1. 2011.03.26 Clinicopathological 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

2. 醫學六 彭佳惠 張家華

3. 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

4.  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

5.  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

6.  2009/9  Transcervical resection (TCR) of submucosal myomectomy

7. 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

8. Family history  Father: Cardiovascular disease  Mother: not contributory  Siblings: not contributory  Cousin: Hepatocellular carcinoma

9. 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

10.  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

11. 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

12. Laboratory data

13.  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

14.  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)

15.  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.

16. Tumor markers 檢驗項目單位 201004201008201009201012 CA-125U/mL17.041.411.28.9 CEAng/mL<0.5 CA15-3U/mL7.09.2 LDHU/L189166198

17. Latest Episodes

18.  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

19.  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

20.  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.

21.  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)

22.  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)

23. 2009/10/292010/4/292010/7/16 Endometrium thickness (mm) 10.0 (asymptomatic) 14.6 (asymptomatic) 38.4 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 20082009 2009/9 TCR-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: FE 9 0 C x4  Taxotere/CDDPx4 -RT -HT: tamoxifen since 2008/6/3 6/38/2 10/9 10/29 11/25 Mastectomy 9/28 TCR-myomectomy 8/6 Staging laparotomy 2011/3 Adjuvant treatment 3/1 chemotherapy 3/7 IMRT to residual tumor GYN F/U Tamoxifen 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