CLINICAL CONFERENCE 14.01.2009

CASE 1

Mrs. A, 55 yo, , P0 (27 years infertility), referred by Budi Asih Hospital to outpatient clinic on November 17^th, 2008, due to right ovarian cyst, with DD/ malignancy. Her chief complain was worsened lower abdominal pain since 2 months before admission. Her bodyweight drop 3 kg in 2 months. She had micturition difficulty since 3 days. She had no other complaint. No important history of previous disease or family disease. She had her menopause at 52 yo.

General status within normal limit.

From gynecological exam: cervix os can't be revealed. Vaginal mucosa was smooth, no mass seen. The cervical os pushed to left anterior wall. Uterus within normal limit. A- 6 cm in diameter-cystic mass was palpable at the inferior aspect of the uterus, originated from cervix.

Ultrasound (17/11/08):

Irreguler echogenic mass occupying uterine cavity sized 47 x 32 mm with RI 0,43 à susp endometrial malignancy. An echointernal filled cystic mass sized 75 x 76 x 85 mm was seen à hemato/pyocolpos. No ascites, both ovaries were normal.

The patient was referred to oncology-gynecology division with diagnosis of endometrial cancer stage II with hematocolpos.

An oncology ultrasound was performed (20/11/08):

Irregular endometrial halo. A cystic mass protruding forward at the anterior part sized 8x7x7 cm, connected with uterine cavity. Thick intracavity wall with echointerna divided into hyperechoic dense area at the upper part and liquid area, mucinous susupected at the lower part. No elevated vascularization. There were bilateral pelvopcalyces dilatation.

Conclusion: endometrial ca suspected with hematocolpos, and bilateral hydronephrosis.

Fluid evacuation was done to the cystic mass (cervical dilatation), and citology was performed (No 082911), with result: no malignant cell found.

After the evacuation, another ultrasound was performed (11/12/08), with result: uterine cavity became smaller (8x5x7 cm), no hydronephrosis.

The assessment became hematocolpos due to vaginal sinechiae. The patient then referred to urogynecology division.

Another ultrasound performed (19/12/08):

Opened uterine cavity filled with homogenic solid echointernal mass sized 50 x 30 mm, from hematometra. Normal endometrial basal line. Homogenic echointernal cystic mass (less solid) sized 40 x 40 mm in cervical canal à hematotrachelos, occupying proximal 2/3 of vagina.

Conclusion: there might be an obstruction at internal uterine os or tranverse septum at proximal vagina (no sign of malignancy).

On December 22^nd 2008, septal excision continued with fractional curettage was performed. The post-operative diagnosis were vaginal septum and susp endometrial ca.

From histopathology result (No. 0808202):

• Endometrial adenocarcinoma, poorly differentiated.
  
• Vaginal septum filled with the same malignant mass.
  

The patient referred back to oncology-gynecology division. The last oncology ultrasound (7/1/09):

Endometrial thickness 26,7 mm, no subendometrial halo, minimal fluid intracavity with solid mass 2,1 x 3,5 cm with increased vascularity at posterior myometrium. Conclusion: endometrial carcinoma extended to more than ½ myometrial thickness.

Assessment: Endometrial Ca stage III

Conference Result:

Planned for radical hysterectomy. Reevaluation under narcose.

 

 

 

 

 

 

 

 

 

 

 

 

 

CASE 2

Mrs. S, 48 yo, P2A1, came to outpatient clinic on May 1^st, 2007 with chief complain of abdominal enlargement since 2 years before admission. There was 8 kg decrease in bodyweight in 2 months. She had constipation for 1 month.

From physical exam: tender, solid, fixed abdominal mass until ½ umbilicus-xiphoid processes.

From gynecological exam: smooth cervix, pushed posteriorly. Uterine sondage: 7 cm. Uterus was not palpable. Solid, fixed, nodulated mass sized 20 x 18 x 18 cm was palpable at Douglas pouch, with severe adhesion.

Ultrasound examination ( May 3^rd, 2007):

No uterus, liver, or kidney abnormality. A multilocular cystic mass occupied Douglas pouch, sized 183 x 144 mm, suspected derived from ovarian neoplasm. There were solid part, papillary growth, and neovascularization with RI 0,37. Healthy ovary cannot be examined. No ascites found.

Conclusion: Cystic ovarian neoplasm with solid part, malignant suspected.

CA-125: 1329 U/ml.

The assessment was cystic ovarian neoplasm with malignancy score 8. Since there was severe adhesion, the chosen treatment was preliminary neoadjuvant chemotherapy with CP for 3 cycles.

After 2 cycles (the last chemo was August 20^th 2007), the CCT was too low to perform the third chemotherapy. Reexamination was performed by oncology consultant, with result: the tumor then already relatively operable.

On January 28^th 2008 the laparotomy TAH-BSO and optimal debulking of paraaortic lymph nodes (5x3x2 cm) and right common iliac lymph nodes (7x2x2 cm) was performed at Royal Progress Hospital. The histopathology result was clear cell cystadenocarcinoma of the ovary, moderately differentiated. There were positive results on the paraaortic and right common iliac lymph nodes and positive cytology result.

The patient loss of follow up after the surgery. On January 9^th 2009 the patient came again with chief complain of lethargy and 7 kg weight loss in 2 months. From physical exam the patient look anemic, no mass found in the abdomen, no shifting dullness. From ultrasound exam, solid intrapelvic mass was found at the tip of vaginal stump sized 3,43 x 2,60 x 2,76 cm. mild left hydronephrosis and mild ascites was also found.

The plan is to perform second line chemotherapy or repeat the first chemo.

Conference result:

The patient show response to first NAC. The therapy can be repeated. No need to perform second line chemotherapy.

CASE 3

Mrs. D, 65 yo, P3A2 (No RM 3249500), postmenopause since 20 years, came to oncology outpatient clinic on October 21^st 2008 with chief complain of vaginal bleeding (3-5 pads/day) since 2 years before admission. The patient referred by RSUD Adjidharma Rangkasbitung due to endometrial adenocarcinoma (from curettage histology result on 8/10/08: invasive papillary adenocarcinoma, well differentiated, low cellular malignancy degree). No weightloss, no other complain. History of hypertension, not regularly treated.

No abnormality found in general status or gynecological status, except for high blood pressure.

Oncology ultrasound result on 22/10/2008: Endometrial thickness 11-12,5 mm, with RI 0,31. Uterine cavity 18,3 mm with echointernal fluid. Anterior myometrial thickness 3,9 mm and posterior myometrial thickness 7,6 mm. Conclusion: endometrial thickening, malignancy suspected with myometrial invasion.

Pre operative assessment: Endometrial Ca stage I

On December 22^nd, 2008, total abdominal hysterectomy and bilateral salphingoovorectomy was performed. Post op diagnosis was endometrial Ca stage IA.

The histopathology result (no 0808170) was endometrial adenocarcinoma with papillary formation, well differentiated. Tumor has reached ½ internal muscle. Cytology result was positive.

Assessment: endometrial Carcinoma stage III

Plan: Radiation, either external radiation only or external and internal radiation.