Case Conference May 25th 2011
01-Jun-2011, Divisi ginekologi onkologi RSCMMrs.S/46 YO/P6/Jamkesmas
Chief Complain
Post second-line Chemotherapy (Oxaliplatin and Gemcitabine)
History
Jun 11 th 2009 : Patient referred from PMI Hospital Bogor with Solid Ovarian Neoplasm suspect Malignancy.
July 15 th 2009 : In the ward She felt ascites and performed pungtie with result : (+) Adenocarcinoma. The diagnosis becomes : advanced Stage ovarian cancer and chemotherapy Cyclophosphamide and Platosin (CP) was given 2 series (CP I : 29-7-2009. II : 27-8-2009). The respon therapy : Partial respon
December 17 th 2009 : the operation was performed with procedural operation : Optimal Debulking : Hysterectomy Radical and Bilateral salpingo-oophorectomy, omentectomy and appendectomy. And continued with adjuvand Chemotherapy CP 4 series. ( CP III:3-2-2010, IV : 8-3-2010, V : 13-4-2010, VI : 17-5-2010 )
September 23 th 2010 : patient complain abdominal erlagement with Ca 125 result increased 585. The diagnosis becames: ovarian cancer advanced stages progressive ( platinum resistant), the patient brought to Case conference and decided : No treatment
March 15 th 2011 : patient complains abdominal erlargement, with massive ascites. Advise to pungtie ascites and give second-line chemotheraphy with cel site
Mei 19 th 2011 : Operation was performed for cell site
General states : BP :110/80, P: 82, RR : 18 x/m, T : 36,2 C
Conj : anemies -/-
Thorax : Within Normal Limit
Abdomen : Abdominal erlargement, ascites (+) massive, midline operation scar 4 finger above umbilicus
Extremities : warm, edema -/-
Gynecological states
Inspeculo : v/u calm
Io : vaginal stump calm, fluxus (-), flour A(-)
RVT : there was palpable vaginal stump calm, vaginal wall smooth, Ampulla rectum not collapses
Supportive Examination :
(15/4/11) : Laboratorium : HB : 10,4 HT : 31,5, Leukosit :8360. Trombosit : 471. SGOT/SGPT 28/12. Alb 3.37 Ur/Cr 26/0,8 GDS 96 Na/K/Cl 144/4,9/102
HbsAg non reaktif.
(12/6/09) : Ca 125 : 3703 (first come)
(23/9/2010): Ca 125 : 585 (pasca chemotheapy)
(19/1/11) : Ca 125 : 1540 (control polyclinic)
(31/3/11 ) : USG :
Metastasis mass (abdominal cavity was filled massive ascites with intestines was swim). In the right para umbilical regio there was hipoechoic mass in surface intestines, size from mm to cm
Histophatology Report : 28-12-2009
Conclusion :Adenocarcinoma ovarii A and B, moderate differenteated
Right and Left pelvic Lymph nodes was 6 with 1 positive tumor mass
Chronic appendicitis with tumor mass
Mesenterium with tumor mass
Diagnosis
Ovarian Cancer Stage III C progressive ( platinum resistant), post chemotheraphy (Oxaliplatin and Gemcitabine)
Problem
Ovarian cancer stage III C progressive ( platinum resistant), post chemotheraphy (Oxaliplatin and Gemcitabine)
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