1. Case study 10 Facilitator: Pawin Puapornpong

2. Case : 52 para 2-0- 1-2 last 25 years, LMP last 2 years, menopause CC : 1 year PTA (28/5/55)

3. PI : 1 year PTA 8/10 bowel habit change 10 PE abdomen : mass PV Vagina : minimal blood discharge Uterus : distend Differential diagnosis : 1. myoma uteri 2. ovarian tumor 3. endometrial carcinoma

4. 11 month PTA (11/6/55) 3 PE : abdomen : marked distension PV : adnexa : midline cystic mass 28 wks size of gestation Endometium curettage : few benign (proliferative) endometium, negative for malignancy CT : large cystic mass in abdominal cavity with several thin internal septation, fine calcification of its wall is observed 24x12cm Lab : LDH 178, CA125 11.56, CA19-9 4.42, CEA 1.2

5. 10 mo PTA (24/7/55) F/U CA125 11.28, CA19-9 4.54,CEA 1.4 7mo PTA (13/11/55) F/U CA125 6.25, CA19-9 6.64, CEA1.7 1mo PTA (14/5/56) F/U CA125 8.66, CA19-9 5.47, CEA 2.5 17/6/56

6. PH : no U/D no food/drug allergy no smoking,no alcohol use C/S 2 at GA28wk FH : HTN CA breast

7. Obs & Gyne history : 14 years old Duration 4-5 Interval amount 2-3 pads/day Menopause 2 years ago First SI 23 years old Last SI 10 years ago OCP

8. gyne organ vagina organ uterus, fallopian tube ovary DDx

9. Myoma uteri – Ovarian tumor –

10. Endometrial carcinoma – Malignancy TAS TVS

11. Pap smear : U/S : a right large cystic lesion with internal thin septation occupying entire abdomen TVS : o uterus : size 5.49x6.49 cm, ET 1.2 cm o ovary: large cyst with internal solid part with multilocular

12. U/S cyst benign malignant septate TVS endometrial hyperplasia malignancy U/S multilocular benign surface epithelial tumor mucin ovarian tumor benign

13. PE : V/S : BT 36.5 C, PR 78 bpm, RR 20/min, BP 130/90 mmHg BW 55kg, height 159 cm, BMI 21.75kg/m 2 GA : A Thai female, good consciousness, not pale, no jaundice HEENT : not pale conjunctiva, anicteric sclera Heart & lung : WNL Abdomen : soft, not tender, normoactive bowel sound, abdominal mass 20 wks size of gestation, surgical scar low midline Ext : no pitting edema

14. Problem list : Abdominal discomfort 1 year PTA Abdominal mass 20 wks size of gestation Imp : ovarian tumor

15. Operative procedure : TAH with BSO with bilateral pelvic lymphadenopathy with omentectomy with appendectomy Operative finding : Rt. ovarian mass size 20x20 cm, clear content, smooth surface, daughter cyst 2 cyst Normal both fallopian tube Normal Lt. ovary Normal uterus, smooth surface of endometrium & endocervical canal Minimal clear ascitis Normal appendix (pelvic type) EBL 350 cc

16. Surgical pathology report Clinical Hx: Ovarian mass Clinical Dx: Ovarian mass Type of operation : TAH with BSO, omentectomy and appendectomy Gross examination: There are 5 containers. 1. Received is a uterus with both adnexa. The whole uterus measures 9x6.5x4 cm. and weigh110 g. The serosal surfaces is smooth and shiny. The cervix measures 3.8x3.5 cm. in mucosal diameter and 3.5 cm. in length. The endometrial cavity measures 4 cm. in length and lined by 0.2 cm. light brown endometrium with 0.6 cm. polyp. The anterior and posterior myometrial wall measures 2.2 and 2.5 cm. respectively. There is a 1.5 cm. intramural well demarcated gray white firm whirl fasiculated myometrial mass. The attached left ovary measures 2.5x1x0.8 cm. and is unremarkable. The left fallopian tube measures 6 cm. in length and 0.5 cm. in diameter and is unremarkable. Representative sections were taken as

17. B1=anterior cervix, B2=posterior cervix, B3=anterior endomyometrium, B4=posterior endomyometrium, B5=myometrial mass, B6=left adnexa. The separated right ovary measures 15x11x7 cm. and shows smooth and shiny surface. Cut surfaces show multiloculated cyst without solid part. The cyst locules are ranging from 1-7 cm. in diameter and is unremarkable. Representative sections were taken as B7=right tube,B8-20=cyst wall.

18. Gross examination 2. Labeled as right pelvic node are multiple pieces of fibrofatty tissue, measuring 5x4.2x0.6 cm. in aggregates, entirely lymph nodes submitted as B21-24. 3. Labeled as left pelvic node are multiple pieces of fibrofatty tissue, measuring 3.2x3x0.8 cm. in aggregates, entirely lymph nodes submitted as B25-27. 4. Labeled as omentum is a 22x5x1 cm. fatty omental tissue, representatively submitted as B28-29. 5. The specimen is received in formalin, labeled with the patients name and additional labeling appendix. The specimen consists of an intact appendi, measuring 4 cm. long and 0.3-0.5 cm. in diameter. The serosal surface is unremarkable. The lumen contains fecal material. Representatively submitted as B30.

19. Microscopic description 1. The sections of right ovarian cyst show single layer of mucinous epithelium lining. There are some foci of epithelial indulation without atypia. No definite hyperplasia of epithelial is detected. The solid areas show fibroadenomatous lesion without mucinous epithelial atypia. 2. The sections show reactive hyperplasia of lymph nodes. 3. The sections show reactive hyperplasia of lymph nodes. 4. The sections show unremarkable fibrofatty tissue. 5. The section show fibrofatty tissue in the tip of appendiceal lumen.

20. Pathological diagnosis 1. Uterus with both fallopian tubes, radical hysterectomy with bilateral salpingectomy. - Cervix : Unremarkable - Endometrium : Secretory phase endometrium - Myometrium : Intramural leiomyoma, 1.5 cm. in diameter - Serosa, Unremarkable - Right ovary : Mucinous cystadenoma, 15x11x7 cm. - Left ovary: Unremakable - Fallopian tube, both sides : Unremakable

21. 2. Lymph nodes, right pelvix, resection : - Reactive hyperplasia in 13 lymph nodes 3. Lymph nodes, left pelvix, resection : - Reactive hyperplasia in 5 lymph nodes 4. Omentum, omentectomy : - Unremarkable 5. Appendix, appendectomy : - Chronic appendicitis obliterans

22. Cytopathological report Clinical Hx: Ovarian mass Clinical Dx: Ovarian mass Type of operation: Peritoneal washing Cytological description : The smears show blood component, debris and few mesothelium cells. No atypical cell is detected. Cytological diagnosis : Negative for malignancy. Category : Benign.