Case Conference Jan 18th 2012
18-Jan-2012, Divisi Ginekologi Onkologi RSCMCASE CONFERENCE
JANUARY 18th 2012
1 OUTPATIENT
Mrs. I, 42 yo, P4, 357-26-52, Jamkesda
HISTORY
September 5th, 2011
Patient came to RSCM with chief complain of heavy vaginal discharge since 1 year before admission. Patient was sent by an OBGYN in Dharmais hospital as Cervical cancer stage II B.
Patient complained of heavy odorless vaginal discharge since 1 year ba. No vaginal bleeding, change tampon 3x daily. Abdominal enlargement felt since 1 month ba. No abdominal pain. Good apetite. No difficulties in micturition and defecation. Patient still has regular period monthly.
Married 2x : I. 14 yo, divorce after 10 years with 2 children
II. 26 yo, husband died after 9 years with 2 children
P4
No history of contraception
Housewife
PHYSICAL EXAMINATION on admission
General status, Compos mentis
BP 120/80 mmHg Pulse 88 x/min RR 20x/min T afebrile
Height 155 cm BW 60 kg
Conjunctiva : non anemic conjunctiva, non icteric sclera
Heart/lung : wnl
Abdomen : enlarged, tensed, shifting dullness (+)
Extremities : warm, edema -/-
Gynecological status
Inspection : wnl, no active bleeding
Inspeculo : exophitic mass on portio size 6x5x5 cm, fragile and easy to bleed, fluor (-), fluxus (-), on anterior vagina 1/3 distal are nodules size Ø 2 cm
VRE : uterus normal, exophitic mass on portio size 6x4x4 cm, rigid right parametrium until pelvic wall, semi-rigid left parametrium, smooth rectal mucose
Histopathology result from Dharmais Hospital (June 8th 2011)
Cervix adenocarcinoma, lymphocitic reaction was hard to assess, lymphovascular emboli was hard to assess
Review Slide result (Sept 7th 2011)
Highly suspicious of endocervical adenocarcinoma/cervical mucinosum. Well differentiated.
Cystoscopy result (Sept 7th 2011)
Cystitic
US examination result (Sept 7th 2011)
· Uterus pushed to anterior, size and shape normal. Homogenic myometrium.
· Regular, thin basal stratum endometrial. Uterine cavity no filled with abnormal masses. Cervix : thickened endocervix (mainly in EUO area) shaped a mass with size of 47x33 mm inhomogenous texture, correspond to cervical malignancy (originate from endocervix). Parametrial free of invasion mass.
· Cranial of uterus until Douglas pouch there was a cystic mass with septum, filled with solid part and papillary growth, size 180x110x171 mm, vol 1800 cc. Mass consist of neovascularization (RI: 0.34, comes from ovarian neoplasm)
· Tumor spreading on posterior peritoneum
· No para-aortic and right-left parailliac lymph nodes enlargement
· Right lobe liver, both kidneys, splein were normal
In left lobe liver there was hypoechoic mass with irregular edge, size 64x34 mm, inhomogenous, might comes from metastatic mass
· Massive ascites
Conclusion :
Cervical malignancy. No signs of invasion on parametrium. Cystic neoplasm with ovarian solid part suspected malignancy (not clear primary single or double?).
Ascites and spreading mass into peritoneum and left lobe liver.
BNO-IVP result (Sept 10th 2011)
Secretic and excretic function of both kidneys were normal, no signs of obstruction. Blurry area on abdominal cavity which pushes bowel to cranial, suggestive soft tissue mas on abdominal cavity.
Chest X-ray result (Sept 10th 2011)
No signs of radiologic on cor and pulmo, no signs of lung metastasis
Abdominal CT-Scan result (Oct 3rd 2011)
· Uterine cervix malignant tumor
· Tumor of right and left pelvic cavity probable of ovarian tumor with ascites
Outpatient Clinic Assessment (Oct 11th 2011)
Cervical Cancer III B + Cystic ovarian neoplasm suspected malignancy
Plan for Frozen Section Laparotomy
Laboratory result (Dec 5th 2011)
CBC : 11.2/36.8/11190/304000/84.2/25.6/30.4
PT/APTT : 1.3xC/1.1xC OT/PT 12/4 Alb 2.97 Ur/Cr 25/0.6 RBG 173
Na/K/Cl 137/3.78/102.1 HbsAg non reactive Ca-125 584.7
Operation result (Dec 8th 2011)
Pre-op Dx :
Cervical cancer stage III B
Cystic ovarian neoplasm susp malignancy
Post-op Dx :
Ovarian carcinoma advanced stage, metastasis to the cervix (cervical cancer stage III B) with DD/ synchronous primary cancer of ovary and cervix
Procedure :
Done Laparotomy Frozen Section, Bilateral Salphingo-Oophorectomy, Resection bladder tumor implant, Appendictomy, and total omentectomy
FS result :
Bilateral ovarian adenocarcinoma
Hystopathology result (Dec 8th 2011)
FS : Bilateral ovarian adenocarcinoma
Conclusion :
· Papilliferum mucinosum cystadenocarcinoma, well to moderate differentiated
· Appendix showed chronic inflamation
· Metastatic tumor cell to omentum and vesica was not found
Outpatient clinic assessment result (January 9th 2012)
Ovarian cancer metastasize to cervix
Plan for consultant’s assessment
Outpatient clinic assessment result (January 17th 2012)
Discussion with dr. Andi DP, OBGYN(C) :
· Clinical signs : no vaginal bleeding on a III B cervical cancer
· Cervical biopsy : endocervical adenocarcinoma/cervical mucinosum
· BSO hystopathology : papilliferum mucinosum cystadenocarcinoma, well to moderate differentiated, chronic inflamation on appendix
Assessed as : suspected ovarian cancer metastatic to cervix
Consideration : Full dose chemotherapy (correspond to ovarian cancer)
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