Case Conference 30 June 2010

30-Jun-2010, Oncology Gynecology Division RSCM

CASE CONFERENCE, June 30th 2010

1. Woman, 52 y.o/P1

Chief complaint : (-).Patient came to oncology clinic for follow up after laparatomy sub optimal debulking due to cystic ovarian neoplasma.

History :
17/04/10 : Came to gynecology clinic with chief complaint : abdominal enlargement. Laboratory finding : Ca-125 : 17.4 U/ml
21/04/10 US exam:
     Uterine was normal sized, pushed to right posterior side.
     Cranial part of the uterine revealed multilocular cystic mass sized 12.9 x 99 x 13.4 mm with irregular solid part. (RI=0.57)
     Dx :  cystic ovarian neoplasm  (RMI=156.6) - suggested to perform   Laparatomy – VC
07/05/10 : Laparatomy sub optimal debulking was done.
      Operation procedure : HT + SOB + Omentectomy + Pelvic nodes sampling + Cytology of peritoneal washing + appendectomy.
      Durante Operation :
     After peritoneum was opened: no ascites - cytology of peritoneal washing (20 ml)
     Uterus normal sized, revealed Lobulated Cystic mass from right ovary size 15 x 10x 9 cm, with  half part content of solid mass, the mass was adhere to rectum and    uterus,adhesiolysis - the mass was rupture - came out serous fluid ± 300 cc.
     VC - Result: malignancy tumour.
     Next exploration : Uterus and left tube were normal.  no enlargement of paraaortic and pelvic limphnodes. There were 2 nodul ( extra lumen) Ø 5 cm and Ø 2 cm adhere to the       rectum and  bowel on the douglas pouch.
     Decided to continue  surgical stagging :  Total hysterectomy, right salphingooovorectomy,  Omentectomy , desection pelvic limph nodes ,   nodule biopsy  at the douglas pouch       and rectum
     Residual tumor at  douglas pouch 2 cm.
23/06/10 :  Came to oncology clinic with no complaint.
    Cytology result (No.PA : 101316): no malignant cell. 
    Histopathology Result (No. PA: 1003266) :
    MACROSCOPIC:
    Received 4 kind of tissue with information :
    I. Cystic mass. Consist of part of VC tissue, vol 10 cc, solid, yellow blackish, 6 blocks, 5 cassette
    II. Cystic mass.Consist of part of VC tissue and cystic mass sized 8x7x8 cm, already being cut,white brownish,solid,smooth surface, internal part was papilated,8 blocks, 8        cassette .
   III. Uterine + left ovary
         Consist of 1 tissue sized 7x5x3 cm, smooth surface, already being cut, uterine cavum was empty, revealed 1 solid mass with irregular border sized 1.5cm.Tuba ovary and      left ovary was found. 6 blocks, 5 cassette
   IV. Right Pelvic LND. Consist of 2 lymphnodes. 2 cassette
    V. Left Pelvic LND. Vol 4 cc. 1 cassette
   VI. Extra lumen mass
         Consist of 2 kind of tissue sized 3x2x1 cm and 1x1x1 cm, white. 5 blocks, 3 cassette
   VII. Appendix.
         Consist of 1 kind of tissue sized 5x1x1 cm. 3 blocks, 2 cassette
  VIII. Omentum.
         Consist of 1 kind of tissue sized 20x5x1 cm, yellow. No lymphnode.  2 cassette
    MICROSCOPIC
    Received 2 part of tissue. First part on Mei 7th 2010, consist of right ovarian tumor (VC tissue). Second part on Mei 10th 2010,consist of uterine, left ovary, Right Pelvic LND,     Left Pelvic LND, extra lumen mass, appendix and omentum. Uterine, left ovary and extra lumen mass at douglas pouch showed spongy tissue appearance and degenerative     appearance, probably fixation liquid problem. This problem made difficult to evaluate the tissue.
    Left ovary showed tumor mass with solid and cystic part. Tumor consist of 2 kind of tissue such as epithelial and mescenchymal. Mescenchymal appearance consist of high grade sarcoma with a lot of mitotic. Bizzare nucleic shape was found. On the other part showed
 epithelial tissue formed  asiner/glandular structure with atypia cell (same appearance with cells originated from mescenhymal tissue / stroma tumor).Extra lumen tissue, almost all of the tissue cannot evaluated, only at lateral part showed tumor mass appearance with dominant mescenhymal part.
    Right and Left Pelvic LND consist of 6 and 4 LND showed histiositosis sinus appearance. Omentum consist of adipose tissue, fibrotic tissue and bleeding area. Showed focus tumor mass with dominant mescenhymal part.
 
    Conc : Carsinosarcoma (Malignant Mullerian Mixed Tumor) on left ovary
               Metastase to omentum and douglas ponch
               No LNDs metastase.
    Dx : Ovarian Cancer St IIIC post suboptimal debulking.
 
Problem : Alternative adjuvant chemotherapy for Ovarian Cancer St IIIC post sub optimal debulking with histopathology Result : Carsinosarcoma (Malignant Mullerian Mixed Tumor) -> Poor prognosis.

2. Woman / 53 y.o/ P3

Chief complaint : (-).Patient came to oncology clinic for follow up after laparatomy optimal debulking due to cystic ovarian neoplasma suspected malignancy.

History :
March 25th 2010 : came to head and neck dept with chief complaint : mass on right side of neck.
    Histopathology Result  FNAB (No.PA 1001978):
          Non Keratinizing Nasopharix carcinoma, no differentiation (WHO3), type A. Moderate malignant level.
          Patient was suggested to underwent radiation (Schedule on May 19th 2010)  
May 5th 2010 : came to oncology clinic, consulted  from Interna Dept. RSCM due to  ovarian mass + KNF T2N2Mo (IVA).

 Physical Examination.
     Abd : revealed cystic mass on right lower abdomen, sized 10x10x10 cm.
     Io : Smooth cervix
     RVT : Revealed cystic mass in right adnexa, sized 10x10x10 cm, mobile.
     Uterus normal sized, AF.
     Rectal mucosa were smooth.
 Laboratory Finding : Ca-125 : 628 U/L.

May 6th 2010 : US Onco :
      Uterine sized was 8x3x4 cm, RF. Inhomogen echostructure, on posterior corpus revealed solid mass, oval, clear border, avascular,
 sized 1x0.5x1 cm, regular endometrium, endometrial thickness 1 mm.
     Right adnexa : Multilocular cystic mass, sized 11x8x9 cm vol 4000 cm3, septal thickness 2.9 mm with papil and solid part. RI 0.42
     Left adnexa was not seen
     Other abdomen organs wnl
     Conc : Right cystic avarian neoplasm with papil and solid part vol 400 cm3 suspected malignancy.
     Uterine with solid mass on corpus posterior.

     Dx :   Cystic Ovarian Neoplasm suspected malignancy + KNF T2N2Mo
     Plan : Laparatomy – VC

June 8th 2010 : Laparatomy Optimal debulking was done
     Operation procedure : TAH + BSO + Omentectomy + Appendectomy.
     Durante operation :
     Ascites serous 500cc  taken for cytology
     Exploration : tumor mass diameter sized 15 cm, lobulated, carcinomatotic appearance, originated from right ovary adhere to rectum,
  uterus. Omentum with omental cake. Liver and spleen were smooth.
  Left adnexa in normal sized adhere to uterus and omentum.
     VC Result : Adenocarcinoma.
     Performed optimal debulking.

June 14th 2010 : Cytology Result (No.PA 101601) : positive adenokarsinoma.

    Histopathology (no. PA 1004029) :
    MACROSCOPIC :
    Received 4 kind of tissue with information.
    I. Cystic mass. Consist of 2 kind of tissue from VC tissue sized 1.5x0.8x0.2 cm and 0.7x0.5x0.2, solid, gray brownish. And 4   kind of tissue sized 2.5x1.5x0.4 cm, 1x1x0.4 cm, 0.6x0.5x0.2 cm and 0.5x0.5x0.2 cm, already being cut, white brownish, solid, smooth surface, internal papillary growing, 8 blocks, 8 cassette 
   II. Uterine.
  Consist of portio, 1 fallopian tube, left and right ovary, no vagina, sized 8x14x6 cm after disliking.
  Uterine sized was 9x5x5 cm, solid, smooth surface, gray brownish, canalis cervicalis and uterine cavum were empty,
  no tumor mass and necrotic mass. After uterine being cut, revealed 1 fibroid mass sized 1.2 in diameter. On one side sized of tube
  was 4 cm and 0.3-0.5 in diameter with sized if the ovary was 2x0.5x0.5 cm. On the aother side of the ovary, sized of the ovary was 7x8x6 cm
  with unrecognized tube. Part of the ovary showed multicystic part, sized 0.3-5 cm. Internal part of the cyst consist of solid part,
  gray yellowish with brown necrotic part.
    IIA.   Ectocervix, 1 block 1 cassette.
    IIB.   Endometrium, 1 block 1 cassette.
    IIC.   Myometrium, 1 block 1 cassette.
    IID.   1st side of tube, 2 block 1 cassette.
    IIE.   1st  ovary, 1 block 1 cassette.
    IIF.   2nd ovary with cyst, 2 block 2 cassette.
    IIG.   Tumor in ovarian cyst (2nd ovary), 5 block 5 cassette.
    IIH.   Parametrium, 2 block 2 cassette.
    Iii.   Fibroid mass from myometrium, 1 block 1 cassette.
    III.   Omentum
            Consist of omental tissue, sized 24x14x0.2-2.5 cm, yellow bronish, solid, necrotic. Lymphnodes was not found. 6 block 5 cassette.
    IV.    Appendix
           Consist of 1 kind of tissue, sized 5.5x3.1 cm, with diameter 0.8 cm, no sign of perforation. External surface ware nodular,
        diameter 0.1-0.2 cm, graybrownish. 
   IVA.  Border of incision, 1 block 1 cassette.
   IVB.  Midle and caudal part of appendix, 2 block 2 cassette.
   IVC.  Appendix with nodular surface, 1 block 1 cassette.

   MICROSCOPIC
   VC tissue from cystic mass consist of tumor tissue showed spongy structure/ glandular structure with papillary growing covered by epitel.
 Pleiomorfik cell, vascular nuclei with nucleolus, a lot of mitotic with hiperchromatic-bizare.Showed stroma invasion and lymphvascular invasion
 with psamoma .Left ovary showed tumor nodule consist of tumor cell. Fibrotic of the tube, paratuba consist of tumor cell.
 Omentum consist of tumor cell. Fibrotic appendix, periappendix consist of tumor cell.Uterine and cervix showed chronic inflammatory process.
 Endometrium and myometrium within normal limit. Perimetrium consist of tumor cell.

    Conc : Cystadenocarcinoma serosum papilliferum ovarii, moderate differentiation, metastatic to contralateral ovary, taratuba, omentum and periappendix.

    Dx : Ovarian cancer stage IIIC post optimal debulking + KNF T2N2Mo

    Plan : Adjuvant chemotherapy CP for 6 cycles.

Problem : Ovarian cancer stage IIIC post optimal debulking + KNF T2N2Mo. Should we perform concurrent chemotherapy CP and radiotherapy or adjuvant              chemotherapy CP followed by radiotherapy?