Case Conference July 13th 2011

21-Jul-2011, Divisi Ginekologi Onkologi RSCM

Mrs. Y/ 41 yo/ P0/ SKTM

Residif ovarian cancer stage IIIC

 

 

September 29^th, 2011

 

History :

Patient was consulted from internal medicine department due to abdominal mass.

The patient complained of having abdominal enlargement since three month before admission. She also complained of having vomitus.

There was no vaginal bleeding, post coital bleeding, decreasing body weight.

Defecation and urination was normal                 

Patient went to PHC given medication, but the complains still persisted, referred to internal medicine department RSCM. And after exploration on gynecology clinic, patient then was consulted to oncology gynecology clinic due to suspected ovarian cancer.

She was married for 7 years, no child.

 

Physical Examination :

 

Abdomen :

Cystic with solid part mass was palpated until 4 fingers below px

smooth surface, lobulated, filled abdominal cavity, limited mobility, no tenderness.

Gynecological status             :

•      I           : v/u looked normal

•      Io         : cervical polyp (+) à extirpation. Portio was smooth, fluxus (+), fluor (-)

•      RVT      : portio was pushed posteriorly, mass palpated ~ cervical polyp Ø 2,5 x2x2 cm. Uterus wnl.  Cystic mass with solid part was palpated until 4 fingers below px, not clear from right or left adnexa, limited mobility. Rectal mucous was smooth.

 

September 27^th 2010

Oncology ultrasound :

• Uterus looked globular, measuring 8,96 X 6,39 X 7,91 cm, AF with a mass on posterior corpus that revealed as myoma measuring 6,1 cm in diameter.
• Endometrium was reguler with endometrial thikness 4,3 mm.
• Right adnexa : ovary was normal in shape, measuring 4,23 x 2,44 x 3,65 cm, with follicles and one cystic mass (dominant follicle? / benign cyst?) measuring 36 mm, no solid part nor vascularization was seen.
• Left adnexa : large multilocular cystic mass was visible, measuring > 25 x 21 x 26 cm with vol > 7300 ml. Septal thickness 3,8 mm, internal echo (+), with neovascularization on solid part (RI 0,24).
• No free fluid at the Douglas pouch.
• No metastasis lesion in liver and spleen.
• Paraaortic LN couldnot be evaluated (covered by mass)
• No hidronephrosis, nor pleural effusion. Ascites in perisplenic.

Conclusion  :

•      Uterus with intramural myoma measuring 6,1 cm.

•      Right ovary normal in shape, contained cyst measuring 3,6 cm suspected benign, differential diagnosis with follicle.

•      Large cystic ovarian neoplasm from left ovary suspected malignancy, volume > 7300 ml.

•      Minimal ascites was visible.

•      No metastatic lesion in liver nor spleen.

•      Hydronefrosis and pleural effusion wasnot seen.

 

Lab on September 8^th, 2010

Ca-125:  54

CEA : 1,63.

 

Assessment  :

Cystic ovarian neoplasm suspected malignancy (MS 8, RMI 162)

 

October 21^st 2010

 

Optimal debulking was performed (left salpingo oovorectomy, total hysterectomy and right salpingo oovorectomy, omentectomy, appendictomy, and bilateral pelvic lymphadenectomy).

There was ascites 500 cc.

On exploration, there was nodular mass on the omentum, and enlargement of pelvic lymph nodes size 3 cm.

 

October 22^nd  2010

 

PA result (PA no 1007370) :  

Adenocarcinoma endometriod, good – moderate differentiated left ovary. Found metastasis in right surface ovary and omentum. The sample from uterus showed leiomyoma. Endometriosis was noted in right parametrium. There was no metastasis in both parametrium, bilateral pelvic lymph nodes, appendix, right and left paracolica, prevesica and also diaphragm.

           

Patient was then assessed as ovarian cancer stage III C

After that, she was given chemotherapy CP 6 series, which last in 10 March 2011.

 

March 14^th 2011 (follow up)

Ca-125  : 5,9  

ultrasound examination : no abnormal mass nor metastasis in the pelvic and abdomen.

 

 

June 5^th 2011

Ca-125 : 110,8

Ultrasound examination  : mass at vaginal stump, liver and spleen, suggested metastasis.

 

June 16^th 2011

Discuss with dr. Sigit Purbadi, SpOG (K)

Thorax x-ray à to exclude metastasis on the lung

CT-Scan à to confirm USG examination

Then bring this case to CC

 

July 5^th 2011

Thorax x-ray: paracardiac fibrosis, left pleural effusion, and  suspected ascites.

 

July 5^th 2011

CT scan: multifocal malignancy lesions at both liver lobes, lower left intraabdomen, perivesika, and peritoneum. Impression : Metastatic lesion at liver with intraabdomen and peritoneal seeding. Massive ascites and left pleural effusion.

 

Physical examination on July 5^th 2011

Patient looked dyspnoe

RR 24 t/m; HR 90 t/m

Abdomen : Ascites (+)

 

Pulmonology consultation :

Minimal bilateral pleural effusion, suggestion : thorax ultrasound.

 

July 6^th 2011

Patient looked dyspnoe and uncomforted, so we performed punction of the ascites à came out 1000 cc serohaemorrhagic fluid, then the punction needle was maintained and patient being asked to release fluid 4 times daily 200-300 cc each time.

 

July 7^th 2011

Patient came and asked for releasing puncture needle

 

ASSESSMENT:

Recurrent ovarian cancer stage IIIC

Quite massive ascites

 

MANAGEMENT PLAN:

• Cytoreduction (?)
• Chemotherapy second line
• Palliative treatment