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)

IntroductionOvarium malignancy is 1st leading caused of death in Gynaecologyerm cell 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 malignant2Shimizu 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

IntroductionMain therapy for germ cell tumour is surgical procedure1-3. Patients still want to continue her pregnancy , so that conservative surgical staging is the right choice1-3. Rare bilaterality and highly chemosensitivity possible conservative surgical1-3.With all that modalities of treatment, most women still have good fertility function1-3. Berek SJ. Berek & Novaks Gynecology 14th Edition. Philadelphia : Lippincot Williams & Wilkins. 2007.

Patient IdentityName: Mrs. AAge : 32 yoAddress: Bekasi Education: Diploma Occupation: -Admission : January 14, 2009

History TakingNot referredChief complain: G3P2A0 18-19 weeks pregnancy complaint abdominal mass since 4 month b.a, as big as adult fist getting bigger as volley ballBleeding 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 VisitHistory of similar disease/breast tumour, GI tract tumour, unknown Abdominal pain +, sometime Dyspneu since 2 weeks b.a Urination and defecation was normal

PHYSICAL EXAMINATIONBlood Pressure : 110/80 mmHgPulse : 84 x/minRespiration : 24 x/minWeight : 68 kgHeight : 148 cm General Condition: Compos mentis

ABDOMINAL EXAMINATION

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

Internal Examination

V/V: no specific signP: 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 : 8,4 gr %Leukosit : 13.200/mm3Trombosit: 682.000/mm3Ht: 26 %SGOT/SGPT: 32/16U/LUr/Kr: 40/0,92 mg/dlNa/K: 130/4,7 mEq/LGDS: 79 mg/dL

Ca 125: 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 wardObservation

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 17.61x13.43Hyperechoic mass in myometrium , Size : 11.05x9.81x7.60 cmPregnancy ~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 ~18 -19 weeks pregnancy

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 ovaryUterine 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 findingMacroscopically :

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 findingMicroscopically :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

PROBLEMS12How to diagnose in this case ?How was management for this case?

Ovarian CancerOvarian malignancy is related with 25% gynecological mortality1-3.On 2003, ACS (American Cancer Society) estimated 25.400 women got ovarian cancer, and 14.300 of them died4,5.Ovarian cancer is among 5 most causes of malignancy mortality, including lung, breast, colon, pancreas2-5.1

Ovarian CancerMostly 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 1:25,0001

Ovarian Malignancy No reliable methods on screening of ovarian malignancy Diagnosed in advance stage in 60-80% patientDetection of clinical, morphological, vascular, biochemical marker

1

Ovarian MalignancyCharacteristic : Fast growingWeight lossAscitesPleural effusionCystic mass with solid part, US confirmed

1

This PatientFast growing tumour (4 months)Palpated solid partConfirmed with ultrasound examination (2x) MALIGNANCYTumor marker for germ cell wasnt check

1

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

Yolk sac tumor Std IV

Germ Cell TumourManagement of germ cell tumour is surgeryYoung women, pregnant women need fertility functionConservativeBilaterality is rareIf any contralateral cyst occurred, cystectomy is recommendedChemotherapy give excellent result1

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

Continue pregnancy by conservative surgical staging 1

(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 ResearchWith all the modalities, all patient with germ cell tumour survive with no evidence of diseaseChemotherapy supress ovarian function, overall in first 1 year, they got their periodeOn conservative group, 5 and 10 years survival rate is 100%In pregnancy the best time to perform surgery after 18 weeks1

Management Of this case : was correct Improvement condition Perform conservative surgical staging Plan for chemotheraphy

Thank You

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