Case Conference April 26th 2017

26-Apr-2017, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

April 26^th, 2017

 

Mrs. A

Ovarian cyst suspect malignancy

“Detecting adnexal mass malignancy with Peritoneal Carcinoma Index (PCI) with laparascopic diagnostic with biopsy and cytology result”

Resident : Prima Ovalina (T3B, Oncology Rotation)

 

Mrs. 39 years old, P1A0, was referred from Cilegon Hospital due to ovarian cyst with solid part suspect malignancy with massive ascites and Ca 125 1950. Patient admitted due to abdominal enlargement since 1 years before admission.

Patient admitted due to abdominal enlargement since 1 years before admission, followed with abdominal pain (VAS 3-4), more intense on the right lower quadrant, without any reffered pain to other body part. Patient never took any pain killers, and never administered any medicine by the referral hospital. Regular menstrual cycle without any disturbance of intercycle bleeding or pain. Decreasing 10 kg body weight on the last 3 months with shrinking appetite.Due to her complain, patient was admitted to RSUD Cilegon with ovarian cyst suspected malignancy with increasing Ca 125 result, and being referred to Oncologoly at Ciptomangunkusumo Hospital.

History of hypertension, diabetes, asthma, allergy were all denied. No recognizable record of ovarian cyst, or breast disease within close family member.

Physical examination remains within normal vital signs, and general state were also within normal limit, except abdominal examination found distended, cystic mass was palpated with solid part, enlargement until xyphoid process, massive ascites, decreased mobility, no tenderness. Gynaecological state were evaluated uterus is pushed to posterior, loose parametrium, palpated cystic mass reaching as high as xyphoid process, no distal mass pole was palpated. Assessed as ovarian cyst with suspect malignancy. Good sphincter tone, smooth mucosa, ampulla not collapsed, no palpated mass.

From the laboratory findings, (8/2/2017) : CBC 12,1/36,8/6170/507.00//79,1/26/32,9, albumin 2,8 g/dl, with Ca-125 marker 1.950 U/ml. The ultrasound (7/2/2017) figured uterus anteflexed, shape and size were within normal limit, homogenous myometrium. Endometrium with regular basal membrane, endometrial thickness. Endocervix and portio were within normal limit. Left ovary was within normal limit. Right adnexa was evaluated comprise of inhomogenous solid mass with cystic part, sized 180 x 100 x 130, corresponds to right ovarian cyst. Hepar and lien within normal limit. Massive ascites. Conclusion massive ascites and solid ovarian neoplasm with cystic part corresponds malignancy. The MRI (3/3/2017) figured homogen mass with solid and cyst intensitas, septa, stinging post contrast on the solid part and septa evaluated from right ovarian suspected maligna. Massive ascites. No limfadenopati region pelvic and abdomen.

 

INTRODUCTION

Defining malignant or benign adnexal masses are vital on pre operative assessment. It is needed to assure and assess the necessity of any kind of surgical procedures, and parallels on patient counseling about management plan, possible risk and complications. The upcoming diagnostic tools are expected with high performance and meet the form of affordable, accessible, avoid radiation exposure, time efficient, and practical.

Currrently, clinical examination, ultrasound assessment, and assays of tumor markers are part pf the standard work-up for an adnexal mass, although none of these indicators alone is very sensitive or specific on detecting malignancy. It is needed for a number reasons including plan management and counseling the patient about future prognosis. Several scoring systems for classifying and scoring the abnormalities in the form of morphological index have been proposed in the past.

Laparoscopy has been proposed to assess tumor spread and resectability. Laparoscopy avoids unnecessary laparotomy and predicts the outcome. These laparoscopic scores, which use four to seven items, have good specificity for ruling out the feasibility of CC-0 but lack sensitivity (positive predictive value [PPV] for CC-0, 57%, when Brun’s score is < 4). For a description of the distribution and extent of metastases, one employs the peritoneal cancer Index (PCI) reported by Jacquet and Sugarbaker.  This index is a quantitative assessment of both cancer distribution and cancer implants size throughout the abdomen and the pelvis. Two components are involved in its calculation. One component is the distribution of the tumor in the abdominopelvic regions and the other is lesion size score.

 

CLINICAL QUESTION

In predicting malignancy of adnexal mass, does peritoneal cancer Index (PCI) have a higher diagnostic value?

 

 

METHODS

Search strategy

 

The search was conducted on Pubmed and Cochrane on April 24^nd 2017, using the search tool containing the keyword “Ovarian cancer AND peritoneal cancer index with laparascopic diagnostic with biopsy AND result cytology” (Table 1). Search results were filtered by the engine according to the following criteria : articles published in the past 10 years, human species, clinical trial and English language. Search strategy, result, and the inclusion and exclusion criteria are shown in the flowchart.

RESULT

The area under the curve of the score was 0.76 (95%CI, 0.67e0.86). The score discriminated between groups with low and high risks of incomplete cytoreductive surgery (4.4% [95% CI, 0e10.5] and 42.9% [95% CI, 26.3e59.4], respectively). Using a cutoff of 4, sensitivity of the score was 92.8% (95%CI, 83.2e100) and specificity was 77% (95%CI, 67.1e84.9) for predicting incomplete cytoreductive surgery.

 

DISCUSSION

Several other scoring systems have been developed. There is general agreement that radiological or laboratory criteria used alone fail to reliably predict the feasibility of cytoreductive surgery, as shown also by the results of our univariate analysis. Fagotti et al. described a score based on laparoscopy findings that is now widely used by many groups, although some of its items no longer contraindicate primary surgery. In 2008, Brun et al. developed a variant of the Fagotti score based on data from 55 patients with advanced ovarian cancer, their score is designed to predict optimal cytoreductive surgery defined as no nodules larger than 1 cm, whereas the current goal is complete cytoreductive surgery defined as absence of visible tumor. Composite scores based on clinical, laboratory, and surgical variables were developed more recently. Gerenstein et al. used the platelet count, CT evidence of diffuse peritoneal thickening, and presence of ascites

Diagnostic tools resulted a malignant lesion. Peritoneal cancer index provide a more detailed subtypes. Adnexa mass more understanding about proper mass measurement, relatively unaffordable in the development country, and still lack off socialization.

CONCLUSION

            Triage and referral of adnexal mass is crucial, to apply proper case distribution for both general Obgyn or Oncology consultant. Peritoneal cancer index composite of multiple parameters having statistically significant association with the risk of ovarian malignancy. The comprehensive meta analysis will towards an optimal “evidence-based” approach. This easy to calculate score may prove useful to identify patients with ovarian peritoneal carcinomatosis in whom complete cytoreductive surgery is feasible

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