Case Confrence 17 February 2010

16-Feb-2010, Oncology Gynecology Division RSCM

1.Mrs K. / 46 yo / P5A0

Chief complain : vaginal bleeding since 2 months ago.
Referred by Cibinong Hospital due to cervical cancer

Patient complaining vaginal bleeding  since 2 months ago after  her 2nd married on October 2009, not periodicly came out and no pain. The vaginal bleeding was not often and not profuse, just in little amount. She went to midwife and got the medicine, but when  medicine stop the vaginal bleeding came out again.
Since 2 weeks ago she was also complaining mass came out from the vagina with no pain.

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

On June 2009 she had irregular menstruation, she went to Atang Sendjaya hospital, underwent USG examination and the result was endometrium hyperplasia and suggested to perform curratage but she refused.

P5A0, age of the youngest child is 21 yo.
Menarche in 15 yo, regular period, dismenorrhea (-).  No history of contraception

From gynecological examination found solid mass Ø 8 x 8 x 6 cm on right lateral vagina wall, 1 cm from introitus vagina, easily bleeding. Uterus and adnexa : wnl.

Jan 8th 2010    Onco-gyne US: Uterus and both adneksa: wnl
                              No metastasis on liver, spleen, and kidney.
                              Vaginal solid  mass, vol 50 cm3.

Laboratory results (Jan 12th 2010) were normal.
 DPL 9,5/11210/6444000, AST/ALT 12/08.

Jan 15th 2010 Histopathological Result :   Melanoma maligna 
  
Jan 18th 2010 CXR  : CTR < 50%, left hillus prominent, nodul metastase (-),suggested Thorax CT Scan

Jan 18th 2010 BNO/IVP :  normal secretion and exretion on both kidney
                                 
Feb 4th  2010    CT Thorax :Kardiomegali
                            No abnormality of lung.

DX : Melanoma maligna
Problem :  What is the best management for this patient ?

 

2.Mrs. C N/ 44 yo / P2A0

Chief complain : post coital bleeding since 3 months before admission with no vaginal discharge and no pain. There was no significant disturbance in mixturition and defecation. There is no symptom of loss body weight and appetite as well.
Reffered by Bekasi hospital with cervical cancer.

Hystory :
Sept 2009 : patient was came to GP clinic and the doctor suggested to underwent papsmear.

Oct 2009  : came to obgyn and ultrasound result was abortus imminens. (3 times visit and no gynaecological examinations).

Nov 2009 :  came to GP clinic again and had explanation to underwent gynaecological examinations and papsmear.

Jan 11th 2010 :  patient came to Bekasi Hospital, from citology result was HSIL, and colposcopy-
                 biopsy  was done with histopathology result : Non Keratinizing Squamous Cell Ca Cervix.  
 
From gynecological examination (Feb 1st  2010) revealed endophytic lession on the serviks, 4x3x3 cm, with invasion to anterior and posterior fornix, and also right lateral of portio, fragile and easily bleeding.

CXR and laboratory results (Feb 2nd  2010)  were normal.

Feb 2nd 2010 Cardiology  : wnl

Feb 5th 2010 Rectoscopy  : wnl, no metastase

Feb 10th 2010 BNO/IVP    : normal secretion and exretion on both kidney

Feb 11th 2010 Cystoscopy :  wnl, no metastase

Feb 11th 2010 US Onco     :  Anteflexi uterus, measuring 13 x 4 x 8 cm, myometrium were thin
                             due to uterine cavity fulfill with mass and echogenic liquid.
                             Hypoechoic inhomogen cervix with unclear border, measuring 3,4 x 2,8 x 3,6 cm, border with vesica urinaria was unclear.
                             Both adnexa : wnl
                             Lymphnodes enlargement on posterior cervix  (at least 5
                             lymphnodes) and 1 right inguinal lymphnodes
                                                 
                Conc : Enlargement of cervix due to liquid static (hydrometra?) ec  ca cx ?  
                       Lymphnode enlargement (parailiac?)

                                                 
Problem : What is the best management for this patient?
Planning : 1.  CT Pelvic
           2.  Gynaecologic examination under anesthesia, if parametrium not involve HR
               Right pelvis lymphnode VC If (-) :  continue HR
                                         If (+) : Chemo-radiation

3. Mrs. N/ 32 yo / P0A0

Chief complaint: Patient came to oncology clinic at RSCM for follow up after 3 cycle chemotherapy  CP.

History:
Nov 29th 2009 :  Referred by Roemani Hospital due to ovarian cancer. Patient underwent
                 laparatomy (Subtotal Hysterectomy + SOB + Omentectomy with severe
                 adhesion uterine and colon) on Okt 2009 with histopathology result Clear Cell
                 Adenocarcinoma Ovarii.

From gynecological examination (Nov 29th 2009) revealed a cystic  mass on cavum douglasi Ø 5 cm, immobile.
Nov 30th 2009 US Onco :  Uterus : fundus and corpus were not found
                                  Cervix normal sized, measuring 2,35 x 2,43 cm
                         Both adnexa were not found.
                         Right pelvic on  posterior cervix revealed multiloular cystic mass,
                         measuring  5,08  x 2,24  x 5,63 cm, vol 33,54 cm3, with septal
                         thickness  3,8  mm, papil (+), no vascularization.
                         Ascites (+), no liver metastase, both kidney were normal
                         Conc : Cystic mass on right pelvic suspected residual tumor.
                                DD. Pseudocyst
                                    Ascites (+)   

Des 1st 2009  :  Dx: Ca ovarium incomplete surgical staging and decided to underwent adjuvant
                     chemotherapy CP 3 cycle ( 9/12/2009; 31/12/09; 28/01/10)

From gynecological examination (Nov 29th 2009) revealed a cystic  mass on cavum douglasi Ø 5 cm, immobile.

Feb 11th 2010  Us Onco   : Uterus and both ovary were not found
                           Intrapelvic, revealed  multiloular cystic mass, measuring  5,7 x 3,7 x 5,4 cm , vol 59 cm3, with septa thickness 1-5 mm,
                           hiperechoic solid area 12 x 16 mm fulfill with anechoic locus, no vascularization.
                           Ascites (+), no liver metastase .  Right pleural effusion.
                           Conc : Mass getting bigger (compared with Nov 30th US Onco)
                                  Ascites and right pleural effusion.

Dx : Ca ovarium progressive disease.
Problem : What is the best management for this patient ?
          2nd line chemotherapy?
          Supportive treatment?