Case Conference Mei 2nd 2012

02-Mei-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

MAY 2^nd 2012

1 OUTPATIENT

 

Mrs N, 51 yo, 3248562, Jamkesmas

Residive vulvar carcinoma, post adjuvant radiation, post radical vulvectomy and inguinal lymphadenectomy

 

January 12th, 2005

•         Patient was referred to RSCM Pasar Rebo with suspected varicous carcinoma

•         CC: Mass in vulvar region, redness (+), itchy (+), vaginal discharge (+)

•         PA Pasar Rebo Hospital (10/10/08): verrucous carcinoma

 

October 23th, 2008

•         RSCM: diagnosed vulvar carcinoma st II

•         slide review: squamous cell carcinoma keratinizing, well differentiated

 

April 30th, 2009

•         Operative: radical vulvectomy, bilateral inguinal lymphadenectomy

 

June 9th, 2009

•         PA (No.PA 0902819): well differentiated vulvar squamous cell carcinoma with keratinization with macroscopically free margin 1.2 mm from the edge of tumor

•         CPC: 1,2 mm àobservation

 

December 27th, 2010

•         CC: new vulvar mass

•         àResidive vulvar carcinoma

 

December 29th, 2010

CC result:

•         if bone scan (+) à radiation, if (-) à under narcose exam

•         if MRI metastase (+) à radiation, if (-) àunder narcose exam

•         resectable: surgery

•         non resectable: radiation

 

27/06/11      MRI: metastase to parametrium, no inguinal lymph node enlargement

13/06/11      Bone scan: no bone metastase

 

June 30th, 2011

Assesment by consultant (dr Sigit P, OBGYN (C):

RT : tumor mass infiltrate right musc bulbocavernous

A: residive vulvar carcinoma, unresectable

P: radiation

 

August 4th – September 30th, 2011

•         external radiation

 

October 11th, 2011

No complain, follow up in 3 months

 

 

January 4th, 2012

CC: pain in mixturition

Gyn St: I: tumor mass (-)

à follow up in 3 months

 

March 13th, 2012

CC:  pain in vulvar region

 

Social and Obstetrical Status:

 

Married       : 1 x, P5 with the youngest child is 18 years old

Occupation : housewife

 

 

Physical Examination:

 

General status, Compos mentis

BP 120/80 mmHg     Pulse 80x/min  RR 18x/min               T afebrile

Conjunctiva   : not anemic

Heart/lung    : wnl

Abdomen       : wnl

Extremities    : edema -/-

 

Gynecological status

Inspection     : hyperemic fourchette, swelling (+)

              RVT                  : not performed due to pain   

 

Discussion with Consultan Prof.Andrijono OBGYN (C),

Biopsy on suspicious lession:

If (+)à niddle radiation

If (-)à follow up

 

March 16th, 2012

Biopsy perineum (suspicious lession)

PA result (16/03/12): well differentiated residive vulvar squamous cell carcinoma with keratinization

 

Assesment:

Residive vulvar carcinoma post adjuvant radiation, post radical vulvectomy and inguinal lymphadenectomy

 

CC result April 4^th, 2012

Prof Heintz

-          Perform MRI (pelvic abdomen) to compare with previous MRI, wheter there is metastase

-          If metastase (-) à radiation/chemotherapy will not give good result à the choice: operative

-          Operative will be difficult due to history of radical vulvectomy and will need flap (join operation with plastic surgery) and there will be healing problem due to post radiation.

-          Flap will be taken from abdomen area (supraumbilical) with abundant vascularization, or upper thigh

 

 

MRI 19/4/12

Residif malignant mass at right labia mayora with infiltration to distal vagina, right m levator ani and m obturator internus, with cloudness peri-rectal fat.

 

Discussion with Prof.dr. Andrijono, Obgyn(C):

Discuss with dr. Arman, Rad about consideration of:

-          Whether we can repeat the resection

-          If  yes, where is the resection margin?

-          If no, is there any radiotherapy intervention?

 

Discussion with dr. Arman, Rad

Patient vulvar carcionam residive post adjuvant radiation (last 30/9/11) post radical vulvectomy + bilateral lymphadenectomy (30/4/09)

-          Resection will be difficult because tumor margin is unclear, possibility or residif will be high (tumor and rectum margin is unclear à risk)

-          Consideration to give TACI 3 series (localized) for 1 monththrough femoralis vessel to minimize tumor size. Evaluate with previous MRI, wheter it is possible to do resection

 

Discussion with Prof.dr. Andrijono, Obgyn(C)

-          Bring the case at CC 2/5/12