whether palliative treatment or second line chemotherapy