Case Confrence 9 June 2010

09-Jun-2010, Oncology Gynecology Division RSCM

CASE CONFERENCE, June 9th 2010

1.Woman/19 yo

Chief complaint: lower abdominal pain since 1 month ago. She also had disturbance to urinated.

History:
April 27th 2010 : she came to gynecology clinic RSCM with chief complaint difficult to urinated
                  and lower abdominal pain. Referred from Depok Hospital due to mass at inferior wall of the uterine.
                  Menstural cycle : regular, LMP April 30th 2010.
                  Physical examination; Abd: mass (-), pain (-)
                  Gynecology status : RT : Revealed solid mass  measuring Ø 5 cm, extra luminer, suspected uterine.
April 29th 2010 : Fetomaternal Ultrasound :
                  Anteflexed uterine, normal shaped and sized. Homogen  myometrium.
                  No abnormal mass reveled  at cavum uteri, Endimetrial thickness 12 mm. 
                  Cervix : OUE and part of canalis cervicalis was opened, fulfill with cystic mass
                           without echointernal, mass was connected to vagina, sized 110 X 80 mm, suspected hematotrakhelos-hematocolpos.
                  Conc: Hematotrakelos-hematokolpos, suspected vaginal septum.
                        DD: hymen occlusion.

May 4th 2010 : CXR : wnl                    
                       
May 4th 2010 : consulted to urology clinic with chief complaint :  pain at lower abdomen.
               Gynecology status :
                      Inspection : brownish fluor albus was found, vagina canal was dilatated by uterine sondage  came out fresh blood ±10 cc.
                               RT: Revealed solid mass at vagina canal until portio (inferior part of the uterine), suspected hematokolpos –hematometra.
                               Io:  Revealed blood at vaginal canal ± 50 cc, cervix cannot identified, vaginal wall were smooth.
                     Dx : Hematokolpos-hematotrakelos suspected obstruction.
                    Plan: excision of the septum (evacuation).

May 10th 2010 : Repeat Fetomaternal US:
                        Anteflexed uterine, normal shaped and sized. Homogen  myometrium.
                        No abnormal mass revealed  at cavum uteri, Endometrial normal.
                        Normal portio and endocervix.
                        Vagina : revealed cyctic mass fulfill with echointernal structure, sized
                                 147x90x94 mm (vol : 652 ml) originated from hematokolpos. 
                        Both ovary within normal limit.
                        No abnormal mass at both adnexa.
                        Conc: Hematokolpos.

May 11th 2010 : exploration of the vagina.
                      
Durante operation : - uterus sondase was inserted  4 cm to vagina canal (blocked by vaginal mass)
                    - Further exploration: revealed necrotic mass at vaginal canal with blood cloth.
                    - Vaginal examination : palpated necrotic mass fulfill vagina canal  suspected myoma uteri (geburt)
                    - Extirpation of vaginal mass sized 14x9 cm suspected cyctic degeneration myoma  sent to histopathology exam.
                    - Total bleeding ± 300 cc.
  

May 20th 2005 : Histopathology Result (no. PA 1003358)
                      
Macroscopic :
Received a tissue without information., consist of yellow-brownish tissue, vol 450 cc, solid, smallest tissue sized 1,5x0,7x0,6 cm
and biggest sized 7x8x4 cm, 5 blocks, 5 cassette      

Microscopic:
Intra vagina tumor mass (clinically suspected mioma geburt) consist of polipoid tumor mass tissue, some of tissue showed leaf-like pattern,
especially at lateral side. Tumor consist of mesenchymal and epithelial part. Mesenchymal part was dominant, more than 25% from total volume tumor.
Mesenchymal part showed high cellullarity, tumor cell with moderate atypia and a lot of mitotic, ± 6-8 mitotic /LPB.
Epithelial part showed asiner structure with cuboid epithelial layer without atypia cell. Necrotic and bloody area was found especially at lateral site.   

Conc : Adenosarcoma with component sarcoma dominant (sarcomatous  overgrowth)

May 21th 2010 : US Conc : solid mass at cervix uterine, sized 6x6x5 cm (suspected new mass/ residif mass)
May 26th 2010 : consulted to Oncologi div.
                Physical exam: Abd : mass (-)
                          Io : reveled mass at portio, sized Ø 5 cm.
                         RVT : pediculated  tumor of the cervix, sized Ø 5 cm. Vagina wall was smooth. Both parametrium free of disease.
          Smooth rectal mucosa.

May 27th 2010 : CT Scan Abdomen
Showed isodens lesion, after contras : mass was absorbed contras homogen, with border not unclear margin at uterine cervix
and pushed uterine fundus to antero-superior side. Sized of uterine : 9,65x5,11x12,82 cm.
Mass measuring 5x5 cm. Border between mass and vesica-rectum were clear margin. Both kidney : wnl.
Right ureter was visualized, left ureter was unvisualized. No enlargement of paraaorta, parailiaca, and obturator lymphnodes.
Other organ : wnl.
Conc : cervical mass (suspected malignancy), no lymphnodes enlargement-->T2N0MX 

Problem :  Adenosarcoma  cervix in young lady after extirpation of the mass.
                 
Problem solving :
1. Chemotherapy
2. Laparatomy (hysterectomy total) follow by chemotherapy
3. Intra-arterial chemotherapy.                          
4. No treatment

2. Woman, 53 th, Ca Ovarium metastases to Cx

Chief complaint : pain when urinating.
22/3/10 S : she came with pain when urinating to RS Islam 20/3/10, then she was reffered to X hospital with suspected cervix ca.
She already complaining about vaginal bleeding since 10 years ago but never seeking for medical assistance. The bleeding was iregular and stopped it self.
she was married twice. Both deforce.the latest was on 2007. With 2 children.
She also complaining about abdominal discomfort  accompany the vaginal bleeeding history for years. And thought it was only gastritis.
She was just realized her abdominal enlargement since january 2010. She felt the enlarging faster this last 3 month.
She also complaining nausea after then and followed by lost body weight.

O : CM
Abd : distended. Mass 15x15x10cm. Mobile(-). Ascites (+)
v/v : insp: endophitic mass spreading till 2/3 vagina distal.
RVT : cervix mass spreading from retroperitoneal with intaabdomenal mass .smooth rectal mucous.

US 1/4/10
Uterus : size 10,5x6,1x6,4cm. Retroflexy. Inhomogen. Hipoechoic lession, round shape with sharp margin.
Size 4,2x3,5x3,9cm vol 30 cm3. No vascularization. ET 2mm. Cervix enlarge inhomogen, 3,7x3,8x3,7cm, vol 20cm3. 4,7x3,8x3,7cm transrectal. RI 0,29
Adnexa: cystic multiloc mass 8,8x7,3x8,4cm. 300cm3. Thick septae 1,4mm. With solid part, no papil. RI 0,44. From left ovarium.  No free fluid in CD.
Liver, no metastases.
No paraaortal limphnodes enlargement.
HN (-). Effusion (-) ascites (-)
Con : enlargement of the Cx, inhomogen susp malignancy. Uterus with myom 30 cm3. Cystic ovarian neoplasma with solid part susp malignancy.

CT Scan :31/5/10
Liver : normal size, smooth surface, homogen. No focal lession. Intrahepatic bilier and vascular normal. Masive ascites. No pleural effusion.
Gall bladder: normal size and shape. No sludge.
Spleen and pancreas normal.
Aorta: caliber normal. No paraaorta limphnode enlargement.
Kidney : normal size and shape. Normal secretion and excretion.
Urine bladder normal.
Uterus: enlargement, inhomogen mass in the corpus. No calsification.
Isodens mass wide spreading in the pelvic cavity up untill abdomen cavity, inhomogen contrast absorbing.
Cystic lesion with septae, with dominant solid part, with atachment to sigmoid and intestine, caused dilatated transverse and ascending  colon.
No calsification. Parailiaca and obturator limphnodes enlargement.  No bone destruction.

Con : ovarian tumor, cystic with solid part dominance; adhesion to colon (carcinomatosis?) + parailiacanodes enlargement, and masive ascites.  malignant
 
Lab : hb 10,9g%, WBC 9,3k/uL, Plt 500k/uL, U/cr 25/0,7, OT/PT 18/17, alb 3,3, BS 151. Ca 125 514,8, LDH 483.

PA biopsy cx , 23/3/10 1002036
Adenocarcinoma cx, serosum papilliferum. Moderate-poor diff. (Very closed to ovarian ca.)

23/3/10 thorax xray WNL, BNO-IVP secretion-excretion normal.
29/3/10 C cardiology WNL
22/3/10 Cystoscopy failed to be done, mass in the periurethra

 

Problem: How to explore the origin of the mass, ovarian to cervix spread  or cervix and ovarian double primer ?

Problem solving :Lap VC + adjuvant chemotherapy
   Lap + radiotherapy