Case conference Nov 30th 2011

30-Nov-2011, divisi ginekologi onkologi RSCM

CASE CONFERENCE

NOVEMBER 30^th 2011

 

1 INPATIENT

 

Mrs. N/45 yo/ P0 A0/ 344 52 37/ Jamkesda

 

 

HISTORY

 

January 1st, 2011

 

Patient was referred by RSUD Tarakan with PA result : endometrioid adenocarcinoma with incomplete staging.

 

Patient already have HTSOB at RSUD Tarakan at December 15^th 2010 due to uterine fibroid. Patient complaint vaginal bleeding before operation à RSAL Mintohardjo and diagnosed with kidney disease. Vaginal bleeding (+) à RSUD Tarakan, diagnosed with uterine fibroid.

 

Patient regular menstrual period, 1x/mo, 7 days, pain (-)

No difficulties in micturition and defecation.

No vaginal bleeding

 

Married 2x

Housewife

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 110/80 mmHg     Pulse 80x/min           RR 20x/min   T afebrile

Conjunctiva    : not anemic

Heart/lung     : wnl

Abdomen       : pressure pain (+), acute sign (-), operation wound clean, bleeding (-), pus (-)

Extremities     : edema -/-

 

Gynecological status

Inspection      : wnl

Inspeculo       : no abnormality was seen in vaginal stump, fluor (-), fluxus (-)

VRE                 : mass (-), pain (-)

 

PA result (RSUD Tarakan 31/12/2010)

Endometrioid adenocarcinoma well-differentiated, infiltrated cervix , more than half of the myometrium

 

Patient was diagnosed with endometrioid adenocarcinoma stage II

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 110/80 mmHg     Pulse 80x/min           RR 20x/min   T afebrile

Conjunctiva    : not anemic

Heart/lung     : wnl

Abdomen       : fixed solid mass until navel, pressure pain (-)

Extremities     : edema on left leg

 

Gynecological status

Inspection      : wnl

Inspeculo       : vaginal apex was clean, fluor (-), fluxus (-)

VRE                 : solid mass until navel, fixed, limited mobility, infiltrated left adnexa

 

Oncology US (20/1/11)

Uterus and both adnexa cannot be seen. Vaginal stump was hipoechoic size 2x1,5x0,6 cm. There was a mass in the cranial side of the stump solid hipoechoic inhomogen, irregular border size 3x3x3 cm

There was solid mass with cystic part in inguinal area size 2,9x1,8x2,9 cm. No free fluid in cavum pelvic.

Intra abdominal organ :

No metastasis in hepar

Paraaortal lymph was not enlarged

No hidronefrosis

No free fluid in pleura and peritoneal cavum

Conclusion : Suspect residual mass in vaginal stump. Suspect residual mass in right inguinal

 

Patient was diagnosed with endometrium carcinoma stage II residual progresif.

Loss of follow up 9 months

  

Thorax PA (24/11/11)

Soliter nodule on the right lung dd/ metastating tuberculoma

Cardiomegaly with elongation of the aorta

 

US examination on November 24^th 2011

-          Anteflexed uterus, enlarged and buldging. There was solid, inhomogen mass in all over of the uterus, size and shape were irregular, clear border, size 120x80 mm. Neovascularisation (+) (RI : 0,6) correspond to malignancy

-          Shrinking cervix, pushed by mass in the uterine corpus

-          Both ovaries were difficult to examine

-          Lymph enlargement in right and left para iliaca size 23x21 mm and 33x33 mm

-          Hepar and lien wnl

-          Bilateral hydronephrosis : 10 mm (right) and 18 mm (left)

-           

Conclusion : Uterine corpus malignancy

 

Discussion with consultant dr. Hariyono, OBGYN (C) :

-          Consider to give hormonal therapy because the cancer was well-differentiated

-          Mass seems inoperable because already infiltrated right and left parametrium and very fixed

-          Advice : paliatif radiation + hormonal therapy à check the receptor first or directly given

 

Problem:

Endometrial cancer stage II with residual progressive tumor

CKD due to suspect nefropati obstruktive

 

Medical Record Round :

(Prof Dr Andrijono + Dr dr Laila SpOG (k) )

Consideration :

- Post operation hystrectomy and SOB with residual tumor progressive and limited mobility à inoperable.

- High Ur/Cr à chemotherapy can not be given due to chronic kidney disease

- Solid and very big mass in pelvic cavity until navel à radiation can not be done.

Decision : palliative supportive