Case Conference March 14th 2018

14-Mar-2018, Divisi Ginekologi Onkologi RSCM

 

Case description

 

 

 

Mrs. NSH, 48 yo, P4 427-21-77

 

 

 

Oncology Clinic 19 February 2018

 

 

 

Chief complaint:

 

Abdominal mass since 6 months before admission, progressively enlarged in last 3 months.

 

(No vaginal bleeding)

 

 

 

History:

 

Patient was initially referred from RSPAD Gatot Soebroto with Cystic Ovarian Neoplasm suspected malignant. Patient was scheduled for surgery at February 2018, but cancelled due to refractory hypoalbuminemia. Patient complained for weight loss, five kilograms in last three months. There was no complaint for vaginal bleeding. Last menstrual period was at November 2017. Patient admitted diarrhea since 3 days before admission, >3x / day. Urination in large volume, difficult to resist the urge of urination since 3 months before admission.

 

 

 

History of previous illness :

 

No history of malignancy

 

No history of Diabetes Mellitus, Hypertension, Asthma, Cardiac

 

 

 

History of illness in family :

 

No history of malignancy in family

 

 

 

History of marriage:

 

1x, since

 

Husband passed away 4 years ago

 

 

 

History of obstetrics :

 

P4A0, all of them were spontaneous delivery

 

1^st child 32 yo, last child 12 yo

 

 

 

Physical exam

 

 

 

Fully alert

 

BP 100/70, Pulse 104, Temp 36.7, RR 18x/min              

 

BW 40 kg, BH 169 cm, BMI 14

 

 

 

General condition

 

Eyes                - pale conjungtiva (+), no icteric sclera

 

Lung                - Vesicular, no rhales, wheezing

 

Heart               - normal S1S2, no murmur, gallop

 

Abdomen        - mass was palpable as high as umbilicus, consistency was hard, fixed

 

Extremity        - warm, no edema

 

 

 

Gynecological status

 

Inspection: normal vulva and urethra

 

Inspeculo: seen mass on portio, cauliflower like, fragile, easily bleed

 

Bimanual exam: mass palpated on portio, parametrium was loose, Douglas pouch was bulging, sphincter ani tonus was good, no mass palpable on rectal mucosa.

 

 

 

Auxilliary examination

 

 

 

RSPAD

 

Laboratorium :

 

Ca 125 22.57    CEA 44

 

 

 

Thorax X-Ray 8 January 2018 :

 

Lung and heart were within normal limit

 

 

 

MRI 20 October 2016 :

 

Solid part with malignancy characteristics with necrotic components at right ovarium, infiltrating anterior part of serous-myometrium uterine corpus, anterior cervical stroma and left posterolateral wall of vesica.

 

Solid mass at eight segments of liver, suspected metastase DD/ focal nodular hyperplasia

 

No enlargement of pelvic and inguinal lymph nodes

 

 

 

RSCM

 

Laboratorium 19 February 2018 :

 

CBC 8.1/24/40.500/572.000

 

PT 1.2x/APTT 0.9x

 

Fibrinogen 106.6 D dimer 800

 

SGOT 22  SGPT 14  Albumin 2.02

 

Ur 42 Cr 0.7 RBG 60

 

Na 137 K 4.46 Cl 89.7

 

PCT 3.87 ng/mL

 

 

 

Working diagnosis

 

Cystic ovarian neoplasm suspected malignant

 

Cervical cancer clinically IB (not yet staging by Oncologist)

 

Anemia

 

hypoalbuminemia

 

 

 

Planning

 

Hospital admission for improvement of general condition (anemia, low intake, GEA)

 

Biopsy of cervical mass

 

 

 

Ward 208B 21 February 2018

 

 

 

Dr. dr. Laila N, OBGYN(C) examination :

 

 

 

Abdomen : cystic mass was palpable as high as navel, size 25 x 25 cm, smooth surface, fixed.

 

 

 

RVT: Vagina was normal, mass at cervix size 1x1x1 cm (exophytic), both parametria was loose, cystic mass was palpable size 25 x 25 x 25 cm, smooth surface, uterus was adhered with mass, rectal mucosa was smooth.

 

 

 

Diagnosis : Cystic ovarian neoplasm suspected malignant, suspected cervical cancer, anemia, hypoalbuminemia

 

 

 

Planning :

 

Diagnostic :

 

-          Wait for cervical biopsy, blood and urine culture

 

-          Find cytology of ascites result from RSPAD

 

-          US FM, US renal – vesical, Thorax x-ray

 

-          MRI abdomen

 

 

 

Therapy :

 

-          PRC transfusion until Hb level >10g/dL

 

-          Albumin 20% target albumin >2.5g/dL

 

-          Consult to urology

 

-          Ceftriaxon 2x1 g IV

 

-          Consult to nutritionist

 

 

 

Monitoring :

 

-          Vital sign

 

-          Fluid balance

 

 

 

 

 

Laboratory result:

 

 

 

Laboratory	20/2/2018	22/2/2018	26/2/2018	27/2/2018
CBC	9.3/27.2/ 30.680/630.000	9.7/28/ 39.810/531.000
Albumin			1.43	1.56
Ur / Cr		50 / 0.80
Na / K / Cl		131/3.5/97.8
PCT		22.18

 

 

 

Blood culture 27/2/2018 : sterile

 

 

 

Tumor markers 23/2/2018 :

 

LDH : 861 U/L

 

CA 125 : 145.3 U/mL

 

AFP : 1.0 IU/mL

 

 

 

Ward 208B 27 February 2018

 

 

 

Dr. dr. Laila N, OBGYN(C) examination :

 

 

 

Abdomen : solid mass was palpable as high as navel, size 25 x 25 cm, fixed.

 

 

 

VT: mass at portio size 1,5x1,5 cm, vagina and parametria was free from infiltration

 

 

 

Urine culture 24/2/2018 :

 

Organism :

 

1.      Klebsiella pneumonia

 

2.      Escheria Coli

 

 

 

Sensitivity :

 

1.      Cefoperazone sulbactam

 

2.      Meropenem

 

 

 

Thorax x-ray (21/2/18) : negative for nodules

 

 

 

Renal and vesical US (23/2/18) : hydronephrosis at left renal grade I

 

 

 

MRI (21/2/2018) : solid part at pelvic cavity, bulging to anterior part of uterus, spread to mesenterium & peritenoeum at pelvic cavity, vesica, infiltrating anterior part of sigmoid colon, part of intestine, malignancy was originated from right ovarium. Ascites with suspected peritoneal carcinomatosis. Multiple lymph nodes at bilateral parailliaca.

 

Biopsy of cervix : Adenocarcinoma endocervical, well differentiated, lymphovascular invasion was negative

 

 

 

Diagnosis : Cervical cancer Ib1, Solid ovarian neoplasm suspected malignant, hypoalbuminemia

 

 

 

Planning :

 

-          Check for Beta-HCG

 

-          Fetomaternal US

 

-          Planned for Laparotomy VC & radical hysterectomy

 

-          Albumer Infusion

 

 

 

Beta-HCG : 0.23 IU/L

 

 

 

Fetomaternal US 28 February 2018 :

 

Uterus anteflexed, normal. Homogen myometrium.

 

Stratum basalis endometrium was regular.

 

Endoserviks and portio was normal.

 

 

 

At anterior part of uterus, there was solid mass, inhomogen, unclear border size 114 x 103 x 87 mm, correspond to solid ovarian neoplasm suspected malignany.

 

 

 

Liver, both renal were normal.

 

Ascites positive.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

Laboratory result:

 

 

 

Laboratory	1/3/2018	4/3/2018	5/3/2018
CBC
Albumin	1.63	1.85	2.12
Ur / Cr	28/0.60
Na / K / Cl	133/3.63/101.4		142/3.64/108.4

 

 

 

Urine culture 7 March 2018 :

 

Organism :

 

1.      Escherichia coli

 

2.      Pseudomonas aeruginosa

 

 

 

Sensitivity :

 

1.      Fosfomycin

 

2.      Meropenem

 

3.      Imipenem

 

 

 

Ward 208B 6 March 2018

 

 

 

Dr. dr. Laila N, OBGYN(C) examination :

 

 

 

 

 

 

 

 

Abdomen : solid mass until 1 finger below the navel (from ovarium)

 

 

 

Inspeculo ; exophytic process at portio (12 – 3 o’clock) size  2 x 2 x 1 cm

 

 

 

 

 

 

Diagnosis : Ovarian neoplasm infiltrating to the cervix with liver metastasis

 

                   DD/ Ovarian neoplasm suspected malignant with cervical cancer IB1

 

 

 

Planning :        Family meeting

 

Correction for anemia, refractory hypoalbuminemia,

 

            explorative laparotomy (biopsy only) if possible clinically

 

 

 

Laboratory result:

 

 

 

Laboratory	9/3/2018	10/3/2018	12/3/2018
CBC	10.8/30.5 27.010/525.000
Albumin	2.17	2.33	1.88
Ur/Cr	35/0.50		32/0.60
Na/K/Cl			138/2.98/104.4

 

 

 

Clinical question

 

What is the best management for patient with ovarian neoplasm infiltrating to the cervix, liver metastasis DD/ ovarian neoplasm suspected malignant with Cervical cancer IB1.

 

Population	Women with ovarian neoplasm infiltrating to the cervix, liver metastasis and women with ovarian neoplasm suspected malignant with cervical cancer IB1
Intervention	Surgical
Comparison	Biopsy continued with chemotherapy
Outcome	Disease free survival Overall survival Quality of Life

 

 

 

SEARCH STRATEGY

 

We did database searching on pubmed, biomed central, and science direct with keywords Ovarian AND Cervical AND Tumor AND Metastasis AND Synchronous looking for a match in title or abstract. Search result were filtered by the engine by the following criteria: articles published in the last 5 years, English language, human species and availability of full access to the article. We found 57 article match with the criteria above and we did further evaluation of the title and abstract and we got 1 full articles that appropriate answering our clinical questions. Our searching flow shown in figure 1.

 

 

 

 

 

 

CRITICAL APPRAISAL

 

From the eligible article, we did critical appraisal and can be seen in following table 1

 

	Study	Type of study	Sample	Validity				Result		Applicability	Total Score
				1	2	3	4	5	6	7
1.	Joseph, et al (2016)	Retrospective	14	+	+	-	+	+	+	?	5/7

 

 

 

DISCUSSION

 

Ovary and cervical neoplasm could be found at the same time. Both synchronous double primary tumor or metastasis case were rarely found. Cervical carcinoma uncommonly metastasize to the ovaries. Joseph et al, reported 14 cases of synchronous and metachronous gynecological malignancies. From 14 cases, only 3 cases of cervical malignancies coexisting with ovarian malignancies. Two cases were primary cervical squamous cell carcinonoma with one case synchronous with ovary papillary serous adenocarcinoma and the other case was synchronous with papillary cyst adenocarcinoma. Last case was primary cervical adenocarcinoma synchronous with mucinous adenocarcinoma of ovary. All of the primary cases were treated with surgery continued with chemotherapy, except the case with second tumor of mucinous adenocarcinoma was treated with surgery and chemotherapy. One methacronous cervical squamous cell carcinoma was reported in the study, the second tumor, adenocarcinoma ovary, was occurring after two years of radiotherapy. The rest of the synchronous or metachronous gynecological tumors were correlated with other gynecological organs (breast, labium major, uterus, and fallopian tube). Unfortunately, there were no prospective data available for the survival or quality of life of the patients.

 

 

 

CONCLUSION

 

Diagnosing invasion in cervical tumors and distinguishing primary ovarian neoplasm was challenging. From all of the double malignancies in Joseph study, female reproductive tract was the most cases found. Primary cervical carcinoma was the most common for first primary tumor. The treatment for both primary and secondary synchronous tumor were accustomed to the stage and histopathology of the carcinoma.

 

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