Case Confrence 12 May 2010

12-Mei-2010, Oncology Gynecology Division RSCM

1. Woman, 65 YO

Chief complaint: mass on left supraclavicule.

History of complaint:

18/5/09 : Came to out patient clinic, came with profuse vaginal bleeding for 2 days. From 3 month ago she complaining about scanty vag disharge followed by leuchorea. 

Urinate and defecate normal.She’s been menopouse for 8 years. She married since 15 yo. And married 3 times. She has 8 children. She had hypertention from 2 years ago, and taking daily captopril.  She was admitted and done cervix biopsy 

On general exam: BW 42 kg, Height 152 cm. 
gynaecologic exam found, Inspekulo : mass exophytic, 3x4x3 cm, RVT: nodule infiltration to pelvic wall left and right parametrium. Rectal mucous smooth.

14/5/09 biopsy PA cervix: Small amount Keratinizing squamous cel ca cervix, well-moderate diff.

11/6/09 biopsy PA from cystoscopy (bladder): non Keratinizing squamous cel ca cervix, moderate diff. cystoscopy suspected meta bladder, rectoscopy normal.no metastases.
 

Lab : Hb 11,8. WBC 10,8K/uL, PLt 408 K/uL, Ot/pt 23/18, U/Cr 54, 1,6
Cardiology consult : Hipertension gr II, Echo LVH, diastolic disfunction  HHD
A : Cx Ca IV A
Decided to give radiation

2/9/09 Recieving external radiation, C-60 50Gy 23/6-30/7/09, int radiation 17 Gy 12/8 and 19/8/09

28/4/10 After completing radiotherapy, she was followed up 3 times, she came with complaint of hematuria.
 O : CM
     Left Supraclavicule nodule 2x2x2 cm, and left axial 3x3x3 cm. 
     gynaecologic exam found, Inspekulo : vaginal wall smooth,  cervix is   small, 
     RVT: no mass palpable, rectum mucous smooth, Cu Af <normal size,

30/4/10 FNAB of the supraclavicule nodule : spreading of cquamous cell ca.

Diagnose :Cervix Ca IV A, progresive desease (distance metastases).
Plan   :adjuvant radiation on  supraclavicular
Problems  :radiation Dept advice : radiation not  treatment choice for supraclavicule and axilla metastase suggesting chemotherapy palliative
Problem solving :due to progresing desease, should the treatment continued or switch to paliatif only?

2.Woman, 63 y.o
Chief complain :nausea and sick since 1 week ago followed by disturbance to urinate.Patient was referred from X Hospital due to Cervical Cancer.

History of complaint:
Nov 2009   : She was complaint profuse vaginal bleeding. She went to Tarakan Hospital and
             underwent cervical biopsy with histopathology  result (Des 7th 2009) was keratinizing
             squamous cell carcinoma, well differentiated. She suggested to perform
             radiotherapy at RSCM.
Nov – April 2010 : She didn’t go to RSCM because the bleeding just a little amount.
April 28th 2010 : She went to ER RSCM due to nausea and sick since 1 week ago followed by disturbance to urinate.
                  Physical exam : compos mentis, BP 110/90mmHg. Pulse: 100x/m
                                  Inspekulo : mass exophytic, 5x4x3 cm, necrotic, easily to bleeding.
                                  VT:both parametrium noduler, fixed to pelvic wall.
                                  Rectal mucose is normal.

Laboratory result (April 28th 2010) : Hb : 4,4 gr/dl; Ht: 13; Leuco: 13.500; Trombo: 305.000  
US Kidney April 29th 2010 : Bilateral hidronephrosis and hidroureter.
                            Bilateral multiple nefrolithiasis.
                            Mass on cervix suggested malignancy process and already infiltrated to bladder wall.   

CXR April 29th 2010 : suspected lung metastase and  pneumonia and suggested to perform CT Scan Thorax
BNO April 29th 2010 : Right distal ureterolithiasis.
Consulted to Urology Dept on April 29th 2010 : Suggested to perfom left nefrostomy on April 30th 2010.

                        Urine/24 hours   Ur/Cr         Na/K/Cl 
Apr 29th 2010  50 cc               11/6,4      136/4,5/108    Blood transfusion
Apr 30th 2010  800 cc   
May 1st 2010   1300 cc                                                    Hb: 7,1 gr/dl
May 2nd 2010  800 cc   
May 3rd 2010  1700 cc         84/4,7         126/3,27/93,1   Hb: 9,7 gr/dl
May 4th 2010  1200 cc   

May 4th 2010 : patient underwent left nefrostomy.
                      FC/24 hours     Left Nefr/24 hours   Ur/Cr 
May 5th  2010     1600 cc             350 cc  
May 6th  2010     1100 cc             100 cc             81/4,2       Hb : 9,7 gr/dl
May 7th  2010     1500 cc             750 cc  
May 8th  2010       100 cc             200 cc  
May 9th  2010       700 cc             110 cc  
May 10th  2010   1400 cc             400 cc             82/4,5       Hb : 9,1 gr/dl
May 11th 2010     

Problem : patient cervical cancer st. IIIB with CKD + bilateral hydronefrosis and hydroureter and
          urine production > 1 cc/kg BW/24 hours.  After she underwent left nefrostomy
          procedure  renal function test (Ur/Cr) still in the same situation and production of
          urine from folley catheter > left nefrostomy.

 

3.Woman, 47 y.o, P4A1

Chief complaint: (-)
                Patient came to oncology clinic at X hospital for follow up β-HCG level after 1 cycle chemotherapy  EMACO.

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
           04-9-09-      29-09-09         19-10-09          16-11-09

           08-9-09       03-10-09         23-10-09          21-11-09
  

βHCG   15-09-09    14-10-09  10-11-09   10-12-09
                2290             172           494            825

US 7 sept 2009 : compare to Us 31/8/09 the mas intra cavum is stable
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 βHCG after 1st chemo ME (14-01-10):  981 mIU /ml                          

Jan 22th  2010 Thorax CT-Scan : Suggested lung and hepar metastasis
Feb 1st  2010  Head CT-Scan  :  brain metastasis (-)
               Dx :  GTN resistant to ME regiment

10/2/10 :Case conference :
Problem : What is the best treatment to this patient ?
Problem solving :  Change regiment : EMACO

12/2/10
S : Vaginal bleeding
O : CM
    Po : Ves +/+ Rh -/-
    Abdomen : mass (-)
    V/v : Nodul (-) livide (+)
    CUAF~normal
A : GTN resistent ME
Lab : 1/3/10 : 13,6g%, WBC 8,36 K/uL, Plt 238 K/uL, alb  4,16, Bun/sc 19/0,8, OT/PT20/16,
P : EMACO

March 2nd 2010 : BW 50 kg, BH 150cm, LPB 1,55
                                                                                                               2/3/10   3/3/10       9/3/10
Dactinomisin 0,5mg/m2                                                                      ѵ          Ѵ 
Etoposid 100mg/m2                                                                        ѵ          Ѵ 
Mtx 100mg push, 200 mg/m2, in 12 hours                                     ѵ  
Folinic asid 20 hours after mtx, 15 mg PO/IV, 10 times/6 hours         ѵ        Ѵ 
Vincristin                                                                                                                                       ѵ
Cyclofosfamid                                                                                                                           ѵ
   

Post kemo Emaco  BHCG 41,3
Lab : Hb 13, g%, WBC 4,36 K/uL, Plt 188/uL, Bun/sc 25/0,8, OT/PT17/14,
                                                                                                            23/3/10  24/3/10         30/3/10
Dactinomisin 0,5mg/m2                                                                        ѵ        Ѵ 
Etoposid 100mg/m2                                                                               ѵ         Ѵ 
Mtx 100mg push, 200 mg/m2, in 12 hours                                        ѵ  
Folinic asid 20 hours after mtx, 15 mg PO/IV, 10 times/6 hours           ѵ     Ѵ 
Vincristin                                                                                                                                    ѵ
Cyclofosfamid                                                                                                                         ѵ
   

Post kemo Emaco  BHCG 1
                                                                                                             14/4/10  15/4/10  21/4/10
Dactinomisin 0,5mg/m2                                                                            ѵ     Ѵ 
Etoposid 100mg/m2                                                                                   ѵ     Ѵ 
Mtx 100mg push, 200 mg/m2, in 12 hours                                        ѵ  
Folinic asid 20 hours after mtx, 15 mg PO/IV, 10 times/6 hours          ѵ     Ѵ 
Vincristin                                                                                                                                   ѵ
Cyclofosfamid                                                                                                                       ѵ
   

 

S : (-)
O : abd : Mass –
Inp V/v nodule vagina (-) , Cu Af normal size, no adnexal mass, rectal mucose is smooth
USG : 5/5/10 : homogen uterus, no PTG lession. No vascularization.
No liver metastases.
Thorax XR result not available yet
Post kemo Emaco  BHCG 1

A: PTG complete respons to EMACO

 

4.Woman, 53th YO. P-3,

Neoplasma ovarian cystic susp Malignancy, SK 6. RMI 4050

Chief complaint:  consulted by surgery dept to general gynecology clinic with malignant mass origin from adnexa.

History of complaint:
19/3/2010 :She came to surgery dept and diagnosed by susp abdominal tumor. Then she underwent CT scan on 26/4/10, and the result was malignant mixed mass, originated from adnexa, with adhession to uterus and rectum,  with liver metastases and right pleural effusion.
    She was consulted to general gynecology  policlinic and reffered to oncology ginecology clinic.
           She feels enlargement of the abdomen about 6 month. She realized the mass enlarge faster during last 3 month. She feels nausea, and decreasing apetite.
    She is not complaining about body weight. She is urinating and defecating normal. No history of vaginal bleeding. She has been menopouse for 6 years.
           She is a housewife, and her husband is merchandise.

O : general condition is fair. CM
    Abd : Mass till navel. cystous concistence, no ascites, mobility is fair. 
    V/v : normal, VT : cervix, uplifted to right. Uterus is normal size, mass in the right  adnexa, mixed solid and cystous concistency, mobility is fair.
    Rectal mucose is smooth. Mass palpable extra luminar.

Lab result : (7/4/10) Hb 8,7 g/dl, wbc 9,13 k/ul, plt 623 k/ul.Ureum 11mg/dl, Creatinin 0,9 mg/dl.
      GOT/GPT 29/11, alb 4,06. Ca 125 451,1, cea 136. Bt/Ct 3,30/13.00
Thorak PA : 6/4/10 Cor/po normal, dd pleuritis

US Onco : 27/4/10
•Uterus :  normal, size 6,7x2,3x3,6cm, anteflexy. Echostructure homogen. No lesion, no mass. ET 3,8 mm.
•Adnexa multilocular cyst, 22x16x20cm. Vol 3700cm3, Septal thicness 2,7mm. Solid part, no papillae, vascularization (+) RI 0,23. can not diferenciated from the right or left origin
•No free fluid.
•Liver normal. No metastases
•Limphnodes cannot evaluated.
•Kidney normal bilateral.

Right pleural effusion . ascites (-).
Neoplasma ovarian cystic , with solid part, vol 3700cm3, maligna
Lesi metastasis hepar (-)
Hidroneprhosis (-)
Efusi pleura kanan
Ascites (-)

CT scan (26/4/10)
•Heterogen mass (cystic and solid component) contrast uptake on the solid part, septation, clear margin on pelvic wall to abdominal cavity up to Ver L3. thick septal, 12,1x18,5x19,4cm. Masa compress bladder, adhere to uterus and rectum, no infiltration. No free fluid in the douglas cavity.
•Liver : not enlarge, smooth surface, no bilier intra and extra dilatation. Multiple nodule in variant size in both lobes. Right pleural effusion.
•Gall bladder: no enlargement, no wall thickening, no SOL.
•Kidney R-L : excretion-secretion normal.
•Uterus: not enlarge, homogen dinsity, no SOL.
•No Limphnodes enlargment on paraaorta,  parailiaca. No destruction and metastase.

Malignant mass heterogen (with cystic and solid part) fro, adnexa, with adhesion to uterus and rectum with liver metastasis.
Fluid collection in douglas.
Effusi pleura kanan.

Anestesi : 4/5/10 ASA II (anemia)
Cardiology 26/4/10 ACC
Digesive ACC joint op 
A : , Neoplasma ovarian cystics susp malignancy, liver Metastases?

Problems :
Diagnosing Advance stage due to liver metastatic, (not visible by US, and clearer diagnosed by CT scan) ?

Problems solving
Laparotomi FZ