Case Confrence 3 March 2010

03-Mar-2010, Oncology Gynecology Division RSCM

1. Mrs. S, 47 YO. P2-27

Ovarian Ca, clinically st IV

Chief complaint: enlargement of the abdomen since 5 month ago.

History of complaint:

14-12-09 :Refered to hepatology dept from Koja hospital. enlargement of the abdomen and diagoned by ascites, ec malignancy? Dd. Chronic inflamation ?
          previously she had been admited to Koja hospital (11/09) for ascites punction and citology, and the result was exudate, without TB or malignancy.

11-01-10 :Being consult to Ob gyn dept, and diagnosed by Ovarian cystic neoplasia, with score 8. And referred to oncology sub division.

FM US : 17/12/09: Adenomiosis, with ascites, bilateral hidrosalphing, solid mass in the CD due to peritoneal specific process, DD Malignancy can not excluded yet.

11-1-10 :US Onco : Cystic ovarian neoplasia, with solid part susp malignancy, with cystic mass in the posterior cervix. Pleural effusion and massive ascites (+)

20-1-10 At oncology out patient clinic, She was diagnosed by musinosum cyst susp malignancy, with pseudomixoma and planned for laparotomi frozen section.
 
26-1-10 Ascites cytology positive adenocarcinoma.
2-2-10 Hospitallized due to low intake status with hiponatremia and hipikalemia.

8-2-10 Advice from consultant NAC, reevaluation for surgery.

 O: general condition is poor. Vital sign within normal limit.
   On gynaecologic axam found massive ascites. Mass cannot palpated from abdomen. V/v : normal, VT : cervix normal. on  the left and right adnexa found solid mass, fixed. Bulging of the CD. Rectal mucose is smooth.

1st US (11/1/10) : uterine is rounded, iregular shape, size 6,10x3,57x4,02cm, anteflexy, hyperechoic homogen, ET 1,5mm. Cervix is normal. There is a unilocular cystic mass posteroir to the cervix in size 2,72x2,25x2,47cm, vol 7,991cm3, no solid part, no blood flow.
                   Right adnexa: multiloc cystic mass, lobulated 3,04x2,38x3,38cm, vol 12,80cm3, septal 2,5mm, solid part, with vascularization. The flow cannot assesed.
                   Left adnexa: multiloc cystic mass, lobulated, 4,48x4,73x4,3cm, vol 51,54cm3, septa 3,2mm. With solid part, RI 0,36
                   Abd: hepar normal. Limphnodes not visible, no HN, left pleural effusion, massive ascites.

 

 

2nd US (22/2/10) after 1st course CP :
                 uterine is rounded, iregular shape, size 6,85x4,19x3,47cm, anteflexy, hyperechoic homogen, ET 2,2mm. Cervix is normal.
                 Right adnexa: multiloc cystic mass, lobulated 3,12x2,58x3,47cm, vol 14,63cm3, septal 2,3mm, solid part, no vascularization.
                 Left adnexa: multiloc cystic mass, lobulated, 6,34x4,88x4,17cm, septa 4,1mm. With solid part, RI cannot assesed.

 Abd: hepar normal. Limphnodes not visible, HN gr I-II on left kidney, pleural effusion (-), massive ascites.
Con: slightly increasing tumor size

Thorax x ray (22/1/10) : right pleural efussion. Ascites.
Thorax x ray (5/2/10):  right pleural efussion, worsening. 

Lab result : (12/2/10) Hb 12,9 g/dl, wbc 14,6 k/ul, plt 248 k/ul.Ureum 38 mg/dl, Creatinin 0,60 mg/dl. CCT 70,39. GOT/GPT 23/15, alb 2,17, CEA 1,22, Ca 125 2305

As: Ovarian Ca, During 1st course CP, progresive desease ?

Problems     1. Should CP continued for another 2 series before reevaluating?
             2. Is surgery a better choice for this patient?

2. Mrs. M, 66 YO

Chief complaint: Pain on left femur

27/7/09: Came to out patient clinic, diagnosed with cerxix ca III B with cervix biopsy PA : Keratinizing squamous cel ca cervix, moderate diff.
 She was planned to drawn research nimotuzumab, and radiation. 

 

 On general exam: BW 42 kg, Height 152 cm.
 gynaecologic exam found, Inspekulo : mass exophytic, 4x4x3 cm, VT: infiltration to left and right pelvic wall. Rectal mucous smooth

5-8-09 biopsy PA : Keratinizing squamous cel ca cervix, moderate diff.

30-7-09 thorax PA : No metastases

4-8-09  cystoscopy, rectoscopy normal.no metastases.
        BNO IVP : excretion-secretion function is normal.

4/9- 4/10/09 Recieving external radiation, C-60 50Gy, int radiation 21 Gy

1/3/10: After completing radiotherapy, and 11th time nimotuzumab, she feels pain on the left femur.
 gynaecologic exam found, Inspekulo : mass (-), cervix is smooth VT: no mass palpable, smooth, Cu Af <normal size, Rectal mucous smooth.
 Bone scan result (25/2/10) : sugestive left fmur and cruris metatasis.

 

Diagnose : Cervix Ca IIIB, progresive desease (distance metastases).
Problems : due to progresing desease, should the treatment continued or switch to paliatif only?

solving: .

Arch Gynecol Obstet. 2009 Dec 2.-->Femur metastasis in carcinoma of the uterine cervix: a rare entity.(Corrado G, Santaguida S, Zannoni G, Scambia G, Ferrandina G)
Gynecologic Oncology Unit, Department of Oncology, Catholic University of the Sacred Heart, L.go A. Gemelli, 1, 86100, Campobasso, Italy, giacomo.corrado@alice.it.
PURPOSE: We report the first case of isolated femur metastasis in a locally advanced cervical cancer (LACC) patients.
CASE: A 40-year-old woman presenting with carcinoma of the uterine cervix, FIGO stage IIb was administered concomitant chemo-radiation
and achieved clinical partial response. Before the planned surgery, she developed an isolated metastatic lytic lesion of the left femur.
After surgical excision of metastasis, she refused palliative chemotherapy, and radiotherapy, and died 3 months later because of progression of the disease.
CONCLUSION: Bone metastasis is not so infrequent in patients with LACC. Because the prognosis of these patients is poor and most of them die within 1 year
after the diagnosis of metastatic disease, the policy of treatment should be directed to maintain their quality of life