Case Conference September 27th 2017

27-Sep-2017, Divisi Ginekologi Onkologi RSCM

Case Conference March 27^th 2017

Effectiveness of different treatment modalities for the management of adult-onset ovarian sex cord stromal tumor of the ovary

Mrs. N

 

RSCM, Juli 7^th 2016

Patient was referred from RSU “45” kab kuningan Hospital due to ovarian cyst with solid part, suspect of malignant tumour

Patient admitted due to abdominal enlargement since 1 months BA, without abdominal pain

Patient never had menstuation about 3 years. Patient had history of vaginal spotting for 1 week in july 2017. Patient felt that her voice is getting heavier. She had gained 20 kg of her body weight on the last 2 years. Urinary and defecation was normal. Patient felt there’s a lump in her neck since a child. Patient felt increases of libido.

Due to her complain, patient was admitted to 45 Hospital, Kuningan suspect of malignant tumour underwent an ultrasound examination being referred to RSCM

 

On general status :

Abdomen: was enlarge until 2 finger below processus xyphoideus, cystic, mobile, no pain

 

On gynecology examination :

I: Vulva/ urethra within normal limit

seen clitotis was enlarged

 

Io: Smooth portio, closed OUE, fluor negative, fluksus negative.

 

RVT: Uterus anteflexed, size within normal limit, loose parametrium, palpated cystic mass on the right part, until 2 finger sub processus xyphoideus

Good sphincter tone, smooth mucosa, ampulla not collapsed, no palpated mass.

 

Laboratory Result 

04/08/17

CBC : 14.5/45.8/7400/310.000//81.6/25.8/31.7

Ul : wnl               RBS 89

Ur/Cr 19/0,9  OT/PT: 19/17

AFP : 1593  Ca125 : 72.1 testosteron  : 3 Prolactin 38.3

 

CRX

No abnormalities in cor and lung

 

Ro pelvic  29/7/2017

Cystic mass with solid part and septa came from right ovary suspected malignancy(sized 17,5x 12,3x10,7 cm)

Enlargement of the lymph node was not seen

 

USG FM 24/7/2017

Right Cyst adenoma mucinous  dd/ borderline

(right ovarian cyst was enlarged filled with cystic mass with septa sized 225x128x266 mm. mass filled with neovascularisation minimal with low resistance (RI 0.15) came from right ovarian cyst borderline type

Normal left ovarian’ Normal ren and hepar

 

 Preoperative diagnose:

 

 

 

-          Cystic ovarian neoplasm suspect cyst adenoma mucinosum dd/ borderline, with :

 

-          Primary infertility 3 years

 

-          Hirsutism

 

 

 

11/08/2017

 

 

 

perform laparotomy salpingoooporectomy dextra

 

 

 

29/08/2017

 

PA result Histologic corespon to ovarian sex cord tumor , sugestif sertologi- leydig cell tumor moderately differentiated

 

 

 

Citology aspiration abdominal fluid :

 

There is no malignancy cell tumor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Problem

 

 

 

            The effectiveness of treatment modalities  for the management of adult onset ovarian sex cord stromal tumor of the ovary whether we need chemotherapy after unilateral salpingo-oophorectomy with preservation of the contralateral ovary.

 

 

 

Problem to be discussed

 

 

 

Do we need chemotherapy after unilateral salpingo-oophorectomy with preservation of the contralateral ovary for this case

 

 

 

Discussion

 

 

 

Granulosa cell tumour is a rare gynaecological tumour of the ovary with recurrences many years after initial diagnosis and treatment. Evidence-based management of granulosa cell tumour of the ovary is limited, and treatment has not been standardised. Surgery, including fertility-sparing procedures for young women, has traditionally been the standard treatment. Adjuvant treatments following surgery have been based on non-randomised trials. A combination of bleomycin, etoposide and cisplatin (BEP) has traditionally been used for treatment of advanced and/or recurrent disease that cannot be optimally managed surgically

 

 

 

The ovarian sex cord stromal tumors are, comprising only 1,2 percent of all primary ovarian cancers⁵. In contrast with epithelial ovarian cancer, most patients with malignant sex cord-stromal tumors are diagnosed with early-stage disease, the tumors are generally considered to be low-grade malignancies.

 

 

Surgery alone is acceptable treatment for most women with sex cord stromal ovarian tumor, since the majority are stage IA and confined to one ovary at the time of diagnosis .Long-term disease-free survival rates are approximately 90 percent⁷. Surgical approach (laparoscopy vs laparotomy) and whether a participant underwent lymphadenectomy or received adjuvant treatment (mostly chemo- therapy) did not appear to impact survival according to univariate analyses. Hauspy 2011 reported a median follow-up of 73 months. Five-, 10-, and 15-year OS rates were 93%, 91% and 87%, respectively⁸_.Surgical approach (laparoscopy versuslaparotomy), type of surgery (conservative versus radical), execution of adjuvant chemotherapy and performance of lymphadenectomy were not associated with recurrence⁹_. In order to select those patient with Sex Cord Ovarian Tumor who should receive post operative therapy and understanding of prognostic factor is essential. For granulosa cell tumor the only prognostic factor that is consistenly significant is stage of disease.  The candidates for post operative treatment include patient with stage I poorly differentiated Sertoli Leydig cell tumor that contain heterolougous element, or metastatic tumor of histologic type

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