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