Case Connfrence 10 February 2010

09-Feb-2010, Oncology Gynecology Division RSCM

CASE CONFERENCE, FEB 10th  2010

1. Mrs N / 35 yo / P0A0
Chief complain : Urine came out from vagina since 1 week ago. 

Patient underwent Laparatomy VC at RSCM (Jan 25th 2010) due to cystic ovarian tumor.
The operation procedure : laparatomy VC, salphyngooverectomy dextra, HT-SOS, lymphadenectomy paraaorta, sampling lymphadenectomy pelvic, omentectomy, appendectomy , peritoneum biopsy.
VC result : Malignant Germ Cell Tumor

Post operative diagnose : Malignant Germ Cell Tumor

From gynecological examination revealed urine in vaginal canal. Methylen blue test (+), urine came out from vaginal stump (¨ª fistula 0,5 cm)

Histopathological result: still no result.

Dx: Malignant Germ Cell Tumor + Vesico-vaginal fistula

Problem : What is  the best  management for this patient?

 

2. Mrs. M, 47 y.o, P4A1
Chief complaint: Patient came to oncology clinic at RSCM for follow up ¥â-HCG level after 1 cycle chemotherapy  ME.

History:
May 13th 2009   : At RSCM, the patient underwent curettage but histopathological
                  examination was not perform.             
June 6th 2009   : Patient still complaining vaginal bleeding after curettage.                                        
                  Fetomaternal US --> Conc. Retain tissue of Mola Hidatidosa
June 7th 2009   : 2nd curettage was perform with histopathological result retain tissue of
                  gestational or pasca molahidatidosa . 
Follow up β HCG level
              June 17th 2009      333.369
              July  1st 2009        200.000
              July 13th 2009       6947
              Aug 28th  2009     229.316
Aug 31th  2009 Onco- US :  Conc. Suspected invasive mole, hepar metastasis (-), ascites (-)
Sept 1st  2009 CXR     :  lung metastasis (-)
MTX
          Seri I                 Seri II              Seri III              Seri IV
      (4-8)/9/09      (29/9-3/10)/09  (19-23)/10/09  (16-21)/11/09
 

β HCG (15-09-09)   (14-10-09)    (10-11-09)    (10-12-09)      
               2290              172                494                825
 
 

Regiment chemotherapy was changed to ME regiment

Des 23th 2009 CXR : Fibroinfiltrat and calcification on upper part right lung. Left lung no infiltrat
Follow up ¥âHCG after 1st chemo ME (14-01-10) :  981 mIU /ml                          
Jan 22th  2010 Thorax CT-Scan : Suggested lung and hepar
Feb 1st  2010  Head CT-Scan  :  brain metastasis (-)
 
Problem : What is the best treatment to this patient ?
         Alternative treatment :  Change regiment : EMACO
                                                      

 Re-discussion

3. Mrs N / 46 yo / P2A0 /MR 336 72 06

Chief complain : vaginal bleeding and mucous discharge since 3 months ago.
Referred by Meilia Hospital due to vaginal cancer,  DD: Sarcoma Batroides

Patient complaining vaginal bleeding and mucous discharge since 3 months ago, not periodicly came out and no pain. The vaginal bleeding was not often and not profuse, just in little amount.
History of contact bleeding (-).
Patient underwent biopsy in Melia Hospital with histopathology result was carcinoma with unkown  origin

Defecation and mixturition still normal. There is no symptom of loss body weight and appetite as well.

She had been married for 21 years. P2A0, age of the youngest child is 25 yo.
Menarche in 15 yo, regular period, dismenorrhea (-).  No history of contraception

From gynecological examination revealed 3 nodul on right lateral vagina wall , measuring ¨ª 3cm, 2 cm, 1 cm, not fragile and not easily bleeding. The repeat biopsy was done and the result was Melanoma Malignum Vagina (PA No. 1000395).

CXR and laboratory results (Jan 20th 2010) were normal.
DPL 12,3/8050/336000, AST/ALT 14/13.

Jan 18th 2010    Onco-gyne US : Uterus and both adneksa: wnl
                                No metastasis on liver, spleen, and kidney.

Feb 1st 2010    MRI : Mass was found in vagina with good heterogen intencity
                      Both on T1 and T2 at vagina, mass absorbed contras along
                      vanginal canal measuring 3,17cm (latero-lateral) x 2,66 cm (antero-posterior) x 6,17 cm (longitudinal), with border not
                      unclear margin, the most distal part seen until introitus vagina, and proximal part closed to uterine cervix.
                      Right lateral border not clear, with border between mass and m.levator ani was unrecognizable.
                      No infiltration with left or right labia mayora, and rectum No mass in vesica urinaria cavity
                      Conc: Vaginal tumor probably infiltrate to right m. levator ani.
                                                                       

Immuno-histochemistry : still no result

Problem : What is  the best  management for this patient?