Case Conference August 10th 2011

10-Aug-2011, Divisi ginekologi onkologi RSCM

Mrs. S/ 33 th/ P1

 

HISTORY

 

July 29th 2011

She was consulted  by Surgeon colleagues with suspected ovarium tumor and adenocarcinoma recti.

June 21st 2011 : she came to Ciptomangunkusumo hospital to surgery departement with cc: obstipation.

2 months before admission, obstipation and bleeding during defecation. Also abdominal pain.

She had regularly period.

 

Physical examination on  July 29^th 2011 :

Gen st :

Abdomen : palpated solid Mass and fixed.

Gyn status :

I : VU wnl

Io: Portio can’t be identified. The Portio cranially retracted.

RVT : solid mass fixed in Douglas cavity, probably from left adnexa. Solid mass in the     right adnexa area fixed.

 

Labarotary finding June 27 2011 :

CBC : Hb 9,5/Ht 31,8%/T 462.000/L 7050

OT 17/ PT 12/ Alb 4,34/ Ur 13/ cr 0,6/ GDS 85 mg/dl

CEA 4,54 ng/ml / AFP 1,3 IU/ml/  Ca 125 349,5 U/ml/ HbsAg (-)

 

USG examination August 2nd 2011 :

Uterus wnl. There are 3 cystic mass with solid part. All three masses have the same pictures: irregular wall, adhered to the bowel and surrounding tissues.

1. Dextrokranial uterus : 113 x 87 x 102 mm
2. Douglas cavity-left adnexa : 100 x 84 x 85 mm
3. Left epigastrium (as high as L3-4) : 94x57x62 mm

Hepar,lien and kidney wnl.

Summary : multiple malignancy mass intraabdominal (probably metastasis)

Primary organ not clear.

 

Colonoscopy July 22th 2011 :

Exophytic mass intralumen 15 until 20 cm from anal, suspected malignancy.

Biopsy was done.

 

Roentgen Thorax : wnl

BNO IVP : right Hydronefrosis and Hydroureter. Left kidney wnl.

 

PA rectal biopsy (1105680) :

Adenocarcinoma papiler.

 

Assessment :

•      Ovarian neoplasm suspected malignancy

•      Adenocarcinoma rectal dd/ metastase.

 

Management

•      Core biopsy