Case Confrence 13 January 2010

12-Jan-2010, Oncology Gynecology Division RSCM

. Miss N./12 years old
• Chief complain : abdominal enlargement since 1 month ago.
About 3 months ago (Sept 11th 2009), patient underwent laparotomy right salphingo-oovorectomy in RSCM due to solid ovarian cyst suspected malignant. Until the patient discharge (26 days after the operation), the histopathology result didn’t known yet. Almost three months later (Dec 29th 2009), she came again to RSCM due to abdominal enlargement since 1 month.
She bring the histopathology result : juvenile granulosa cell tumor and cytology of ascite was negative
• Chief complain : abdominal enlargement since 1 month ago.
About 3 months ago (Sept 11th 2009), patient underwent laparotomy right salphingo-oovorectomy in RSCM due to solid ovarian cyst suspected malignant.Until the patient discharge (26 days after the operation), the histopathology result didn’t known yet. Almost three months later (Dec 29th 2009), she came again to RSCM due to abdominal enlargement since 1 month. She bring the histopathology result : juvenile granulosa cell tumor (No. PA 0905866) and cytology of ascite was negative (No. PA 092199).
• USG, LAB, CXR

Jan 4th 2010 USG     :       Solid ovarian neoplasm > 17x13x12 cm, RI 0,27, suspected malignant. Ascites (+) at pelvic and perihepatic, with liver metastasis, right pleural effusion, and right HN gr III.
Jan 5th 2010     DPL   10,7/7660/328000,  AST/ALT   81/11,       Alb 3,86,    Ur/Cr   19/0,6      Ca 125 504,9 / AFP 5,2   
(July 29th 2009)    278,9 / 2,1 /  hCG < 1
Jan 6th 2010 CXR : Metastasis (-), right pleural effusion.
Problem
• Patient with residif juvenile granulosa cell tumor with elevation of Ca125 level.
 (post right salphingo-oovorectomy 3,5 months ago).
• Question : What is the best treatment option for this patient?
• Treatment options :
– Chemotherapy (PVB/VAC/BEP) proceed to laparotomy, or
–  Laparotomy à what is the procedure exactly that we are going to do?
• Left salphingo-oovorecomy only
• Left SO + other procedures.
         
2. Mrs Ponirah / 57 yo / P0
• Chief complain : abdominal dyscomfort since 2 months ago.
Referred by Haji Hospital (Jan 13th 2009) for chemotherapy CP due to incomplete surgical staging with histopathology result : clear cell ovarian cancer (PA No. 80984). But the patient just came to RSCM ten months after the referral letter (Oct 26th 2009).
• History
About 1 year ago (Dec 28th 2008), patient underwent laparotomy inadequate surgical staging (HT-BSO, partial omentectomy)  in Haji Hospital due to cystic ovarian neoplasm. After the histopathology result had been known (Dec 31st 2008), the patient was directly suggested for chemotherapy as soon as possible, but she refused. She was never complaining any symptoms, until the last two months. She has been felt abdominal dyscomfort, like hardened sensation on her abdomen since 2 months ago. Defecation and mixturition still normal. There is no symptom of loss body weight and appetite as well.She had been married two times. The first when she was 31 yo, divorce after 15 years engage. The second, when she was 48 yo for 5 years. Her second husband passed away in 2004.She has never been pregnant, and has no child.Menarche in 13 yo, regular period, dismenorrhea (-). She had  already been menopause since 9 years ago.
Since physical examination revealed normal, no palpable mass intraabdominally, and US result (Oct 26th 2009) was normal, so that CT scan  with contrast was performed.
• LAB, CT SCAN, CXR
CT scan result (Nov 6th 2009)There is no mass and no other patologic lesions in pelvic cavity.
CXR and laboratory results (Oct 27th 2009) were normal
(DPL 14,0/6000/220000, AST/ALT 19/21,  Alb 3,86, Ur/Cr  29/0,7).
Onco-gyne conference (Oct 11th 2009 --??) : Close follow up with Ca 125 and TVUS.
 Ca 125  level
April 5th 2009           19,1
July 28th 2009              149,4
Aug   6th 2009                    209,6
Oct 22nd 2009   1998,2     
Dec 23rd 2009   3663
Jan 5th 2010    Onco-gyne USG     Suspected peritoneal carcinomatosis
 Susp. Pseudocyst 8x4x6 cm vol 100 cm3 with ascites (+).
• PROBLEM
Patient with residif ovarian cancer (clear cell) post inadequate surgical staging about one year ago with highly elevated Ca125 and suspected peritoneal carcinomatosis.
Plan to give chemotherapy CP.