Case Conference June 15th 2011

15-Jun-2011, Divisi ginekologi onkologi RSCM

Case 1

Mrs. O/ 51 yo/ P3A0/ Jamkesda

20/04/2011
Anamnesis :
She was referred by RSUD Karawang with adenocarcinoma endometrioid. She complained of having vaginal bleeding since 3 year ago. The complaint was not accompanied by urination nor defecation abnormalities. She then went to RSUD Karawang. Fractionated curettage was performed and the result was adenocarcinoma endometrioid.

Physical examination :
General status   : within normal limit
Gynecological status  :
 I : v/u within normal limit
 Io : smooth vaginal wall, smooth portio, fluxus (+), fluor (-)
RVT : CUT as big as a goose egg, AF, loose parametrium, smooth rectal mucous

Review slide (04/05/2011) :
Papillary adenocarcinoma from uncertain origin
(tend to originate from the cervix)

USG Oncology Oncology (09/05/2011) :
• Uterus : round, measuring 7,91 X 5,90 X 6,32 cm, AF, irregular endometrium, no endometrial line visible but forming a lesion to the whole miometrium measuring 4,95 x 6,04 x 5,48 cm with vol 85,86 cm3.
• Both adnexas : not visible, no mass.
• No free fluid at the Douglas pouch.
• Normal liver, no metastasis lesion.
• Paraaortic LN not visible.
• No hidronephrosis.
• No pleural effusion nor ascites.
Assessment : irregular endometrium, vol of lesioj 86 cm3, suspected as malignancy penetrating almost the whole miometrium (> ½).
The patient was planned to undergo a surgery (BSO and HT).

Operation Report (31/05/2011) :
• Pre operative diagnosis : endometrial cancer, high risk
• Post operative diagnosis : optimally debulked advanced stage endometrial cancer
• Operation procedure   : TAH-BSO, lymph nodes debulking
o Midline incision
o On exploration : uterus was enlarged, pelvic LN enlargement (right : 2 x 1 x 1 cm and left : 3 x 3 x 3 cm), paraaortic LN enlargement (2 x 3 x 1 at the level of IMA, 6 x 4 x 4 cm at the level of left renal vein), no tumor implant on peritoneum and omentum. Liver and spleen were within normal limit.

o Post operation uterine section, it was found that the tumor infiltration > ½ thickness of the myometrium (at fundal site)

Post operative histopathology result :
• Adenocarcinoma endometrium endometrioid type, moderate differentiation.
• Lymphatic invasion.
• Cervicitis.
• The deepest invasion > ½ myometrial layer.
• Right ovary : cystadenoma serosum ovary.
• Right pelvic LN (1 node) and left pelvic LNs (4 nodes) revealed tumor mass.
• Paraaortic LNs (4 of 6 nodes) revealed tumor mass.

Analysis :
Advanced stage endometrial cancer with tumor mass at pelvic and paraaortic LNs and the deepest invasion > ½ myometrial layer --> plan for adjuvant therapy.

Plan management :
• Radiation ? the coverage area might not be sufficient for paraaortic region.
• Chemotherapy :  VAC.
   Carbo-taxan.

Case 2

Miss. N/ 19 yo/ Jamkesda

19/04/2011
Anamnesis :
She was referred from gynecology policlinic with cystic ovarian neoplasm with solid part suspected as malignancy. She complained of having abdominal enlargement since 6 months before admission. The complaint was not accompanied with breathing difficulties, urination or defecation abnormalities, decreased body weight nor pain. She then went to RSUD Karawang and was told that she was suffering from tumor. She was referred to RSCM.

Physical examination :
General status :
Abdomen : cyctic tumor mass was palpable until proc. xipoideus, no solid part was palpable, fixed, no shifting dullness.

Gynecological status :
I : v/u within normal limit
RT : CUT was within normal limit, cystic mass was palpable with supple lower pool, not   
 adhered to rectum, smooth rectal mucous.

Tumor marker :
• Ca 125 : 963,3
• AFP : 110,4
• LDH : 520
• hCG : < 1

USG FM :
• uterus within normal limit, AF, homogenous myometrium.
• Uterus was pushe posteriorly.
• Endometrium : regular basal stratum 10 mm.
• Endocervix and portion within normal limit.
• Normal right ovary.
• There was cyctic mass occupying abdominal cavity, multilocular, with unhomogenous solid part and papillary growth, originating from left ovary.
• Slight ascites.
• Liver, spleen and both kidneys within normal limit.
• Right hidroureter.
Assessment : cystic ovarian neoplasm with solid part and papillary growth suspected as malignancy.

CT scan :
Cystic mass, with solid part and calcification at pelvic and abdominal cavity, ascites and bilateral inguinal lymphadenopaty.

The patient was planned to undergo a surgery (Frozen Section).

Operation report (30/05/2011) :
Pre operative diagnosis  : Cystic ovarian neoplasm susp malignancy
Post operative diagnosis  : Advance Stage Ovarian Cancer (Clinically stage III C)
Operation procedur    :  Conservative surgery, optimal debulking (Salphingo- ooverectomy sinistra, Total omentectomy, 
Appendectomy)
- Midline incision
- Exploration : serous ascites about  200 cc (taken for cytology).  Left ovarian cyst with solid part sized 42x30x30 cm, smooth surface, slightly adhere to right peritoneum.  Right ovary slightly enlarge with smooth surface. Uterus normal. Multiple tumor implant at cavum douglasi sized  Ø 5 cm, Ø3 cm Ø1 cm,  milliary nodule at omentum,  smooth peritoneal surface, liver and spleen wnl, no pelvic and paraaortic LN enlargement.
- Performed adhesiolysis and  salphingo-ooverectomy sinistra --> sent to frozen section.
- Performed resection of multiple  tumor implant at cavum douglas.
- Continued by total omentectomy and appendectomy
- FS : Teratoma with immature focus.

Post operative histopathology result :
• Imature teratoma of left ovary, histology grade 3.
• Mature tumor implant at the omentum and Douglas pouch.

Post operative cytology result of the ascites :
No malignancy.

Analysis :
• Clinically stage III C ovarian cancer.
• Histopathologically stage III C ovarian cancer (with different types between the main tumor mass and the tumor implant)
• Medical status round ? plan for adjuvant chemotherapy (BEP).

Plan management :
• Tumor marker prior adjuvant chemotherapy.