Case Conference June 22nd 2011

22-Jun-2011, Divisi ginekologi onkologi RSCM

1. Mrs. M/74 yo/P12/JAMKESMAS

 (23/05/11) Patient come to CM hospital with chief complain mass protruded in front of vagina

History:

Patient felt there was a mass in front of vagina since 1 year ago. First, patient went to  alterntive medicine, but the mass still growth, then patient went Adjidarmo hospital (Lebak). D/ tumor from labia mayora, referred to CM hospital.
23/05/2011  perform biopsy from the mass and FNAB at right inguinal lymph node.
27/05/2011  FNAB result (111358)  positive carcinoma metastases.
30/05/2011  PA (1103917)  Epitelial malignant tumor probably adenocarcinoma, origin hard to defined.
07/06/2011  perform Ro thorax and BNO-IVP
14/06/2011 USG FM and staging by consultant
Staging by consultant  vulvar cancer stage IIIA  planned for radiation.
15/06/2011  Clinical Conference  It was decided to performed examination under anesthesia, in order to determined resectability tumour mass, because the mass too large, the radiation will not give good response therapy.
20/06/2011  Performed gynecologic examination under anesthesia  There is vulvar mass measuring approximately 11 cm (laterolateral) x 5 cm (kraniokaudal) x 11 cm (anterior posterior). The mass came from ½ of the right vulva up to the anterior border (a border between vagina and the anterior vulva). Urethra hard to identify. The pedicle of the mass measuring 5 cm in diameter. There is palpated lymphnode on the right inguinal area measuring 3x2x1 cm. Impression T3N1M0, stage III
Patient married once with twelve children. Menopause since 20 years ago.
No difficulties in defecation but felt pain when micturition.
  
NOW
General status conscious, mildly ill, vital sign BP 130/80 mmHg, HR 84x/minutes, RR 24 x/minutes, temp afebris
Conjunctiva not anemic
No enlargement of supraclavicular, axilla and enlargement at right inguinal lymph node
Cor and pulmo wnl
Abdomen : normal, no mass palpated.
Extremities were warm, edema -/-

Gynecological status
I   : There is  mass originated from right labia minora and border of vagina - vulva anterior, size 11 x 5 x 11 cm, the mass fragile and easy to bleed.  Another vagina wall was smooth.
RVT :  portio and uterine was atropic. Mass pushed the urethra. Rectum mucous is smooth, mass (-). Ampulla rectum not collapses.

SUPPORTIVE EXAMINATION
(11/06/11) Blood Count : Hb : 9,8, Leuco : 11.070, Trombo : 409.000
Gluc : 91 Ur/Cr: 22/0,5,   Alb: 2,6, AST/ALT : 17/18
(14/06/11) US (FM)
 Uterine retroflexion size and shape normal.Miometrium homogen
 Endometrium stratum basale thin, portio and endocervix normal. Both ovarian atrophy.
 There was echogenic mass at right inguinal size 3,2 x 1,9 cm probably originated from lymph node metastases.
 Bladder, both kidney and liver was normal
 No ascites.
Conclusion: No abnormality at internal genitalia organ. Mass at vulva with lymph node enlargement susp metastases.

06/06/11  Ro Thorax: No signs of metastases
07/06/11  BNO IVP: Excretion and secretion both kidney normal
 
PROBLEM :
Vulvar cancer stage IIIA with right inguinal lymph node metastases.

PLAN:
Debulking follow by radiation.

2. Mrs. Y/52 yo/P0/JAMKESMAS

25/10/2010  Patient came CM hospital with chief complain irregular vaginal bleeding since 1 year before admission. Bleeding was not profused, 1-2 pads/day. Os cannot remember her last menstrual due to irregular bleeding. No abdominal enlargement, there is no history of vaginal discharge and post coital bleeding  performed USG.
25/10/2010  USG result was endometrium thickening suspect malignancy  planned for DC  25/11/2010   Performed DC.
30/11/2010  PA (1008311) result was adenosquamous carcinoma moderate differentiated.
14/12/2010  Consultant assessment at policlinic  surgical staging.
31/01/2011  Performed subtotal hysterectomy and bilateral salpingoovorectomy, with residual tumour diameter 3 cm at ileum.
08/02/2011  PA (1100826) : Adenocarcinoma endometrial poor differentiated with deepest invasion until serosa uterine wall.
07/03/2011  Assesment consultant at policlinic  adjuvant radiation or chemotherapy AP  brought to Clinical conference
09/03/2011  Clinical conference  it was decided to Chemoradiation AP  after complete followed by ileum resection.
11/03/2011  Consult to Radiotherapy department
19/04/2011  CT Scan  Malignant mass at abdominal lower right and pre rectal; upper margin at level vertebra L5 and spread to the left side. Appaerantly caecum already involved with infiltration to abdomen anterior wall. Limfadenopathy mesenterica multiple and also hepatomegaly.
21/04/2011  Answer by Radiotherapy department  Planned for radiation at 2nd Mei 2011. Advised followed by concurrent chemotherapy.

Follow up
- Tgl 06/5/2011 

Ur/Cr  :   31/0.4 ; CCT : 48,56 ; Volume Urine : 630 mL 

- Tgl 23/5/2011 

Ur/Cr  :   27/0.5 ; CCT : 42,25 ; Volume Urine : 1.250 mL

- Tgl 30/5/2011 

Ur/Cr  :   30/0.6; CCT : 45,03 ; Volume Urine : 715 mL

-Tgl 19/6/2011 

Ur/Cr  :   25/0.4; CCT : 51,12; Volume Urine : 1.450 mL

NOW
General status conscious, mildly ill, vital sign BP 120/80 mmHg, HR 84x/minutes, RR 28 x/minutes, temp afebris
Conjunctiva not anemic
No enlargement of supraclavicular, axilla and inguinal lymph node
Cor and pulmo wnl
Abdomen : Palpated solid mass with cystic part until 2 fingers below umbilical. Mass Surface noduler, fixed. Operation scar mediana
Extremities were warm, edema -/-

Gynecological status
Inspeculo: portio was smooth. atrophy no mass,
RVT:  Solid mass palpated until 2 fingers below umbilical, it was fixed
Rectum mucous, mass (-).Ampulla rectum not collapses.

SUPPORTIVE EXAMINATION
(21/06/11) Blood Count : Hb : 12,7, Leuco : 12.860, Trombo : 213.000
Ur/Cr: 20/0,5,  CCT : 42,35  Na/K/Cl : 140/1,76/90,5

20/06/11  Ro Thorax: No signs of metastases

PROBLEM :
Endometrial cancer post subtotal hysterectomy residive.
Lower CCT

PLAN:
Chemotheapy AP with radiation.
Adjuvant radiation only.