Case Conference November 21st 2012

21-Nov-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

 

Mrs. RM, P1 .43 y.o, 3723160.ASKES

 

Progresif ovarian carcinoma on Chemotherapy Carboplatin AUC 5 and Paclitaxel 2^nd series, not respons

Hypoalbuminemia

 

 

12/9/12

 

CC : abdominal lump since 1 month

History :

January 2012

Patient complained about difficulty of mixturition, no abdominal enlargement, no decreasing of body weight, normal defecation.

Patient came to Otorita Batam Hospital, had catheter for mixturition then reffered to obgyn depart in the same hospital.

Performed USG : ovarian tumor with diameter 10 cm, ‘covered’ the womb.

Pebruary 2012

Patient was performed the operation in Malaka ( Mahkota Hospital ). From PA report, the procedure were : BSO_HT, omentectomy, appendectomy.

When controled, patient was suggested  get chemotherapy, but patient refused because financial problemns.

Patien has been had abdominal enlargement since 1 month, had alternative therapy, no improvement then patient came to RSCM.

 

Menarche 14 yo, married 1994

P1, 6 YO

 

Clinical Examination :

 

Gen state :

Body weight ; 46kg  Height : 158 cm

Eyes : pale conjunctiva -/-, icteric-/-

Cor and pulmo : normal

Abdomen : enlargement of abdomen, ascites massive (+) à pungsion : redish fluid à cytology examination.

Gyn state :

I : v/u normal

 

Io : smooth vaginal stump

V/RT : palpated solid mass with border of pool  in stump of vagina; nodulated mass was palpated measuring 10x5x3 cm.

Palpated susp extralumen mass of the rectum  anterior, lobulated

 

CT – scan (17/2/12) Mahkota Medical

Impression :

1.     Pelvic mass suggestive of ovarian tumour with metastatic illiac and aortacaval nodes

2.     Right lumbal mass? Omental mets or part of tumour

3.     Liver cyst

 

Histopatology report (18/2/12)

A.   Uterus , fallopian tubes and ovaries, compatible with poorly differentiated and high grade transisional cell carcinoma of left ovary associated with involvement in the right fallopian tube and widespread peritoneal spread (T3b)

B.   Omentum: foci metastatic carcinoma in the omental tissue

C.   Appendix : metastatic carcinoma in the appendecular wall

 

Cytology report L lab no 14120132

Ascites cytology : mainly blood sacnty degenerated atypical cells

 

CT-scan (11/8/132) Otorita Batam Hospital :

·        Intra peritoneal fluid collection, thickness of bowel wall

·        Hepar, lien, pancreas, bilateral  kidneys and bladder within normal

·        Absence of solid mass .

 

 

US (13/9/12) FM

Massive Ascites and multiple nodul on peritoneum and liver from malignancy metastasis

 

US september 20^th 2012 (oncology depart)

Absence of uterus and both adnexa

The presence of solid mass, irregular border, above vaginal stump measuring 4.3x4,8 cm

Anechoic Free fluid is filling pelvic cavity

Inta abdominal organs :

Hepar : echoparencim, hypoechoic homogen, hard to evaluated caused by the ascites

No enlargement of  paraaortal and parailiaca LNds

Solid mass  implanted to the rigt kidney

Left kidney was difficult to be evaluated, caused bye solid mass that adhered to abdominal wall, measuring 7 cm

No pleural free fluid

Anechoic Free fluid intra cavum peritonei

 

Corespond to massive ascites with solid mass intra abdomen pelvic susp carcinoma ovarium progresif.

 

BNO-IVP : ascites(+), filling defect on medial major calix and left kidney inferior and left pelviocalices

 

 

Chest- x ray : normal

Ca 125 (13/9/12)  : 6713

Ur  19/ cr 0.50  CCT : 49.05

Na/k/cl : 126/5.46/86

 

Discussion with prof Andrijono :

Patient with PA result : high grade transitional cell  carcinoma of the cervix à could be from bladder à consult to urology departement

 

While waiting for answer for urology departement , patient got chemotherapy I series carbo   (AUC 5)+ paclitaxel

 

22/10/12

Consultation result from Urology depart :

ü Susp recurrens ovarian carcinoma  with susp bladder mass

ü Planning : review slide from malaca

ü Cystoscopy evalation à TUR-BT

 

DPL : 10.7/L 7360/tr 720.000

AST/ALT : 109/130

Albumin : 2.52

Ur/cr : 18/0.40

 

CCT : 68.85

Na/k/cl : 128/5.11/86.7

 

Assessment :

 

Progresif ovarian carcinoma dd/ bladder carcinoma

liver function impairment

Hypoalbuminemia, hyponatremia and hypoclorida

 

 

Discussion with (Dr.dr.Laila.OBGYN (C)

 

Planning :

cystoscopy evaluation

Review slide from malaka

General condition Improvement  àpreparation for 2 nd series -chemotherapy  

Discussion in CC

 

Case Conference October 24^th  2012

 

·        From CT-scan findings : Hipodens lession on liver could be implantation, omental cake (+), massive ascites (+)

·        From PA result : transcisional cell à one of possibility is from ovarian carcinoma

·        Planning : 3 series chemotherapy, then performe CT scan

·        Re-discuss in CC

 

 

 

 

November  13 ^th 2012

 

S; patient was hospitalized planning chemotherapy and to improve the condition   She complained about  abdominal discomfort and enlargement, already underwent 2 series chemotherapy ( carboplatin AUC 5) + paclitaxel.

O :

Gen state : vital sign within normal limit

Abdomen : ascites massive , with cystofix

Gyn state :

Bleeding (-)

Lab findings :

Hb : 9,5 /L: 5000/tr.798.000

Albumin : 2,17

A: Progresif ovarian carcinoma , on chemotherapy ( carboplatin AUC 5) + paclitaxel, not respon, hypoalbuminemia

P: discussion with DPJP , Prof.Andrijino :

·        Clinically  there is  still massive ascites , with stable Ca 125

·        Impression : not respons with chemotherapy ( carboplatin AUC 5) + paclitaxel,

·        Re-discuss in CC

 

 

 

	Chemo	Ca 125	Asites	USG
13/9/12		6713	+++
20/9/12				Solid mass above stump of vaginal : 4,3x4,8 cm Solid mass
1/10/12	Chemo I
25/10/12	Chemo II
14/11/12		7323	+++