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PRESENTASI KASUS

KANKER OVARIUM

INDRIANI – 406172103
Pembimbing – dr. Andriana Kumala Dewi, Sp.OG
Kepaniteraan Obstetri dan Ginekologi
RS Sumber Waras- FK UNTAR
Identitas Pasien

 Nama : Ny. W
 Usia : 56 thn
 Status Pernikahan : Menikah
 Suku : Jawa
 Pekerjaan : Ibu Rumah Tangga
 Agama : Islam
 Alamat : JL. Pedongkelan Dalam RT 10/16 No.154
Anamesa
 Dilakukan pada tanggal 29 Juni 2018 pk 10.20 secara autoanamesa
 Keluhan utama :
 Nyeri
perut + berdebar-debar + keputihan + massa pada perut kanan
bawah
Riwayat Penyakit Sekarang
 P1A0 dengan keluhan nyeri perut kanan bawah, nyeri dirasakan panas,
hilang timbul dan menyebar ke punggung.
 Terdapat benjolan pada perut kanan bawah namun tidak nyeri apabila
ditekan.
 Pasien mengeluh keluar cairan berwarna putih susu, konsistensi kental dari
kemaluannya, bau (-), darah (-)
 Tidak mengeluhkan lemas, penurunan berat badan dan pusing
 BAB dan BAK lancar
Riwayat Penyakit Dahulu

 Riwayat Hipertensi sebelumnya disangkal oleh pasien


 Riwayat DM (+)
 SC, TBC, Miom/Kista ovarium, Asma, Penyakit Jantung, Alergi,
endometriosis (-)
Riwayat Penyakit Keluarga
 Riwayat hipertensi (+)
 Riwayat keluhan serupa disangkal oleh pasien
 Riwayat alergi, DM, TBC, asma, penyakit jantung (-)
Riwayat Obstetri dan Ginekologi
 Pasien menarche usia 13tahun
 Haid dikatakan teratur, setiap 28 hari  Riwayat KB suntik tiap 3
 P1 A0 bulan, selama 1 tahun.
 Pasien sudah menopause sejak 5
tahun yang lalu

No. Tahun Tempat Umur Jenis Penolong Penyulit Anak


Kehamilan JK BB Keadaan sekarang
1 1991 Rumah Aterm Spontan Bidan - P 3300 gr Sehat
bidan
Riwayat Kebiasaan & Asupan Nutrisi

 Pola makan baik, porsi cukup, 3x sehari makanan bervariasi


Pemeriksaan fisik
Pemeriksaan Umum
 Keadaan umum : Baik
 Kesadaran : Compos mentis GCS 15 (E4V5M6)
 Suhu : 36,5 ◦C
 Tekanan darah : 108/93 mmHg
 Nadi : 103x/menit; reguler, isi cukup
 Pernapasan :18x/menit, teratur, tipe pernapasan
thoracoabdominal
 Berat badan : 60.5 kg
 Tinggi badan : 160 cm
Pemeriksaan Fisik
 Kepala :
 konjungtiva anemis (-/-), sklera ikterik (-/-), coated tongue (-)
 Leher : Bendungan vena jugularis (-), pembesaran KGB (-), pembesaran
kelenjar tiroid (-)
 Thorax :
 Inspeksi : pergerakan napas simetris, retraksi otot pernapasan (-)
 Auskultasi: Suara nafas vesikuler +/+, ronkhi basah -/-, wheezing -/-

 Jantung :
 Auskultasi : BJ I/II Normal, murmur (-), gallop (-)
 Abdomen
 Inspeksi
 Tampak perut membesar ke depan, striae (-)
 Auskultasi
 BU + normal
 Palpasi
 Teraba massa padat, mobile, batas atas 1 jari dibawah pusat, batas kanan dan
kiri sejajar dengan MCL dextra et sinistra, batas bawah diatas simphisis, nyeri
tekan (-)
 Anus dan Genitalia
 Anus:
 Inspeksi : tampak tenang, perineum tidak menonjol, fisura (-), benjolan (-)
 Genitalia
 Tampak normal, hiperemis (-), pembesaran kelenjar (-), pemeriksaan dalam
tidak dilakukan
 Ekstremitas dan tulang belakang:
 Ekstremitas:
 CRT <2 detik, akral hangat, edema (-)
 Tulang belakang:
 Kifosis (-), lordosis (-), skoliosis (-), postur tegak
 Kulit
 Turgor kulit baik
 Kelenjar Getah Bening
 Tidak terlihat adanya pembesaran kelenjar getah bening
 Pemeriksaan Neurologis
 Tidak dilakukan
PEMERIKSAAN PENUNJANG
 USG : kista 10.65 x 9.86cm dengan pertumbuhan kapiler (+), septa
(+)
 Lab darah:
 petanda tumor
 CEA : 4.04ng/ml (N : <5.00 bukan perokok)
 CA 125: 6.663.00 U/ml (N : 0.00-35.00 U/mL)\

 RMI = U x M x Ca 125 x S
= 4 x 4 x 6.663 x 2
= 213.216 (suspek ganas)
Resume
Anamnesis :
 Pasien perempuan 56 tahun P1A0 dengan nyeri perut kanan bawah, panas, hilang

timbul dan menyebar ke punggung


 Terdapat benjolan pada perut kanan bawah

 Mengeluh mengeluarkan keputihan pervaginam

 Memiliki riwayat DM (+) dan riwayat keluarga hipertensi (+)


Resume
Pemeriksaan Fisik :
 N : 103x/menit
 Abdomen
 Inspeksi : tampak perut membesar kedepan
 Palpasi : teraba massa padat, mobile, batas atas 1 jari dibawah pusat, batas
kanan dan kiri sejajar dengan MCL dextra et sinistra, batas bawah diatas simphisis,
nyeri tekan (-)
Resume
 Hasil pemeriksaan USG: kista 10.65 x 9.86cm dengan pertumbuhan
kapiler (+), septa(+).
 Lab darah
 Pertanda tumor
 CA 125: 6.663.00 U/mL
Diagnosa Kerja
Susp. ca ovarium
Rencana Diagnostic
 Rujuk untuk dilakukan biopsi dan pemeriksaan Patologi Anatomi
Rencana Evaluasi

 Evaluasi perkembangan massa pada abdomen


 Evaluasi keputihan dari kemaluan
 Evaluasi mengenai berat badan pasien
Edukasi
 Menjelaskan kepada pasien tentang penyakit yang diderita
 Menjelaskan rujukan pada spesialis onkologi kepada pasien
Prognosis
 Ad vitam – dubia
 Ad sanationam – dubia
 Ad functionam – dubia
OVARIAN CANCER
 The most important is a family
history of breast or ovarian
cancer
 For the other 90-95% with no
identifiable genetic link for
their ovarian cancer, most risk
factors are related to a pattern
of uninterrupted ovulatory
cycles during the reproductive
years
Genetic Screening
 >90% of inherited ovarian cancers result from germline mutations in
the BRCA1 or BRCA2 genes.
 Patient with a personal risk of >20-25% should undergo genetic risk
assessment
Genetic Screening
 it is reasonable to offer genetic risk assessment to any individual with
greater than a 5-10% chance of having an inherited predisposition
Patophysiology
 These are two tumor-suppressor
genes : BRCA1 and BRCA2 
Interact with
recombination/DNA repair
proteins to preserve intact
chromosomal structure
 Mutation of BRCA1 and BRCA2
 disfx  genetic instability &
subjects cells to a higher risk
 of malignant transformation
EPITHELIAL OVARIAN CANCER
 Serous tubal intraepithelial carcinoma is a precursor condition for a
significant percentage of serous carcinomas, which were formerly
thought to arise spontaneously on the ovarian or peritoneal surface
Classification

Cancerous ovarian tumors start from


three common cell types:
 Surface Epithelium (90-95%) - cells
covering the outer lining of the
ovaries
 Germ Cells (5-10%)- cells that are
destined to form eggs
 Stromal Cells (5-10%) - Cells that
release hormones and connect the
different structures of the ovaries
Histologic Type

 Grossly, there are no


distinguishing features among
the types of epithelial ovarian
cancer.
 In general, each has solid and
cystic areas of varying sizes
Diagnosis

 Ovarian cancer “silent” killer,  Women with malignant masses


without appreciable signs or typically experience symptoms
symptoms until advanced disease of notable severity 20-30x per
is clinically obvious
month
 Often symptomatic for several
months before the diagnosis 
difficulty distinguishing from
that normally occur in women.
Diagnosis

Sign and symptoms

 Increased abdominal size  Abnormal vaginal bleeding


 Bloating occurs rarely.
 Urinary urgency, and pelvic pain  Occasionally, patients may
 Additionally present with nausea, vomiting,
 fatigue,indigestion, inability to and a partial bowel obstruction
eat normally, constipation, and if carcinomatosis is particularly
back pain may be noted widespread.
Diagnosis

Physical Examination

 A pelvic or pelvic-abdominal  In general, malignant tumors tend


mass is palpable in most to be solid, nodular, and fixed
patients with ovarian cancer  The presence of a fluid wave, or
less commonly, flank bulging,
suggests the presence of
significant ascites.
 Woman + pelvic mass + ascites
 ovarian cancer
Laboratory Testing

 20-25% of patients will present with  In postmenopausal women with a


thrombocytosis (platelet count
400x10^9/L) pelvic mass, a CA125
 Hyponatremia, typically between 125- measurement may be helpful in
130 mEq/L  a clinical picture predicting a higher likelihood of
suggestive of a SIADH. malignancy
 The serum CA125 test is integral to the
management of epithelial ovarian cancer.  OVA1 test appears to improve
 90% of patients presenting with the predictability of ovarian
malignant nonmucinous tumors  cancer in women with pelvic
CA125↑
masses
Imaging
Sonography.

 transvaginal sonography (TVS)


 malignant tumors are
multiloculated, solid or
echogenic, and large (5 cm),
and they have thick septae with
areas of nodularity (A)
 Other features may
include papillary
projections or
neovascularization–
demonstrated by
Doppler flow (B&C)
Imaging

Radiography Computed Tomography Scanning.

 Patients with suspected ovarian  The main role of CT scanning is in


cancer should have a chest the treatment planning of women
with advanced ovarian cancer.
radiograph to detect
 Preoperatively, it may detect
pulmonary effusions or disease in the liver,
infrequently, pulmonary retroperitoneum, omentum, or
metastases. elsewhere in the abdomen and
thereby guide surgical
cytoreduction
Histologic Grade

 The presence of ascites or evidence  Grade 1 (well-differentiated)


of abdominal or distant metastases  Grade 2 (moderately differentiated), and
should prompt consideration of  Grade 3 (poorly differentiated) lesions
referral
 Additionally, premenopausal women
with elevated CA125 levels
(i.e.,>200 U/mL) or an OVA1 score
>5.0 and postmenopausal women
with any CA125 elevation or an
OVA1 score >4.4 are at higher risk.
Management

Adjuvant Chemotherapy

 In selected cases, fertility  As noted, patients with stage IA or


sparing surgery may be an IB, grades 1&2 are adequately
option if disease appears treated with surgery alone
confined to one ovary  However, women with stage IA or IB,
grade 3 epithelial ovarian cancer
(adnexectomy) and all stage IC and II tumors should
 In some cases, postoperative be treated with three to six cycles of
chemotherapy may be carboplatin (Paraplatin) and
required. paclitaxel (Taxol) chemotherapy
Management of Advanced Ovarian Cancer

 2/3 of patients will have stage  initial treatment with


III-IV disease, thus multimodality
therapy is particularly important chemotherapy followed by
to achieve the most successful interval debulking surgery
outcome (Earle, 2006). might achieve equivalent results
 Ideally, surgical cytoreduction is
initially performed to remove all
gross disease, followed by six
courses of platinum-based
chemotherapy.
Surveillance Cytoreduction

 After completion of treatment, patients  There are several reasons why resecting ovarian
with early-stage ovarian ancer may be cancer implants is believed to prolong survival:
followed every 2 to 4 months  surgery removes large volumes of chemoresistant
tumor cell clones.
 for the first 2 years, then twice yearly for  Second, the removal of necrotic masses improves drug
an additional 3 years, then annually. delivery to remaining well-vascularized cells.
 Third, small residual tumor implants should be faster
 At each visit, complete physical and growing and therefore more susceptible to
pelvic examinations should be performed. chemotherapy.
 In addition, a serum CA125 level may be  Fourth, reducing the numbers of cancer cells should
require fewer cycles of chemotherapy and reduce the
indicated if it was initially elevated chances of chemoresistance.
 Finally, removal of bulky disease potentially enhances
the immune system.
 Women with advanced ovarian cancer if less than
2 cm residual disease can be achieved by
cytoreduction.