Case Confrence 16 June 2010

16-Jun-2010, Oncology Gynecology Divison RSCM

1. Woman/ 57 yo / P1

Chief complaint: slight  abdominal discomfort
She was came to out patient clinic for regular follow up after 6 cycle CP . She was feeling abdomen discomfort. Normal urinating and defecation.

History :
Sept 2009 : came to gynecology clinic X Hospital, referred from RSUD Bekasi due to cystic ovarian neoplasma.
Physical Exam : Abd : cystic mass was palpated until 3 finger below the navel, mobile.
                 Io : Cx smooth
                 RVT: Uterus was normal size, AF
                      Cystic mass was palpated in pelvic cavity until 3 finger below the navel.
                      Rectal mucosa were smooth.

Laboratory finding (19/8/09) : Ca-125 : 147,9 u/ml
                       US FM : Cystic ovarian multi cystic, borderline type
Dx : Cystic ovarian neoplasma (MS : 4)--> planned to laparatomy - VC

Oct 14th 2009 :Lap-VC was done by Gynecology div.
               Durante op: found cystic mass size 20x20x15 cm, from right ovary--> perform Right SO--> VC.
               Continued with total hysterectomy and left SO.VC result was adenocarcinoma consulted to oncology div.
               Exploration : found nodule at the mesenterium, liver and appendix were smooth--> performed omentectomy, appendectomy and mesenteric biopsy.
               No enlargement of pelvic and paraaortic LN’s.

Oct 20th 2009 :
Cytology ascites result (no.PA : 092441) : positive adenocarcinoma.
Histopathlogy result (no.PA :0906424) : Clear Cell Adenocarcinoma, poorly differentiated, metastatic to omentum.
 
Dx : Ovarian cancer Stage III C pasca optimal debulking, planned to perform adjuvant chemotherapy CP for 6 cycle.

Follow up chemotherapy
1st cycle 2nd cycle 3rd cycle 4th cycle 5th cycle 6th cycle
5/11/09          3/12/09 07/01/10   3/3/10 26/03/10 26/04/10

May 26th 2010 : follow up after 6 cycle chemotherapy with no complaint.
Physical exam : Abd : midline scar, no mass palpated, ascites (+)
                 Io : stump vagina was smooth
                 RVT: stump vagina smooth, no mass palpated in pelvic cavity.Rectal mucosa were smooth
 
Laboratory finding (26/5/10) : Ca-125 : 14,5 U/ml.
    US Onco  (26/5/10): pelvic mass (-) Ascites massive

Dx : Progressive ovarian cancer after adjuvant chemotherapy CP.
Conference 2 Juni 2010
Suggesting to perform ascites cytology. If negative should followed by laparoscopy second look.
11/06/10 : Result  of the cytology (No 101625) Positive Adenocarsinoma.

Problem : Ovarian Ca stg III C,  Resistent platinum
Problem solving : No treatment or change to secondline chemotherapy.

2. Woman/59 yo 

Chief complaint:  follow up after 6 cycle Carboplatin-Paclitaxel. At this time patient with no complaint in her abdomen.
                  Mixturation and defecation within normal limit.
History:
March 2005  : patient was diagnosed as Cystic Ovarian Tumor suspect malignancy.
              Laboratory finding : Ca-125: 6794 U/ml.
March 27th 2005 : patient underwent laparatomy sub optimal debulking with residual tumor at douglas pounch, sized 3x3x2 cm.
                  Histopathology result: Cystadenocarcinoma serosum papilliferum, poor differentiated, metastase to omentum and lateral ovarii.

Dx: Ovarian cancer St. IIIC
    She was suggested to underwent adjuvant chemotherapy CP for 6 cycle.

Follow up adjuvant chemotherapy :

1st cycle 2nd cycle 3rd cycle 4th cycle 5th cycle 6th cycle
17/05/06 19/06/09 05/07/06 15/08/06  13/9/06 12/10/06

Follow up after adjuvant chemotherapy CP :
Laboratory finding :  Nov 14th 2006 = Ca-125: 22,1 U/ml
                    March 14th 2006 = Ca-125: 14,5 U/ml.

April 3rd 2008 : Ultrasound finding :
- pelvic mass, sized 4,03 x 3,02 x 3,45 cm
- Massive ascites.
                     
Laboratory result : Ca-125 : 975 U/ml.

Dx : Recurrent Ovarian Cancer pasca sub optimal debulking + pasca adjuvant chemotherapy CP for 6 cycle.
     She was sugessted to underwent repeat chemotherapy CP for 6 cycle.

Follow up 2nd chemotherapy CP
1st cycle 2nd cycle 3rd cycle 4th cycle 5th cycle 6th cycle
08/04/08 05/06/08 26/06/08 18/07/08 15/08/08 17/09/08
Oct 28th 2008 : follow up after 2nd chemotherapy CP
                Ca-125 : 52,3 U/ml

Feb 5th 2009 :  Ultrasound finding : no mass and no ascites
                 Laboratory result : Ca-125 : 82,4 U/ml

March 13th 2009 : Physical examination : palpated mass at douglas pounch, sized 3 x 4 cm.
                  She was suggested to underwent 2nd line chemotherapy (Carboplatin-Paclitaxel).

Follow up chemotherapy Carboplatin-Paclitaxel
1st cycle 2nd cycle 3rd cycle 4th cycle 5th cycle 6th cycle
28/05/09 01/06/09 28/07/09 07/09/09 01/11/09 01/12/09

Jan 15th 2010 : Ultrasound finding : No mass and no ascites.
                 Laboratory result :  Ca 125 : 114,1 U/ml
                     
June 8th 2010 : controlled to oncology clinic. At this time patient with no complaint in her abdomen. Mixturation and defecation within normal limit.
Physical examination: Abd: midline scar (+); no mass palpated
Gynecological status : Io : Vagina wall were smooth
                      RVT : Palpeted mass at douglas pouch, sized Ø 5 cm.
                            Rectal mucosa were smooth

Ultrasound finding : Multi lobulated  mass, sized 7,3x6,2x6,6 cm at pelvic cavity.
                     Multiple cholelithiasis.
                     Minimal ascites

Laboratory result ;  Ca-125 : 1087,0 U/ml
    
Dx : Recurrent ovarian cancer after chemotherapy Carboplatin-Paclitaxel + after adjuvant chemotherapy CP (2 complete cycle) + after sub optimal debulking

Problem : Recurrent Ovarian cancer after  chemotherapy Carboplatin-Paclitaxel + after adjuvant chemotherapy CP (2 complete cycle) + after sub optimal debulking.

Problem solving : Supportive  treatment.
 

3. Woman/32 yo 

Chief complaint:  follow up after 6 cycle Carboplatin-Cyclophosphamid. At this time patient with no complaint in her abdomen.
                  Mixturation and defecation within normal limit.
History:
Aug 20th 2009  : patient came to oncology  clinic X Hospital with chief complaint abdominal enlargement since 4 month ago.
Patient referred from another Hospital in Pontianak due to Ovarian cancer.
On May 2009 patient was underwent laparatomy (sub optimal debulking with residual pelvic mass because of severe adhesion).
Histopathology Result : Endometrioid Adenocarcinoma, poorly differentiated.

Physical examination:
Abd : midline scar (+), palpated cystic mass with solid part, sized Ø 20 cm, limited on mobility.
Io : smooth cervix
RVT : palpated cystic mass with solid part in pelvic cavity, sized Ø 20 cm, limited on mobility. Uterine cannot identified. Rectal mucosa were smooth.

Sept 9th 2009 : Fundal and endometrium of the uterine were cannot identified.
Cervix was identified below the bladder.
Both adnexa cannot identified. Solid mass with cystic area at pelvic cavity, sized 15,7x14,9x14 cm; RI : 0,4
Massive ascites.
Dx : Ovarian cancer advance stage post sub optimal debulking.
     She was suggested to underwent interval chemotherapy.

Follow up chemotherapy
1st cycle 2nd cycle 3rd cycle
17/9/09         08/10/09 12/11/09

Nov 19th 2009 : follow up after interval chemotherapy
US Onco :
Border of the uterine was unclear. At right adnexa revealed solid mass with cystic part sized 9,7x7,8x9,8 cm and 7,6x6,1x6,1 cm. At left adnexa revealed cystic mass with solid part sized 10x8x5,4 cm.
Other abdomen organs with in normal limit.
Conc : Decreasing of volume mass and ascites.

Laboratory finding : Ca-125 : 231,5 U/ml.

Dx : Ovarian cancer advance stage + partial response post interval chemotherapy  CC +  post sub optimal debulking
     She was suggested to underwent laparatomy debulking.

Feb 11th 2010 : Consulted to cardiology dept.
       Result : CHF fc.II, MR severe  moderate risk.

 

Feb 15th 2010 : Secoundary debulking  (sub optimal debulking) was done.
Durante operation:
-Cystic mass sized 10x10x10 cm, irregular surface, attached to retroperitoneal surface.
-Further exploration : cystic mass sized 10x5x5 cm, attached to descendens colon wall. Cystic mass at right pelvic area, sized 8x9x10 cm attached to the appendix.
-Omental nodule was found, lien and liver were smooth surface. No lymphnode enlargement.
-Omentectomy was done, followed by biopsy of peritoneal nodule sized 3x3x2 cm (at incision area).
-Uterine and both ovary cannot idenfied. Residual mass at pelvic cavity sized 4x5x5 cm.

Histopathology Result (No.PA: 1001181) :
-Endometrioid Adenocarcinoma, poorly differentiated.
-Metastatic to omentum and meso appendix.

Dx : Ovarian cancer stage IIIC post sub optimal debulking + interval chemotherapy CC 3 series + CHF fc.II, MR severe.
Patient was suggested to underwent adjuvant chemotherapy CC 3 series.

Follow up adjuvant chemotherapy CC
1st cycle 2nd cycle 3rd cycle
10/03/10 09/04/10 14/05/10

June 16th 2010 : follow up after adjuvant chemotherapy.
At this time patient with no complaint in her abdomen. Mixturation and defecation within normal limit.

US Onco :
Uterine : cervix was identified sized 2,6x2,0 cm, revealed solid mass with cystic part, sized 6,4x5,0x6,2 cm; vol 100 cm3.
Adnexa : revealed solid mass revealed solid mass with cystic part, sized 6,7x5,3x5,6 cm vol 100 cm3.
No free fluid in pelvic cavity.
At right umbilical area revealed cystic mass with solid part, sized 3,6x3,2,2,9 cm; vol 17 cm3, no vascularization.
Other abdomen organs : wnl.
Conc : 2 pelvic solid mass with cystic part and 1 abdominal cystic mass with solid part at umbilical area.

Laboratory finding : Ca-125 : 226,5 U/ml.

Problem :  Progressive ovarian cancer after adjuvant chemotherapy CC + post sub optimal
                debulking.
 
Problem solving :
- 2nd line chemotherapy.
- Only supportive treatment.