Case Conference November 7th 2012

07-Nov-2012, Divisi Ginekologi Onkologi RSCM

MISS M

 

Patient has been felt abdominal enlargement since  September 2009

US abdomen  (Koja hospital  21/1/2009): lower intra abdominal tumor, diameter 13,4 cm, susp ovarian tumor

 

13/1/2010

Patient was performed laparatomy sub optimal de bulking  (dr.Basuki OBGYN)at Koja Hospital. From operation report  , pre op diagnostic : uterine myoma post op diagnostic : intra ligamen ovarian tumor . The mass was from left ovary sized 20 cm,  intraligamenter,uterus right tube and ovarian were normal. Performed de bulking tumor. PA result  (21/1/2010 no K210.0059) : dysgerminoma à Review PA result : (no PA 1009079)

After surgery, patient didn’t control regularly.

At October 2010, patient started feel abdominal lump, distended abdomen and defecation problems. and came to Koja Hospital at November 2012 with anemia, had heavy menstrual bleeding and  got transfusion then refered to RSCM with left lower abdominal lump.

 

Clinical examination  (on admission):

Gen state :

Abdomen : nodulated  solid mass , fixed, was palpated, up 3 fingers above the navel.

 

Gyn state :

RT : normal uterus, solid nodulated  mass was palpated, sized 15x20 cm,press rectal lumen, adhered (+), imobile. Normal TSA, smooth mucosa.

 

Lab findings (27/12/2010):

Hb: 10.8  L:5.8  Trombocyt : 260.000 

AFP : 3.3

ur/cr : 68/3.30  ALT/ASLT : 44/9  LDH : 2084

31/1/2011

ur/cr : 60/3.80  CCT: 12.38, not done CT-scan caused by renal impairment

 

chest x-ray  (5/1/11): normal

 

US (5/1/11):

Solid ovarian neoplasma with volume > 3400 cm3 ( size more than 20x15x22 cm)suspected maligna,no  metastasis lesion at hepar and lien, paraaortal Lnds.

minimal ascites, pleural efusion (-)

 

Review slide  PA result (7/1/11): dysgerminoma

 

Assessment : Dysgerminom, post inadequate surgical staging outside (Koja Hospital), with renal impairment and bilateral hydronephrosis

 

From CC discussion ( 12/1/11):

·         Consult to urology departement for inserting dj stent/nefrostomy

·         Evaluation for chemoà after urology procedur 

 

Patient’s follow up

 

Date		US	LDH	Ur/cr	CCT
3/1/11				60/3,80	12,38
30/1/11				114/6.9
1/2/11				105/6,8		On nefrostomy ec CKD
14/2/11	Carbo VB seri I
18/4/11					43,14
25/4/11					58,04
5/5/11					58.9
6/5/11	Carbo VB seri 2
19/5/11						Clinical exam: uterus was slighly enlarge (dd/from adnexal)
13/6/11					52.81
15/6/11	Carbo VB seri 3
21/6/11			311			AFP :3,1
12/7/11			361		63,14	AFP :3,1
13/7/11		Post left oovorectomy. Uterus  was normal.right adnexal adhesion and hydrosalphing (45x8 mm) No new mass or metastasis
19/7/11	Carbo VB seri 4
26/7/11			355
15/8/11					43.39
18/8/11					61,76
5/9/11	Carbo VB seri 5
4/10/11	Carbo VB seri 6		447
12/10/11			299			AFP: 3.3
18/11/11		Right adnexal mass  susp from adhesion mass ( ec right adnexal inflamation). Compared with last usg : hydrosalphing right adnexal and adhesion.
16/11/11			447
30/11/11			328			AFP 3,9
15/12/11			340		CCT 71.32
27/12/11						CT-SCAN :right adnexal mass 3.1x2.7x2,3 cm, hepatomegaly ec non specific, metstasis(-)
23/2/12		No new mass, right adnexal mass (+) equal sized compared with CT-scan
6/5/12			342			AFP2.2
10/5/12		No new mass, right adnexal mass (+) equal sized compared with CT-scan
2/8/12		No new mass, right adnexal mass (+) equal sized compared with CT-scan	335
2/11/12			345

 

 

18/11/11

Discussion  with dr hariyono.OBGYN (C)

·         LDH before chemo : 2026 à  after chemo :447 ,

·         clinically : no new mass

·         US : the sized of the mass is small

·         Planning : CT-scan for consideration performe laparascopy

 

24/11/11

patient is not eligible for ct-scan exam, caused bye abnormal GFR.

Discussion with dr.Sigit.OBGYN (C):

Considering :

·         Residual mass was not present at last operation report (from Koja Hospital)

·         LDH before chemo : 2026 à  after chemo :447 , but the increasing LDH was present after 3 series chemo (360)

·         Patient has been stoped chemo quite long

Planning : LDH evaluation ( last chemo was already 8 weeks ), CT-scan

 

 

CT-SCAN 27/12/11

:right adnexal mass 3.1x2.7x2,3 cm,à residual ?

 hepatomegaly ec non specific,

No LNds metstasis

 

Discussion with Dr.dr.laila OBGYN (C):

We could ofered 2 options to patient :

1.      Closed observation per 2 monts, evaluation  tumor marker and US

2.      Laparascopy biopsy

Patient and family has chose close observation .

 

16/5/12

CC discussion :

·         Observation

·         LDH evaluation

 

5/11/12

Patient controled to policlinic with no complain

Gen state ; wnl,

Gyn state :

RT : normal uterus, no adnexal mass, was palpated loose parametrium, normal TSA, smooth rectal mucose

 

US (2/8/12)

No new mass, right adnexal mass (+) equal sized compared with CT-scan

A/ dysgerminoma post SOS outside, ( oct 2010),  post  six series PVB  (4/10/11), with  right adnexal mass.

 

Discussion with dr.Fitriyadi OBGYN © :planning observation, discusss in CC.