Case Conference July 6th 2011

06-Jul-2011, Divisi ginekologi onkologi RSCM

Mrs. E/ 56 years old/  JAMKESDA

29 April 2011 à Patient came to RSCM referred by "MK" Hospital with suspected ovarian cancer with ascites. In RSCM patient diagnose with  ovarian neoplasm suspected malignancy and we perform USG. Ultrasound revealed right solid ovarian neoplasm correspond with malignancy appearance.

3 May 2011 à Ca-125 : 552,7 U/L

16 May 2011 à pleural  cytology (PA 111226) : no malignancy cells was found

19 May 2011 à ascites fluid cytology (PA 111317) : no malignancy cells was found

10 June 2011 à CT scan: solid mass in the pelvic cavity until abdominal cavity sized 15,8x15,5x15,8 cm, clear margin, with no cystic component originated from ovary accompanied with massive ascites and right pleural effusion.

10 June 2011 à Assesment by consultant at policlinic à prepared for laparotomy

20 June 2011 à Performed laparotomy exploration, biopsy of tumor implant at peritoneum, biopsy of the ovary, biopsy of peritoneum wall.

Operation report:

After peritoneum opened, there was ascites 7,2 litres serous fluid.

On further exploration, revealed right ovarian cyst size 20x 15x15 cm, lobulated, with solid part, adhesion with uterus, colon transversum, ileum, at posterior part until pelvic floor. Uterus within normal limit. Left ovary can’t be identified.

The impression was unresectable ovarian cancer case. There was milliary nodul at liver surface and spleen were smooth.

There was tumor implant on omentum sized Ø 1,5 cm, taken for biopsy

Continued by biopsy of the ovary(cystic wall) and peritoneum wall

28 June 2011 à Pathologic examination report : Malignant Mullerian Mixed Tumor (carsinosarcoma) in the ovarium and omentum

Patient married once à P3, Menopause since 6 years ago

 

Physical examination

General status conscious, mildly ill

Vital Sign BP 110/70 mmHg, HR 90 x/’, RR 24x/’, T 36,8

Conjunctiva not anemic

No enlargement of supraclavicular, axilla and inguinal lymph node

Thorax : attached WSD à serous 50 cc

Abdomen : enlargement, shifting dullness (+), solid mass until 2 fingers above umbilical.

Operation Wound :

-          Produced serous fluid at two places on 3^rd day postop

-          Produced seropurulen fluid on 11^th day postop

 27/06/2011 à culture result : isolate I : staphylococcus epidermidis. Sensitive to :  oxacillin, ampicillin, cefoxitin, tetracyclin, ampicillin-sulbactam, lincomycin,  ceftriaxone.

Tapping ascites postop  (4/07/2011)  came out 2000 cc serous hemorrhagic fluid

 

RVT:  Palpated solid  untill  2 fingers above umbilical, limited in mobility, Rectum mucous is smooth, mass (-). Ampulla rectum not collapses.

Extremities were warm,

 

Supporting Data

Laboratory result (04/07/2011):         

CBC: 9,3/ 29.2/ 25.530/ 717.000

SGOT/SGPT : 73/19, Ur/Cr : 39/1,3   Alb 2,81, Na/K/Cl 128/ 4.51/93.6

Rontgen Thorax  (04/07/2011): right pleuropneumonia , WSD tip on IC 6-7

Consult to Thorax Surgery:

Inserting WSD for 10 days, then performed pleurodesis

 

Consult to Pulmonology of Internal Medicine:

Problem: Hospital Acquired Pneumonia. Plan for pleural fluid culture.

 

Problem:

Ovarian cancer advanced stage (PA : Mixed Malignant Mullerian Tumor)

 

Plan:

Chemotherapy