Case Conference October 12th 2011

12-Oct-2011, Divisi ginekologi onkologi RSCM

Ny. R/ 19 yo/ Jamkesda

 

HISTORY

 

October 4th 2011

 

Patient came to RSCM with chief complain pain at the inguinal area. Referred by regional hospital in Bekasi with PA : malignant tumor, germ cell, yolk sac type.

 

There was mass developed in 5 months on April 2010 at the left labia mayor, reddish and painful, size as duck egg in diameter. She went to the general surgeon. She was operated in November 2010 by general surgeon at RSUD Bekasi.

PA result was malignant. She was referred to RSCM, but due to financial problems, didn’t come to RSCM.

One month after operation, there were mass at the site of operation size 2 cm in diameter. The mass was then enlarged and after another mass appear at inguinals and enlarged and painful feeling appeared, patient came to Bekasi hospital and then she was reffered to ER RSCM on July 2011, but due to financial problems, she went home.

 

October 4th, 2011 she came back, due to enlarged mass and painful, and she can use health security system (Jamkesda).

Micturition and defecation wnl.

Food intake : good, only sometimes nausea

Menarche at 15 yo, regular, 30 days cycle, duration of 5 days, bleeding normally, No dysmenorrhea.

No coital history

History of leuchorrhea (vaginal discharge) : yes

Irregular menses : no

 

PHYSICAL EXAMINATION on October 4th 2011

 

General status, Compos mentis

BP 90/60 mmHg         Pulse 104x/min            RR 26x/min     T: 38

Height 160 cm            BW 55 kg

Conjunctiva     : anemic

Heart/lung       : wnl

Abdomen        : no mass palpated at medial part, but there was mass on inguinal and left lower part of abdomen.

Extremities      : edema -/-

Axilla and neck lymph node : no enlargement

Inguinal region : there were multilobulated exophytic solid masses, size 40 x 40 x 10 cm (left) until upper part of left femur region and enlargement of right inguinal lymph node size 10 cm in diameter, immobilized, painful and reddish.

 

Gynecological status

Inspection       : there was lobulated exophytic masses fulfilled the entire vulva until left gluteus, symphisis, upper region of thigh, malodour

RE : couldn’t be done due to severe pain

 

Histopathology (RSUD Bekasi, November 30^th, 2011)

Microscopic : specimen was consist of skin layer with tumor mass at the dermis part. The tumor mass was consist of solid layers with micsoid stroma or microcytic. The tumor cells was pleomorfik, rough chromatin, and distinc nucleus. Mitosis could be found.

Conclusion : Malignant tumor, germ cells tumor, yolk sac tumor type.

 

LAB

Parameter	28-07-2011	05-10-2011	06-10-2011	07-10-2011	08-10-2011	09-10-2011
Hb Ht L Tr MCV/H/HC	10.9 34 6500 299000 77/25/32	7.4 23 15900 306000 72/24/33	8.1 26.4 13780 332000 82/25/30	9.3 29 13850 265000 80/25/32		11.9 37.3 13620 292000 82/26/31
PT/c APTT/c Fib D-dimer					15.8/11 37.6/31 193.5 300
UL	Wnl
Ur/Cr Na/K/Cl	20/0.8 145/4.1/ 109	22/0.5 118/5.8/ 96	125/4.8/ 96.7			127/4.3/ 96
SGOT/PT Albumin LDH	19/12 4.2 1426	37/12 1.9		1282
Bi -direct -indirect	0.2 0.3
RBG		115
AFP CEA Ca-125				228 9.72 320

 

USG EXAMINATION (ER) on July 2011

Uterus was anteflexed 6.5 x 2.49 x 3.19 cm; regular endometrium 6 mm; both ovaries were normal. Both kidneys and liver were normal. Enlargement of parailiaka lymph nodes (both sides).

 

USG (FM) examination : October 10,  2011

Left Pleural effusion, pericardial effusion

Enlargement of bilateral external and internal parailliac lyph node

Pelvic and Femur Radiology examination on October 10th, 2011

 

Soft tissue mass on left inguinal region until 1/3 left femoral region, with symphysiolysis and suspected destruction on medial surface of rigt and left pubicle symphysis

 

 

Ro Thorax  October 4th 2011

 

Cannot be found and the patient still refused to performed it again

 

Review slide examination by dr Emil Taufik, SpPA

 

By phone with Hystopathologic department resident :

The result haven’t completely re-check after typing by dr Emil Taufik, SpPA

Conclusions :

Sinus Endodermal Tumor (yolk sac tumor)

 

Assessment :

 

Vulvar Cancer stage IV

Suspected bone metastases

 

Plan :

 

Chemotherapy followed by radiation or

Palliatif treatment