Case Conference July 27th 2011

27-Jul-2011, Divisi ginekologi onkologi RSCM

Mrs. N/ 53 yo/ P4/ SKTM

 

HISTORY

 

July 7^th 2011

Patient was referred by “P” Hospital for radiotherapy.

Complain right now is bleeding from vagina. Hystory of massive bleeding before and uncomfortable feeling at the right side of the abdomen. Normal micturition and defecation.

 

On May 26^th 2010

Patient was perfomed subtotal hysterectomy and right salpingo oophorectomy (?) at “KP” Hospital due to ovarian tumor.

Pathology result revealed epithelial malignancy, tend to cystadenocarcinoma ovarii musinosum and uterus specimen showed endometrium. Patients was suggested to performed ozon therapy, but she didn’t do it because economic matter.

 

On January 12^th 2011

Pap smear examination was perfomed and the result was normal.

 

On February 28th 2011

Patient  was said to suffer from AGUS with atypical cell, and suggested for curettage.  Then the patient referred to gynecology oncologist.

 

On March 4th 2011

She was diagnosed as ovarian cancer, already metastasis to cervix. Patient was suggested for chemotherapy, continued by operation, followed by chemotherapy or patient can directly performed operation, followed by chemotherapy 6x. Both with combination radiotherapy for cervical metastatic lesion. But patient did not come anymore.

 

On mid June 2011

Patient complained of massive vaginal bleeding, and went to Pelni hospital. She got transfusion.

Then, by gynecology oncologist, cervical biopsy also performed and the result was squamous cell carcinoma cervix, non keratinized. On June 26th 2011 ultrasound was performed at Pelni Hospital. The result was : unilocular cystic mass size  7,4x6,0x6,3 cm (cyst with solid part, unclear margin), no asites.

Patient was referred to RSCM for chemoradiation.

 

LABORATORY FINDING

 

19/6/2011       

CBC : 10,5/8210/311000/3,63/32      

Na/K/Cl : 139/3,7/102  Ca/Mg : 8,6/2,1

RBG : 133      

20/6/2011       

Albumin 3,4    Ur/Cr : 28/0,5 SGOT/SGPT : 18/11  BT/CT : 1’40”/3’50” 

CEA 3,5          Ca 125 : 30

23/6/2011    

CBC : 11,7/32,4/15.200/329.000

 

 

PHYSICAL EXAMINATION

 

General status :

• Still within normal limit
• No enlargement of supraklavicular or inguinal lymph node
• No palpated mass on the incision site on the skin

Gynecological Status :

•      Insp v/u : normal

•      Inspeculo : exophitic and part of endophitic mass at the cervix sized 4 x 4,5 x 1 cm (LL-AP-CC)

•      VT and RT : exophitic and endophitic portio, right parametrium was retracted, and suspected some processes on right sacrouterine ligament. An immobil mass was palpated on the right adnexa sized 9 x 8 x 8 cm.

•     Cervical lesions clinically corresponded to cervical cancer stage II

 

USG examination :

•      No uterine corpus and both of ovary (post SOB and subtotal HT)

•      On cervix there was echogenic mass, unclear border, inhomogen texture, hipervascular, came from recidual malignancy mass

•      To the anterior part, invasion of the mass through bladder wall invaded the mucosal part.

•      To the posterior only within the vaginal lumen, not penetrated the vaginal lumen).

•      To the cranial, mass was attached to peritoneum and part of intestine. Sized of the mass was 94 x 60 mm.

•      No enlargement of paraaorta and para-iliac lymph node.

•      Liver, spleen and kidney within normal limit.

•      No ascites.

Conclusion as : Cervical malignancy with invasion to the bladder mucous.

 

Thorax X-Ray : within normal limit

CT Scan examination :

Homogen mass with necrotic part in minor pelvic cavity with the possibility of infitration to posterior bladder wall. Mass at lower abdomen in subcutaneous tissue from the previous operation incision site. Right multiple lymphadenopathy inguinal. Litic lesion in vertebra corpus L5

July 20th 2011

Review slide from Kartika Pulomas and Pelni Hospital

•      Conclusion : Both slide corresponded to transisional cell carcinoma of ovary that probably already reached the uterine cervix. Moderate until poor differentiation.

 

Cystoscopy : Suspected bladder metastases

Hystopathology : metastatic lesion on vesica confirmed as transisional and squamous carcinoma.

 

Assessment :

•      Ovarian cancer that metastastic to uterine cervix and vesica

•      Suspected litic lesion on lumbar vertebrae V

•      Suspected mass at the incision site

 

Management

•      Chemoradiation for cervical metastatic lesions

•      Followed by full dose chemotherapy for ovarian cancer