Case conference Nov 23rd 2011

24-Nov-2011, Divisi ginekologi onkologi RSCM

CASE CONFERENCE

November 23^rd  2011

1 OUTPATIENT

 

Ms. Kodriyah/49 yo/P0A0/357-70-03,

 

 

 

HISTORY

 

September 13th, 2011

Patient was referred by from Pelabuhan Hospital with PA result Adenocarcinoma Endometrium. Patient has been operated Total hysterectomy –Salphingoovarectomy Dextra on July 25^th 2011 with indication mioma uteri and post-op diagnosis is miosarkoma. PA result Adenocarcinoma Endometrium. Nowadays the operation wound is good with no pain. Micturition and defecation wnl. Before the operation patient complained heavy menstrual bleeding,  had been changing  tampon 10 times a day and prolong menstrual day

until 14 days ( usually only takes five until six days). Mass in abdomen (-), abdominal pain (-).

Got DM since 4 years ago with continuing regular  therapy of glibenclamid and metformin.

Not Married

Elementary School Teacher

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 130/80 mmHg     Pulse 89x/min           RR 18x/min   T afebrile

Height 150 cm           BW 48 kg

Conjunctiva    : not anemic

Heart/lung     : wnl

Abdomen       :  mediana incision wound dried(+), solid mass on right abdomen size 15x10 cm, immobilize

Extremities     : edema -/-

 

Gynecological status

Inspection      : wnl

Inspeculo       : smooth portio, closed OUE, Fluor (-) ,fluxes(-)

RVE                 : Uterus cannot be felt (+). No mass in vaginal stump, adnexal mass -/- , smooth rectal mucosa(+).

 

PA 7^th July 2011

Adenocarcinoma Endometrium with poor differentiation also sarcomatose metaplasia

 

A/  Carcinoma endometrium high risk post HTSOB

 

 

 

 

Lab 14^th September 2011

CBC 10.2/31.1/7600/546.000//74.4/24.4/32.8

OT/PT 20/6 Ur/Cr 23/0.9 Alb 3.77 FBG/2PPG 106/165

Na/K/Cl 142/2.92/101.4

 

FM USG 15^th September 2011

Vaginal stump wnl,no uterus and ovarii. Rectal mucose edema mass. Liver and both kidneys were normal, no ascites. There’s enlargement of parailliaca lymph node size 52x19 mm. There’s mass on right pelvic wall with neovascularization RI 0.25, size 78x27x71 mm ,volume 87 cc Conclusion : Metastatic residual process

 

On 15^th  September 2011

Patient assessed as Endometrial Cancer stage III, suspect residual progresif  with NIDDM

From discussion with Consultant (dr.Laila,OBGYN ( C )) : agreed to have adjuvant radiotherapy, plan to consult to radiotherapy

 

15^th September 2011 :

Cardiology consult : mild risk, agree to operate or doing chemotherapy

Anesthesiology consult : ASA II ,agree to operate

Endocrine Metabolic consult :  moderate risk, agree to joint operation

 

October 10^th 2011

Consult to radiotherapy  department for adjuvant radiotherapy

 

Abdominal CT scan 3^rd November 2011 (asked from radiotherapy department)

Residual Mass from the top of the vagina suspected to be infiltrated vesical wall and rectal. There’s lymph nodes enlargement along the para aorta, parailliaca and right obturator

 

On 16^th November 2011

Patient assessed as Endometrial Cancer stage III, radiotherapy suggested to have chemotherapy first. à consult back to OBGYN

 

On 18^th November 2011

From discussion with consultant (dr.Haryono, OBGYN (C ) ), suggested to have assessment by consultant for the resectability of the mass, if it is resectable then we could perform debulking.

 

On 22^th November 2011

Direct assessment by Prof. Andrijono à the mass was inoperable, there were vaginal bleeding.  Plan to have radiotherapy palliative because vaginal bleeding à CC.