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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
醫學六 彭佳惠 張家華
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
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)
Present illness
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
Past history
Past history
2009/9
Transcervical resection (TCR) of submucosal
myomectomy
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
Family history
Father: Cardiovascular disease
Mother: not contributory
Siblings: not contributory
Cousin: Hepatocellular carcinoma
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 pale
CHEST:
Bilateral clear and symmetric breathing sound
HEART:
Regular heart beat without audible murmur
No audible S3; No audible S4
ABDOMEN:
Soft and mild obese
No shifting dullness
RLQ 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
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
Laboratory data
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)
Course and Treatment
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)
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.
Tumor markers
檢驗項目 單位 201004 201008 201009 201012
CA-125 U/mL 17.0 41.4 11.2 8.9
CEA ng/mL <0.5
CA15-3 U/mL 7.0 9.2
LDH U/L 189 166 198
Latest Episodes
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
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
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.
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)
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)
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+)
2007 2008 2009
2009/9TCR-myomectomy : leiomyoma
2010
2010/7/20 D&C: malignant tumor-adenosarcoma with sarcomatous overgrowth
2010/8 Hold Tamoxifen
8/06 Staging Laparotomy- adenosarcoma with sarcomatous overgrowth, stage Ib (T1bN0M0)
2010/8-12 Adjuvant therapies -Chemotherapy 6 cycles
-Breast endocrine therapy--> change to aromatase inhibitor
2011/1 ER-KUB: no specific finding
2011
2007/12-2008/7 Breast adjuvant therapies-Chemotherapy: FE90C x4 Taxotere/CDDPx4
-RT
-HT: tamoxifen since 2008/6/3
6/3 8/210/9 10/2911/25
Mastectomy
9/28
TCR-myomectomy
8/6
Staging laparotomy
2011/3 Adjuvant treatment
3/1 chemotherapy
3/7 IMRT to residual tumor
GYN F/UGYN F/UTamoxifen 26 months
2/18
Palliative surgery
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
3/16 CT: re-growing of tumor
3/17 RT to the re-growing tumor for decompression