Case Conference 27 October 2010

27-Oct-2010, Oncology Gynecology Division RSCM

1. Mrs Y, 34 years old, P1, Jamkesmas
History :
• Patient first came to RSCM in 29/6/2009, referred from RSU Tangerang with ca ovarium std IIIc post optimal debulking.
 Histopahtology post op: cystadenokarsinoma serosum papiliferum with focus clear cell carcinoma. Planning: chemo 3 series,
 but there is no adequate equipment Refer to RSCM  performed (6x) completed CAP (1 sept 2009, 25 sept 2009 , 30 Okt 2009, 23 Nov 2009, 17 Des 2009, 14 jan 2010)
• 1 July 2010  patient came to RSCM with chief complaint: abdominal mass since 2 months before. Urinate/defecation normal.
 PE: (1/7/10) post operation scar (+), solid and cystic mass diameter 8 cm  aspiration : 8 cc  yellowish fluid  cytology.
 CT scan abdomen: malignant mass from anterior abdominal wall L4-L5, reach cutis and subcutis, infiltration m. rectus abdominal.
 Dx: ca ov IIc recurrent suspect metastasis in cutis and subcutis at ca ovarium stad IIc (post optimal debulking 1 year ago + post chemo CAP 6 series)
• Cytology 1/7/10 : positive, carcinoma could be from metastasis ca ovarium  pro chemotherapy AP
• Chemotherapy AP performed 3 series (1: 21/7/10 2: 27/8/10, 3: 20/9/10)
• P1, married once (25 yo)

Physical examination:
Abdomen: Mass is enlarging 8x6x6 cm, solid, exophytic, fragile, ulcerative

Histopathology  RSU Tangerang (13/6/09)
Cystadenocarcinoma serosum papiliferum with clear cell carcinoma foci
No infiltration to omentum or uterus

Review Histopathology Slide (23/7/09)
Clear cell adenocarcinoma
Laboratory (20/10/2010)
Hb 9.5 g/dl. Ht 29 %. WBC 10.070/uL. Plt 281 K/uL.AST/ALT 24/20 U/L. Alb 3.84. Ur/Cr 16/1.1. Na/K/Cl 139/4.84/97.4
Ca 125 (18/8/09) 11.5 U/ml

US Oncology (20th Ag 2010)
Uterus and both adnexa not visible
Vagina hipoechoic homogen 0.46x1.19x1.9
No free fluid at pelvic cavity
Hepar: no nodul, echoparenchym homogeny
Aorta abdominalis caliber normal, no enlargement of lymph node paraaortal and parailiaca
Right and left renal : no dilatation
No free fluid in pleura cavity and peritonei cavity
Conclusion: progressive mass (-)

 

Operation report Tangerang (13/6/2010) diagnosis pre operative: NOK with solid part suspect maligna.
Diagnosis post operative: suspect ca ovarium stadium IIIc. Operation: optimal debulking. Tissue : uterus + both tuba + ovarium, omentum, appendix

Chemotherapy:
1. CAP
• 1 sept 2009
•  25 sept 2009
•  30 Okt 2009
• 23 Nov 2009
• 17 Des 2009
• 14 jan 2010
2. AP
•  21/7/10
• 27/8/10
• 20/9/10)

Diagnosis:
Ca ovarium IIc residive abdominal wall (clear cell ) platinum resistance

Plan:
Palliative – supportive

2. Mrs I, 35 years old, , P0A2, private

History

Chief Complaint: vaginal bleeding since 2 months before admission (referral from RS Avisena with ca endometrium)
Performed curettage in Avisena Hospital : adenocarcinoma endometrium. Post coital bleeding (+). Smoking (-). Weight loss (?). Loss of appetite (?).
Married 1x. P0A2.

Physical Examination:
St gen:
Conj : anemia -/-
Thoraks : normal
Abdomen: rigid
Extremities: warm
St gin:
I: v/u calm
Io: portio ektropion, smooth, fragile, easy to bleed, fl (-), flx (-)
RVT: CUT morphology and size normal, adnexa no mass, pain (-), portio pain (-)

Histopathology (12/10/2010) : adenocarconima endometrium well-moderately differentiated

US Oncology (8/10/2010)
Uterus: normal morphology, 5.5x4.3x3.3 cm, retroflexion to the left, echostructure parenchyma normal homogen, endometrium 12 mm, not invading miometrium,
 subendometrial halo irregular, no fluid intra cavum, blood flow from endometrium not increased.
Right adnexa: ovarium ovoid, 3.3x2.2x1.7 cm, follicles inside, no SOL
Left adnexa: ovarium ovoid, 3.3x1.8x3.2 cm, follicles inside, no SOL
No free fluid in Douglasi cavum
Hepar no nodule, echoparenchymal homogeny
Aorta abdominalis caliber normal, no enlargement of of lymph node
Right and left kidney: no dilatation
No free fluid in pleural cavity and peritonei cavity
Conclusion: thickening endometrium suspect malignancy, no invasion to miometrium.

Chest X-ray (6/10/2010):  fibrosis in both lungs (old process)

Lab (7/10/2010):  Hb 13.6 g/dl. Ht 41.4 %. Plt 344 K/uL. WBC 10640/ uL. BT/CT 2.3/12. PT/K 11.5/12.9 seconds APTT/K 29.5/33.9 D-dimer 100.
    Fibrinogen 232.5. AST/ALT 15/15 Alb 4.79. Ur/Cr

 

Diagnosis:
Ca endometrium stadium I
Cervicitis

Plan:
Hormonal therapy