Case Conference December 27th 2017

27-Dec-2017, Divisi Ginekologi Onkologi RSCM

 

CASE CONFERENCE

 

December 27^th, 2017

 

Mrs. D, 22yo, P1A1, 415-04-07

 

 

 

I.      Case Description

 

       The patient had a molar pregnancy and had curettage done in 2011. The patient then had pregnancy and gave birth in 2015 (normal delivery). 1.5 year after delivery (September 16^th, 2016), the patient complained of vaginal bleeding for 4 month accompanied by nausea, vomitus and abdominal pain. The patient went to Tangerang Hospital and was referred to Cipto Mangunkusumo Hospital with GTN High Risk. The patient had EMACO chemotherapy on September 22^nd, 2016 – November 03^rd, 2016, but the patient turned out that she was resistant to the regiments. Then the chemotherapy changed to EMA-EP and the patient had it from November 24^th, 2016 to May 15^th, 2017 (9 sessions) and it turned that the patient was also resistant to the regiments. The chemotherapy once again changed to Carboplatin-Paclitaxel from July 24^th 2017 to November 14^th, 2017

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II.    Physical Examination on December 14^th, 2017

 

a.      General status:

 

CM. BP: 110/70 mmHg, HR: 95 x/min, T: 36°C, RR: 20 x/min,

 

Head: Pale conjungtiva (-/-) icteric sclera (-/-)

 

Thorax: symmetry shape and movement of hemithorax

 

Lung: vesicular breath sound on both lungs, neither wheezing nor rhales

 

Cardia: no murmur, no gallop

 

Abdomen: flat, supple, intestine sound (+), ascites (-), tenderness (-) mass (-)

 

Extremity: warm, no edema

 

 

 

b.      Gynecology examination:

 

Inspection: vulva and urethra were normal, no bleeding

 

RVT: anteflexed uterus, the vaginal wall was smooth, the cervix was normal. The rectal mucosa was smooth. The tone of the both sphincter ani were good.

 

 

 

III.   Work Up

 

a.        Laboratory Result on November 9^th, 2017

 

CBC: 9.7/28.4/5880/109000

 

Diff: 0.3/0.2/63.5/24.8/11.2

 

SGOT/SGPT: 23/22

 

Ur 20 Cr 0.60 eGFR 129.8

 

Beta-HCG: 76.45

 

 

 

b.        Laboratory Result on November 13th, 2017

 

CBC: 10.2/29.3/6150/141000

 

Diff: 0.2/0.3/67.4/22/10.1

 

SGOT/SGPT: 23/21

 

Albumin: 4.64

 

Ur 15 Cr 0.70 eGFR 123.4

 

Na/K/Cl: 144/2.89/99.6

 

 

 

c.         Laboratory Result on  December 14^th, 2017:

 

CBC: 11.8/35.3/7100/409000

 

Diff: 0.3/0.4/70.9/19.2/9.2

 

SGOT/SGPT: 17/14

 

Albumin: 4.66

 

Ur 14 Cr 0.60 eGFR 129.8

 

Random Blood Glucose: 121

 

Na/K/Cl: 140/3.28/96.9

 

Beta HCG: 605.80

 

 

 

d.        Chest X-Ray Result on September 19^th, 2016

 

Description: The heart was not enlarged. Cardiothoracic ratio: < 50%. The aorta and superior mediastinum were not enlarged. Trachea was in midline. Both hila were not thickened. Multiple nodules appeared with variant size in both lungs. The arch of the diaphragm and the costophrenicus angle were normal. The visualized bones were intact.

 

Conclusion: Multiple nodules in both lungs DD/ lung metastasis. There was no radiologic abnormality in the heart

 

 

 

e.        Chest X-ray Result on May 16^th, 2017

 

Description: The heart was not enlarged. Cardiothoracic ratio: < 50%. The aorta and superior mediastinum were not enlarged. Trachea was in midline. Both hila were not thickened. Multiple nodules appeared in the upper, middle and lower area of both lungs. The arch of the diaphragm and the costophrenicus angle were normal. The visualized bones were intact. The soft tissue’s density of bilateral coli region was increasing and thickening.

 

Conclusion: Compared to previous Chest X-Ray on September 19^th, 2016: Multiple nodules in both lungs, the number and size was decreased significantly. There was no radiological abnormality in the heart, stqa. The soft tissue’s density of bilateral coli region was increasing and thickening, stqa.

 

 

 

f.          Chest X-Ray Result on June 14^th, 2017

 

Description: The heart was not enlarged. Cardiothoracic ratio: < 50%. The aorta and superior mediastinum were not enlarged. Trachea was in midline. Both hila were not thickened. Multiple nodules appeared in the upper, middle and lower area of both lungs. The arch of the diaphragm and the costophrenicus angle were normal. The visualized bones were intact. The soft tissue’s density of bilateral coli region was increasing and thickening.

 

Conclusion: Compared to previous Chest X-Ray: Multiple nodules in both lungs, the number and size was decreased. There was no radiological abnormality in the heart, stqa. The soft tissue’s density of left coli region was increasing and thickening, stqa.

 

 

 

g.         Chest X-Ray Result on December 14^th, 2017

 

Description: The heart was not enlarged. Cardiothoracic ratio: < 50%. The heart filled < 1/3 retrosternal space. The retrocardial space was not narrowed. The aorta and superior mediastinum were not enlarged. Trachea was in midline. Both hila were not thickened. Fibrosis appeared in the middle area of the right lung. No infiltrate / nodule. The arch of the diaphragm and the costophrenicus angle were normal. The visualized bones were intact. The soft tissue’s density of bilateral coli region was increasing and thickening. Conclusion: Compared to previous Chest X-Ray Result: There were no more visible nodules in both lungs. Fibrosis appeared in the middle area of the right lung. There was no radiological abnormality in the heart, stqa. The increasing and thickening of soft tissue’s density of bilateral coli region was decreasing.

 

 

 

h.         US Result on September 21^st, 2016

 

Description: anteflexed uterus, enlarged, in the anterior of corpus there was vascular mass extra cavity sized 100 x 98 mm. The basal stratum of endometrium was regular, 5 mm thick. Endocervix and portio were normal. Both ovaries were within normal limit. (There were multiple lutein cysts in the right ovary).

 

Conclusion: Extra cavity vascular mass derived from choriocarcinoma

 

 

 

i.           US Result on May 17^th, 2017

 

Description: uterus anteflexed, enlarged, in anterior corpus, there was vascular mass (minimal) in extra cavity sized 11 x 8 mm (mass size decreased than the previous US).  In anterior and posterior corpus, there was hypoechoic mass, the margin were firm sized 9 and 5 mm, derived from intramural uterine myoma (small). Endometrium basal stratum was regular, 1 mm thick. Endocervix and portio were normal. Both ovaries were within normal limit. There was no abnormal mass in both adnexa. The liver and both kidneys were normal.

 

Conclusion: Extra cavity vascular mass derived from choriocarcinoma (the size of the mass decrease than the previous US). Intramural uterine myoma

 

 

 

 

 

 

 

 

j.           US Result on June 15^th, 2017

 

Description: Normal shape and size of the uterus, slightly enlarged. In the anterior of the corpus there was a hypoechoic mass with irregular shape and texture, sized 20x15 mm, derived from the GTN mass. In the posterior of the corpus there were intramural uterine myomas (9mm and 6mm). The uterine cavity contained no abnormal mass. The basal stratum was regular, 3mm thick. Endocervix and portio were normal. Both ovaries were normal. There was no abnormal mass in the adnexa. The liver, both kidneys and bladder were normal. No ascites was found.

 

Conclusion: Mass of gestational trophoblastic neoplasia. Compared to the previous US Result, the mass was enlarged, suspected active.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

k.         US Result on December 14^th, 2017

 

Uterus was 8,14x5,32 cm, with avascular mass in the uterine cavity sized 2,09x1,83 cm. There was right ovary follicle sized 2,5x1,96 cm and left ovary follicle sized 1,6 cm.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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