Case Conference Jan 18th 2012

18-Jan-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

JANUARY 18^th 2012

1 OUTPATIENT

 

Mrs. I, 42 yo, P4, 357-26-52, Jamkesda

 

 

 

HISTORY

 

September 5th, 2011

 

Patient came to RSCM with chief complain of heavy vaginal discharge since 1 year before admission.  Patient was sent by an OBGYN in Dharmais hospital as Cervical cancer stage II B.

 

Patient complained of heavy odorless vaginal discharge since 1 year ba.  No vaginal bleeding, change tampon 3x daily.  Abdominal enlargement felt since 1 month ba.  No abdominal pain.  Good apetite.  No difficulties in micturition and defecation.  Patient still has regular period monthly.

 

Married 2x : I. 14 yo, divorce after 10 years with 2 children

                      II. 26 yo, husband died after 9 years with 2 children

P4

No history of contraception

Housewife

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 120/80 mmHg     Pulse 88 x/min          RR 20x/min               T afebrile

Height 155 cm           BW 60 kg

Conjunctiva    : non anemic conjunctiva, non icteric sclera

Heart/lung     : wnl

Abdomen       : enlarged, tensed, shifting dullness (+)

Extremities     : warm, edema -/-

 

Gynecological status

Inspection      : wnl, no active bleeding

Inspeculo       : exophitic mass on portio size 6x5x5 cm, fragile and easy to bleed, fluor (-), fluxus (-), on anterior vagina 1/3 distal are nodules size Ø 2 cm

VRE                 : uterus normal, exophitic mass on portio size 6x4x4 cm, rigid right parametrium until pelvic wall, semi-rigid left parametrium, smooth rectal mucose

 

 

Histopathology result from Dharmais Hospital (June 8th 2011)

Cervix adenocarcinoma, lymphocitic reaction was hard to assess, lymphovascular emboli  was hard to assess

 

Review Slide result (Sept 7th 2011)

Highly suspicious of endocervical adenocarcinoma/cervical mucinosum.  Well differentiated.

 

Cystoscopy result (Sept 7th 2011)

Cystitic

 

US examination result (Sept 7th 2011)

·      Uterus pushed to anterior, size and shape normal.  Homogenic myometrium.

·      Regular, thin basal stratum endometrial.  Uterine cavity no filled with abnormal masses.  Cervix : thickened endocervix (mainly in EUO area) shaped a mass with size of 47x33 mm inhomogenous texture, correspond to cervical malignancy (originate from endocervix).  Parametrial free of invasion mass.

·      Cranial of uterus until Douglas pouch there was a cystic mass with septum, filled with solid part and papillary growth, size 180x110x171 mm, vol 1800 cc.  Mass consist of neovascularization (RI: 0.34, comes from ovarian neoplasm)

·      Tumor spreading on posterior peritoneum

·      No para-aortic and right-left parailliac lymph nodes enlargement

·      Right lobe liver, both kidneys, splein were normal

In left lobe liver there was hypoechoic mass with irregular edge, size 64x34 mm, inhomogenous, might comes from metastatic mass

·      Massive ascites

Conclusion :

Cervical malignancy.  No signs of invasion on parametrium.  Cystic neoplasm with ovarian solid part suspected malignancy (not clear primary single or double?).

Ascites and spreading mass into peritoneum and left lobe liver.

 

BNO-IVP result (Sept 10th 2011)

Secretic and excretic function of both kidneys were normal, no signs of obstruction.  Blurry area on abdominal cavity which pushes bowel to cranial, suggestive soft tissue mas on abdominal cavity.

 

Chest X-ray result (Sept 10th 2011)

No signs of radiologic on cor and pulmo, no signs of lung metastasis

 

Abdominal CT-Scan result (Oct 3rd 2011)

·      Uterine cervix malignant tumor

·      Tumor of right and left pelvic cavity probable of ovarian tumor with ascites

 

Outpatient Clinic Assessment (Oct 11th 2011)

Cervical Cancer III B + Cystic ovarian neoplasm suspected malignancy

Plan for Frozen Section Laparotomy

 

Laboratory result (Dec 5th 2011)

CBC : 11.2/36.8/11190/304000/84.2/25.6/30.4

PT/APTT : 1.3xC/1.1xC     OT/PT 12/4     Alb 2.97     Ur/Cr 25/0.6     RBG 173

Na/K/Cl 137/3.78/102.1     HbsAg non reactive     Ca-125 584.7

 

Operation result (Dec 8th 2011)

Pre-op Dx :

Cervical cancer stage III B

Cystic ovarian neoplasm susp malignancy

Post-op Dx :

Ovarian carcinoma advanced stage, metastasis to the cervix (cervical cancer stage III B) with DD/ synchronous primary cancer of ovary and cervix

Procedure :

Done Laparotomy Frozen Section, Bilateral Salphingo-Oophorectomy, Resection bladder tumor implant, Appendictomy, and total omentectomy

FS result :

Bilateral ovarian adenocarcinoma

Hystopathology result (Dec 8th 2011)

FS : Bilateral ovarian adenocarcinoma

Conclusion :

·      Papilliferum mucinosum cystadenocarcinoma, well to moderate differentiated

·      Appendix showed chronic inflamation

·      Metastatic tumor cell to omentum and vesica was not found

 

Outpatient clinic assessment result (January 9th 2012)

Ovarian cancer metastasize to cervix

Plan for consultant’s assessment

 

Outpatient clinic assessment result (January 17th 2012)

Discussion with dr. Andi DP, OBGYN(C) :

·      Clinical signs : no vaginal bleeding on a III B cervical cancer

·      Cervical biopsy : endocervical adenocarcinoma/cervical mucinosum

·      BSO hystopathology : papilliferum mucinosum cystadenocarcinoma, well to moderate differentiated, chronic inflamation on appendix

Assessed as : suspected ovarian cancer metastatic to cervix

Consideration : Full dose chemotherapy (correspond to ovarian cancer)