Case Conference September 21st 2011

21-Sep-2011, Divisi ginekologi onkologi RSCM

Mrs. HK/46 yo/ P2

 

HISTORY

 

On August 8^th 2011, patient came with chief complain poor intake, feeling fatigued, patient underwent operation at “RS”in Sukabumi (Obgyn), 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 RS Hasan Sadikin, but patient didn’t came again. Patient admitted having abdominal enlargement on left lower quadrant, till it finallt bursts, came out yellowish fluid, patient went to RSUD 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 RS Syamsudin : 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

 

Chest x-ray                                        

04/08/11: Suspected bronchopneumoniaàTherapy,  first got antibiotic azithromycin and  cefriaxone (consultation with                                                                                              pulmonology division)

26/08/11: infiltrat decresedà Therapy,  got antibiotic amikacyn and ampicillin

sulbactam fro pulmonology division.

08/09/11  : fibrocalsification in top andà Therapy, no need further antibiotic from Pulmonology middle pulmo                                      

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

19/08/11 :2.52 g/dL

08/09/11 : 2,45 g/dl

11/09/11  : 2,06 g/dl

18/09/11  : 1,51 g/dl

 

Fistula x-ray 15/08/11: sinus tract left lower anterior abdominal wall

Care together with digestive surgery: sinus tract à conservative management

02/09/11 : rupture from abscess mass on the left abdomen, first came out greenies  fluid, then become faecolite fluid just like  as  the first fistula. Norit test tested positive.

 

Culture fluid from fistula:      

04/08/11 :  Escherichia coli à Therapy Ceftriaxone   1 x 2 gr

14/08/11 :  Klebsiella pneumonaie à Therapy Cefoperazon 2 x 1  gr

23/08/11 :  Klebsiella pneumoniae + Strep. Viridans à Therapy Amikacyn + ampicillin sulb

13/09/11 : E. Coli à Therapy Meropenem 3 x 1 gr i.v

       

Lab :

13/09/11: DPL : 9,8/29,5%/ E 3,38/ L 14.470 / T 207.000

17/09/11: DPL : 6,5/20 % / E 2,57 / L 12.200/ T 290.000

 

During treatment in the ward,  patient given enteral feeding with soft food 1200 kcal, increased gradually to 1500 kcal and finally 1900 kcal/day untill now.

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

Nutrition plan was discussed with nutritionist.

 

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.

 CC  24/08/11 :

-          Assesment from radiologist : No liver metastasis

-          To do the core biopsy from left abdomen.

 

26/08/11 : FNAB abdominal mass,: positive, metastastic SCC keratinized could be from  ovarii.

 

Round with Prof Dr dr. Andrijono SpOG (k) :

è Consult digestive  to perform colostomy then chemotherapy with PVB.

Medical record round  (dr Sigit P SpOG (k)):

è Radiation

 

Problem: the next plan for management of this patient. Her condition is better than before treatment.

 

Plan: Chemotherapy PVB vs Radiation