case conference October 26th 2011

26-Oct-2011, Divisi ginekologi onkologi RSCM

Case Conference Oktober 26, 2011

Ny E/38 years old/ 341 82 21

 

HISTORY

First consulted from internal medicine with ovarian neoplasm suspeced malignancy.

Patient came first time from Puskesmas with ascites to the  internal medicine then being consulted to us. She complaint about abdomen enlargement, decreasing body weight, with fluor albus. Micturition and defecation normal.

P1. married 1x,  27 yo. P 3. SC 2x

DM (-) Hipertensi (-)

 

Physical examination on  September 6^th 2011 :

Gen status :

No enlargement of axilla, inguinal and supraclavicula lymphnodes

Abdomen : enlarged, shifting dullness (+) , palpated mass  2 finger above the umbillicus.

 

Gyn status :

I : vulva urethra, normal

Io: portio normal, pushed to anterior

RVE : uterus normal,  fixed mass  fulfilled the pelvic cavity to abdomen, smooth rectum mucous,

 

Oncology USG (August 31st 2010) : Bilateral ovarin cystic neoplasm with papil and solid part susp. Malignant. Uterus normal. Hepar with hiperechoic lession 1.4 cm susp. Hemangioma, no hidronefrosis or pleural effusion, and with massive ascites.

 

Discussion with consoultant, dr.Gatot OBGYN (C), September 2nd 2010 : Agree to do ascites cytology and neoadjuvant chemotherapy (NAC).

 

BNO IVP (17/12/10)

Secretion and function of both renal wnl

No obstruction.

 

Cytology of ascites, September 6th 2010 :  ascites consist of adenocarcinoma cells

 

She loss of follow up due to financial problems.

She came again in March 2011 with chief complain of dyspneu.

Roentgen Thorax : Pleura effusion

à Cytology from plaura effusion : consist of adenocarcinoma cells

 

Discussion with consoultant, dr.Gatot OBGYN(C),March 7th 2011 à Advanced stage Ovarium carcinoma  due to cytology results (adenocarcinoma). Do chemotherapy with NAC with CP

 

CP I   23/3/ 2011

CP II  18/04/2011

CP III  12/05/2011

 

Chest X-ray, July 15th 2011 : Left pleura effusion, no special treatment.

 

Tumor Marker :

CA 125 September 2010 : 3012

CA 125 May 2011: 3112

CA 125 pasca chemotherapy CP III : 2831

 

Operation report, August 8th 2011 :

Exploration:liver and spleen with multiple nodules, enlarge of paraaortic lymph node

Laparotomy omentectomy and right ovarian biopsy.

 

Histology report:

1. Correspond to cystadenocarcinom serosa papiliferum right ovary.
2. From Omentum : there were tumor spread on the omentum

 

ASSESMENT :

Ovarian cancer advanced stage

 

PLAN :

Paliative supportive.