Case Conference September 28th 2011

28-Sep-2011, Divisi ginekologi onkologi RSCM

Mrs. Y/ 56 yo / P0 /  344 1323/ Gakin

 

History :

Complain of abdominal enlargement since September 2010.

On April 5^th 2010 patient was performed laparoscopy SOD at “K” Hospital due to  right ovarian tumor.  PA result (April 9^th 2011) was Endometriosis of right ovary, no sign of malignancy. Then, the patient did not control to Koja Hospital.

Patient went to CiptoMangunkusumo hospital on November 29^th 2010. She also complained of difficulty in defecation. No complain in micturition.

Patient married twice (1977 & 1982), P0, Menopause for 8 year.

 

Physical examination (December 27^th 2011):

General status :

BP 110/80 mmHg, HR 86x/minutes, RR 20 x/minutes, temp 36,8˚C

Height is 156 cm, weight is 61 kg

Conjunctiva not anemic

No enlargement of supraclavicular/axilla/inguinal limphnodes

Heart: wnl

Lung : no rales, no wheezing.

Abdomen : abdominal  enlargement until 2 finger below umbilicus. Palpated solid mass with cystic part size approximately 10X10 cm and limited in mobilization

Extremities were warm

 

Gynecologic status:

I : no vaginal bleeding

Io: portio smooth, fluxus (-)

RVT : uterus normal, right parametrium were fixed. There was palpated solid mass with cystic part until 2 fingers below umbilicus and limited in mobilization, compressing  the rectum. No mass on the rectum

 

Tumor marker :

CA-125 : 1277 U/L. (December 13^th 2010)

LDH : 657 U/L (January 27^th 2011)

AFP : 3,9 IU/mL (January 27^th 2011)

CEA : 2.38 ng/mL (November 30 2010)

 

CT Scan (December 3^rd 2010)

Solid mass with cystic part at pelvic area sized 9,07x10,5x8,8 cm originated from internal genitalia organ (dd/ ovarian, uterine). Thickening rectosigmoid wall à (dd/ secondary malignancy). Enlargement of several parametrium lymphenodes with the largest size 1,8 cm. Mass at subcutis area and abdomen wall à metastasis. Right hidronefrosis and hidroureter.

 

FM-US (December 8^th 2010)

Uterus size normal, anteflexi. At anterior corpus there was hypocehoic mass, fine border size 5 x 17 mm come from myoma. At posterior corpus there was hyperechoic mass with no find border size 25 x 124 mm come from adenomiosis. Endometrium regular. Endocervix normal.

Both adnexa until douglas cavity and cranial uterine there is solid mass with cystic part, margin blur, adhere to surrounding tissue, irregular with texture not homogen, size 88 x 80 x 86 mm (right) and 78 x 45 x 84 mm (left), with neovascularization RI 0,54 originated from bilateral ovary suspected malignancy. At cranial uterus, mass from right adnexa spread until omentum, peritoneal, and fascia (until suprafascia) size 70 x 80 mm.

Ascites (-), Hydronefrosis at right kidney.

 

Conclusion: Solid with cystic part ovarian neoplasm suspected malignancy, Invasion until suprafascia.

        Small myoma uterine intramural and adenomyosis. Severe intrapelvic adhesion

 

BNO – IVP (December 17^th 2010)

Secretion and excretion the right kidney couldn’t be evaluated until 120^th minute.

At the left kidney there was narrowing left ureter at vertebra S1 and hidroureter proximal from narrowing. There was mass with soft tissue density from pelvic until abdomen which indentation the superior vesica.

 

FNAB (December 28^th 2010)

FNAB contain amorphic fluid, solid leucocyte and macrofag cell, no malignant cell

Conclusion : Inflamation cyst (Abses ?)

 

Chest X-ray (January, 4^th 2011)  :

There were no abnormality in lung and heart. No metastases in the lung.

 

PA from Review slide no 1100054 (January 11^th2011) : correspond to endometriosis cyst.

 

Gynecological US finding (January 26^th 2011):

Uterus normal, at posterior corpus there was hyperechoic area, no fine border size 3 x 2 cm. Multilocular cystic mass size 9,6 X 10X 7 cm, septum thickness is 5-8 mm, echointernal (+), RI negative.

Left Adnexa : empty. Minimal anechoic fluid on Douglas cavity.

 

Abdominal US finding:

Liver normal, no metastases. No enlargement of paraaortic lymphnodes.

Pelviectasis on both kidneys with cortex thickness right 14 mm & left 13 mm.

No free fluid at pleural and peritoneal cavity

There was suprapubic mass, multiloculer, separated from intraabdominal mass

Conclusion :

Right cystic ovarian neoplasm suspected residive endometrioma

Bilateral hydronephrosis grade II

Adenomyosis

Subcutis abcess on suprapubic area.

 

ASSESMENT :

·         Right cystic ovarian neoplasm suspect malignancy

·         Post laparoscopic SOD outside (PA: Endometriosis)

·         Subcutis Abcess

·         Adenomyosis (size 3x2 cm)

·         Thickening rectosigmoid wall --> DD/secondary malignancy

 

MANAGEMENT :  

Laparotomy biopsy of the tumor mass, omentectomy and colostomy on March 3^rd 2011 :

Preop diagnosis : Ovarian cyst suspect malignant with subcutaneous abcess

Postop diagnosis : Clinically stage III ovarian cancer

Operation Report:

Subcutis mass was infiltrated until peritoneum, sized 6 cm, perfomed excision biopsy on the subcutis mass à Frozen section : cystadenocarcinoma

Exploration :

Complex mass intraabdominally, compossed by ovarian masses, uterine, sigmoid colon, severe adhesion in the pelvic cavity (frozen pelvis)

Multiple tumor implant at omentum largest sized Ø 2 cm, intestine sized 1 cm, and milliary nodules at sigmoid colon

Sigmoid colon was enlarged due to partial obstruction

Perfomed adhesiolysis à hardy bleeding, decided to perform biopsy at ovarian mass, omentectomy

Digestive surgery : perfomed colostomy at the level of transverse colon

Plastic surgery : add more 2 cm excision of skin and subcutaneous tissue (from tumor origin) for evaluation of the border

 

PA Result 1101671 :

Histologically appropriate with cystadenocarcinoma of ovary, poor differentiation grade 3. Tumor type was most probably serous type. Tumor spreading on 13 lymphnodes.

 

March 8^th 2011 :

Discussion with Prof. DR. dr. Andrijono, OBGYN (C) à continued with chemotherapy

 

Chemotherapy Ebetaxel 210 mg + Gemzar 1200 mg 3 series (March 14^th 2011 ; April 27^th 2011; May 6^th 2011)

 

Evaluation post chemotherapy :

US (July 13^th 2011) : Cystic mass on Douglass pouch no fine border sized 110x84x103 mm (vol 500 cc), adhered to sorrouding tissue, with solid part and papillary mass, originated from malignant ovarian neoplasm.

Ca 125 (June 22^nd 2011) : 152.8 U/mL

 

Abdominal CT-Scan on August 4^th 2011 ;

Ovarian cancer post chemotherapy, compared with CT scan on March 2011, increase on size of left adnexal mass sized ± 11,77x12,45x11,61 cm. The mass was widespreading to posteroinferior bladder and obliterating perivesical fat, suspected an infiltration. Bilateral hydronephrosis and hydroureter, particularly on the right side.

Cystic lesion at the caput of the right femur

Hernia abdominalis

 

Radiograph on pelvis  (Sept 22^nd 2011) :

No abnormality of pelvic bones

 

Radiograph on Femur (Sept 22^nd 2011) :

No abnormality of bilateral femoral bones

 

PROBLEM :

Ovarian cancer advanced stage, post chemotherapy

Progression after 3 series of chemotherapy

 

TREATMENT :

Palliative care ?