Case Conference 20 July 2010

20-Jul-2010, Oncology Gynecology Discussion RSCM

1. Women/40 yo/ P2

Chief complain :  Diarrhea 7 x/day since 10 days before come to Hospital.
                      (referred by Hospital "X" due to enlargement of abdominal wall since 3 month operation of suboptimal debulking pro chemotherapy)

History :
Since 6 month ago patient complain there was enlargement of abdominal wall and getting bigger in the last 3 month. Patient came to Hospital "X" and it was said there was Cystic Ovarian Neoplasm
and  patient was planned to be performed laparoscopic prosedur to take out the mass, On march, 17th 2010, patient was undergo Laparoscopic operation then converted to laparotomy due to difficulties
in procedures.It was said there were 2 tumors, but the doctor only be able to take out 1 mass as big as possible, the tumor was already spreaded out everywhere. Ten days after the operation,
it was said that the tumor was malignant ( Histopathology result/March 19th 2010 : clear cell carcinoma) and was referred to Hospital "Y" to proceed the treatment, but the patient was delayed
to come to Hospital "Y" due to scare of getting adjuvant chemotherapy.  Dyspneu (-), not clear loss of appetite , no complain of defecation, no complain of urinary, no vaginal bleeding, dismenorrhoe +.
Patient has been  come to CM Hospital twice before suffering from diarrhea for preparation .
Parity 2 from the second married, married twice , story of IUD contraception (6 years, it took out in 2007)), the period is still reguler. No history of the same condition in family

Operation Report, March, 15th  2010 at Koja Hospital :
Pra Operation   : Ovarian cyst
Post Operation  : Ovarian cyst suspected malignant with severe adhesion, mioma uteri
Surgery         : Diagnostic laparoscopic, Laparotomy debulking

Operation report :
Patient was under general anaesthesia
On the Laparoscopic view : there was cystic mass, ruptured and come out serous hemorrhagic 1500 cc.  there was omentum covered the whole of the cyst, uterus enlarge severe attached 
                           to the bowel and cyst.Consider difficulty in procedure, it was considered to convert laparotomy.
On the laparotomy view   : it was succeeded to take the cyst wall out made severe adhesion with bowel and omentum difficult to release, easy to bleed . Uterus was enlarge as man fist
                           (myoma uteri) no ascites, It was suspected that the mass from left ovary. Both tube and right ovary were difficult to be viewed due to severe adhesion. It was decided to perform debulking. 
                           It was done situational suturing. It was suggestive ovarian carcinoma. Abdominal  wall was clean and inserted intraabdominal drain   

Histopathology result/W-10522 ( hospital"Z"), March 19th, 2010   :  Carcinoma ovarii, type clear cell carcinoma

In the ward :
General status is good,length 147 cm, Weight 66kg, conjunctiva anemies ( HB 5,5 got transfusion, HB 10,9), there are no enlargement of limphnodes. There was a solid mass in the abdomen until 2 finger
above the umbilicus lobulated, mediana scar.

Gynecological status :
Inspekulo : portio was smooth, no fluxux, no flour
RVT :  It was palpated solid mass lobulated until 2 finger above the umbilicus, sized 15X10x8 cm fixed , Uterus was pushed to the left by the tumor. Parametrium was smooth. Ampula rectum was smooth, no collapse.
 
June, 28th  2010 : US finding :
Uterus was normal ,RF, echoparenkim homogen, no mass, eddomtrium thickness was 1,9 mm.
Right pelvic there was Cystic ovarian neoplasm multiloculer , echo interna + size 8,98x8,28x10,60 cm vol 413 ml3, septal thickness is 2,6 mm, no solid part or neovascularization .
Left Pelvic there was cystic ovarian neoplasm multiloculer, echo interna + , size 10,46x6,84x8,28 cm vol 310 ml3, papil +, septal thickness is 4,1 mm, no clear solid part. There was  neovascularization with RI 0,63, 
No ascites. No Hidronephrosis , no enlargement of limphnodes, no metastase in hepar or lien, no pleural effusion

July,  6th, 2010 : BNO-IVP finding : excretion and secretion function were good 

July, 04th  , 2010 : Thorax X-ray : Cor and pulmo were within normal limit
 Lab finding : DPL  : HB  10,9 (post transfusion) / leuco 16,640/ tromb 564,  ; albumin : 2,59, ur/cr 26/1.00, CCT 45,60 ( urine volume 3000), blood creatinin 1.00, urine creatinin 24 hours 0,60 g/24 hours

July, 12th  2010, Review Histopathology/ 1004796  :   Clear cell adenocarcinoma

PROBLEM
Incomplete debulking in Ovarian carcinoma minimally stage IIC low CCT

PLAN :
1. NAC (carboplatin –paclitaxel) half of doses 3 series proceed Interval Debulking

NOW :
The patient still  refuses to get directly chemotherapy, want to discuss with the family

 

 

2.Women,/28 yo/G4P2A1

Chief complain : vaginal bleeding in 20 weeks pregnancy (July, 8th 2010)

History
Patient is pregnant. LMP is February, 14th 2010, first control to Hospital "X:. It was only examined by ultrasound and was diagnosed as gravid sixteen weeks gestational age. 
One  week after, patient came again with heavy vaginal bleeding and was done inspeculo. It was said there were mass in the vagina and was done biopsy.
July 2nd, 2010 ,histopathology result was Squamous cell carcinoma insitu and referred to Hospital "D".
July 8th 2010 It was done another biopsy by obgyn in Hospital "D". The histopathology result was Squamous cell carcinoma keratinized, poor diff.   
Six hours before admission patient was complain of heavy vaginal bleeding since 1 day before come to hospital "C" No post coital bleeding before, no flour, no spoting.
P2 : 4 yo and 2 yo, spontaneous delivery, no history of bleeding.Regular menstruation, married once. No contraception.

In ward :
Generalis status is good. CM,  conjunctiva sub anemis, no enlargement of limpnodes (supraclavicular, axilla, inguinal), Abdomen enlarge correspond to gravid 20 weeks gestational age. Others within normal limit

Gynaecologic status : fundal utery was 2 finger below the umbilicus, no contraction, no bleeding.
Inspection and Inspeculo : there were exofitic mass size 3 cm below the OUE, fragile and easy to bleed. There were also 2 small bluish mass on the fourchete. It was also 1 hyperaemic flat mass
on the 1/3 proximal vagina on the right lateral posterior wall. Portio was smooth and livid, ostium was  closed, fluksus -, flour -.
RVT : uterus was enlarged as 20 weeks gestational age , no mass in adnexa, parametrium were free. Ampulla recti was smooth .

Laboratorium finding : Hb 10 (after transfusion), leukocyte 15.300, trombocyte 312.000, ur/cr 17/0,6; Ot/Pt 22/12 ; albumin 3,1
 
PROBLEM :
Carcinoma vagina in Gravid 20 weeks gestational age

PLAN :
1. Conservative : Keep the pregnancy until 35 weeks gestational age ? C-section then  proceed radiotherapy
2. Terminated pregnancy ? Hysterotomy proceed radiotherapy