Case Conference Jan 25th 2012

25-Jan-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

JANUARY 25^th 2012

1 OUTPATIENT (PRIVATE PATIENT)

 

Mrs. A, 30 yo, P0, 352-75-86, Umum

 

 

 

HISTORY

 

November 16th, 2011

 

Patient came to RSCM with chief complain of back pain spreading downwards extremities since few weeks before admission.  Patient was sent by an OBGYN in Pelni Hospital for chemotherapy and CT Scan due to ovarian carcinoma.

 

Patient complained of back pain spreading downwards extremities which come and go (colic) since few weeks before admission.  Once suspected as ureteric stone, with CCT on admission was 93.8.  Patient had underwent surgery at Puri Indah Hospital with hystopathology report of “Adult Granulose Cell Type”, according to the surgeon the abdominal cavity was clean with cyst ruptured.  No problem on  apetite.  No difficulties in  miction and defecation. 

 

Married 1x

P0

No history of contraception

Housewife

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 110/80 mmHg     Pulse 84 x/min          RR 20x/min               T afebrile

Height 148 cm           BW 48.5 kg

Conjunctiva    : non anemic conjunctiva, non icteric sclera

Heart/lung     : wnl

Abdomen       : palpated mass on the left lower quadrant until 3 fingers above navel, fixated, tenderness (-)

Extremities     : warm, edema -/-

 

Gynecological status

Inspection      : v/u calm, no active bleeding

Inspeculo       : patient refused to be examined

VRE                 : patient refused to be examined

 

 

 

 

Abdominal US Result in Puri Indah Hospital (August 28th 2011)

·      Hyperechoic lesion in uterus size 7.6x7.57x5.53 cm, suspected a uterine myoma with surrounding blod clot with right ovarian functional cyst

·      Contracted gallbladder (non fasting)

·      No abnormality seen in abdominal organs (liver, splen, pancreas, both kidneys)

·      Advice : Transvaginal US

 

Part of Surgery Report in Puri Indah Hospital (September 5th 2011)

·      During laparotomy found mass in right ovary with size of an adult’s punch and bleeding, impression of an ovarian tumor torn apart, performed oophorectomy, and in left ovary size 3 cm performed partial oophorectomy. 

·      Uterus slightly enlarged. 

·      In omentum there was a hardened mass suspected coming from the tumor, performed omentectomy.  Performed abdominal lavage and cytology examination of abdominal fluid. 

·      Performed DC, there was an exophitic mass which came from uterus, suspected a growth of a tumor, done hystopathology examination

 

Hystopathologic Result in Puri Indah Hospital (September 5th 2011)

Biggest probability is juvenile granulose cell tumor spread into omentum and endometrium

 

Review Hystopatologic Slides Result (September 29th 2011)

Hystologically correspond to Malignant Mullerian Mixed Tumor (Carcinosarcoma) in uterus  and both ovaries

 

Review Cytologic  Slides Result (September 29th 2011)

Tumor which can not be identified the type, tend to be poorly differentiated carcinoma

 

Laboratoric Results (November 19th 2011)

CBC : 11.1/34.9/9370/562000/81.7/26/31.8     Na/K/Cl 139/3.54/104.2

OT/PT 52/36       Alb 2.93      Ur/Cr 10/0.5       CCT 120.78     Ca-125  725    UL wnl

  

Assessment at Polyclinic (November 16th 2011)

·      Complains of back pain which come and go (colic) à suspected ureteric obstruction.

·      Patient only brought data of CCT 93.8, other datas were left at home.

·      Discussion with dr. Hariyono, OBGYN(C) :

Patient still procede to chemotherapy today and needed to be consulted to urology division, scheduled for BNO-IVP, and given analgetic for colic condition.

·      Patient was asked to bring all other datas, all laboratoric results which had not been examined should be checked in the ward.

·      Plan for chemotherapy with B-E-P

·      Assessed as : Ovarian carcinoma susp stadium III  and susp ureteric colic

·      Planned for : Cemotherapy with B-E-P (Carboplatin 423gr, Bleomycin 15 mg, Etoposide 100gr)

 

Chemotherapy with B-E-P

The 1st series à November 18th 2011

The 2nd series à December 20th 2011

 

BNO-IVP Result (December 7th 2011)

Secretion and excretion function of both kidneys are normal.  Partial obstruction in right ureter.

 

US Examination Result (January 2nd 2012)

·      Anteflexed uterus, uterine fundus and corpus were normal.  Homogenous myometrium.  Regular basalic endometrial stratum.  Enlarged cervix, consisted of inhomogenous mass, irregular edges, not clear borders, size 45x19 mm, connected with endometrial mass, probably came from invasion of malignancy mass.

·      There are multiple solid masses with connected to each other in the Douglas Pouch, cranial from uterus until subhepatic with Ø 73 mm, 80 mm, 100 mm, and 80 mm, came from malignancy mass.

·      Liver : in right lobe there are 2 nodules with Ø 70 and 80 mm, came from metastatic mass.  Splen, bladder, and both kidneys are normal.  There is ascites.

Conclusion :

Ascites and multiple solid neoplasms intra abdominal, possibility came from ovarian malignancy with metastatic.  Liver masses suspected metastatic mass.  Cervical mass suspected invasion or metastatic through endometrium.

 

CT-Scan Result in RSCM (January 13th 2012)

Ovarian tumor with metastatic to  right lobe liver and lymph node enlargement with possibility already infiltrating to the uterus.

 

Outpatient Clinic Assessment (January 20th 2012)

Discussion with dr. Hariyono, OBGYN(C) :

·      From clinical judgement : the state of the ovarian cancer now is progressive due to unresponsiveness to the chemotherapy given; CT-Scan result showed signs of metastatic to right lobe liver and lymph node enlargement with possibility already infiltrating to the uterus; and from US examination showed suspected metastatic mass on liver and cervical mass suspected invasion or metastatic through endometrium.

·      Bring to the case conference for further consideration on wether to give second line chemotherapy or palliative care for next management of this patient.