Case conference Feb 15th 2012

15-Feb-2012, Divisi Onkologi Ginekologi RSCM

CASE CONFERENCE

FEBRUARY  15^th 2012

1 OUTPATIENT

 

Mrs. A/, 29 yo, G1 14 wga, 353-37-39

 

 

 

HISTORY

 

Patient was admitted to RSCM on 2^nd January 2012, referred from Cibinong hospital with G1 7-8 weeks of gestational age (wga) with left ovarian cyst suspect malignancy.

Patient’s last menstrual period was 5^th November 2012, corresponded to 8 wga on her first admission to the hospital, and 14 wga at this present time.

Patient had her 1^st antenatal care at Cibinong hospital, and during ultrasound examination, she was told to have an ovarian cyst with possibility of malignancy. She was then referred to RSCM.

Further history taking revealed that she had complained of abdominal abdominal enlargement since the past 2 years, however, no treatment has ever taken. She also complained of dysmenorrhea. Her defecation and urination were unremarkable. There were no vaginal bleeding, lose of body weight, decrease of appetite noted.

 

Before the pregnancy, her menstrual period had always been regular, with 30 days cycle, 7 days length, and was using approximately 3 pads/day

 

Married 1x, March 2011

Occupation: work as a labor

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 120/70 mmHg     Pulse 88x/min           RR 18x/min   T afebrile

Height 150 cm           BW 42 kg      

Conjunctiva    : not anemic

Heart/lung     : wnl

Abdomen       : cystic mass with solid part until navel, limited mobility,

                              tenderness (+).

Extremities     : edema -/-

 

Gynecological status

Inspection      : wnl

Inspeculo       : portio could not be identified

VRE                 : portio was palpated on left cranial position, smooth. Uterus was enlarged to the size of 14 wga, mobile. Two adnexal mass were palpated on each side of the uterus, fixed to the uterus, mass on the right size approx. 12x12 cm, on the left side 9x8 cm, adhered to the uterus. Spinchter ani tone was good, no collapse ampulla, lower pool of the mass was palted.

 

Tumor marker examination:

Ca125             1093U/mL  (January 3^rd  2012)

 

CBC: 8.7/28.6/10.000/554000/68.6/20.9/30.4

 

 

US examination on January 3^rd 2012

Anteflexed uterus, enlarged, and lobulated. Several hypoechoic mass with regular border were found on the anterior corpus with the size of 50 x 50 mm, corresponding to intramural uterine myoma. Uterine cavity contains gestational sac with fetal echo, CRL 14 mm, FHR (+)

-          Portio and endocervix normal.

-          On both adnexa, there were cystic mass, septated, with papillary growth, size 142 x 98 mm ( right cyst), and 110 x 70 mm ( left), with neovascularisation (RI 0.49), suggesting bilateral ovarian neoplasm.

-          Liver, spleen and both kidney normal

-          Ascites (-)

Conclusion :

·         Pregnancy of 7 weeks gestational age, intrauterine, singleton life fetus.

·         Intramural uterine myomatas

·         Bilateral multiloculare ovarian cystic neoplasm with papillary growth, suggesting malignancy dd/ bilateral endometriosis cysts

 

Malignancy score:

GP score: 4 ( ca 125 and solid part +)

RMI: 3219

 

February 13^th 2012

Gen state:

Cystic mass was palpated on each side of the abdomen, the mass on the left side was 12 x 12 cm, and the mass on the right side size 8x9 cm.

Gynj state:

On inspeculo examination: portio was not visualized

VRT: portio was palpated on left cranial. Lower pool of the mass was palpated with adhesion

 

Assessment: G1 14 wga with bilateral ovarian cysts suspect malignancy

 

PLAN

 Two options of the management plans that need further discussion on clinical conference:

1. Laparotomy or laparoscopy for biopsy or VC

2. Laparotomy + VC to remove the left ovary and to do the biopsy on the right ovary, followed by chemotherapy