Case Conference November 7th 2012

07-Nov-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

 

Ny.M, 59^th, 370 05,JAMKESMAS

 

Ovarian Carcinoma Advance Stage post sub optimal de bulking, with previous NAC 3 series, stable disease

 

 

May 23 ^th 2012

Patient came to ER theatre at 3^rd floor RSCM with chief complain nausea and vomiting 1 week before admission. Decreasing appetitte and body weight (+). Abdominal enlargement since January 2012, had been hospitalized at Pringsewu Hospital-Lampung, was done the surgery at April 2012, only performed ascites pungsion, not performed the biopsy because of fragile and easily bleed tissue.Cytology result :positive adenocarcinoma. Patient was refered to Abdoel Moeloek Hospital and refered to RSCM then. Normal mixturition and defecation.

 

History of illness :

Hypertention (+)

Menarche 15 yo, married 41 yo, P3, menopause 8 yo

 

Clinical Examination :

 

Gen state :

Abdomen :massive  ascites  until 2 finger below px

Gyn state :

Io : smooth portio

V/RT :uterus normal, pushed to anterior, loose parametrium. There was solid mass filled pelvic cavity until 2 finger below navel with massive ascites (+)

 

Cytology result ( Bumi Waras Hospital 19/4/12): adenocarcinoma

Ca 125 (25/5/12) :949,8

Chest x-ray : kardiomegali, metastasis(-)

US (25/5/12)

Uterus was  normal 6.02x2,6x3.3 cm, solid mass with distuingush part at cranial  uterus 12,4x13,2x11,6 cm, volume 1004 mL,inhomogen, hypoechoic, vascularisation (+). Anechoic free fluid  at douglas pouch.Aorta abdominalis, pancreas, paraaorta and parailiac LNds couldn’t be identified caused by massive ascites.

Coclusion :

Massive ascites, susp solid ovarian neoplasma susp maligna

 

cytology  (13/6/12):positive adenocarcinoma

 

US (21/9/2012) post NAC III

Uterus was  normal 47x24 mm, with cystic mass and solid part , , 17x14x15.6 cm  vol 1945 cm3, vascularisation (+), RI :0.33, susp from right adnexa, massive ascites (+)

Conclusion :

Solid ovarian neoplasma 17x14x15.6 cm,bigger compared with USG 29/5/12 (12.4x13,2x11,6 cm)

Ca 125 : 455,8

 

15/6/12 - 14/8/12:

3 series chemo with carboplatin 450 mg Paclitaxel 300 mg

Assessment :

Advance ovarian carcinoma, post 3 series ( stable disease ) with increasing tumor mass and decreasing ca 125

 

 

CT whole abdomen  27/9/12

Heterogen mass 15,5x19x13,23 cm , with necrotic componen, at pelvic cavity, origin from adnexa, pushed bladder posterior inferiorly.

Conclusion :

Ovarian mass with massive ascites, cholelitiasis, right nephrolythiasis

 

Laparotomy - Suboptimal debulking.(22/10/12)

Subtotal hysterectomy, Bilateral salphingoophorectomy

Abdominal packing

Pre-operative diagnosis 

Ovarian Carcinoma post neoadjuvan chemotherapy, with response stable

Post-operative diagnosis :

Ovarian carcinoma advanced stage

 

o   After peritoneum was opened, there was serohaemorhagic ascites  about 10.000 cc. Slowly evacuated.

o   On exploration, there was cystic mass with solid part, size 25 cm x 20 x 20 cm which adhered to sigmoid colon, anterior abdominal wall and part of the mass entraped at the pelvic region.

o   After adhesiolysis we can identify that the mass was coming from left ovary. Uterus and right adnexa was normal.

o   When ligated the left hypogatric artery ,the hemodynamic of the patient was not stable. BP was about 70/50, there was ST depression also.

o    This patient has cardiac problem before operation. And also informed, that the bleeding already 2000 cc.

o   Decided to performed only hyterectomy and bilateral salpingooophorectomy.

o   Continued by ligating the right hypogastric artery, à, there was laceration on the right hypogastric vein.

o   GIve pressure at the point of laceration. à  directly continu to performed debulking.

o   The adhesion of the tumor with left ureter was separated by skeletonized the ureter and continued by subtotal hysterectomy and bilateral salpingooophorectomy.

o     DId the hemostasis on the laceration of the hypogatric veins, was identified there was laceration around 2 mm at the vein à hemostate the laceration

o   Performed hemostatis sutured on the tumor bed at the peritoneum of anterior abdominal wall, the retzii cavity, the periuretereal region and other placed that was bleeding.

o   Bleeding was already reach 5000 cc.

 

o   Since clinical appearance of the operating field was still some part show small diffuse bleeding, and DIC was predict to be happened, and the haemodinamic patient still unstable, we decided to stop the procedure.

o   For controlling the bleeding, 7 big roll gauze  was inserted intraabdominal and intraperitoneal drain.

o     Blood loss 5000 cc, urine 150 cc clear

 

Now patient was hospitalized in the  ward after  aff tampon  ( 2 days post lap suboptimal de bulking ) and  taken care in ICU, with blood  culture: SMRE, got antibiotics and plan to go home

Assessment :

Ovarian Carcinoma Advance Stage post sub optiaml de bulking, with previous NAC 3 series, stable disease

 

Discussion  with DR.dr.Laila, OBGYN (C), discuss in  CC about regiment of  chemotherapy, after giving  NAC 3 series, à stable disease with increasing tumor mass