Case Confrence 10 March 2010

09-Mar-2010, Oncology Gynecology Division RSCM

1.Miss 19 yo
On Feb 15th 2010 came to oncology clinic x hospital with chief complaint abdominal enlargement since 1,5 year ago. Pain (+), Defecation and mixturition still normal. Symptom of loss body weight (+) 

History:
Nov 28th 2008 : patient came to oncology clinic RSCM due to abdominal enlargement and  decided to perform chemotherapy
(case conference Jan 7th 2009 with consideration:
-  woman 18 years old with solid ovarian tumor, LDH: 2403; Ca-125: 106,1 ? probably Dysgerminoma
-  Cancel laparatomy + VC
-  Perform NAC PVB for 3 cycle and reevaluation).

Jan 12th 2009  : patient received 1st cycle of chemotherapy PVB and  loss of follow up because financial problem.

Physical Examination (Feb 15th 2010):
Abd : revealed solid mass 4 fingers bellow px, immobile, pain (-)
RT :  revealed pelvic solid mass 4 fingers bellow px, fulfill cav.douglasi, immobile, pain (-), rectum mucosa smooth.

US Report
Nov 28th 2008: Uterus wnl, Cavum Douglasi--> inhomogen solid mass 88x63x50 mm (right ovary), RI 0,42
               Left cranial uterus --> solid mass 136X90x132 mm, RI 0,45
               Hepar & both kidney wnl
               No Ascites
               Conc. Bilateral solid ovarian tumor with cystic part suspected malignant

Feb 15th 2010: Uterus wnl Lobulated solid ovarian mass, measuring 22,55 x 14,40 x 21,95 cm, RI 0,21
               Right hydronefrosis grade IV
               Left hydronefrosis grade II
               Bilateral pleural eff.
               Ascites

Laboratory finding
 Des 2008 Feb 19th March 1st March 7th
Ca-125 106,1         696,8  
AFP 0,9   
hCG 13,1   
LDH 2403         27  
Ureum   85  102  140
Creatinin  1.90  1.70  1.90
CCT   10.85    19.91
Haemoglobin  10.0  11.0 
Leko   6.240  8.33 

Feb 17th 2010 : thorax RO suspect bilateral pleural effusion.

Consult with Pulmunologi Div: minimal bilateral pleural effusion, suggested to perform sputum cult. BTA 3 x ? Result (-)

Consult with Renal-Hypertention Div (2/3/2010) : Suggested to perform Kidney US and nefrostomy.

Us Kidney March 5th 2010  :
Right Kidney 7,51 x 4,59 cm, cortex thickness 0,46 cm with unclear differentiation medulla cortex.
Left Kidney 9,07 x 7,09 cm, cortex thickness 1,30 cm, with clear differentiation medulla cortex.
Conc : Bilateral hydronefrosis and hydroureter  
       Right pleural effusion.

Consult with Urologi March 7th 2010 : suggested to perform right nefrostomy

Dx : Solid Ovarian tumor inadequate treatment

Problem :
Young lady with solid ovarian tumor (probably Dysgerminoma) and renal insufficiency
Problem solving:
  1. 2nd line chemotherapy
  2. no treatment

2. lady, 35 YO. P1-17
Ovarian Ca, Advance stage.

Chief complaint:  -

History of complaint:

April 2007 :History of laparotomi at abdulmuluk hospital, with ovarian malignancy ? PA results was not available.

Oct 2008 :Distended abdomen again with decreasing body weight. After 3 month she was admitted
   to x Hospital for aspiration of the ascites (?) at Jan 2009.
   Without any cytology result. She was done another punction ascites 3 month later, and reffered to xx hospital.

06-04-09 :Distended abdomen again, and diagnosed by residive ovarian ca. 

O: general condition is poor. Vital sign within normal limit.
   On gynaecologic exam found permagna cystic mass, ascites (-).
   V/v : normal, VT : cervix normal. on  the left and right adnexa found cystic mass, 25x25x20cm, fixed. Bulging of the CD. Rectal mucose is smooth.

1st US (06/04/09) : uterine is rounded, normal shape, size 5,34x2,74x3,01cm, retroflexy, homogen, ET 2,0mm. Cervix is normal.
                    Right adnexa: permagna multiloc cystic mass, size 27,20x24,85x28,41cm, vol>10054 ml, septal 10 mm, solid part, with vascularization.
                                  RI 0,22
                    Left adnexa: normal ovary. 3,20x2,40x2,80cm, with folicle, no mass, increasing vascularization, RI 0,38.
                    Abd: hepar normal. Limphnodes not visible, no HN, no pleural effusion, no  ascites.
                    Con : permagna right ovarian neoplasia suspected malignancy.

Thorax x ray (16/4/09) : normal.
BNO-IVP :  (16/4/09):  excre-secre function was normal.
Anestesi : ASA 2, Cardio : Normal 

Lab result : (5/5/09) Hb 13,6 g/dl, wbc 7,9 k/ul, plt 484 k/ul.Ureum 21 mg/dl, Creatinin 0,60 mg/dl. GOT/GPT 19/8, alb 4, Ca 125 26,1

As: Cystic Ovarian neoplasia, susp malignancy, GS 6

Planned for lap VC

5/5/09 :Op report: General OTT + epidural anelgesia
     Midline incision up to 3 f below px.
     Cytology peritoneal, tumor punction 11 litre.
     Solid mass 15x15x10cm, cauli flower
     Was done VC, the result was adenocarcinoma.

Diagnosis post operation : adeno ca, advance stage, was done biopsi and sub optimal debulking.

19/05/09 : Histopatology result : Adeno ca, serusum papiliferum, well differensiated.
 
1/6/09 : BW 44kg, BH 146 cm, (1,32 m2)
 I Ajuvant chemotherapy : CP
 II (24/6/09); III (4/8/09); IV (27/8/09); V (1/10/09); VI (21/10/09).
 
28/10/09 :
S: -
O : no palpable mass.
Lab : Ca 125 18,8

Follow up US : uterine is normal, size 6,2x3,4x2,7 cm, retroflexy,  homogen, ET 4 mm.
Right adnexa: mass, 8,2x5,9x7,0 cm, vol 180 ml. Cystic multiloc, anechoic, with papil, solid area (-), vascularization (-),
Left adnexa: not visible.
Abd: hepar normal. Limphnodes not visible, no HN, no pleural effusion, no  ascites.
Con : recurrent mass.

As : Ca Ovarium advance stage, after 6 course CP

Observation 3 month

4/03/10 :
S : -
O: Abdomen :  scar up till 3 f bpx, mass 8x8x8cm in abdomen. Ascites (-),
   v/v: portio smooth, adnexa : palpable at adnexa 8x8x8 cm.

Follow up US : uterine is normal, size 7,1x4,2x4,4 cm, retroflexy,  homogen, ET 7,3 mm.
Right adnexa: mass, 8,6x6,9x8,5 cm, vol 250 ml. Septa 4,1 mm. Cystic multiloc,  with papil, solid area (-), vascularization RI 0,39,
Abd: hepar normal. Limphnodes not visible, no HN, no pleural effusion, no  ascites.
Con : recurrent mass.

A: ovarian Ca advance stage, progresive desease.  

Problem

Problem solving Resisten platinum
Second line chemotherapy
Secondary cytoreduction