Case Confrence 19 May 2010

19-Mei-2010, Oncology Gynecology Division RSCM

1.woman, 37 yo ,P1
Chief complaint : follow up after 4 cycle chemotherapy Taxotere – Oxaloplatin.
History:
Des 29th 2009 : admitted to RSCM due to vaginal bleeding after she underwent laparatomy at Bakti Asih Hospital on Des 2nd 2009. Operation
                procedure was subtotal hysterectomy (severe adhesion and enlargement of the cervix) and SOS.

Histopathology result  (IPECA laboratory) Des 2nd 2010; Conc:
1.Uterus : histology confirm as  metastase at myometrium, probably the origin was from ovary.
2.Ovary : “undifferentiated carcinoma of the ovary” probably metastase to uterus.

Gynecology Examnination; 
Io : tumor mass at portio, measuring 4x3x3 cm, smooth surface, easily to bleeding.
RVT : palpated mass on the cervix, measuring 4x3x3 cm, fundus and corpus uteri
      was not palpable, both adnexa wnl, rectal mucosa were smooth.

-->Biopsy of the cervix
Jan 15th 2010 : Review slide at RSCM :
Undifferentiated carcinoma of the ovary, already infiltrated to uterine wall.
Biopsy result showed same type of tumor; probably Undifferentiated carcinoma of the ovary already infiltrated to uterine wall and cervix uteri.

Dx : ovarian carcinoma infiltrated to uterus and cervix.

Jan 20th 2010 : Laboratory result Hb: 13,3 gr/dl, WBC 8500, Trombo: 262; Ur/Cr: 42/3,4 mg/dl; Urine volume : 2900 cc; CCT: 11,82 ml/mnt.
Jan 20th 2010 : US kidney : Bilateral hidronephrosis Gr I-II

Planning : Ovarian carcinoma with insufficiency renal  Regimen chemotherapy : Taxotere 100 mg – Oxaloplatin 150 mg.

Follow up chemotherapy
 Laboratory result 
1st cycle (25/01/10):1/1/10: Ca-125: 108,5 U/ml, 
       20/1/10: Hb: 13,3 gr/dl, WBC 8500, Trombo: 262; Ur/Cr: 42/3,4 mg/dl; Urine volume : 2900 cc; CCT: 11,82 ml/mnt. 
       3/2/10 :Liquid came out from scar pfanensteil incision (suspected leackage urine)
       5/2/10:Bilateral Nefrostomy

2nd cycle (2/03/10): 28/02/10 : Ur/Cr : 26/0,9 mg/dl; CCT 65,28 ml/mnt 

3rd cycle (1/04/10): 29/3/10 : Ur/Cr : 25/0,8 mg/dl CCT 74,48 ml/mnt, Ca-125 (6/4/10) : 51,7 U/ml 
            16/4/10 : evaluation of chemotherapy respon : stable desease.
      27/4/10: Rehecting fistula on scar pfanensteil incision (sized of fistula was Ø 0,5-1 cm)

4th cycle (3/05/10):2/5/10 : Ur/Cr: 14/0,8 mg/dl; CCT : 57,02 ml/mnt,
      7/5/10 Ca-125: 82,8 U/ml 
      15/05/10 : urine came out from rehecting scar--> inserted colostomy bag

Follow up US Onco

Feb 18th 2010
Uterus :
Enlargement of Cx sized 3,1 x4,3x3,9 cm; inhomogen hypoechoic parenchyma; unclear border between Cx and other organ.
Right adnexa cannot identified.Mass on posterior uterus; like donat shape, hypoechoic,  sized was 4,9x2,8 cm, unclear border.
Dilatation of both pelviocalyces system.Other organ : wnl
Conc:
Bilateral hydrinephrosis Gr.I
Enlargment of cervix
Pelvic mass susp progressive 

April 6th 2010
Uterus:
Enlargement of the cervix; irregular; sized 7,8x5,5x5,6 cm; Cx vol 125 cm3; with vascularization. RI:0,59
Right and left adnexa were not seen
No hydronephrosis (stent in situ)
Conc:
Irregular enlargment of cervix vol 125 cm3

May 17th 2010
Uterus :
fundus and corpus not seen (post subtotal hysterectomy) Enlargement of the cervix sized 6,06x4,71x4,95 cm) Cx vol 74 cm3; with vascularization. RI:0,59
Right Adnexa : wnl
Left adnexa : not seen
Bladder : showed thickening of bladder wall measuring 30 mm; formed inhomogen irregular mass measuring 7,14x5,46x6,44 cm; showed a fistula 3 mm from bladder wall to abdominal wall.
Bilateral hydrinephrosis;
Right gr.II (cortex 22mm)
Left gr.I (cortex 21 mm)
Other organ: wnl
Conc:
Cx vol 74 cm3
Bladder : showed thickening of bladder wall measuring 30 mm and a fistula 3 mm from bladder wall to abdominal wall.
Bilateral hydrinephrosis;
Right gr.II and Left gr.I

2.Woman, 26 YO. G1P0
Gravida 27-28 Weeks GA, NOK susp Maligna, RMI 270
Chief complaint : -

3/5/10 : 
S : Reffered from RS family Medical Center, Bogor with Gravida 26 WGA and ovarian multilocular cyst. (First she came to general obstetri clinic then she was consulted to oncology clinic)
    She was pregnant 7 month and had her first prenatal care during  7 month pregnancy at midwife.
    During that time was  found cystic mass by the midwife and immediately, she was sent to ObGyn for sonography.
    LMP 19/10/09. Before pregnant  she had regular menstruation. No complaint about abdominal mass.
    She had no history of gynaecological exam before.
    No history any medical deseases.
    She has been married for 10 month.
    She and her husband are elementary school teacher.

O : CM, BP 110/70mmHg, P 84x/m, H : 150cm, BW 61kgs
    General exam : wnl
    Gin/ob exam : Mass  about  half px-navel. Cystous. With fetus palpable in the lower abdomen. Head press. FHB (+). Uterine contraction (-)

    Inp : V/V normal, no cervical opening
    RVT : head palpable as pressentation. No mass palpable from RVT
    Rectal mucouse smooth

    Lab : 4/5/10 Hb 11,6g%, WBC 11,5K/uL, Plt 242 K/uL, Bt/Ct 2,30/5’, BS 80mg/dl, CA 125 90,30. OT/PT 20/14, U/Cr 9/0,6

    C  cardiology : 15/5/10, no contraindication

    General obstetri US : 3/5/10
    27 WGA pregnancy, fetal development and activity normal. O major morfology defect.
    With multilocular cystic neoplasia, susp malignancy could not been excluded .

    Onco US 10/5/10
    Bilateral cystic ovarian neoplasma vol > 6237 ml, susp malignancy(right), susp benign cyst (left). Ascites (+)

A : Gravida 27-28 WGA, Cystic ovarian neoplasma, susp malignancy.

P : Laparotomi VC in tocolotic

Problems :Preterm pregnancy, with  Cystic ovarian neoplasma, susp malignancy, should emmediate surgery is mandatory ?

Problem solving :Immediate cystectomy surgery in tocolotic to avoid preterm labor
Delaying surgery for fetal maturity over 35 weeks pregnancy, followed by  SC +lap frozen section

3.woman, 40 YO, P1 -7 yo

Endometrial Ca (low risk) + Cystic ovarian neoplasma susp malignancy
Chief complaint : she was complaining of irregular vaginal bleeding since 7 month ago

17/3/10
Chief complaint : she was complaining of irregular vaginal bleeding since 7 month ago.
S : She thought it was a perimenopousal sign. Once around November 2009, she went to RS X (North Sumatra)
    she had a curettage for hyperplasia endometrium without PA result. During that time she also had blood transfusion. She didn’t complain about abdoment enlargement. No nausea, normal urinating and defecation.
    On 18/3/10 on the policlinic she was suggested to had microcurettage biopsy.
    She was married 1 x, has 1 child. She is a housewife. Her husband is goverment officer
    On 10/4/10 She complaining of afasia, and lost of power of half of the body. And being consulted to neurology dept.

O : CM
    Hemiparesis dextra
    Others general state WNL
    Gin : Abdomen : ascites (-), cystic mass 10x10x8 cm, in cranial to the womb. Mobility (+). Pain (-)
   InsP : V/V cervix smooth
    RVT : uterus AF, normal size
          Cystic mass palpable on right adnexa in size 10x10x8cm, rectal mucouse is smooth

PA Microcurettage (18/3/10) Endometroid adenocarcinoma endometrium, well diff.
US Feto (17/3/10): Endometrial thickening susp endometrial hyperplasia. Cystic ovarian neoplasma susp malignancy with RI 0,4 and solid part.
Oncology US 25/3/10 : endometrial hyperplasia, cystic ovarian neoplasma susp maligna
Lab : Chest X ray normal(23/3/10)
BNO-IVP : Excretion and secretion normal
Brain CT scan  (19/4/10)Infark periventrikel, metastase (-)
Lab (19/4/10):Hb 13,2 g%, WBC 9,42K/uL, PLt  267K/uLm BT/CT 2/12, AST/ALT 24/24, alb 4,3,BS puasa 114mg/dL , bs 2 jpp 165 U/C 28/0,8  Ca 125: 179
Anesthesia C: ASA II
Cardiology C: normal
C neuro : no  surgery contra indication

A: Endometrial Ca (low risk) + Cystic ovarian neoplasma Susp Malignancy
P : HT BSO +Laparotomy VC
During pra operation the case was prepare to endergo laparoscopy surgery  HT BSO and Frozen section.

3/5/10 :
Surgery report
- Litothomi Position ( to maintain patient position ), general anesthesia, performed colpotomizer insertion
-  Insuflation abdominal cavity with CO2 until 20 mmHg presure to inserting trocars and decrease CO2 pressure until 14 mmHg
-  Trokar insertion 11 mm at umbilicus and 1 trokar 5 mm at supra symphisis  and 2 others 5 mm at right and left lower quadran
-  Performed peritoneal washing  citology examination
-  On exploration : there was cystic mass on the right ovarii size 12 x 7 x 5 cm , smooth surface, no adhesion on the surounding
   organ , uterus and  contralateral adnexal was normal.
- No enlargmen at pelvic limphnode L/R, no enlargment of para aortic limphnode, liver and and spleen were smooth
- Performing total histerectomy, vaginal vault closed transvaginally
- Suturing the abdominal puncture wound with monocyn 3.0
- Washing of abdominal cavity with steril water  500cc.
- Blood loss during operation  500 cc, urine 200cc, clear

Sitology (11/5/10) : Inconclusive, suggestive malignancy
PA (14/5/10): Adenocarcinoma ovarii, cervicitis with nabothian uvula.
Tumor invasion exceeding half of   myometrium thickness.
Endometrium, miometrium ovarium bilateral contain the same tumor.

Ovarian Ca + Endometrial Ca
Problem : Inadequate Staging
Prblem solving : Adjuvant chemoterapy 3-6 course
Or chemoradiation, followed by complete debulking