Case Confrence 2 June 2010

02-Jun-2010, Oncology Gynecology Divison RSCM

CASE CONFERENCE, June 2nd 2010

1. Woman/ 39 yo / P1

Chief complaint: follow up after laparatomy  sub optimal debulking. At this time patient with no complaint in her abdomen. Mixturation and defecation within normal limit.

History :
Jan 2009 : She was underwent laparatomy at X Hospital Sukabumi. Operation report revealed: -Ascites 500 cc-->cytology
-Uterus : wnl     
-Left solid ovarian mass, attached to intestine, omentum and Cytology ascites report (19/01/09) : suspected adenocarcinoma metastase              
 Histopathology report (19/01/09) : Papillary serous cystadenocarcinoma.
 Reffered to RSCM but the patient didn’t come because financial problem.

April – July 2009 : abdomen getting bigger again.

July 13th 2009 : came to oncology clinic X Hospital
                 Physical exam : Abd : midline scar incision. Revealed solid mass until 3 finger above the navel, measuring 15x10x10 cm, limited in mobility.  
                        Gynecology exam : Io : portio was smooth, pushed to anterior side.
                                         RVT : Uterus was pushed to anterior, normal size.
                                               Revealed solid mass in pelvic cavity, measuring 15x10x10 cm, limited in mobility.
                                               Smooth rectal mucosa.

July 15th 2009: US Onko: Bilateral Cystic Ovarian Neoplasma suspected malignancy.
July 31th 2009: Laboratory result : Ca-125 :941 U/ml
Aug 5 th 2009 : CXR  : wnl
                BNO-IVP : secretion and excretion on both kidney : wnl
Aug 21th 2009 : Review Slide at RSCM
                Cytology Result : no malignant cell
                Hystopathology Result : Serous papilliferum borderline ovarii with focus-focus
                                                            invasion.
Aug 25th 2009 : Decided to perform Neoadjuvant chemotherapy.
1st cycle  2nd cycle  3rd cycle 4th cycle
10/09/09 05/10/09 27/10/09 12/11/09

Des 8th 2009 :  Decided to perform laparatomy debulking  with colon preparation.
Jan 13th 2010 : Right ovarian mass getting bigger 150%; left ovarian mass getting smaller 70%.
Jan 18th 2010 : underwent laparatomy sub optimal debulking  with residual tumor at anterior
                part of the rectum, measuring 2x3 cm.Joint operation with Digestive dept, on exploration found severe adhesion
                between posterior part of the tumor and sigmoid  performed adhesiolysis.
Feb 1st 2010 : controlled to oncology clinic with chieft complaint : pain at the abdomen.
               Operation wound : good conditition.
Feb 15th 2010 : Histopathology Result : - Serous papilliferum cystadenoma, borderline type with implantation to omentum
-Leiomyoma uterus
-Adenomyosis uterus
-Hydrosalphix simplex.
              
Dx : Ovarian Cancer Stage III C, post suboptimal debulking + post NAC 4 cycle.
     Planed to underwent adjuvant chemotherapy.

Feb 16th 2010 : came to oncology clinic with chieft complaint diarrhea (5-7 x/day) and fever
                       since 3 days ago.
                      Laboratory result on Feb 17th 2010:
                      Hb         : 9,5 gr/dl    Na+ : 129 mEq/L
                      Leuco      : 11,93 . 10^3 /µl   K+  : 4,76 mEq/L
                      Trombo     : 363.10^3 / µl   Cl-  : 98,5 mEq/l
                      Alb        : 3,27 gr/dl
                      Ur/cr     : 136/3,40 mg/dl

Suggested to hospitalization.

Feb 17th 2010 : Patient was hospitalized to corrected her general performance.
Feb 22th 2010 : patient was complaint her stool came out from vagina.
                Physical examination :
                   Gynecology status : Inspeculo : stump vagina was necrotic, no urine. Stool in vagina
                                             RVT : Stump vagina : not completely smooth. 1f inger atypical hole in the left corner. 
         Rectal mucosa were smooth, no mass or fistula palpable along rectum.
                                                        
Dx : Ovarian cancer stage IIIc post suboptimal debulking + suspect fistula sigmoido-vagina ?

Planing : Evaluation of the fistula :
-Methylen blue test and norit test.
-Cystoscopy and rectoscopy to evaluated fistula and metastatic lesion.
-Consult to digestive surgery dept.

Feb 25th 2010 : Methylen blue test (-)
                Norit test (+)
                Anuscopy : no fistula
Feb 26th 2010 :
               Inserted rectal tube  to necrotic vaginal stump  stool leakage from the tube.
               Consulted to Digestive dept : planned to perform:  -colonoscopy
         -Klisma 2x/day
         -Low fiber diet.

March 2nd 2010  : her family decided to bring patient home (go to alternative).
May 17th 2010  : she came to oncology clinic to controlled her condition. At this time she had no
                  Complaint  about her abdomen, mixturation and defecation with in normal limit.
  Physical Examination : Abd : midline incision until 3 finger above the navel. No mass.
                                        Io : stump vagina smooth, no fistula
                                       RVT : stump vagina smooth, no mass palpated in pelvic cavity.
                                             Smooth rectal mucosa.

May 24th 2010 : Laboratory result; Ca-125 : 21,3 U/ml.
May 26th 2010 : US Onco : Normal pelvic, no mass.
May 31th 2010 : CXR : wnl

Problem : Ovarian cancer Stage IIIC post suboptimal debulking,  clinically without residual mass 
          and laboratory finding : normal level of Ca-125, should we perform adjuvant chemotherapy?

Problem solving :  Adjuavant chemotherapy or close of follow up.    

2. woman/ 42 yo / P3

Chief complaint: follow up after 6 cycle Carboplatin Brexel.

History :
2007    : underwent laparatomy Total  Hysterectomy + SOD  at X Hospital.
          (Durante operation : cyst was ruptured)
Sept 1st  2008 : Re-enlargment of the abdomen  (cyst measuring ø 17 cm, Ca-125 : 40,3  U/ml)
                 she underwent relaparatomy  (SOS) at Bukit Tinggi Hospital with histopathology result : Granulosa cell tumor.
                 After that she received 2 cycle chemotherapy BEP  (Okt 13th 2008 and Nov 6th 2008).

Feb 2009 : Referred to RSCM due to Ovarian cancer + post chemotherapy BEP for 2 cycle.
           Histopathology result : Granulosa cell tumor.
           Physical exam   : Abd : Pfanensteil scar was found. No mass palpated.
           Gynecology exam : Io  : stump vagina were smooth.
                              RVT: stump vagina were smooth, no mass palpated

Feb 16th 2009 : US Onco
                Conc : Solid pelvic mass measuring vol 2,57 cm^3 suspcted residual mass.
                       And cystic mass measuring 3,27 cm^3 suspected pseudocyst.
-->Suggested to underwent chemotherapy.

Feb – June 2009 : loose of follow up.
June 5th 2009 : came to oncology clinic.
Laboratory Result : Ca-125 : 1986 U/ml
June 17th 2009 : US Onco : suspected progressive mass with ascites.
-->Planned to perform chemotherapy Taxoter (100mg) – Carboplatin (550 mg)

1st cycle 2nd cycle 3rd cycle 4th cycle 5th cycle 6th cycle
24/06/09 22/07/09 13/08/09 08/09/09 01/10/09 22/10/09
                            
Nov 2nd 2009 : Laboratory Result : Ca-125 : 28 U/ml
Nov 19th 2009 : came to oncology clinic for follow up after 6 cycle chemotherapy.
                US Onco : No residual tumor.

Feb 15th 2010  : Laboratory Result : Ca-125 : 193,30 U/ml
Feb 18th 2010  : 2nd follow up after 6 cycle chemotherapy Taxoter – Carboplatin. 
   Gynecology Exam : Io : stump vagina were smooth
                               RVT : revealed solid mass at left pelvic cavity, measuring  Ø 2 cm: fixed.
US Onco : No residual tumor
          Dx : Ovarian cancer after chemotherapy Taxoter – Carboplatin suspected progressive deasese.
 Plan : close follow up.

May  5th 2010 : Laboratory Result : Ca-125 : 5,421.70 U/ml
May 24th 2010 : 3rd follow up after 6 cycle chemotherapy Taxoter – Carboplatin.
Gynecology exam:  Abd : no mass palpated.
                   Io : stump vagina were smooth
                  RVT : No mass in pelvic cavity. Both parametrium were noduler, fixed to pelvic wall    
CXR : wnl.

May 27th 2010 : 
US Onco;  Conc : cystic appearance at posterior  vesica wall.
                 Cystic lesion at right iliaca region.
                 Ascites (+)

Dx : Progressive Ovarian cancer after 6 cycle chemotherapy Taxoter - Carboplatin
Problem :  - Type of histopathology not define yet.
      - Should we perform

3. Woman/ 57 yo / P1

Chief complaint: follow up after 6 cycle CP .

History :
Sept 2009 : came to gynecology clinic X hospital, referred from RSUD Bekasi due to cystic ovarian neoplasma.
            Physical Exam : Abd : cystic mass was palpated until 3 finger below the navel, mobile.
                             Io : Cx smooth
                             RVT: Uterus was normal size, AF
                                  Cystic mass was palpated in pelvic cavity until 3 finger below the navel.
                                  Rectal mucosa were smooth.

Laboratory finding (19/8/09) : Ca-125 : 147,9 u/ml
US FM : Cystic ovarian multi cystic, borderline type.
Dx : Cystic ovarian neoplasma (MS : 4)  planned to laparatomy - VC

Oct 14th 2009 :    Lap-VC was done by Gynecology div.
                   Durante op: found cystic mass size 20x20x15 cm, from right ovary--> perform
                   Right SO-->VC. Continued with total hysterectomy and left SO.
                   VC result was adenocarcinoma consulted to oncology div.
                   Exploration : found nodule at the mesenterium, liver and appendix were smooth--> performed omentectomy, appendectomy and mesenteric biopsy.
                                 No enlargement of pelvic and paraaortic LN’s.

Oct 20th 2009 :
Cytology ascites result (no.PA : 092441) : positive adenocarcinoma.
Histopathlogy result (no.PA :0906424)   : Clear Cell Adenocarcinoma, poorly differentiated, metastatic to omentum.
 
Dx : Ovarian cancer Stage III C pasca optimal debulking, planned to perform adjuvant chemotherapy CP for 6 cycle.

Follow up chemotherapy
1st cycle 2nd cycle 3rd cycle 4th cycle 5th cycle 6th cycle
5/11/09          3/12/09 07/01/10 3/3/10         26/03/10 26/04/10

May 26th 2010 : follow up after 6 cycle chemotherapy with no complaint.
Physical exam : Abd : midline scar, no mass palpated, ascites (+)
                 Io : stump vagina was smooth
                 RVT: stump vagina smooth, no mass palpated in pelvic cavity.Rectal mucosa were smooth
 
Laboratory finding (26/5/10) : Ca-125 : 14,5 U/ml.US Onco  (26/5/10): pelvic mass (-) Ascites massif 
Dx : Progressive ovarian cancer after adjuvant chemotherapy CP.
 
Problem : Should we perform 2nd line chemotherapy or close of follow up?
Problem solving : 2nd line chemotherapy if supported by government.