Case Conference September 7th 2011

07-Sep-2011, Divisi ginekologi onkologi RSCM

Mrs. S/ 33 yo/ P1/SKTM

 

HISTORY

 

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

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

She had regular period.

 

July 29th 2011

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

 

Physical examination on  July 29^th 2011 :

 

Gen st :

Abdomen : palpated solid mass sized 10 x 8 x 8 cm and fixed

Gyn status :

I : VU wnl

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

RVT : Solid mass in in the abdomen suspected came from right adnexa, filling the Douglas cavity and the rigt adnexa, probably from right adnexa. There were also solid mass in the right adnexa area and also fixed. Rectocele (+)

 

Laboratory 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 (-)

 

August 8,2011            

LDH 336 U/L

August 10, 2011         

CA 19-9    11,9 U/mL

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.

 

CT scan Abdomen :

Multiple cystic mass with solid part from pelvic cavity until abdomen infiltrated the bowels. The primary  organ is not clear. Suspected from both ovary. No lymph node enlargement.

 

PA rectal biopsy (1105680) :

Adenocarcinoma papiler.

 

CC August 10, 2011 September 6

CT-Scan : tend to be rectal cancer (or adnexal mass?)

Signet Ring Cell ? à evaluate Ca 19-9

Plan to have Joint Discussion with digestive surgery, pathology and radiology department à possibility to posterior exenteration

Check immunohistochemistry

 

Immunohistochemistry (110555) :

CK 7     : strong positive for cytoplasmic membrane of tumor cell

CK 20   : weak positive for cytoplasm / cytoplasmic membrane of a part of tumor cell

CK 117 : negative

Conclusion : Morphologic and immunohistochemistry pattern supported to tumor spread of papillary carcinoma originated from ovary

 

Problem :

•      Ovarian cancer with metastatic to rectum

Management

• Possibility to perform posterior exenteration

Joint Discussion with Digestive Surgery, Pathology and Radiology department