Case Conference December 19th 2012

19-Dec-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE                              

 

6/2/2008

 

 

Patient came to policlinic with abdominal lump since 1 year before admission, At the beginning the lump was in lower abdomen , as big as marble then getting bigger as big as coconut size. Decreasing body weight (+),

Normal defecation and urination.

 

Clinical examination

Gen state :

Abdomen: solid mass was palpated , nodulated, reached  1 finger above umbilical navel , limited mobility, irregular surface

Gyn state :

RT : solid mass was palpated , nodulated, reached  1 finger above umbilical level, uterus was dificult to be evaluated. Normal TSA, smooth rectal mucosa

 

Another supportive data:

CT scan  (January 31 th 2008) :  myoma uteri, right hydronephrosis and left nephrolitiasis

 

US  ( 6/2/2008):

Cystic ovarian neopasma with solid part suspected teratoma, right hydronephrosis

 

Lab (March 10 ^th 2008            )

LDH : 1141  AFP : 2,6  BHCG : 46,8  Ca 125 : 105,1

 

BNO – IVP :

Non visualized- right kidney, partial obstruction ec mass compression to pelvic minor

 

 

10/3/2008

Underwent laparatomy sub optimal de bulking

Pre op diagnostic : cystic ovarian neoplasma suspected maligna

Post op diagnostic :Ovarian carcinoma-stage IIIB (dysgerminoma)

 

Operative procedure :

Sub optimal de bulking : total hysterectomy, salphingoovorectomi dextra; omentectomy, peritoneal biopsy : paracolica and paravesica

 

 

operative findings :

On the exploration there was no ascites, performed peritoneal washing for citology examination.

Solid tumor, was presence ,  originated from  right ovarian 15x12x6 cm, adhered with peritoneum, omentum dan bowel ( ileum and colon), adhesiolisis. Was performed .

Underwent tumor biopsy à VC : dysgerminoma

Tumor mass made fusion with uterus à decided to performed total hysterectomy and SOD.

Tumor mass was taken out, there was residual tumor , adhered with pelvic wall, volume > 2 cm.

There was tumor infiltration to  1/3 proximal vaginal wall

There was tumor metastasis on omentum 2x1x1 cm, underwent partial omentectomy and pelvis peritoneum / paracolica  and prevesica biopsy

 

 

PA result (10/3/12 no. 0801689):

Non conventional dysgerminoma, already spread widely to many organs/ intra abdominal area, with intravascular embolisation, necrosis/ infarc/ desmoplastic and spotting ( no Lnds macro-microscopic)

 

 

Discussion with dr.Sigit OBGYN © : chemo with PVB

 

Patient got chemo with PVB from 30/3/8 until 4/9/8 with PVB 6 series, with LDH post chemo 345.

 

 

10/12/8

patient had hospitalized with bronchopneumonia  dd/suspected lung metastasis

 

Already discuss in CC in Case Conference (17/12/8) with discussion :

Have to make sure the diagnosis:

Planning FNAB (biopsy) guided CT-scan, from the pleural (by dr,Arman SpRad)

Conference with pediatric division after have biopsy result

 

2/1/09

CT-scan : infiltrat as free fluid appearance in both of lung, no coin lession

Diagnosed :  TB duplex active

 

7/1/9

Join conference :

ACC to hospitalized in pediatric pulmonology for dispneu  exploration and improving  the condition.

Dr.Darmawan’s sugestion  :

Chest x-ray

Test mantoux

Antibiotic : cefotaxim

 

From oncology :

Cek LDH and   US evaluation every 3 months

 

 

14/11/11

 S: patient controled to policlinic

O : US result (Mass as heigh as promontorium level )

     LDH : 566  Ca 125 : 51,5

      CT – scan : mass in right pelvic, sized 4.09x4.99x3,98 with distinguished border with rectum and vasica dd/ recurrens mass

Right hydronephrosis and hydroureter

Right parailiaca lymphadenophaty

A: suspected recurrens dysgerminoma

P: discussion with prof Andrijono, :

     FNAB, guided ct-scan or chemo with PVB

    

 

10/5/12

S : patient controled to policlinic, no complained. Patient didn’t performed FNAB

O : gyn state :

       RT : mass 5x3 cm as high as  iliaca comunis at bifurcatio, hypogastric , fixed to posterior wall

A: dysgerminoma post sub optimal de bulking

Assessment dr. Sigit OBGYN © :

Evaluated 6 monts or if  there was complained

 

16/11/12

S : patient controled to policlinic with problems in defecation since 2 weeks. Information with father’s patient : patient has primary hypertention pulmoar.

O :

Abdomen : solid mass was palpated ½ umbilical- simphysis, irregular border, pain (-)

RT : solid mass was palpated  in douglas pouch; ½ umbilical- simphysis, fixed to posterior wall, smooth rectal mucosa

 

US (onco-gyn 20/11/12): right pleural efusion; right hydronephrosis , grade severe and  sinistra, grade mild

Mass was near  aorta abdominalis  suspected lymphadenophaty suspected recurrens

Pelvic mass suspected recurrens dysgerminoma

 

 

 

 

CT scan (27/11/12) :

Suspected reccurrrens dysgerminoma, pelvic mass has already infiltrated to bladder and possibility invasion to rectum with paraaorta, paracava and para-iliaca bilateral  lymphadenophaty.

 

Lab findings :

 Hb : 12/L 8.170/trombocyte : 429.000

LDH : 1379/ AFP : 3,2

 Cardiology consultation :

Severe PH, mild moderate MR, no contraindication for chemotherapy

 

 

A: recurrens dysgerminoma post sub oprimal de bulking + 6 series-BEP

P: discussion with Dr.dr.laila OBGYN (C) and  dr.Sigit OBGYN (C):

Consideration for having chemotherapy with BEP

Discussion in CC with right time line

 

1.      Chemotherapy with BEP

2.      Chemotherapy with PVB for recurrens or advance stage dysgeminoma