Ovarian Malignancy in G3P2A0 19-20 weeks

pregnancy
Presented by :
Adib Ahmad S .
Moderator :
dr. Yan O Neil .
Resource Person :
dr. Yudi M.H,
SpOG(K)

Introduction
malignancy is 1 leading
Ovarium
caused of death in Gynaecologyerm cell
st

tumour must be firstly considered on

reproductive women with pelvic mass.
60-90% of all ovarian tumour on pre
menarche to 20 y.o. patient is germ cell.
One third of cases are malignant2

Shimizu Y, Komiyama S, Kobayashi T, Nakata K, Iida T. Successful management of endodermal sinus tumor
of the ovary associated with pregnancy. Gynecol Oncol 2003;88:44750

Introduction
therapy for germ cell tumour is surgical
Main
procedure .
still want to continue her pregnancy
Patients
, so that conservative surgical staging is the
1-3

1.

right choice1-3.
Rare bilaterality and highly chemosensitivity
possible conservative surgical1-3.
With all that modalities of treatment, most
women still have good fertility function 1-3.

Berek SJ. Berek & Novaks Gynecology 14th Edition. Philadelphia : Lippincot Williams
& Wilkins. 2007.

Patient Identity
Name
Name

:: Mrs.
Mrs. A
A

Age
Age

:: 32
32 yo
yo

Address
Address

:: Bekasi
Bekasi

Education
Education :: Diploma
Diploma
Occupation
Occupation

:: --

Admission
Admission

:: January
January 14,
14, 2009
2009

History Taking
Not referred
Chief complain :
G3P2A0 18-19 weeks pregnancy complaint
abdominal mass since 4 month b.a, as big
as adult fist getting bigger as volley ball
Bleeding from birth canal ( - ) .
she went to Cipto Mangunkusumo Hospital
and was said her pregnancy with ovarian
tumor. She had scheduled for operation,
because that time was too long, she went
to Hasan Sadikin

Additional anamnesis/Home Visit

History of similar
disease/breast
tumour, GI
tract tumour, unknown
Abdominal pain +, sometime
Dyspneu since 2 weeks b.a
Urination and defecation was
normal

PHYSICAL EXAMINATION
General
GeneralCondition
Condition :: Compos
Composmentis
mentis
BBlood
lood PPressure
ressure
Pulse
Pulse

:: 110/80
110/80 mmHg
mmHg
:: 84
84x/min
x/min

Respiration
Respiration

:: 24
24 x/min
x/min

Weight
Weight

:: 68
68kg
kg

Height
Height

:: 148
148cm
cm

ABDOMINAL EXAMINATION

Flat, soft
DM (-), shifting dullness ( - ),
Tenderness ( - )
FH : 2 finger above pole
FHR
: 152-156 x/m
UC : (-)
Ballotement (+)
Palpable Mass cystic with solid part, size
20x16x10 cm, Tenderness ( - ), irregular surface,
fixed, ascites (-)

Internal Examination
V/V
: no specific sign
P
: Thick, soft
CU
: ~ 18-20 week pregnancy
Palpable Mass cystic with solid part, size
20x16x10 cm, Tenderness ( - ), irregular
surface, fixed
CD
: not bulging, tenderness
(-)

Laboratory Result

Hb
Leukosit
Trombosit
Ht
SGOT/SGPT
Ur/Kr
Na/K
GDS
Ca 125

:
:
:
:
:
:

: 8,4 gr %
: 13.200/mm3
682.000/mm3
26 %
32/16U/L
40/0,92 mg/dl
130/4,7 mEq/L
79 mg/dL

: 614,8

Diagnosis
G3P2A0 18-19 weeks pregnancy ; Susp
ovarian malignancy

Management

IVFD, blood reserved, cross match

Plan for USG in 17 ward
Report to oncologist consultan
advis:
Hospitalization in 17 ward
Observation

Patient was hospitalized for 14

days
Have performed insertion CTT due
to
pleural effusion
Hospitalization for improvement
condition
USG examination performed for
twice

USG Examination
1st ( 15 - 1- 2009 ) :
Retroflexi uterine with heterogenous density, size 21.5 x
17.61x13.43
Hyperechoic mass in myometrium ,
Size : 11.05x9.81x7.60 cm
Pregnancy ~18 -19 weeks pregnancy
Conclusion : pregnant, singleton, alive ~ 18-19 weeks
pregnancy + Susp Uterine fibroid

Operation post phoned

Advice from Consultant :

Postphoned operation
Plan for 2nd USG
examination

USG Examination
2nd ( 23 - 1- 2009 ) :
Uterus : singleton, alive
pregnancy

~18

-19 weeks

Adnexa : Solid mass ,size :22.76x13.59 cm

Neovascularitation ( + ), RI : 0.14
Conclusion : pregnant, singleton, alive ~ 18-19
weeks pregnancy + Susp Ovarian malignancy

Advice from Consultant :

Plan for operation at january 27th ,
2009
Informed consent

Operation performed at January 27th , 2009

:
Result
- Ascites 1000 cc 10 cc for cytologi

Mass, irregular surface, white reddish, size 25x20x20

cm, carcinomatous, easy bleeding, adhesion descenden
colon, sigmoid, omentum.
Further exfloration mass was right ovary
Uterine enlarged ~ 18-20 pregnancy . Left adnexa within
normal limit
Tumor seeding in omentum >2 cm.
Liver and diafraghm within normal limit
Conclusion : Ca ovarium std IIIC; 18-20 pregnancy .
Decided to perform : suboptimal debulking (right
salpingo-ovarektomi dekstra + partial omentektomi )
-

Hystopathological finding
Macroscopically :
Right ovarium : weight 2.75 g. White
brownish,
crumbly, irregular surface,
containing thick fluid jelly like
appearance

Omentum
: weight 280 g with
white
solid mass.

Hystopathological finding
Microscopically :
Ovarial specimen shows round cell,
hyperplastic, make papillary structure ,
polimorf nuclei with schiller duval bodies
( central vessel and mantle of
endoderm )

Same appearance on omentum mass.

Conclusion :

Yolk sac tumor right ovary with

omentum metastatic

schiller duval bodies

Citology finding ( pleural fluid )

Macroscopic : yellow reddish fluid
Microscopic : inflamatory cell,
limfosit, atypical cell with round
nuclei& hyperchromatic
Conclusion :
Atypical cell in pleural fluid susp
metastatic from ovary

PROBLEMS
1

How to diagnose in this case ?

How was management for this case?

Ovarian Cancer

Ovarian malignancy is related with

25%
gynecological mortality .
On 2003, ACS (American Cancer
Society)
estimated 25.400 women
1-3

got ovarian cancer, and 14.300 of

them died4,5.
Ovarian cancer is among 5 most
causes of malignancy mortality,
including lung, breast, colon,
pancreas2-5.

Ovarian Cancer
Mostly it was diagnosed in
advanced
stage. Overall, 5 years

survival rate is about 53%3.

Germ cell is 20% from all ovarian
neoplasm. Affect women under 30
y.o., especially 20 y.o. 3.
Incidence ovarian malignancy in
pregnant women 1:10,000
1:25,000

Ovarian Malignancy
No reliable methods on screening
of
ovarian malignancy
Diagnosed in advance stage in 6080%
patient
Detection of clinical,
morphological,
vascular,
biochemical marker

Ovarian Malignancy
Characteristic :
Fast growing
Weight loss
Ascites
Pleural effusion
Cystic mass with solid part, US
confirmed

This Patient

Fast growing tumour (4 months)

Palpated solid part
Confirmed with ultrasound
examination
(2x) MALIGNANCY
Tumor marker for germ cell
wasnt
check

Diagnose
Diagnose wasnt correct Atypical
cell was found in lung suggest
metaststic

Yolk sac tumor Std IV

Germ Cell Tumour

of germ cell tumour is
Management
surgery
women, pregnant women need
Young
fertility function
Conservative
Bilaterality is rare
any contralateral cyst occurred,
Ifcystectomy
is recommended
Chemotherapy give excellent result

This Patient
Must be check tumor marker if the
patient
< 30 y.o
Advantage :
Confirm diagnose
Monitoring of disease

Continue pregnancy by conservative

surgical
staging

(From Berek JS, Hacker NF. Practical gynecologic oncology, 4th ed. Philadelphia: Lippincott Williams
& Wilkins, 2005:513, with permission.)

How was management for this case?

Several Research
all the modalities, all patient
With
with germ cell tumour survive with

no evidence of disease
Chemotherapy supress ovarian
function, overall in first 1 year, they
got their periode
On conservative group, 5 and 10
years survival rate is 100%
In pregnancy the best time to
perform surgery after 18 weeks

Management Of this case : was

correct
Improvement condition
Perform conservative surgical
staging
Plan for chemotheraphy

Thank
You

Case Presentation
Monday, April 27 , 2009

Misdiagnosed of Intrabadominal Bleeding

Which Diagnosed as Heterotypic
Pregnancy on G1P0A0 7 8 month
Pregnancy And Dengue Haemorrhagic
Fever
By :
Josef W , dr
Moderator :
Resource person :
Dr., SpOG(K)

Case Presentation
Thursday, April 2, 2009

Testicular feminization syndrome on

patient who underwent vaginoplasty with
prior history of bilateral orchidectomy
By:
Annisa, dr.
Moderator:
Carmellia, dr.
Resource person:
dr. RM Sonny S, SpOG(K)