Case Conference May 25th 2011

01-Jun-2011, Divisi ginekologi onkologi RSCM

Mrs. M/ 51 years old/P6A0/ JAMKESDA

Anamnesis
She was referred by PKM Pangkal Pinang with uterine cancer.
Vaginal bleeding like menstrual bleeding was complained since 5 days before admission that last for 2 days, then continued with vaginal spotting. Post coital bleeding nor foul vaginal discharge was denied.
Since 2 weeks before admission, she complained of having tense abdomen and abdominal enlargement. Complaint was accompanied with urination and defecation difficulty. She then went to PKM Pangkal Pinang. She was catheterized and examined with USG, which revealed uterine cancer.
She then was referred to RSCM.

She was married at 22 years old, with her youngest child is 18 years old.
Her menarche was at 16 years old. Her period stopped 6 months ago.

General status :
Abdomen : solid mass was palpated as high as the umbilicus, immobile, shifting dullness (+)

Gynecological status :
I : v/u within normal limit
Io : smooth vaginal wall, smooth portio, fluxus(-), fluor(-)
RVT : CUT within normal limit, solid mass was palpated as high as the umbilicus, immobile, rectal
  mucous was smooth

USG Oncology Gynecology (February 18. 2011) :
• Uterus was 5,5 X 2,1 cm, retroflexed
• Homogenous echostructure, no mass/lesion
• Regular endometrium 2,4 mm
• Adnexa : cyctic multilocular lesion, 22 X 15 X 18 cm, septa 2,4 mm, internal-echo (+), papilla (+), solid part (+), vasscularization at the solid part with RI 0,40, can’t be determined from left or right ovarium
• No free fluid at Douglas pouch
• Liver and spleen within normal limit, no metastasis lesion
• Paraaortic LN can’t be evaluated due to the mass
• No hidronefrosis
• Bilateral pleural effusion
• Massive ascites

Assessment :
Cystic ovarian neoplasm with papilla and solid part suspected as malignancy
Tumor marker (February 15. 2011) :
Ca 125 : 2.362

Cytology of ascites (February 23. 2011) :
Glandular neoplasm, DD/ : 1. Adenoma borderline
        2. Adenocarcinoma can’t still be excluded

Assessment :
Cystic ovarian neoplasm suspected as malignancy

Plan of treatment :

frozen section

March 3. 2011
Pre operative diagnosis  : cyctic ovarian neoplasm suspected as malignancy
Post operative diagnosis : advanced stage ovarian cancer, post suboptimal debulking
Operation procedure  : TH-SOB, omentectomy, appendectomy
During operation :
• RVT under anesthesia : cervix retracted anteriorly, normal sized uterus displaced posteriorly, palpated 15X15X15 cm solid mass fixated to posterior pelvic, sensation of severe adhesion
• After peritoneum was opened :
o Serous ascites approximately 2.500 cc
o Normal uterus surrounded by fragile polypoid mass 20X20X20 cm originated from bilateral ovaries extending to Douglas pouch, adhered to rectosigmoid colon, 2X2 cm nodule on ventral right lobe, no pelvic and paraaortic LN enlargement.
o There were tumor implants on the peritoneum.
• TH-SOB, omentectomy and appendectomy were performed.
• There were residual tumor mass on anterior rectum approximately 4X4X1 cm, 2X2 cm on right liver lobe.
• Bleeding 1.300 cc.

Post operative histopathology result (March 14. 2011) :
• Adenocarcinoma serosum papilliferum of right and left ovaries, poor differentiation.
• Tumor spread was found at appendix and omentum.
March 24. 2011 :
• USG FM :
o Residual mass showing malignany at vaginal stump, measuring 74x44x58   mm
o No ascites
o Lever and spleen within normal limit
• Ca 125 : 311,4
March 25. 2011
Discussion with consultant - Dr Hariyono Obgyn(C) :
• Chemotherapy with CP : 3 series
• Reexamination (PE, USG, Ca 125)
• Followed with interval debulking (with possibility of colostomy)
Chemoterapy (CP) :
1. March 25. 2011
2. April 18. 2011
3. May 10. 2011

Post chemotherapy examination :
• PE :
o No supraclavicula/axillar/inguinal LN enlargement
o Abdomen : no mass, no pain
o I : v/u within normal limit
o Io : smooth vaginal wall, smooth vaginal stump, flx(-), flr(-)
o RVT : NED
• USG :
o Residual tumor at vaginal stump, measuring 29X24 mm with neovascularization and irregular border
o Liver and spleen within normal limit
o No ascites
• Ca 125 : 73,3

Before Operation
Symptoms before operation : Abdominal enlargement
Physical Examination : Solid mass palpated, as high as the umbilicus
USG : cyctic multilocular lesion, 22 X 15 X 18 cm, septa 2,4 mm, internal-echo (+), papilla (+), solid part (+), vasscularization at the solid part with RI 0,40, can’t be determined from left or right ovarium
Liver and spleen within normal limit, Massive ascites
Ca 125 : 2.362
Residual tumor : -

During Operation
Symptoms during operation : -
Physical Examination : Fragile polypoid mass 20X20X20 cm originated from bilateral ovaries extending to Douglas pouch, adhered to rectosigmoid colon, 2X2 cm nodule on ventral right lobe
USG : -
Ca 125 : -
Residual tumor : Residual tumor mass on anterior rectum approximately 4X4X1 cm, 2X2 cm on right liver lobe

Before Chemotherapy
Symptoms Before Chemotherapy : No complaint
Physical Examination : NED
USG : Residual mass showing malignany at vaginal stump, measuring 74X44X58 mm, no ascites
Liver and spleen within normal limit
Ca 125 : 311,4
Residual tumor : Residual mass showing malignany at vaginal stump, measuring 74X44X58 mm

After Chemotherapy
Symptoms After Chemotherapy : No complaint
Physical Examination : -
USG : Residual tumor at vaginal stump, measuring 29X24 mm with neovascularization and irregular border, No ascites, Liver and spleen within normal limit
Ca 125 : 73,3
Residual tumor : Residual tumor at vaginal stump, measuring 29X24 mm

Plan options :
1. Laparascopic interval debulking
2. Continue with chemotherapy

Mrs. S/ 53 years old/P3A0/JAMKESDA

January 28. 2003
• Anamnesis :
o She was referred by an Obgyn with ovarian cyst
o Abdominal pain since 5 months before admission
o No urination and defecation abnormality

• Gynecological status :
o I : v/u within normal limit
o Io : smooth portio, flx(-), flr(-)
o VT : CUT slightly enlarged, mass at left adnexa measuring 5 cm in diameter, pain (-)

• USG FM :
o Uterus within normal limit, retroflexed
o At the back of the uterus, there was cystic mass with solid part measuring 125X84X109 mm, RI 0,4
o Left ovary can’t be identified
o No ascites
o Liver and both kidneys within normal limit
o Assessment : Cystic ovarian neoplasm with solid part

February 10. 2003 :
Pre operative diagnosis  : cystic ovarian neoplasm
Post operative diagnosis : Ovarian cancer (IIIC)
Operation procedure  : TAH-BSO, omentectomy, appendectomy, lymphadenectomy, paracolical
  Biopsy

During operation  :
• Cystic multilobulated mass with solid part, with cystic mass measuring 2-4 cm in diameter, from the right to the lef adnexa, expanded to Douglas pouch, measuring as big as an adult fist, partly ruptured
• Milliary residual tumor at the Douglas pouch from the adhesion site of the tumor
• Bleeding 500 cc

Postoperative histopathology (February 18. 2011) :
• Carcinoma endometrioid cell, moderate to good differentiation
• Omentum : no significant abnormality
• Appendix : light inflamation
• Right pelvic LN : 1 sinus catarrh
• Left pelvic LN : 2 sinus catarrh
• Right paracolica peritoneum : light inflammation
• Left paracolica peritoneum : no significant abnormality

February 20. 2003 :
Planned to give chemotherapy (AP)  approved by Dr Gatot Purwoto Obgyn(C)

Chemotherapy (AP) :
1. February 25. 2003
2. March 24. 2003
3. April 22. 2003
4. May 19.2003
5. June 18. 2003
6. July 24. 2003

June 8. 2004 :
USG FM :
• No mass at the pelvic cavity
• Normal liver and spleen
• Assessment : no tumor mass at the pelvic cavity

August 25. 2005 :
Follow up : NED  re-follow up in 1 year time

May 15. 2007 :
Follow up : NED, CR  re-follow up in 6 months time

December 13. 2007 :
Follow up : NED
       USG : residual tumor mass (-), pelvic LN enlargement (-), ascites (-)
       Ca 125 : 27,2
       Re-follow up in 6 months time

November 4. 2008 :
Follow up : NED
       USG : residual tumor mass (-), pelvic LN enlargement (-), ascites (-)
       Ca 125 : 26,6
       Re-follow up in 6 months time

December 8. 2009 :
Follow up : NED
       USG : residual tumor mass (-), pelvic LN enlargement (-), ascites (-)
       Ca 125 : 36,8
       Re-follow up in 1 year time

June 10. 2010 :
Follow up :
• RVT : mass palpable measuring 2 cm at vaginal stump
• USG : mass at right pelvic measuring 2,64X1,57X2,14 cm
          mass at left pelvic measuring 1,86X1,237X1,25 cm
          liver with suspicion of metastasis
• Ca 125 : 35,4
• Assessment : recurrent ovarian cancer with platinum sensitive
• Plan of treatment : 2nd line chemotherapy
        No treatment
• Patient was given a counseling

November 29. 2010
• Came to RSCM and ready for chemotherapy

Chemotherapy (CP) :
1. November 30. 2010
2. December 22. 2010
3. January 24. 2011
4. February 23. 2011
5. March 25. 2011
6. April 26. 2011

Evaluation after chemotherapy :
• RVT : mass palpable measuring 2 cm at the right side of vaginal stump
• USG FM :
o Uterus and both adnexas are not visible
o At the right pelvic cavity behind the bladder, there is echoic solid mass measuring 24X14X16 mm, with intra mass neovascularization (RI 0,8)
o Normal vaginal stump
o Normal bladder and rectovaginal wall
o No enlargement of iliac LN
o Liver, spleen and both kidneys within normal limit
o No ascites
o Assessment : residual mass of ovarian carcinoma
• Ca 125 : 21,3
• Assessment : recurrent ovarian cancer with platinum sensitive

Before Operation
Symptoms before operation : Abdominal enlargement
Physical Examination : CUT slightly enlarged, mass at left adnexa measuring 5 cm in diameter, pain (-)
USG :  Uterus within normal limit, retroflexed at the back of the uterus, there was cystic mass with solid part measuring 125X84X109 mm, RI 0,4 Left ovary can’t be identified,No ascites,         Liver and both kidneys within normal limit
Ca 125 :  -
Residual tumor : -

During Operation
Symptoms during operation : -
Physical Examination :
Cystic multilobulated mass with solid part, with cystic mass measuring 2-4 cm in diameter, from the right to the lef adnexa, expanded to Douglas pouch, measuring as big as an adult fist, partly ruptured
USG : -
Ca 125 : -
Residual tumor : Milliary residual tumor at the Douglas pouch from the adhesion site of the tumor

After 1st Chemotherapy
Symptoms After 1st Chemotherapy : No complaint
Physical Examination : NED
USG : Mass at right pelvic measuring 2,64X1,57X2,14 cm, Mass at left pelvic measuring 1,86X1,237X1,25 cm, Liver with suspicion of metastasis
Ca 125 : 35,4 
Residual tumor : Residual tumor mass at right pelvic measuring 2,64X1,57X2,14 cm and at left pelvic measuring 1,86X1,237X1,25 cm, Liver with suspicion of metastasis

After 2nd Chemotherapy
Symptoms After 2nd Chemotherapy : No complaint
Physical Examination : Mass palpable measuring 2 cm at the right side of vaginal stump
USG : Uterus and both adnexas are not visible, At the right pelvic cavity behind the bladder, there is echoic solid mass measuring 24X14X16 mm, with intra mass neovascularization (RI 0,8),  Normal vaginal stump, Normal bladder and rectovaginal wall, No enlargement of iliac LN, Liver, spleen and both kidneys within normal limit, No ascites   Assessment : residual mass of ovarian carcinoma
Ca 125 : 21,3
Residual tumor : Residual tumor at the right pelvic cavity behind the bladder, there is echoic solid mass measuring 24X14X16 mm, with intra mass neovascularization (RI 0,8)   

Plan of treatment : - debulking
                                - no treatment