Case Confrence 3 Februari 2010

02-Feb-2010, Oncology Gynecology Division RSCM

1. Ms I, 24 YO. P-0, 

NOK susp Maligna,DD Endometriosis Cyst

Chief complaint: abdominal pain and dysuria.

History of complaint:
1998 :Laparotomy for  abdominal cyst at Tasikmalaya Hospital. No Histopathology result. After the surgery she had an upper urinary infections for 2 weeks.

2003:She had an DG stent insertion for 1 week and ureterolitotripsi.

May 2007 :Recurrent abdominal mass, and diagnosed by endometriosis cyst. She had laparotomy II at RS Mitra Bekasi.  PA : Endometriosis cyst. She had been told due to massive attachment of the ginecology organ, she was planned to have Leuprorelin asetat inj. She was refusing the therapy.

2007-2009 :She calls for traditional remedies.

April 2009 :She went to RS Pasar Rebo, and diagnosed by recurrent endometriosis cyst, and planned for III surgery. She has been told that she has kidney problem and suggest to Dialysis.
 
30-12-2009 She came to RSCM emergency unit because of dysuria and polakisuria.
     
O: general condition is average. Vital sign BP 130/100
   anemic.

Gynaecologic axam found cystic mass wich height around umbilical 15x15x12 cm. immobile
Inspekulo : cervix is normal. Uplifted by the mass.
RVT : Uterine size is normal, douglas pouch is bulging and uplifted the cervix, cystous consistence. Fix to the rectum.

7/12/09 : US abdomen: uterus normal, cystic mass left pelvic vol : 1191 ml, susp malignancy.
                      No metastatic lesion in the liver, no ascites. No limphnodes enlargement.
Kidney US (31/12/09) Bilateral hydronephrosis and hydroureter proxymal. Found pelvic mass.
BNO-IVP (31/12/09) : no secretion and excretion function. No urinary lithiasis.

2/01/10 : went for bilateral nephrostomy

7/1/10 : Abdomen CT
Cystic mass fulfill the pelvic cavity, pushing the bladder and uterus  to right anterio-lateral and the rectum backward.
Bilateral hydronephrosis and hydroureter. There is no regional lymphnodes enlargement.
No ascites.

Thorax x ray: <CTR 50%, mediastinum and aorta normal,
Normal bone and chest soft tissue.

Hystopathology : 23/05/07 : endometriosis ovarium.

Lab result :

 16-12-09 10-01-10 16-01-10 19-01-10
Hb        8,8                       7,6       10,7
Wbc     6,69                    10,29      8,4
Plt        194                      450       459
Ca 125 173,3   
CEA    4,90   
Bun      180       166         172      164
Sc        10,4       7,2           6         5,0
cct    
alb                                    3,6 
Got       14                        12 
gpt         6                           7 
 
A: Neoplasia ovarian cystic susp malignancy DD/ endometriosis cyst , CKD Stg V, with bilateral Hydroneprosis hydroureter, post bilateral nephrostomy.

Problems 
1. What is the treatment option for this patient ?
 
Mrs Neneng / 46 yo / P2A0 /MR 336 72 06

Chief complain : vaginal bleeding and mucous discharge since 3 months ago.
Referred by Meilia Hospital due to vaginal cancer,  DD: Sarcoma Batroides

Patient complaining vaginal bleeding and mucous discharge since 3 months ago, not periodicly came out and no pain. The vaginal bleeding was not often and not profuse, just in little amount.
History of contact bleeding (-).
Patient underwent biopsy in Melia Hospital with histopathology result was carcinoma with unkown  origin

Defecation and mixturition still normal. There is no symptom of loss body weight and appetite as well.

She had been married for 21 years. P2A0, age of the youngest child is 25 yo.
Menarche in 15 yo, regular period, dismenorrhea (-).  No history of contraception

From gynecological examination revealed 3 nodul on right lateral vagina wall , measuring Ø 3cm, 2 cm, 1 cm, not fragile and not easily bleeding. The repeat biopsy was done and the result was Melanoma Malignum Vagina (PA No. 1000395).

CXR and laboratory results (Jan 20th 2010) were normal.
DPL 12,3/8050/336000, AST/ALT 14/13.

Jan 18th 2010    Onco-gyne US     :      Uterus and both adneksa: wnl
No metastasis on liver, spleen, and kidney.

Feb 1st 2010    MRI :Mass was found in vagina with good heterogen intencity Both on T1 and T2 at vagina, mass absorbed contras along
                     vanginal canal measuring 3,17cm (latero-lateral) x 2,66 cm (antero-posterior) x 6,17 cm (longitudinal)  with border not unclear margin, the most distal part seen until introitus
                     vagina, and proximal part closed to uterine cervix.Right lateral border not clear, with border between mass and m.levator ani was unrecognizable.
                     No infiltration with left or right labia mayora, and rectum No mass in vesica urinaria cavity Conc: Vaginal tumor probably infiltrate to right m. levator
                     ani.

Problem : What is  the best  management for this patient?

 

2.Mrs J / 58 yo / P2A0

Chief complain: vaginal bleeding and abdominal enlargement since 3 mouth ago.

Vaginal bleeding not periodicly came out and no pain. 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.
Defecation and mixturition still normal.

History:
Sept 26th  2000:  Cervical Cancer Stage IIB and performed external radiotherapy and bracytherapy (Oct 4th 2000 – Nov 15th 2000)

annually papsmear until November 24th 2009.
Due to the patient she was reffered to have biposi but she refused.

Nov  4th  2010   USG : Suspected cervical carcinoma, metastatic to uterine corpus

Jan 19th  2010 :  Biopsy result necrotic tissue.

Jan 19th 2010 USG : Cervix with metastatic mass to uterine corpus and fundus.
                                           Solid ovarian mass with cyctic part (Vol 900 cm3)
 
Jan 27th 2010 CT scan:  Tumor abdomen suggested primary recurrent of cervical carcinoma

Problem : What is the best treatment for this patient ?

 

3. Mrs. L, 36 y.o, P1
Chief complaint: Patient came to oncology clinic at RSCM for follow up β-HCG level after 6 cycle chemotherapy  ME.
History:
September 5th 2009   :Was diagnosed as GTN with lung metastatic
                      β-HCG level (04/09/09): 798298; 
                      WHO score : 16    Given ME Regimen

ME
   Seri I          Seri II      Seri III       Seri IV       Seri V      Seri VI

            (7-11)/9/09     (2-6)/10/09  (29/10-02/11)-09    (1-5)/12/09  (21-25)/12/09  (10-14)/01/10

βHCG 04-09-09      17-09-09     22-10-09   11-11-09    08-12-09    02-01-10
              798,298     110,747         3,100          2,351         13,311       1,568

βHCG Jan 30th 2010 : 2,747
Problem : What is the best treatment to this patient ?
          Alternative treatment :  1. Change regiment : EMACO
                                   2. TAH + chemo ME