Case Conference January 2th 2013

02-Jan-2013, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

2nd January 2013

 

 

Mrs. K, 44 yo

 

 

Patient came to outpatient clinic RSCM, referred by Koja hospital due to cervical cancer st II.

Chief of complain : vaginal bleeding since 8 month

Postcoital bleeding since 2008( 4 years)

Normal miction and defecation

P4 oldest child 24 yo, youngest 7 yo, spontaneous delivery

 

Contraception : DMPA

 

Clinical Examination

I: v/u normal

IO : endophytic mass at portio 5x4x3 cm barrel shaped

RVT : right and left parametrium wnl

 

Histopathology examination

29/03/2012

Squamous cell carcinoma non keratinized, moderate- poor differentiation no lymphatic invasion found

 

Chest Xray 24/02/2012

Cor and pulmo wnl

 

BNO IVP 24/02/2012

Secretion and excretion function of both kidney was good

No sign of obstruction. Lumbal spondylosis

 

 

US examination

20/03/2012

Right hydrosalping, ca cervix, no hydronefrosis

 

Staging dr. Sigit P SpOG(K) 12/4/2012

Tumor size 6x5x4 cm, endophytic bulky lession, barrel shape, limited at cervix, normal uterus size.

Cervical cancer IB, barrel shape

Plan for chemoradiation or NAC

 

Performed NAC 3x ( 1/5/2012, 4/6/2012, 9/7/2012)

 

US examiination 24/06/2012

Hydrosalphing was vanished, cervical ca, decrease in size (march 5.3 cm, now 3.9 cm) no hydronephrosis.

 

 

Assessment :

Cervical carcinoma IB partial response (dr sigit P SpOG(K))

Plan : HR

 

After Performed HR at 30/8/2012

Histopathology result

31/8/2012

Squamous cell cervical cancer non keratinized, moderate-poor differentiation, invade right parametrium and endometrium at fundus. There was limfovasculer invasion and metastasis to the right obturator and left pelvic lymph nodes

 

Postop there was urinary retention and surgical site infection, patient was discharged at day 21 postop after rehecting

Plan for external radiation.

 

After 20th external radiation patient complain of urine came out from vagina, performed methylene blue test, there was blue liquid came out from vaginal stump.

Discussion with dr. Haryono W, SpOG(K)

Fistula might be due to operation complication, or due to radiation if there’s still tumor on radiation site.

Discuss at CC to do fistula repair or diversion.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mrs. Masturoh / 47 yo / P5 / 372 92 06 / Jamkesmas

(Gyn clinic RSCM, 2/11/2012)

•      Chief complain : abdominal mass at the lower left side since 2 mo.

History :

          abdominal mass since 2 mo, hard consistency, size was fix. Decrease weight 20 kg in 3 mo. Decrease appetite +. Abdominal pain -, vaginal bleeding -.

•      Benign cyst à laparotomy SOS at RSUD bekasi, june 2012 à PA : cystadenoma mucinous ovary

•      Menarche in 13 yo, not regulary, no menstrual pain. She has been married 1 times.

•      P5 à normal delivery, contraception -.

 

Physical examination

General states : height 155 cm, weight 58 kg

•      Neck : mass 3x2 cm at left side of clavicula

•      Abd : hard mass at left illiac, not mobile

Gynecological state :

•      RVT : uterus wnl, mass was palpable at anterior uterus, at the left side of vesica

 

US Fetomaternal  November 9^th 2012

•      Right ovary wnl, at the side of ovary there was vascular dilatation ~ pelvic congestion synd.

•      Theres no left ovary (post SOS) at lateral adnexa there was multiple echogenic mass with solid line Ø 56 mm, 30 mm, 60 mm, from left para illiac lymph node.

•      There were same mass at para aorta, multiple, Ø 26-43 mm, at L2-L4. its origin from para aorta lymph node

Conclusion  : multiple solid mass at parailliac and paraaorta from dilatation of lymph node. Susp. Came from malignancy, susp. Limfoma malignum dd/ metastase from Ca ovary (residif).

 

 

Laboratory result (14-12-2012)

•      CBC: 9.1/29.1/16000/582000/82.9/25.6/31.7

•      PT/APTT : 1.05/1.08 x control

•      Ureum/creatinin: 34.3/1.8

•      AST/ALT : 9/8

•      RBG : 150

•      e : 146/3.98/105.6

•      CEA 4.86

•      CA 125 47.9

 

histopathology examination

•      FNAB supraclavicula : + metastase from carcinoma, it could be from Ca ovary.

•       FNAB intraabdominal mass susp. Lymph node : + metastase adeno Ca, it could be from ovary.

•      Review slide : cystadenoma mucinous ovary

 

Imaging

•      CT scan (12/18/2012) :

there was lobulated irreguler mass at the pelvic cavity, with cystic and solid part. It came from left adnexa. After contras was given, mass was stabbing inhomogens. Mass size 11.93 x 8.85 x 5.98 cm. The mass infiltrate the postero-inferior part of vesica and left side of rectum. Vesica and rectum was pushed to the right. Lymph obturator was bigger. Bone wnl.

à Malignancy at left adnexa which infiltrate the vesica and rectum with lymphadenopathy obturator, para-aorta, and para-illiaca. Pelviektasis and left hidroureter until L3 due to compression by lymphadenopathy para-aorta.

•       BNO – IVP (11/29/2012): theres no sign of stone at urinary tract, both kidney function was good, theres no sign of obstruction. Susp. Mass at the left side of pelvic cavity.

•      Thorax photo (11/23/2012) : cardiomegaly with elongation aorta.

 

 

 

Disscusion with dr.sigit purbadi SpOG(K)

Assesment

Ovarian cancer advanced stage IV with supraclavicular lymph nodes metastassion

à Discussion for treatment option NAC or palliative