1 / 23

2011.03.26 Clinicopathological conference

2011.03.26 Clinicopathological conference. 指導醫師 : 婦產科 賴瓊慧醫師 趙安琪醫師 一般外科　 陳訓徹醫師 腫瘤科　 張獻崑醫師 影像診斷科　 許銘益醫師 放射治療科　 黃意婷醫師 病理科 翁世樺醫師 Moderator: 孫建峰主任. 醫學六 彭佳惠 張家華. Medical History. General Data Chart number : 2371XXX 40-year-old female

bryce
Télécharger la présentation

2011.03.26 Clinicopathological conference

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 2011.03.26Clinicopathological conference 指導醫師: 婦產科 賴瓊慧醫師 趙安琪醫師 一般外科　 陳訓徹醫師 腫瘤科　 張獻崑醫師 影像診斷科　 許銘益醫師 放射治療科　 黃意婷醫師 病理科 翁世樺醫師 Moderator: 孫建峰主任

  2. 醫學六 彭佳惠 張家華 Medical History

  3. General Data • Chart number : 2371XXX • 40-year-old female • Occupation: Housekeeper (previous worker) • Marriage status: married Chief Complaint (2010/7/16) Vaginal spotting for more than one month with foul odor

  4. Present illness • LMP: 2010/06/04, denied dysmenorrhea • Prolonged vaginal spotting with foul odor for over one month • Right lower quadrant tightness with contraction sensation • No fever or chills • Right flank pain • Medication in vain • Echo showed endometrial thickness 38.4 mm • Right adnexal cyst (64*40 mm) and myoma (55 mm)

  5. Past history • 2007/11 • Left breast cancer, s/p left partial mastectomy and dissection of axillary lymphatics • Grade III invasive ductal carcinoma, stage IIA (T1cN1Mo) with PR (3+), ER (3+) and Her-2 (1+) • 2007/12~2008/07 Breast adjuvant therapies • Chemotherapy : Epirubicin, 5-FU, and cyclophosphamide (FE90C) x 4 cycles Taxotere+CDDP x 4 cycles • Radiotherapy (2008/6~2008/7) • Tamoxifen (20mg/day) since 2008/6/3

  6. Past history • 2009/9 • Transcervical resection (TCR) of submucosal myomectomy

  7. Obstetric history • G7P1A6, cesarean section once 16 years ago Personal history • No known food or drug allergy. • No hypertension or DM. • Smoking: 1/2 pack per day for 15 years • HBV carrier

  8. Family history • Father: Cardiovascular disease • Mother: not contributory • Siblings: not contributory • Cousin: Hepatocellular carcinoma

  9. Physical Examination (2010/7/16) • BH: 156.2 cm; BW: 67.7kg; BMI: 27.7 • Fair looking; Conscious clear, E 4 V 5 M 6 • HEENT:  Sclera: not icteric  Conjunctiva: not paleCHEST:  Bilateral clear and symmetric breathing sound  HEART:  Regular heart beat without audible murmur  No audible S3; No audible S4

  10. ABDOMEN:  Soft and mild obese  No shifting dullnessRLQ abdominal tenderness with radiation to right flank  No rebounding pain or muscle guarding  Bowel sound: normoactive • BACK: Knocking pain over right flank area • EXTREMITIES: No joint deformity; Freely movable; No pitting edema • SKIN: intact

  11. Pelvic Examination (2010/7/16) • Cervix: smooth • Uterus: enlarged to 18th wk of gestational age • Vagina: smooth, dirty bloody discharge and foul smell • Adnexa: hard to be examined • Positive lifting pain of the uterus • Pregnancy test: negative

  12. Laboratory data

  13. Course and Treatment • Dilatation and curettage (D&C): malignant tumor favoring adenosarcoma with sarcomatous overgrowth • Oncology survey • CT scan: A pedunculated polypoid tumor (83 mm) invaginated to fundal portion in the cavity Pelvic LN(-), PALN(-), Liver(-), Lung(-) • Bone PET: No bony metastasis • Tamoxifen held (Tamoxifen use: 2008/6/3~2010/8/2)

  14. 2010/8/6 Staging laparotomy • Total abdominal hysterectomy+bilateral salpingo-oophorectomy+pelvic lymphadenectomy+ paraaortic lymph node dissection+ partial omentectomy + appendectomy • High grade uterine adenosarcoma with sarcomatous overgrowth, invading to less than 25% of the myometrium. Cervix (-), vagina (-), bil.adnexa (-), omentum (-), pelvic LN (0/9)+ PALN(0/5), resection margin (-)  FIGO Stage Ib (T1bN0M0)

  15. 2010/8~2010/12 • Adjuvant chemotherapy for EM adenosarcoma : • cisplatin + ifosfamide alternative with • doxorubicin + ifosfamide, totally 6 courses • Adjuvant endocrine therapy for breast cancer changed to aromatase inhibitor since 2010/8.

  16. Tumor markers

  17. Latest Episodes

  18. 2011/1/13 • Emergency room (ER): severe lower abdominal pain KUB: no specific findings • 2011/1/20 • GYN OPD: unremarkable PV+PR: no palpable mass; atrophic vaginitis. Adhesion ileus was suspected. • Medical oncology OPD: unremarkable

  19. 2011/02/13 • ER: severe abdominal pain and chills. Palpable right upper abdominal mass • CT scan: a heterogeneous 15*15*10 cm abdominal tumor with peritoneal seeding and ascites • CA-125 : 80.4 U/mL (12/17: 8.9) • PET scan: increased uptake in abdominal area and left supraclavicular area. • Fine needle aspiration cytology of L’t neck: negative

  20. 2011/2/18 Surgery • Tumor resection with palliative right hemicolectomy and omentectomy • Op finding: One large tumor (20*18*15cm) and fragile tumors diffusely adhered with abdominal wall, small intestine and colon. Multiple small nodules scattered over mesentery and omentum. Superior mesenteric vein was encased by the tumor. Residual tumor 4 cm at SMV root.

  21. Post-op adjuvant treatment Chemotherapy : Darcabazine (DTIC) + ifosfamide on 3/1 Radiotherapy : Intensity-modulated radiotherapy (IMRT) to the residual tumor over SMV root. Total dose: 3500 cGy/14 fx (3/7~3/25)

  22. 2011/3/15 RTO clinics: Complained of poor appetite with persistent nausea and vomiting, lower abdominal pain and distension. PE revealed a firm mass over lower abdomen. CT simulation on 3/16 showed a heterogeneous mass with more than 15x15x10 cm in size occupying the right lower abdomen and pelvic cavity  Re-growing of EM sarcoma within post-op one month Palliative RT to the right lower abdomen and pelvic mass for 1900 cGy/7 fx (3/17~3/25)

  23. 2007/12-2008/7 Breast adjuvant therapies • Chemotherapy: • FE90C x4 Taxotere/CDDPx4 • RT • -HT: tamoxifen since 2008/6/3 2009/9 TCR-myomectomy : leiomyoma • 2007/11 38 y/o • Left breast cancer, T1cN1M0, s/p BCS • Pathology: • Invasive ductal carcinoma, Gr.III • LN(1/19)+, ER (3+), PR (3+), Her-2 (1+) 2/18 -Partial tumor resection -Palliative right hemicolectomy and omentectomy -Residual tumor over SMV root 2/13 ER -CT: heterogeneous 15*15*10cm abdominal tumor with peritoneal seeding and ascites. - CA-125 : 80.4 U/mL 2010/8-12 Adjuvant therapies -Chemotherapy 6 cycles -Breast endocrine therapy--> change to aromatase inhibitor • 2011/3 Adjuvant treatment • 3/1 chemotherapy • 3/7IMRT to residual tumor 8/06Staging Laparotomy - adenosarcoma with sarcomatous overgrowth, stage Ib (T1bN0M0) • 2010/7/20D&C: malignant tumor • adenosarcoma with sarcomatous • overgrowth 3/16 CT: re-growing of tumor 3/17 RT to the re-growing tumor for decompression 2011/1 ER -KUB: no specific finding 2010/8Hold Tamoxifen Staging laparotomy TCR-myomectomy Mastectomy Tamoxifen 26 months GYN F/U Palliative surgery GYN F/U 6/3 8/2 2008 2009 2010 2011 2007 9/28 2/18 10/9 11/25 10/29 8/6

More Related