Case Confrence 27 January 2010

26-Jan-2010, Divisi Onkologi Ginekologi RSCM

1. Ny. id, 46 Y.O. P4.

Chief complaint: oral intake disturbance.

History of complaint:
17-11-09 : Came to out patient clinic, diagnosed with cerxix ca III B with cervix biopsy PA : adeno Ca) and ovarian cyst  neoplasm, susp. Malignancy. She was admitted to hospital for tranfusion. 
Physical exam : cachexia.
On gynaecologic exam found distended abdomen. Ascites (+) with cystic mass which height around procesus xyhoideus.  Inspekulo : mass exophytic, 4x4x4 cm, VT: infiltration to left and right pelvic wall. On adnexa found cystic mass as mentioned above.
She had history of examination on private hospital and planned for surgery and choose RSCM.
 
 
11-8-09 Well differenciated villoglandular adenocarcinoma. No vascular emboli on the slide. (H090001944-dharmais)

28 -12-09
CT scan :
No enlargement of the liver.the surface is smooth. No dilatation of inta and ekstra bilier hepatic system. Nodul non absorbed contras 1,42 cm at segmen 7 and 0,5 cm at segmen 2. Ascites and left pleural effusion. No enlargement of vesica velea, no SOL.
Mass with heterogen density, absorbing contrast fulfill the whole abdomen. Suppressing the pancreas, liver, spleen and intestine. No infiltration.
Aorta: size normal. No limph enlargement on paraaorta, parailiaka, obturator and inguinal.
Kidney: both size normal, smooth surface. Kortex and medulla normal, there is enlargement of pelviocalices right kidney. No SOL and stone.
Uterus: no enlargement. Inhomogen density in the lower segment. Indentation in the lower uterine. Margin not confine. No vesical wall thickening, no SOL.
Dilatated distal rectum and irregular thickening. No contrass indentation.

Impression: intra abdomen tumor fulfill pelvic and abdomen cavity with pleural effusion and ascites, suspected liver metastasis.
Cervical ca with probability metastatic to rectum. Right hydronephrosis.

7-11-09 thorax PA : bilateral pleural effusion.

18-1-10:Left pleural effusion and inferior lobe atelectasis
10-11-09 Rectoscopy : no rectal mucosa metastasion

11-11-10 BNO-IVP: secretion and excretion function is normal. No stasis and mass indentation.

9-11-09  Uterus : size 8,59x4,73x4,62 cm, anteflexy, inhomogen myometrium 5,9 mm. cervix : 5,62x4,52x4,4 cm, RI 0,50
         Adnexa: multilocular cystic permagna 23,33x14,61x19,91cm (3553,32cm3) septal thickness 8,7mm, with solid part. RI 0,17.
                 Free fluid on pelvic.
         Liver : fatty appearance, no metastasis lesion. Limphnods cannot evaluated. Right kidney Hydronephrosis gr II. Ascites(+)

        Impression : ovarian cyst neoplasia suspect malignancy
                     Hydronephrosis gr II
                     Right pleural effusion
                     Ascites.
 
 
Laboratory
      7/11/09   16/11/09  14/12/09 19/1/10
Hb        7,4        11,8                      11,5
Wbc      16        13,81                   13,52
Plt        769         517                      672
Ca 125              786,4  
Bun        19          18          19 
Sc         0,7         0,4         0,5 
cct                                  55,68 
alb                     2,87  
Got                      35  
gpt                       26  
 
                             result  standard
pH                     7,40       7,370-7,450
pCO2                 39,60       32,00-43,00
pO2                    95,00       71,00-104,00
hCO3                  24,90       21,00-25,00
Total CO2            26,10       21,00-27,00
BE                        0,80       -2 -+3
O2 sat                  97,30       94,00-98,00
Standar HCO3        25,3       21,0-26,0
Standar Base Excess  0,9 

Others dept consultation : 

Digestive :
             Plan for joint operation

Cardiology :
             Tolerantion to operating cancel for echo

Pulmonology:
             Tolerantion cancel for tapping

Problems :  
Stage of the desease ?
Management option?

 

2.Kasus CPC  Ny. H/ 48 th

Keluhan :
Perut membesar sejak 2 bln yll. Perdarahan dari kemaluan (-)
BAB/BAK dbn.  Siklus haid teratur, Riwayat KB (-). R. penurunan BB (-), P2A0
Psn rujukan dr RS Ananda Bekasi
 
KU baik, cm, 
Pemeriksaan ginekologi
Massa 17x22 cm, mobile, uterus ukuran normal terdorong ke posterior, mukosa rektum licin.

Lab  CA 125 : 1.193,0 u/ml, lain2 dbn
Hsl USG:NOK suspek maligna
Thoraks foto: pleuropneumonia kanan (dalam terapi)
BNO/IVP: dbn

Konsultasi
Digestif : acc joint operasi
Kardiology : cardiac risk minor
Anestesi: ASA II
SK= 4
Frozen section result „³ carcinoma endometrioid
PA :

Diskusi :
-Apakah adenokarsinoma ovarium metastasis kolon, ataukah adenokarcinoma kolon metastasis ovarium?
-Ataukah double primary tumor karsinoma ovarium dan karsinoma kolon?

Reevaluasi dan diskusi hasil patologi oleh konsulen Patologi Anatomi.

 

3.Kasus Ny. A/50 thn/P4

S : Keluhan utama : benjolan padat di perut sejak 2 bulan yl.
    Pasien datang dengan keluhan benjolan padat di perut sejak  bulan. Penderita pertama kali berobat ke RS Budi Asih  dan didiagnosa  sebagai tumor curiga ganas. Pasien disarankan rujuk ke RSCM. BAB/BAK biasa. Pasien tidak ada keluhan penurunan berat badan.
O: Status generalis : KU sedang, CM
                      T:110/70 mm Hg, nadi 76x/m, r: 20x/m. t 37C
Cor/Po : dbn
Abdomen : distensi (-), Bising usus normal,  lemas. Teraba  massa padat (+) 2 jari bwh pusat
St Gin: vagina licin,portio licin, uterus kesan normal, terdapat massa padat adneksa kanan ukuran + 10x6 cm,  mobilitas terbatas.

Lab :  dbn
CA 125: 4182
USG :uterus  normal ukuran 8x3x2 cm, endometrium 6,7 mm.
     Adneksa kanan massa solid batas tak tegas, ukuran 4,7x5,8x5,8 cm
     RI 0,38. Adneksa kiri tak tampak.Asites (+)
     Kesan: NOP susp maligna

Foto thoraks : dbn

EKG  : low risk
Anestesi : ASA II

A: NOP susp maligna

4/1/10. Dilakukan laparotomi VC : ditemukan cairan ascites, dilakukan pmeriksaan sitologi 20 cc. Kemudian ditemukan juga  perlengketan antara omentum dengan rectum, colon dan uterus bagian fundus. ovarium kanan diameter 5x5x5 cm, dan ovarium kiri 3x5x5 cm, dilakukan ooforektomi dekstra, omentektomi, dan sitologi.
Ditemukan juga masa tumor padasigmoid dan rectum. (sub optimal debulking)

Hasil PA : No : 100031 (8/1/10) Kes: Kisadenocarcinoma papilliferum serosum berdifferensiasi sedang.
Sitologi : positif, cenderung adeno carcinoma.

Kesimpulan : Ca ovarium Std III C

Masalah :
Sumber tumor primer ?
Penanganan operatif optimal ?

 

4. Ny.T/ 51YO
Chief complaint: weakness.

History of complaint:
15/12/09 :Referred by Banjarnegara with cervix cancer and ovarian neoplasm susp malignancy. PA result (13/11/09): epidermoid cell ca, poorly diferenciated.
 
On gynaecologic exam found distended abdomen. Ascites (+) with cystic mass.  Inspekulo : mass exophytic, 4x4x4 cm, VT: infiltration to left and right pelvic wall. On adnexa mass cannot evaluate properly.
 
Biopsy (16/12/-09) (PA 0907913) : Adenocarcinoma cervix, well-moderate diferenciated.

Cytology of the ascites; (16/12/09)positif carcinoma ( mesotel and leucocyt, pleomorfic nuclear, coarse chromatin.

Thorax Ro (2/12/09): Appropriate to lung matastases (Multiple nodule on both lung).

BNO IVP (2/12/09) : secretion and excretion both kidney normal.

Rectoscopy (26/11/09) : no metastase
Cystoscopy (9/12/09): cystitis

USG Oncology (25/11/09) :
Solid mass susp maligna on right adnexa. Cervix enlargement susp maligna. (there is a an irregular mass on the right adnexa, 7,5x8,7x10cm, inhomogen hipoechoic with anechoic cystic mass. No increasing blood flow)

 

17/12/09 A: Ovarian Ca metastases to cervix (consultant evaluation)
         P: CP 3 series then reevaluation ( H: 147 cm, BW : 56 kg „³ 1,51m2
            Carboplatin 1,51 x 250 = 378 mg
            Cycloposfamid 1,51 x 600mg = 906 mg
           (Seri I --> 21/12/09, seri II--> 11/1/10)

21/1/10

S: After 2 course, She feel so weak , heavy cough.

O : anemic, cachexia
    Abdominal distention, mass cannot palpable.

v/v no bleeding

Lab: Hb 6,3 g%, leko 7,9 k/uL, plt 250 KuL.

USG oncology follow up (26/1/10)
Ovarian neoplasm susp malignancy with volume 1000 cm3 (bigger than the USG 25/11/09). Enlarge cervix with vol 20 cm3 susp maligna
Uterine with intra cavum blood. Bilateral pleural effusion. Massive ascites.

A: ovarian Ca progressing desease

Problems?
Non respond to chemotherapy regimen ?
What is the treatment option ?
 
        20/1/10         23/1/10
Hb           6,8           10,4
Wbc        7,96          5,34
Plt             250         163
Ca             125         754 
Bun            5,2 
Sc              0,9 
cct            52,6 
alb                            2,87
Got                           35
gpt                            26