Case Conference May 30th 2012

30-Mei-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

May 30^th, 2012

1 OUTPATIENT

 

Mrs N, 52 yo, P5, 3542777, Jamkesmas

Adenosarcoma post TAH-BSO

DM Type II

 

March 14^th, 2012

•         Came to RSCM, referred by RSUD Bekasi with leiomyosarcoma

•         CC : vaginal bleeding since 4 months

•         Menopause 2 years

•         Post coital bleeding (-)

•         Went to RSUD Bekasi on Nov 2011 à diagnosed as cervical polyp à extirpation à PA result: ~cervical polyp

•         2  months later repeat vaginal bleeding à diagnosed as cervical polyp à extirpation à PA result: ~cervical polyp

•         1 month later, vaginal bleeding again à diagnosed as pedunculated submucosum uterine fibroid à extirpation à PA: leiomyosarcoma dd/ stromalsarcoma à referred to RSCM

•         Weight loss (-), nausea (-), normal micturition and deffecation

 

History of previous illness: DM type II

 

Obsgyn, social history

•         Menarche 14 yo, regular cycle, dismenorrhea (-)

•         Married 2x, age 19 yo and 34 yo

•         P5

•         History of contraception: DMPA        

•         Housewife, husband: labor

 

Physical Examination:

General status: wnl

Gynecological status

I: V/U normal appearance.

Io: smooth portio, there was mass came out from external ost, fragile, easily bleed, sondage 8,5cm

RVT: portio intact, with tissue cameout from external ostium, size 2x2x1cm, uterus size slightly enlarged, smooth anal mucosa, mass(-)

 

Oncology US:

Uterus: RF, globular, size 68x55x54mm, ekostrukutur parencym hypoechoic inhomogen, unclear border, irregular margin, size 26x21x22mm at posterior submucous, endometrial lining 12 mm, subendometrial halo, intracavity fluid  not visible. Bilateral adnexa can’t be visualized. No free fluid at douglass pouch. Intraabdomen organs, liver difficult to be assessed due to bilateral hyperechoic homogen and enlarged; abdominalis aorta was normal caliber, no paraaortal and parailiac  lymph nodes enlargement.

Both kidney no pelviokalices system dilatation.

No free fluid on pleural cavity and abdominal cavity. Lien 12 cm, hipoechoic homogen.

~ Fatty liver, nonspesific hepatosplenomegaliy. Endometrium thickening susp hyperplasia

   Susp malignant myometrium mass

 

 

Lab:

CBC: 12.7/38.3/8470/254000/87/28/33

FBG/2PP: 125/178 Alb:4.2 Ur/cr: 19/0.6

Na/K/Cl: 132/3.3/95 OT/PT: 94/73

HbsAg: non reactive

 

Ro Thorax: wnl

 

BNO IVP:

Secretion and excretion both kidneys wnl

 

Review slide result:

Adenosarcoma, well-moderate diff

 

Assessment: Adenosarcoma

                        DM type II

 

Planning:

       Laparotomy TAH-BSO

 

 

May 3^rd, 2012

Performed laparotomy TAH-BSO

 

 

May 10^th, 2012:

Adenosarcoma, invasion to more than half myometrium thickness and endocervix

 

 

DISCUSSION

What is the next plan for this patient?