Case Conference August 24th 2011

24-Aug-2011, Divisi ginekologi onkologi RSCM

Mrs. H/ 46 yo/ P2/ GAKIN

 

HISTORY

 

On August 8^th 2011, patient came with chief complain poor intake, feeling fatigued, patient underwent operation at RS hospital, did total hysterectomy and bilateral salpingo-oophorectomy. Pathology result: malignant transformation. From her obgyn, patient referred to RS Hasan Sadikin, was advised to have chemotherapy by obgyn in  HS hospital, but patient didn’t came again. Patient admitted having abdominal enlargement on left lower quadrant, till it finally bursts, came out yellowish fluid, patient went to general hospital at cibinong. From there, patient sent to RSCM. Weight loss (+), poor intake (+), vomiting (-), nausea (+), loss of appetite (+) micturition problem (-), defecation problem (+), patient had watery stool for approximately since January 2011.  

 

Patient married 1 x, P3 (youngest child 14 yo)

Housewife

 

PHYSICAL EXAMINATION on admission

 

General status : compos mentis, looked cachexic,

BW 22 kg, Height 145 cm, BMI 10.4 ~severely malnourished

 

BP 110/70 mmHg, HR 90x/minutes, RR 24 x/minutes,       

Conjunctiva anemic +/+

No enlargement of supraclavicular/axilla/inguinal limph nodes

Heart/Lung :  wnl

Abdomen: mass at left lower quadrant abdomen, upon palpation, came out fluid suspected feces à suspected enterocutaneous fistula, did norit test

Extremities were warm

 

Gynecologic status : On admission

I:no vaginal bleeding

Inspeculo: porsio seemed normal, pushed to posterior

VRE: portio smooth ~ subtotal hysterectomy, abnormal mass (-)

 

Pathology result from “S” hospital  : leiomyoma uteri, cystic teratoma with malignant transformation into epidermoid carcinoma left ovary

 

Patient was assessed as ovarian cancer, suspected enterocutaneous fistula and severely malnourished

 

Fetomaternal ultrasound 05/08/2011 Cystic mass between intestines, origin undefined (residual mass/metastasis/adhesion), suspected metastatic nodule on liver sized 16x17 mm.

 

CT scan 06/08/11: bilateral pleural effusion, multiple liver cyst, bilateral kidney cyst with right pelvioectasis, multiple calcification at the spleen, hypodense lesion at left mammae suspected cystic lesion

 

Fistula x-ray: sinus tract left lower anterior abdominal wall

Care together with digestive surgery: sinus tract à conservative management

 

Chest x-ray:Suspected bronchopneumonia, got antibiotic azithromycin and cefriaxone from consultation with pulmonology division. From ct scan bilateral pleural effusion pulmonology division did thorax ultrasound: no impression of pleural effusion.

 

Review pathology: squamous cell carcinoma, keratinized, moderate-well differentiated, highly possibly from malignant transformation of dermoid cyst

 

CA 125 31.6 U/ml, AFP 2.4 IU/ml, LDH 506 U/L

 

Albumin 04/08/11 1.48 g/dL à 2.07 g/dL à 2.52 g/dL on 19/08/11

 

09/08/11 PT/aPTT 0.9x/ 1x, Fib 387, BT/CT 2’/12’,

04/08/11 Na/K/Cl 128/2.89/97, Ur/Cr 35/0.2, SGOT/SGPT 19/10

21/08/11 Hb 9 , Ht 28.8/ Leukocyte 19380, Trombocyte 435000

 

Culture pus: Klebsiella pneumonia and Escherichia coli, sensitive to cefoperazone and cefriaxone

 

Culture fluid from fistula: Klebsiella pneumonia, sensitive to cefoperazone

 

During treatment in the ward, patient given enteral feeding with soft food1200 kcal, increased gradually to 1500 kcal and finally 1900 kcal/day

Protein given to patient at first 50 gr and increased gradually till 100 gr/day

Nutrition plan was discussed with nutritionist.

 

Norit test tested negative, from fistula x-ray, patient has sinus tract on left lower anterior abdominal wall.

 

Did Fetomaternal ultrasound 22/08/11: post laparotomy with widespread metastasis. Nodule on liver sized 18x20 mm, left kidney hypoechoic mass size 56x70 mm, attached to colon and abdominal wall. Left iliac region: solid mass, adhered to intestine and abdominal wall.

 

 

Problem: what is the next plan for management of this patient? Her condition is better than before treatment. With results from ultrasound  and  CT scan, do we need further diagnostic tool to ensure diagnosis in this patient?