Case Confrence 26 May 2010

26-Mei-2010, Oncology Gynecology Division RSCM

1.Woman/ 38 yo / P1A5

Chief complaint: lower abdominal pain and decreasing of appetite since 1 mouth ago.

History :

Aug 28th 2009 : came to oncology clinic RSCM and she was diagnosed as Cervical cancer Stage
                III  B (histopathology result was squamous cell carcinoma, poor differentiated).

Sept 9th – Nov 24th 2009 : underwent concurrent external radiation (25x) + chemotherapy (3x)
                           and  followed by brachytherapy (3x)

Feb 9th 2010 : controlled  to Radiotherapy. Result : progressive disease.

Feb 9th 2010 : came to oncology clinic.
               Gynecology  exam: Abd : palpated solid mass 2 finger above symphisis.
                                  Io : found exophitic mass, measuring 2x2x1 cm
                                  VRT: palpated exophitic mass, measuring 2x2x1 cm.
                                       Parametrium left and right : noduler,
                                       fixed to pelvic wall.
                                       Rectum mucosa were smooth.

Dx : Cervical Cancer Stage IIIB partial response.

--> Decided to perform chemotherapy PVB 3 cycle--> reevaluation

March 1st 2010 : underwent 1st cycle chemotherapy PVB
 
March – May 2010 : loose of follow up because financial problem.

May 11th 2010 : came to oncology clinic with lower abdominal pain and decreasing appetite since 1 month ago.
  She also complaint about disturbance to slept at night.
                     
        Gynecology  exam: Abd : palpated solid mass 2 finger above symphisis.
                           Io : found exophitic mass, measuring 2x2x2 cm
                           RVT: palpated exophitic mass, measuring 2x2x2 cm.
                                Parametrium left and right : noduler,fixed to pelvic wall.
                                Rectum mucosa smooth.

Laboratory result (May 20th 2010):
Hb : 8,2 gr/dl    Alb : 2,90 mg/dl  Na+ : 130 mEq/L
Leuco : 19,12. 10^3   Ur/Cr : 14/0,4 mg/dl  K+  : 2.81 mEq/L
Trombo 348.10^3               Cl- : 87,6 mEq/L

Problem : Cervical cancer stage IIIB partial response after complete radiotherapy
 Radio resistance
 Should we continue chemotherapy PVB ? (rationality to continue PVB regiment)

Problem solving : 
-Change chemotherapy regiment
-Palliatif treatment

 

2. 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)--> Ca-125 (1/1/10): 108,5 U/ml, 20/01/10: 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 
   16/04/10 : evaluation of chemotherapy respon : stable desease.
   27/04/10: 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 Ca-125 (7/5/10) : 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

Problem :
1. Ovarian carcinoma infiltrated to uterine and cervix with insufficiency renal (bilateral
    hydronephrosis) and  already given 4 cycle chemotherapy  Taxotere - Oxaloplatin.
    Respon treatment was stable tumor.
2. Management of insufficiency renal.

Problem solving :
-Change chemotherapy regiment or only palliative treatment
-Bilateral nephrostomy should be permanent.

 

3. Woman, 45 YO P-0

Solid ovarian Tumor susp malignancy, CHF(MR moderate, TR moderate,  AR mild,), FC II-III.
Chief complaint: abdomen enlargement

14/4/10:S:
She came with main complaint abdominal enlargement since 4 month before admitted. She felt tired, lack of appetite, and nausea. She also complaint about edema in both legs.
She came to PMI hospital bogor and underwent examination. And diagnoses with ovarian tumor suspected malignancy.  Then she was reffered to RSCM.
Since acouple of years she also complaining about weakness and decreasing of body weight. She didn’t have any medical xamination for any medical problems including cardiology.
She had her first menstruatuion at 15 yo. 28 days. No dysmenorhea. She has been married for 12 years and 1 history of  spontaneus abortion
Both of She and husband are teacher.

O :
CM, BP 110/70 mmHg, P 92x/m, RR 24x/m. BH 160cm, BW 46kgs, BMI 17,96
Anemic +/+, icteric -/-
Cor S1-2 reguler, murmur +Po Ves +/+, Rhales-/-

Abd :
Solid mass about navel, mobility(+), pain (-) with ascites(-)
Gyn :
Insp V/V normal
Cervix uplifted, smooth,
RVT : uterus size normal. Palpable solid mass up till navel, mobile, no pain , Size 15x15x15cm.

Ext: edema pitting

Lab: 18/4/10 Hb 8,7 g%, hct 32%, MCH/MCHC 20,3/26,9, WBC 5,3, PLt 309 K/uL, SI 8(37-145), TIBC 260 (228-428), sat transferin 3% (15-45),feritin 7,9 (13-150)
Erythrosit : hypochromic microcytic, anisopoikilositosis, pencil sel(+)
BT/CT 4/14, OT/PT 36/28, alb 3,56, BS 84mg/dL, Na/K/Cl 137/3,30/102, U/Cr 11/0,4. Ca 125 59,20

US onco 20/4/10
Uterus normal, 5,2x2,1x2,7cm, anteflexy, echostructure normal homogen, no lessio,ET 4,8mm.
Right adnexa solid mass 17x12x16 cm. Vol 1700ml, RI 0,21
Left adnexa : ovarium normal. 4,3x1,5x2,6cm.
No free fluid
Liver : echostructur increased,  no metastases. GB wall thickening.no HN, no effusion no ascites.
Con :Solid ovarian tuomr vol 1700ml, susp malignancy.
Hepatomegaly, fatty liver. No metastatic lesion in the liver. Cholesistitis. No HN, effusi (-). Ascites (-)
Thorax PA 5/5/10 : Cardiomegal appropriate to MI-MS

Echodoppler 27/4/10 : LA and RV dilatation, MR moderate, MVP PML TR moderate, PH sevre, AR mild, Susp cardiomiopaty dilatation, lowering RV function, and lowering LV sistolic.

C Anestesi : 12/5/10 ASA III (CHF Fc II, cardiomegali CTR 75%, Anemia.  LA and RV dilatation, MR moderate, MVP PML TR moderate, PH sevre, AR mild, Susp cardiomiopaty dilatation, lowering RV function, and lowering LV sistolic.

C cardio 12/4/10 tolerantion severe.
C hematology : mild tolerantion

A : Solid ovarian Tumor Susp Malignancy, CHF Fc II-III, MR moderate, MVP PML TR moderate, PH severe, AR mild,
P: Laparotomy FZ

Problem :Surgery in a high risk cardiology problems.
 
Problem solving :Preoperation optimalization in cardiology dept (ICCU), and immediate cardio care after surgery.

4. Woman, 45 YO, Ca CX IB 1, P4-8 YO, 331 29 05
   Chief complaint : mass in the lower abdomen

History

2/6/09 :

Two month before admitted she had contact bleeding hsitory, followed by leucorhea. Then  she came to maternitiy clinic (bunda Mulia) and refered to Obgyn. She underwent biopsy cervix and the result waskeratinixzing squamous cell Ca(05/5/09)Pa no DP/090890.
She didn’t have any urinary nor defecatation problems.
She is a housewife, she had married twice. 1st 17 YO and have 3 children, 2nd at 3 YO and have 1 child. Her husand is a merchandise.

O : CM, BP 110/80, BP 80x/m, rr 20x/m
Gen : WNL
Gin : abd : mass(-), ascites   (-)

Insp :V/V mass 2x2x1cm in the cervix only.
RVT : uterus normal ize. Adnexa mass (-), no nodal involvement on parametrium, rectal mucous is smooth.

Lab: 3/6/09
Hb 13,1g%, WBC 5,8K/uL, Plt 334K/uL, OT/PT 19/23, U/Cr 17/0,6, alb 4,3

PA : 0903571 2/6/09
Keratinizing squamous cell ca , well diff.
Chest XR : 9/6/09 normal
BNO-IVP normal
Anaestesiology (18/609): ASA I
Cardiology : Normal
Cystos-rectoscopy normal

A : Ca CX IB1

P: Radical HP PLND

9/7/09
Performed Radical histerectomy, bilateral  salfingooforectomy and pelvic limphedenectomy bilateral. (Johnson/Nugraha/DrSigit P SpOGK)

6/8/09 Fup
PA 10/7/09 no PA 0904459

Makro:
1.Uterus dan ovarium
2.Jaringan uterus dan kedua adnexa: 11,5x4,5x5,3cm, coklat padat kenyal. Adnexa sisi A tuba 6 cm, diameter 0,7cm. Ovarium 2,5x1x0,5cm. Adnexa sisi B tuba 5,5cm diameter 0,7cm. Ovarium 3x1,5x0,7cm. Tampak masa tumor putih seperti bunga kol, ukuran 0,5x0,7cm, menonjol dari dinding servik ke arah vagina. Kanalis servikalis terdesak tumor. Cavum uteri kosong. Tebal uterus 1,5-1,7cm. Kedua ovarium tampak padat dengan 1 buah rongga kista berisi cairan bening dan berdiameter 0,6cm.
Sebagcet:
1a. Batas sayatan vagina: 2 kup 2 kaset
1b. Serviks 2 kup 2 kaset.
1c. Parametrium sisi A : 1 kup 1 kaset
1d. Parametrium sisi B :  1 kup 1 kaset
1f. Endometrium : 3 kup 2 kaset
1g. Adnexa A: 2 kup 1 kaset
1h. Adnexa B : 2 kup 1 kaset
II. KGB pelvik kanan. Isi 1 jaringan 6x4x3cm. Pada pembelahan ditemukan 9 KGB diameter 0,3-1,5cm.semcet 9 kup, 3 kaset.
III. KGB pelvik kiri. Jaringan 4x2x2cm. Pada pembelahan 4 kgb, diameter 0,3-1,5cm semua cetak 4 kup, 2 kaset.
IV. KGB iliaka komunis kiri : jaringan 1,5x1,5x0,3cm, sem cet 1 kup 1 kaset.
V. KGB iliaka komunis kanan.  Uk 1,5x1x0,3cm, semcet 1 kup 1 kaset.
VI. KGB parametrium kanan. Jaringan 1x1x0,3cm. Semcet 1 kup 1kaset.
Mikros : sediaan terdiri dari uterus dengan serviks mengandung masa tumor ganas epitel gepeng berlapis yang tumbuh infiltratif. Sel pleomorfik dengan inti hiperkromatik dan mitosis ditemukan. Tamapak mutiara tanduk. Reaksi limfosit ringan. Tampak pula emboli limfatik.
Endometrium fase sekresi. Batas sayatan vagina, parametrium bebas tumor.
Ovarium kanan dan kiri serta tuba falopii tanpa kelainan.
Ditemukan sepuluh (10) kelenjar getah bening pelvik kanan, 6 (enam) kelenjar getah bening pelvik kiri, dua kelenjar getah bening iliaka kiri, dua kelenjar getah bening iliaka kanan dan satu kelenjar getah bening parametrium, seluruhnya tidak mengandung anak sebar.

Con : karsinoma sel skuamosa berkeratin servik. Diferensiasi baik dan sedang. Emboli limfatik ditemukan.
Ujung sayatan bebas tumor.

P : monitoring @ 3 month. 29/10/09 and 9/11/09

5/3/10
O : mass fixed on right lateral rectum 4x5 cm
Planned for US

18/5/10
S: solid mass on lower abdomen. No urinating and defecation problems. No  vaginal bleeding.
O: CM
Abd: mass (-), ascites (-)
V/v mass (-)
Vaginal stump smooth surface, immobile. Frozen pelvic. Rectal mucous smooth

A: Cx Ca IB1 post HR locoregional residive

Chest X R : 18/5/10 no metastases

US 18/5/10
Pelvic: no uterus and no ovarium.
On the vaginal stump area there’s a solid irreguler lession, size 4,9x3,0x4,8 cm, vol 40cm3, no vascularization.
No free fluid on pelvic
Liver no metastases
No paraaorta nodes enlargement
Dilatation of right kidney pelviocalices, cortex thickness 13mm. Left kidney normal
No pleural effusion, no ascites

Con: solid mass 4cm3 in the pelvic. HN gr II
Bone scan : not yet been done

5.Woman, 26 YO, P-1
  Ovarian Ca , Progresive desease
  Chief complaint : -

History

30/11/09:

S :
Enlargement of the abdomen 2 month before admitted. She didn’t have urinate and  bowel disturbance. She didn’t complaining about nausea, but had  lost of body weight about 5 kgs in this 6 month.   She was already seeking doctor to Koja hospital. Underwent examination including US and Abd CT . She
BB turun 5 kg (dlm 6 bln).  Siklus haid tdk teratur, saat ini os menggunakan KB susuk (sejak 1 thn yll). P1A0
USG pertama kali dikatakan mioma uteri. Hsl CT scan (21/11/2009 di RS Koja : Tumor intra abdominal bawah dengan ukuran 19x18x11 cm.
She had an iregular menstruation. Sometimes bleeding during the cycle. She used depo subcutan implant.

O :
CM. Vital sign WNL
Gin : solid mass 20x18x10 cm, lobulated and immobile
V/V : cervix smooth.
RVT : uterus enlarge app to 18-20weeks GA. Cystic mass at posterior uterus fixed.
Rectal mucous is smooth. Mass is fixed to the perirectum.

Lab 7/1/10 Hb 10,7g%, WBC 8,7K/uL, Plt 426K/uL, Ot/PT 18/10, alb 4,3, U/Cr 12/0,8,BT/Ct 2,30/12.CA 125 : 4685 u/ml,

US Onko: 2/12/09
mioma uteri intra mural with cystic ovarian neoplasma suspect benign.
HN gr 2 dekstra, Gr 1 sinistra.
Thoraks foto/IVP :  dbn
 
2/12/09
cardiology : WNL
C Anestesi: ASA I
Digestive dept  agree for joint op

A :  Uterine Myom  + cystic ovarian neoplasma

11/1/10:

Patient underwent surgery
Setelah peritoneum dibuka tampak cairan asites minimal, dibilas dengan NaCl 0,9% dan diambil 20cc → sitologi.
Pada eksplorasi terdapat tumor pelvis noduler yang mengisi seluruh pelvis mayor sampai 2 jari atas pusat. Bladder melekat pada massa tumor.
Karena tumor melekat pada dinding anterior, maka pendekatan retroperitoneal dilakukan dengan membuka retroperitoneal anterior dilanjutkan ke lateral sampai dengan daerah paracolica kanan. Ureter hidronephrosis, dipreparasi.
Ligamentum infundibulopelvikum dikenali, diklem dan diligasi. Dilakukan pembukaan retroperitoneal kiri, ureter dikenali dan ligamentum infundibulopelvikum diklem dan diligasi.
Massa tumor melekat pada rectosigmoid dan mesorectal, dilakukan adhesiolisis sampai pada kavum Douglas.
Ureter ditelusuri sampai masuk vesika, vesika dibebaskan dari tumor dengan membuka perlekatan dari lateral.
Massa tumor dari ovarium kanan-kiri dan uterus yang telah bersatu dikeluarkan dalam satu blok, dan dilakukan pemeriksaan Frozen section Hasil VC : tumor ganas epitelial kistadenokarsinoma sero musinosum
Terdapat perdarahan diffuse dari tumor bed (rektosigmoid, pelvic wall, fundus bladder). Perdarahan dirawat dan ditampon sementara.
Pada eksplorasi lebih lanjut terdapat tumor pada caecum dan mesocaecum. Tumor juga terdapat pada mesokolon pada kolon transversum

Mengingat perdarahan telah mencapai 3000 ml, reseksi tumor metastase ditunda. Tamponade dibuka, dilanjutkan pencucian dengan aquadest, masih terdapat perdarahan diffuse => diputuskan untuk pemasangan kasa tampon 2x24 jam. Dipasang drain

11/1/10 at 1800 wib.
During observation
O: T 81/49, P 150x/m
Urine 700cc/5 h. Drain 550cc/3h

A : post lap incomplete debulking+ abdominal bleeding

11/1/10 23.00 WIB underwent hemostasis surgery to control the bleeding, and re packacking  tumor bed.

12/1/10, aff packing
   
12/1/10
Pneumothorax underwent WSD by the thorax surgery

18/1/10 PA 1000213: Cystadenocarsinoma serusom papiliferum moderate diff ovarium, with limphatic invasion, infiltrating to uterus and omentum

25/1/10 she was discharge from hospital in well condition And plan for ajuvant chemo CP for 3 cycles and plant for relaparotomy hemicolectomy

She had 3 cycles CP On 5/2/10-12/3/10-12/4/10

7/5/10:

S: -
O: CM
Abd : no mass palpable
V/V vaginal stump smooth
RVT : fixed solid nodular mass on the top of vag stump spreading left and right para vagina till cavum douglasi. Rectal mucous is smooth

US onco : 20/5/10
Solid mass in the pelvic anterior rectum vol 200cm3, suspected progressive mass.
Liver No metastases lesion, no paraaortal nodes enlargement. No ascites.

A: Ovarian Ca  III C, post incomplete debulking, after 3 cycles Adjuvant CP, Progressing desease

Problem

Problem solving Progresing desease due to emerging new mass in the anterior rectum during adjuvant

Should this case left No treatment ?