Case Conference September 26th 2012

26-Sep-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

September 26 ^th 2012

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Mrs.I, 31 yo, Ivan  32 yo 3540140

 

Ovarian carcinoma advanced stage post SOS outside post optimal debulking complete resection and adhesiolysis , with chemotherapy 6 series

 

Oct 2010

Patien had performed the operation due to ovarian cyst (cystectomy ) She didn’t know about the PA result

 

Okt 2011

Performed c-section and salpingooopherectomy unitaletal with PA result malignant. Sugested chemo but patient refused and went back to Padang.

 

January 2012

Patient went to padang (parent’s house),  had complain about  abdomen enlargement , had dyspneu à pleural efusion à cytology was malignant cell

Backt to PELNI jakartaà suggest chemo

 

Maret 2012-: June 28 ^th 2012 :

Got  chemo 4series with carboplatin and paclitaxel

 

P1, SC 1 X

 

Gen state :

Vital signs : normal

Enlargement of left  coli LN

Gyn state :

I  :  v/u normal

Io : smooth portio and vagina

V/RT :mass in  left cranial uterus, adhered to uterus, mobile from surrond tissue

 

 

Supportive data :

 

PA 20112044 18/October 2011 (post sc_SOD)  result :

 Epithelial  ovarian malignant tumor, adenoca worst differentiation.

 

Pleural cytology (31/1/2012) :

Efusion/ adenocarcinoma metastasis

Ca 125 ( before chemo 21/2/2012) : 1515

Ca125 ( after chemo  7/6/2012) : 1097

 

CT scan  27/7 2012

Ovarian carcinoma, post chemo, there is right pelvic mass with ascites and bilateral hydronephrosis

Right pleural efusion  with bone metastasis

 

 

Chest-x ray

21/2/12

Right pleural efusion with right basal lung infiltrat, susp metastasis

8/3/12

Massif dextra  pleural efusion

6/7/12

right pleural efusion.

19/7/12:

Decreasing pleural efusion

 

 

US FINDINGS

US 23/2/12

Ovarian mass  was hard to assess due to massive ascites, minimal  right lung pleural efusion

US 14 /6/12

Corespond to left  cystic ovarian neoplasma ( no normal ovarian appearance )

 

8/8/2012

 

pre-operative disscussion :

CT scan :  bone metastasis , no fracture

Planning : bone scan

Considering : radiotherapy

Patient with high risk fracture

Assessment Dr.Arman : no vertebra metastase, susp pelvic metastase

 

 

9/8/2012

Pre-operative diagnosis  :

Ovarian carcinoma advanced stage post SOS, post NAC bone metastastic and suspected clavicula lymphnode metastatic

Post-operative diagnosis :

Ovarian carcinoma advanced stage post SOS, post NAC bone metastastic and suspected clavicula lymphnode metastatic.with optimal debulking complete resection, adhesiolysis

 

Subtotal Hysterectomy and right salpingooophorectomy

Total Omentectomy

Resection implant tumor at abdominal wall

 

q Palpated implant tumor at abdominal wall in the area midline insicion

q there was right cystic ovarian mass measuring 5 x 4 x 4 cm adhered to the posterior of the uterus

q On exploration, the left ovary not seen ( post Left Salpingo-oophorectomy outside).

q  Uterus within normal limit. There was adhesion between sigmoid and left lateral uterus, performed adhesiolysis and opening the retroperitoneal space.

q there was no  nodule at the  liver and lien, but there was nodule at omentum at flexura hepatica .

 

PA result (9/8/12) no. 1206606

q Histologic corespond to carcinoma undifferentiated ( ovarum ?) with adhesion and uterus invasion  reach to  myometrium

q Ovarium and peritoneum consist metastasis

 

 

 

September 18^th 2012

Patient had 6^th series of chemoteraphy ( Carboplastin 400 mg, Paclitaxel 260 mg )and continued with Bonefos drip

 

September 20^th 2012 :

09.00 WIB

Patient complained about her fever  ( mostly after got chemo , could be until 1 week).Patient had fever until 39º C . Decreased of consciousness.

Report        ed to dr. Hariyono, W, OBGYN (C ) à postponed  Bonefos until 1 week later. Observation of fever.

21.00 WIB

Neurology consultation :

Funduscopy :  round and sharpe border of papil, orange, a:v = 2:3, bleeding +/-, flare shaped, exudat (-) à retinal bleeding OD

Assessment :

1.     Decreased of consciousness, right hemipaese due to suspected SOL due to metastasis of ovarian cancer.

2.     Ovarian cancer post chemotherapy with bone metastasis

3.     Hipocalemia and hipomagnesemia

Plan :          Brain CT scan

          Dexamethason 10 mg loading IV à mainatance with 4x5 mg IV

          Ranitidin 2x50 mg IV

          Ondansetron 3x8 mg IV

          Join care with oncology neurology

 

 

Psyciatric consultation :

Assesment :

Axis I          : delirium due to suspected metabolic imbalance or electrolyte dd/ metastasis intracranial

Axis II        : no diagnosis

Axis III : ovarian cancer advanced stage post chemotherapy

Axis IV: no diagnosis

Axis V        : GAF current 40

 

Plan : Haloperidol 1x0,5 mg à if the patient still delirium can be given haloperidol ½ amp IM

Supportive psychotherapy and psycoeducation

 

September 21^st 2012:

Patient in compos mentis, complain of nausea.

Grand round with Dr. dr. Laila Nuranna, OBGYN (C ) :

1.    Re-discussion about location of bone metastasis at pelvic

2.    Rediscussion about Bonefos protocol

3.    Discussion about  alternative for giving another  3 series chemotherapy after operation

Discussion in CC