Case Conference September 26th 2012

26-Sep-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

September 26  ^th 2012

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Miss.R,18 yo, 3722823,JAMKESMAS

Solid  pelvic neoplasma susp seminoma , with severe adhesion to surronding organs

suspect partial androgen insensititivity.

 

CC : Patient was refered from tangerang Hospital to urogyn depart with ambigous genitalia and intra abdominal solid tumor.

History :

Patient has been felt about her enlargement of abdomen since 2 years.She’s never been hospitalized before.

After finished the insurance (jamkesmas) patient came tp tangerang hospital , was and refer to RSCM ( urogyn depart).

Patient has never got the menstrual periode, no development of theb breast, but she has pubic and axilla hair. Sex organ looks like mixture between male and female appearance. Mixturition from the ‘hole’ below the penis . normal defecation. She has  male sexual interest . Sometimes she has an erection mostly in the morning. Decreasing body weight since 2 years, but has normal appetite  .

Education : finished junior high school

Gen status :

Vital signs : wnl  Body weight : 44 kg, height : 165b kg

Eyes : not pale, not icteric

Mammae : tenner M1P3

Throat and neck : normal

Adomen : enlargement of the abdomen up 1 finger above navel with solid mass, irregular border, fixed, pain (-)

 

Gyn stat

I : clitoromegaly (micropenis) was seen. Ostium uretra externus 1 cm  below penis. Labia mayora+/+, labia minora +/+. Introitus vagina (+) with sondage (+) 4 cm. pubic hair (+)

RT : Vaginal was not palpated.

solid mass palpated, filling  douglas puch and pelvic cavity, adhered to rectum and lateral and anterior pelvic  wall ,fixed .the mass reach 1 finger above the navel, irregular border.   Pool posterior tumor was palpated 5 cm from anus.

 

US( FM 14/9/12)

There’s no  uterus, both ovarians couldn’tbe identified. There’s hiphoechoic mass, homogen, 28x22 mm, in anterior of the vaginal ostium, which is there’s no uretra canalis inside of, corespond to macro clitoris. Canalis uretra is in lumen anterior of distal vagina.

In retrovesica area, there;s solid mass, inhomogen, iregular, distinguish border, 205x140x195 mm (vol 2700 cm3). The mass contains neovascularisation (RTI 0,35), from  malignancy of neoplasm . the mass adhered  with bladder wall, bowel and peritoneum.

Hepar, both of kidneys , bladder and urethra normal.

Conclusion :

No uterus, macroclitoris dd/ microglandpenile.

Solid neoplasma pelvic susp malignancy suspect from susp frome gonad tumor ( susp seminoma- if the cromossom is XY)

Severe adhesion with surrounding organs ( including bladder, bowel and peritoneum)

Lab findings :

Hb ; 11.4  L: 5400  ht : 34  trombocyt : 374.000  LED : 83 

ALT/AST : 29/11  blood glucosa : 74 ur : 16  cr : 0.8

LH : 25,16  FSH : 79,5  A2 : 14  testosteron : 208,90

Chromosom analysis : XY ,

no anomaly of  chromosom’s major structures suspect partial androgen insensititivity.

CT scan   whole abdomen ( Tangerang Hospital 1/8/12) :

Tumor witrh calcification, lobulated in pelvic-abdomen, suspected leomyoma uterine dd/ ovarian tumor

Assessment :

Solid  pelvic neoplasma susp seminoma , with severe adhesion to surronding organs

suspect partial androgen insensititivity.

Planning :

Analysis DNA for detecting androgen receptor mutation

Finding the gonad/testis location with radiologis examination, laparascopy or exploration laparatomy

Multidicipline tim consultation of Disorder Sex Development

Disussion and  direct assessment dr.Hariyono obgyn (C):

Pelvic tumor susp seminoma with severe adhesion , high risk  laparatomy procedure.

Discussion in CC