Case Conference September 28th 2011

28-Sep-2011, Divisi ginekologi onkologi RSCM

Mrs. SN/ 48 yo/ P2/ Jamkesda

 

HISTORY

 

May 8th, 2011

 

Patient came to RSCM with chief complain abdominal enlargement since 2 months before admission. Patient was referred from regional hospital with suspected ovarian cyst.

 

Patient already menopause since 2 years ago.

Decreasing BW (+), 4 kg in 2 months.

No difficulties in micturition and defecation.

No vaginal bleeding. Post coital bleeding (-). Dyspareunia (-).

 

Married 1x, 22 yo. P2, youngest child 15 yo

Housewife

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 120/80 mmHg       Pulse 98x/min  RR 24x/min     T afebrile

Height 157 cm            BW 56 kg

Conjunctiva     : not anemic

Heart/lung       : wnl

Abdomen        : cystic mass with solid part until navel, limited mobility, acute sign (-)

Extremities      : edema -/-

 

Gynecological status

Inspection       : wnl

Inspeculo         : smooth portio, fluor (-), fluxus (-)

VRE                : uterus hard to asses, cystic mass filling abdominal and pelvic cavity, parametrium was loose, rectal mucose smooth

 

Tumor marker examination on May 9^th 2011 (first admission)

Ca125              354.9 U/mL

AFP                 5.4 IU/mL

CEA                2.67 ng/mL

 

 

US examination on May 13^th 2011

-          Anteflexed uterus with multiple intramural myoma size 28-38 mm. Regular endometrium.

-          Cystic mass on right adnexa with solid part, irregular shape and border, RI 0.28 could be originated from right ovarian neoplasm

-          Normal left ovary

-          Liver, spleen and both kidney normal

-          Ascites (+)

Conclusion :

Ascites and cystic mass with solid part of the right ovary, suspected malignancy

 

May 13th, 2011

Assessment by consultant : dr Haryono W, SpOG (K)

Cystic mass until navel with minimal ascites

Solid part of the mass was palpated on RVT sized 7-8 cm in diameter

RVT : Paracervix area was  lose (still mobile)

 

May 19^th 2011

Cytology result from ascites was Positive. Adenocarcinoma.

 

CT-Scan on June 17^th 2011

-          Mass with solid and cystic component on pelvic-abdominal cavity ~ ovarian neoplasm

-          Left kidney calcification and simple cyst on both kidney

-          No infiltration from mass to surrounding organs

 

Patient was diagnosed as Advanced stage ovarian cancer and planned to have neoadjuvan chemotherapy, followed by interval debulking.

 

NAC were given for 3 series using Cyclophosphamide 852 mg and Platosin 71 mg.

 

NAC schedule

 

I.                   June 8^th 2011

II.                June 28^th 2011

III.             July 26^th 2011

 

Evaluation after 3 series of NAC

 

Patient complain about her abdominal mass is getting bigger.

No difficulties in micturition and defecation.

 

Ca125 level

decreased to 58.49 U/mL (July 20^th 2011, after 2^nd chemotherapy)

and 58.3 U/mL (August 19^th 2011,  after 3^rd chemotherapy).

 

PHYSICAL EXAMINATION on September 27th, 2011

 

General status, Compos mentis

Abdomen        : cystic mass with solid part until 1 finger above navel, limited mobility, acute sign (-), ascites (-)

 

Gynecological status

Inspection       : wnl

Inspeculo         : smooth portio, fluor (-), fluxus (-)

VRE                : uterus hard to asses, cystic mass filling abdominal and pelvic cavity, parametrium was loose, rectal mucose smooth

 

US examination (August 22^nd 2011)

-          anteflexed uterus with multiple intramural and subserous myoma size 27-46 mm. Regular endometrium.

-          right adnexa : cystic mass with solid part, regular size and shape, size 182x110x184 mm (vol~1950 cc), neovascularization (+) RI 0.37 ~ right ovarian neoplasm.

-          Normal left ovary.

-          Ascites (-).

-          Normal liver, spleen, both kidney and bladder.

 

Conclusion :

-          Intramural and subserous myoma

-          Cystic neoplasm with solid part suspected malignancy (from previous ultrasound, mass volume is getting bigger).

 

ASSESMENT

 

Advanced stage ovarian cancer post NAC CP 3 series, stable disease or progressive

(the mass was larger than before, but no exact data about the size on previous ultrasound)

 

PLAN

 

Palliative treatment

Or

Interval debulking