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Sample
Case
The
following is an example of an MDExpert second opinion
 MDExpert
believes that the best second opinion is one received at a major
cancer center where a physical examination and direct interaction
with a physician are part of the overall assessment. MDExpert
uses information from previous doctor visits and studies to augment
care with written opinions from leading academic experts in appropriate
oncology specialties.
CASE/
DIAGNOSIS:43-year
old female with recently diagnosed stage IIIB endometrioid adenocarcinoma
of the right ovary
HISTORY
OF PRESENT ILLNESS:
The
patient is a 43-year-old G0P0, post-menopausal woman who presented
in 2/01 with vaginal spotting. Ultrasound showed a multi-cystic
right ovary, and CA-125 levels were elevated to 754. Pre-operative
CT scan showed a 4 x 5 cm mass of the right adnexa suspicious
for ovarian neoplasm, with nodular peri-hepatic cystic changes,
a small right pleural effusion and right lung base nodularity,
suspicious for metastatic disease in patient with rising ovarian
tumor markers. In addition, a nodular enhancing lesion posterior
to the liver was seen that was thought to be a benign hemangioma.
No lymphadenopathy was seen.
She
was taken for laparoscopy 3/7/01, which was immediately aborted,
and instead had laparotomy with total abdominal hysterectomy,
right salpingo-oophorectomy, lymph node dissection and omentectomy.
(Left ovary was not present, having been removed as a child).
The surgeon reported that there were widely scattered, small tumor
implants on the anterior peritoneal surface, measuring 2-3 mm
in size. The densest population was above the liver, where there
were significant adhesions, and an area of studding approximately
15-10 cm with miliary type seeding on the right diaphragm. There
was no evidence of tumor on the liver capsule, the omentum, or
the bowel mesentery. In addition, small miliary studding on the
anterior and posterior cul-de-sac was seen. No lymphadenopathy
was apparent.
Pathology
showed a Grade II-III endometrioid adenocarcinoma (5 x 3 x 2.5
cm) with multiple implants on the uterine serosa, metastatic adenocarcinoma
of the omentum, and metastatic adenocarcinoma from a peritoneal
wall biopsy. Pelvic and pericaval lymph node tissue was negative
for tumor.
From
3/01-7/01, the patient then received six cycles of carboplatin-taxol
chemotherapy. She tolerated the chemotherapy well. CA-125 levels
decreased to 489 following surgery, and have continued to decline
on chemotherapy. Her most recent level in 7/01 was 12.
Follow-up
CT scan in 5/01 showed decrease in size of the perihepatic cystic
changes and decreased prominence of pleural nodularity. No new
lesions were noted, and there was no lymphadenopathy. The posterior
hepatic lesion was stable, and still felt to represent a hemangioma.
CT
scan in 7/01 showed mild decrease in size of the perihepatic cystic
lesions, compared to 5/01, and noted that the small effusion and
pleural nodularity seen in March were no longer evident. On this
CT scan, the posterior hepatic lesion appeared slightly smaller.
The radiologist felt the change could be due to technique, and
felt that it remained unclear whether the lesion was a hemagioma
or a metastasis.
At
this point, her oncologist has offered her two options: 3 month
follow-up and serial CA-125 levels versus being randomized to
a consolidation study with Taxol, in which the patient would be
randomized to either 3 or 12 months of additional Taxol chemotherapy.
The patient is seeking another opinion at this point. She is
currently doing well, and recovering from the chemotherapy.
PAST
MEDICAL HISTORY:
-
History of occasional sinus headaches
- Anemia
which required a blood transfusion at birth
- Patient
was on an antidepressant approximately a year and a half ago
for sign and symptoms associated with perimenopause
OB-
GYN HISTORY:
This
patient is Gravida 0. Para 0. Her last menstrual period was two
years ago. The patient stated that she was menopausal around
approximately age 39. Her last pelvic exam was done in November
2000 and was negative. Her last mammogram was in December 2000
and was also negative. The patient had menarche at age 12. Her
cycles are always around 21 days with three to five days of flow.
PAST
SURGICAL HISTORY:
- Total
abdominal hysterectomy and right salpingo-oophorectomy with
lymph node dissection and omentectomy on 3/7/01
- Right
inguinal hernia repair in 1982
- Abdominal
scar revision in 1971
- Left
salpingo-oophorectomy secondary to pain as a child in 1963
- Tonsillectomy
and adenoidectomy in 1960
ALLERGIES:
NKDA
MEDICATIONS:
- Estrodiol
- Vitamins
- Essiac
herbal tea
SOCIAL
HISTORY:
The
patient is a registered nurse. She admits to three to five glasses
of beer or wine a week with no use of
illegal drugs or tobacco.
FAMILY
HISTORY:
The
patient has one surviving brother who is healthy. Her father passed
secondary to prostate cancer and coronary artery disease. Her mother
is still alive and was diagnosed with cervical cancer in 1964.
Her father’s parents have both passed on. Her father’s mother died
of stomach cancer, and her father’s father died of throat cancer.
Her maternal grandparents have both passed on. They both died from
complications of coronary artery disease. There is no other known
significant history of breast or ovarian cancer in her family.
REVIEW
OF SYSTEMS:
A
complete 12-point review of symptoms was completed by her doctor
on 8/1/01, which was found to be negative.
PERTINENT
PHYSICAL FINDINGS: 8/01/01
- BP
112/76, Weight 70.6 kg
- Alert,
oriented and pleasant
- Alopecia
- The
neck is supple with a full range of motion. No anterior or
posterior cervical lymphadenopathy is noted
- Lungs
clear to auscultation
- Cardiovascular
regular rate and rhythm with no murmurs
- Abdomen
soft, non-tender, non-distended. Bowel sounds present. No
masses or nodularity palpated. Midline incision is well healed.
- No
edema
- Pelvic:
External genitalia are within normal limits. Speculum exam
reveals a pink, moist vaginal mucosa and well healed vaginal
cuff. No lesions or exudates are noted. Bimanual exam reveals
a surgically absent uterus, cervix. No masses or nodularities
were palpated.
- Rectal
exam confirms the absence of masses or nodularity
LABORATORY
STUDIES:
- 7/24/01:
HgB: 9.8; WBC: 3.5; plts: 137K
- CA-125
- Pre-op
754
- 2/20/01
489
- 4/10/01
577
- 5/1/01
122
- 5/21/01
28
- 6/12/01
15
- 7/3/01
14
- 7/24/01
12
RADIOGRAPHIC/DIAGNOSTIC
STUDIES:
- CXR,
3/6/01: 3 x 2 cm faint soft tissue density extending from the
right hemi-diaphragm, and small curvilinear density in the right
lower lung compatible with discoid atelectasis or benign fibrotic
scarring. Soft tissue density at right hemidiaphragm is compatible
with liver lesion when correlated with CT dated March 2, 2001.
- Abdomen
and Pelvis CT Scans:
- 3/2/01:
4 x 5 cm mixed attenuation mass lesion at right adnexa with
nodular perihepatic cystic changes. There may be some right
lung base nodularity with small pleural effusion as well.
Findings are suspicious for ovarian neoplasm recurrence with
mesenteric and pleural based metastasis. There is nodular
enhancing lesion posteriorly within the liver. It is possible
this prepresents benign hemangioma. Comparison with any previous
liver imaging studies or tagged RBC study would be useful
to confirm this impression.
- 5/18/01:
There has been decrease in size of the perihepatic cystic
changes. Findings are consistent with some resolution of
peritoneal metastatic disease. Previously noted pleural nodularity
has decreased in prominence. Previously noted right adnexal
mass lesion is no longer present. The mixed cystic and nodular
enhancing lesion within the posterior right lobe of the liver
is stable and most likely a benign hemangioma. No abnormal
lymphadenopathy.
- 7/26/01:
Stable CT scan with mild decrease in size of the right perihepatic
cystic area since the last exam. The irregular nodular enhancing
lesion posteriorly in the right lobe of the liver also appears
mildly smaller in size. However, this may be technical and
it remains unclear whether this is a hemagioma or a metastasis.
The mild pleural fluid and pleural nodularity described in
March is no longer evident. No retroperitoneal adenopathy
is demonstrated. No definite mesenteric seeding is identified.
PATHOLOGY
REPORTS:
- TAH,
RSO, tumor debulking, omentectomy and lymph node adenectomy,
3/7/01:
- Grade
II-III endometrioid adenocarcinoma (5 x 3 x 2.5 cm) involving
right ovary with multiple implants on the uterine serosa
- Leiomyomata,
myometrium
- Adenomyosis,
focal myometrium
- Simple
hyperplasia without atypia, endometrium
- Pelvic
lymph node negative for tumor
- Fibrofatty
tissue, no tumor seen, left pelvic lymph node
- Pericaval
lymph node negative for tumor
- Metastatic
adenocarcinoma, omentum
- Metastatic
adenocarcinoma, biopsy, peritoneal wal
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