Case Conference January 23rd 2013

23-Jan-2013, Divisi Ginekologi Onkologi RSCM

CLINICAL CONFERENCE 23/1/2013

(continue CC 16/1/2012)

1.     Ms. M CT / 33 yo / P0A0 / 3772536 / UMUM

 

(gyn clinic, 21/11/2012)

Chief complain : Dysmenorrhea since 8 years before

 

History :

dysmenorrhea more severe 3 years later (vas 6-7), always use ponstan. Control to RS Satya Negara à endometriosis cyst (5 cm) at left ovary à suggested to do surgery. Regular menstrual cycle, LMP 20/11/2012, bleeding was normal 2-3 path/day. No abdominal mass, defacate and urinate wnl. Not married yet, never had sexual activity.

 

Physical ex. à normal

Gin ex. à

I        : v/u wnl

RT     : CUT RF, size and shape wnl, mass 4 cm at left adnexa, and 5 cm at right adexa, solid nodule about 1 cm at posterior fornices.

 

US FM 12/11/2012

•      Retroflex uterus, enlarge and lobulated. At posterior part of uterus there was hiperechoic mass with unclear border, filled echointerna. Size 54 x 54 mm, from adenomyoma. Endometrium was reguler, 6 mm thickness.

•      Both ovary was enlarge, cystic mass, filled with homogenous echointernal. Size (right) 56x66x51 mm, (left) 40x24 mm, from endometriosis cyst.

•      Result : adenomiosis dan bilateral endometriosis cyst.

(22/11/2012)

•      Thorax Ro : cor and pulmo wnl

•      CA-125 1288 U/mL

(29/11/2012)

•      CA-125 494,30 U/mL

Conclusion

•      Dysmenorrhea due to adenomyosis and bilateral endometriosis cyst.

Plan :

•      Laparoscopy adenomyosis resection, bilateral cystectomy, and adhesiolysis

•      Doxycycline 2 x 100 mg

 

Operation 13/12/2012

•      Pre-op : dysmenorrhea due to bilateral endometriosis cysts, adenomyoma.

•      Op procedure :

-         Laparoscopy right cystectomy, adhesiolysis

-         Laparotomy left cystectomy, myomectomy

•      Post-op : bilateral endometriosis cyst, adenomyoma, severe internal genitalia adhesion.

•      GA, 3 trochar was inserted

•      Finding : uterus was enlarged, lobulated with the posterior and left side severe adhered to the bowel.

•      Exp : subserous fibroid 6 cm, in posterior part severe adhered with the bowel, there was cystic mass 6 cm ame from right ovary, and cystic mass 4 cm from left ovary adhered with bowel. Both tubes wnl.

•      Performed right cystectomy, came out chocolate fluid correspond to endometriosis cyst.

•      When tried to perform adhesiolysis and left cystectomy, found difficulties à mass is adhered and filled to entired douglas pouch, the uterus is hard to elevated à convert laparotomy  

•      On laparotomy, after peritoneum was opened, the uterus can elevated after did blunt dissec and recognized tumor mass. à left cystectomy and myomectomy. During performed myomectomy, came out chocolate fluid from the myoma correspond to adenomyoma.

FOLLOW UP

•      Patient taking care for 2 days in ward, condition was good.

•      9/1/2013 à controlled to clinic, no complain, bring histopathology result

HISTOPATHOLOGY

Result :

1.     Uterine adenomyosis

2.     Clear cell adeno CA, high grade which origins from right endometriosis cyst.

3.     Histopathology result correspond to endometriosis cyst with lutein cyst bleeding at left ovary.

DISCUSSION FROM CLINICAL CONFERENCE 16/1/2013

1.     Wait for ther slide review to decide further plan of treatment.

Histopathology Review Result. :

1.     Uterine adenomyosis

2.     Clear cell adenocarcinoma, high grade which occur from endometriosis cyst of the right ovary

3.     Histologically correspond to endometriosis cyst with hemoragic lutein cyst from the left ovary.

Re evaluation 21/01/2013

All the specimen was reviewed and discussed with gynaecology consultant of histopatholog specialist. The conclusion was not changed, there was focus correspond to clear cell adenocarcinoma, on the right endometriosis cyst.

DISCUSSION :

·        Management plan for this patient?