Case 3

Reproductive Pathology

 

 

 

Radiology images

            CT of pelvis 10-30

            Chest X-ray

            CT of chest and abdomen 12-9

Radiology Reports

Admission H&P

Operative Report

Surgical Pathology Report

Laboratory Data

CEA and CA-125

Discharge Summary

Oncology Evaluation

Follow-up one year later:

            History and Physical 9-17

            Operative Report 9-26

            Discharge Summary 9-27

            Post Operative office visit 10-7

            Post Operative office visit 10-28

 

 

 

Radiology Images:

 

CT of pelvis 10-30 with bilateral ovarian masses:

 

 

 

Chest X-ray 10-30:

 

 

CT of chest and abdomen for staging 12-9:

 

 

 

 

 

 

 

 

 

 

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Radiology Reports

01/28/2004

ABD 2V,AP/OB/CO

CLINICAL HISTORY: Abdominal pain.

FINDINGS: No comparison. Moderate amount of stool is present in
the colon. Bowel gas pattern is normal. On the upright view
there is curvature of the thoracolumbar spine, convex to the
right. Changes of osteitis pubis are noted. Phleboliths are
present in the pelvis.

IMPRESSION:

NO RADIOGRAPHIC EVIDENCE OF ACUTE ABDOMINAL ABNORMALITY.

 

01/21/2004

THORAX CT W/CO

THORACIC CT SCAN 1/21/04

HISTORY: Follow-up lung nodules.

TECHNIQUE: This exam was done during intravenous injection of
contrast medium, with images taken at 6.5 mm intervals. Comparison
is made with a study done on 12/9/02. Some of the images on
previous studies cannot be imported for observation.

FINDINGS: On today's exam, we see essentially no change. The lung
fields remain clear and no significant pulmonary nodules are
identified. Tiny nodules discovered on previous study could well
have represented vessels on end, but I see nothing to suggest
metastatic disease. The lucencies seen in the liver are again
noted. They represent cysts. There is no pleural effusion.

The mediastinal structures are unremarkable.

IMPRESSION:

NO CHANGE. NO SIGNS OF ACUTE DISEASE.

 

01/21/2004

ABD CT W/CONT

ABDOMINAL CT SCAN, 1/21/04

Comparison is made with previous report dated 12/9/03.

HISTORY: Gastric adenocarcinoma.

TECHNIQUE: CT of the abdomen and pelvis was performed after the
uneventful administration of oral and IV contrast. 6.5 mm
transaxial slices were reformatted from helical acquisition,
extending from the lung bases inferiorly through the symphysis
pubis.

FINDINGS: A well circumscribed 10.5 cm hypodensity is seen at the
liver capsule of the left lobe on image #6, which has not changed
from the previous exam. A second para-falcine hypodensity measures
12 mm and is also unchanged. It shows mild peripheral increased
enhancement. A 2 mm hypodensity in the posterior segment of the
right lobe on image #7 is not changed from the previous exam.

The gallbladder remains unremarkable. The common duct and pancreas
are normal. The spleen again demonstrates two hypodense structures
on images #6 and 10, which measure approximately 6 and 5.5 mm in
their greatest diameters respectively. These are also stable. The
adrenal glands remain normal. The kidneys show no masses. A small
hypodense lesion in the posterior cortex of the inferior pole of
the right kidney is stable.

Mild retained stool is present in the ascending colon and hepatic
flexure, with extension through the transverse colon to the splenic
flexure. The descending colon is decompressed. No focal dilation
or transition zone are
seen. There are no masses. A few scattered

small lymph nodes are present; the most prominent is seen adjacent
to the descending aorta near the level of the splenic vein and
measures up to 9 mm in diameter. These findings are also not
significantly changed from the previous exam.

IMPRESSION:

HYPODENSE LESIONS WITHIN THE LIVER ARE STABLE, AS ARE SPLENIC AND
RENAL FINDINGS. THE RELATIVELY SHORT INTERVAL OF APPROXIMATELY SIX
WEEKS DOES NOT PRECLUDE NEOPLASTIC PROGRESSION, HOWEVER. ADDITIONAL
IMAGING COULD BE PERFORMED IF INDICATED, AND MIGHT INCLUDE PET SCAN
WHICH IS SENSITIVE TO ADENOCARCINOMA. ALTERNATIVELY, SIX-
MONTH FOLLOW-UP CT
COULD BE OBTAINED TO DOCUMENT STABILITY OF THE

ABOVE FINDINGS.

 

01/21/2004

PELVIS CT W/CON

PELVIC CT SCAN 1/21/04 COMPARISON: 12/9/03

HISTORY AND TECHNIQUE: See report of abdominal CT scan.

FINDINGS: The visualized loops of bowel are normal in size and
configuration. There is no mass or free fluid. The uterus is
surgically absent. Scattered sub-centimeter lymph nodes are again
demonstrated.

Phleboliths are present within the pelvis. The urinary bladder is
partially distended and otherwise unremarkable.

Bone windows show minimal degenerative change in the lower lumbar
spine facet joints. No focal sclerotic or lytic lesions are
identified.

IMPRESSION:

UNREMARKABLE PELVIC CT.



12/09/2003

ABD CT W/CONT

HISTORY: Gastric adenocarcinoma with Krukenberg’s tumor.

TECHNIQUE: 6.5 mm thick slices at 5 mm intervals were obtained
from the lung bases through the iliac crest following
administration of IV and oral contrast. Images were reviewed in
bone, soft tissue, in lung windows. There were no complications.

COMPARISON: None.

FINDINGS:
Liver: There are several well circumscribed hypodensities within
the liver. One measures approximately 2 mm at the dome of the
diaphragm and is best seen on image 5, nearby is another measuring
1 cm with a density of 40 Hounsfield units. On image number nine
there is a 2 mm lesion in the posterior right lobe, and on image
13 there is a poorly defined 1 cm lesion in the medial segment of
the left lobe. These lesions become more dense on the delayed
images.

Gall Bladder: Normal.

Spleen: There to ill-defined sub cm hypodense lesions in the
superior portion of the spleen, best seen on images five and
seven.

Pancreas: Normal.

Kidneys: There is a 5 mm hypodense lesion in the cortex of the
right kidney that is too small to characterize. Otherwise, the
kidneys are normal in size and appearance. Normal excretion of
contrast.

Adrenals: Normal.

Vessels: Normal.

Bowel: Adequately opacified loops of bowel show no bowel wall
thickening or adjacent fat stranding.

Lymph Nodes: There is scattered adenopathy throughout the
mesentery and periaortic lymph node chain.

Lung Bases: No abnormal opacification or effusion.

Bones: Probable hemangioma in the vertebral body of T11 with mild
degenerative changes of the spine.

Other Findings: No abnormal fluid collections; postsurgical
changes are also noted.

IMPRESSION:
1. There are several lesions within the liver and spleen that
are highly suspicious for metastatic disease.

2. Scattered lymph nodes, which may be reactive (less than 1 cm
in size) in nature but merit follow-up.

 

12/09/2003

PELVIS CT W/CON

HISTORY: Gastric adenocarcinoma.

TECHNIQUE: 6.5 mm slices at 5 mm intervals were obtained from the
iliac crest to the pubic symphysis following the administration of
IV and oral contrast. Images were reviewed in bone and
soft-tissue windows there were no complications.

COMPARISON: None.

FINDINGS:
Bowel: Adequately opacified loops of bowel are normal.

Vessels: Normal.

Bones: Mild degenerative changes of the spine and pelvis.

Uterus and Ovaries: Surgically removed.

Bladder: Normal with delayed images showing contrast reaching the
bladder.

Lymph Nodes: Scattered reactive sized lymph nodes.

Other Findings: No abnormal fluid collections.

IMPRESSION: Unremarkable CT examination of the pelvis. Abdominal
findings are documented in the abdominal CT report; please refer
to that dictation.

 

12/09/2003

THORAX CT W/CO

THORACIC CT SCAN 12/9/03

HISTORY: Gastric cancer.

TECHNIQUE: 6.5 mm thick slices at 5 mm intervals. Oral and IV
contrast.

FINDINGS: There is a hemangioma at the T11 vertebral body. There
is no evidence of mediastinal lymphadenopathy. There is a 2 mm
nodular density in the right middle lobe on image 38. There is a
2 mm nodule in the left lower lobe on image 38. There is a 2 mm
nodule in the lateral left lower lobe on image 34.

IMPRESSION:

THREE VERY SMALL PULMONARY NODULES WHICH MAY REPRESENT
GRANULOMATOUS DISEASE. HOWEVER, METASTATIC DISEASE CANNOT BE
EXCLUDED. THEREFORE, A SHORT TERM FOLLOW-UP IN 3-6 MONTHS MAY BE
INDICATED.

 

10/30/2003

US PELVIC NONOB

PELVIC ULTRASOUND 10/30/03

HISTORY: Pelvic mass.

FINDINGS: Transabdominal ultrasound evaluation of the pelvis was
performed.

There are two separate solid masses within the pelvis. One is
identified posterior to the uterus measuring 11.1 x 8.3 x 14.5 cm.
The second is identified in the left pelvis measuring 5.8 x 4.2 x
5.6 cm. The ovaries are not seen as separate structures, and these
masses are likely arising from the ovaries. The uterus is grossly
normal without evidence of mass or fibroids.

Limited evaluation of the kidneys shows no evidence of
hydronephrosis.

A transvaginal study was subsequently performed, and that exam is
dictated separately.

IMPRESSION:

TWO LARGE SOLID PELVIC MASSES WHICH APPEAR TO BE ARISING FROM THE
OVARIES. TRANSVAGINAL STUDY WAS SUBSEQUENTLY PERFORMED AND IS
DICTATED SEPARATELY.

 

10/30/2003

US TRANS VAG

TRANSVAGINAL PELVIC ULTRASOUND 10/30/03

HISTORY: Ovarian masses.

FINDINGS: Transvaginal ultrasound evaluation of the pelvis was
performed following transabdominal exam.

As seen on the transabdominal exam, two pelvic masses are
identified. One is seen posterior and to the right of the uterine
fundus. This mass measures 10.3 x 6.2 x 14.1 cm. The right ovary
is not seen as a separate entity. No right ovarian tissue can be
seen. Within the left pelvis, a mass identified measuring 7.0 x
4.5 x 7.6 cm. This can only be seen on transabdominal imaging. No
left ovary is identified distinct from this mass.

The uterus appears normal.

No free fluid is identified.

IMPRESSION:

BILATERAL SOLID PELVIC MASSES, WITH THE OVARIES NOT IDENTIFIED AS
DISTINCT ENTITIES. BILATERAL SOLID OVARIAN MASSES SUCH AS FIBROMAS
COULD HAVE THIS APPEARANCE. IF CLINICALLY INDICATED, FURTHER
EVALUATION WITH MRI MIGHT BE HELPFUL. OTHER ETIOLOGIES SUCH AS
ENLARGED LYMPH NODES OR LYMPHOMA COULD HAVE THIS APPEARANCE.

 

10/30/2003

CHEST XRAY 2VWS

History: Stomach tumor.

P.A. and lateral view of the chest show that the heart and lungs
are within normal limits.

Impression: No acute disease.

 

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Laboratory Data

10/30/03

CBC with PLATELET COUNT

Name

Result/Unit

 

Ref Interval

Status

WHITE BLOOD CELL COUNT

8.0 K/uL

 

3.2-10.6

 

RED BLOOD CELL COUNT

4.74 M/uL

 

3.88-5.46

 

HEMOGLOBIN

14.1 g/dL

 

12.1-15.9

 

HEMATOCRIT

40.9 %

 

34.3-46.6

 

MEAN CORPUSCULAR VOLUME

86.0 fL

 

77.8-94.0

 

MEAN CORPUSCULAR HEMOGLOBIN

29.7 pg

 

26.5-32.6

 

MEAN CORPUSCULAR HGB CONC

34.4 g/dL

 

32.7-36.9

 

RED CELL DISTRIBUTION WIDTH

12.6 %

 

10.8-14.1

 

PLATELETS

312 K/uL

 

177-406

 

MEAN PLATELET VOLUME

6.8 fL

 

5.9-9.8

 

 

10/30/03

COMPREHENSIVE METABOLIC PANEL

Name

Result/Unit

 

Ref Interval

Status

ALKALINE PHOSPHATASE

64 U/L

 

38-126

 

POTASSIUM

3.9 mmol/L

 

3.3-5.0

 

SODIUM

142 mmol/L

 

136-144

 

GLUCOSE

92 mg/dL

 

64-128

 

BILIRUBIN, TOTAL

0.7 mg/dL

 

0.2-1.3

 

CALCIUM, SERUM OR PLASMA

9.0 mg/dL

 

8.4-10.2

 

ALBUMIN

3.8 g/dL

 

3.5-4.6

 

TOTAL PROTEIN

7.5 g/dL

 

6.3-8.2

 

CREATININE, SERUM - mg/dL

0.9 mg/dL

 

0.7-1.2

 

CHLORIDE

110 mmol/L

H

98-107

 

ASPARTATE AMINOTRANSFERASE

25 U/L

 

14-50

 

UREA NITROGEN

10 mg/dL

 

6-22

 

CARBON DIOXIDE

27 mmol/L

 

22-29

 

ANION GAP

5 mmol/L

L

8-14

 

ALANINE AMINOTRANSFERASE

27 U/L

 

9-52

 

 

10/30/03

PROTHROMBIN TIME

Name

Result/Unit

 

Ref Interval

Status

PROTHROMBIN TIME

13.6 sec

 

12.0-15.5

 

 

10/30/03

PARTIAL THROMBOPLASTIN TIME

Name

Result/Unit

 

Ref Interval

Status

PARTIAL THROMBOPLASTIN TIME

30 sec

 

26-37

 

 

10/30/03

BETA-HCG, URINE QUAL

Name

Result/Unit

 

Ref Interval

Status

BETA-HCG, URINE QUAL

NEGATIVE

 

NEGATIVE

 

 

10/30/03

CANCER ANTIGEN 125

Name

Result/Unit

 

Ref Interval

Status

CANCER ANTIGEN 125

13 U/mL

 

0-35

 

 

 

10/30/03

CARCINOEMBRYONIC Ag

Name

Result/Unit

 

Ref Interval

Status

CARCINOEMBRYONIC Ag

2.2 ng/mL

 

0.0-3.0

 

 

 

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Results (01/01/003 to 04/09/2004)

Date

CANCER ANTIGEN 125

CARCINOEMBRYONIC AG

Hct

Na

K

BUN

Creat

PT

PTT

WBC

PLT

01/15/04 10:35 AM

--

--

--

142

4.0

9

0.7

--

--

--

--

01/15/04 10:35 AM

--

--

36.7

--

--

--

--

--

--

5.9

258

11/20/03 02:39 PM

--

--

--

142

3.9

16

0.9

--

--

--

--

11/20/03 02:39 PM

--

--

38.1

--

--

--

--

--

--

11.0

422

11/07/03 05:49 AM

--

--

--

136

4.0

5

0.7

--

--

--

--

11/07/03 05:49 AM

--

--

31.5

--

--

--

--

--

--

10.68

--

11/06/03 07:09 AM

--

--

--

136

4.4

9

0.7

--

--

--

--

11/06/03 07:09 AM

--

--

31.9

--

--

--

--

--

--

14.66

--

11/04/03 01:55 PM

--

--

--

--

--

--

--

13.7

--

--

--

11/04/03 01:55 PM

--

--

--

--

--

--

--

--

29

--

--

11/04/03 01:55 PM

--

--

41.7

--

--

--

--

--

--

8.22

292

10/30/03 12:10 PM

--

--

--

142

3.9

10

0.9

--

--

--

--

10/30/03 12:10 PM

--

--

--

--

--

--

--

13.6

--

--

--

10/30/03 12:10 PM

--

--

--

--

--

--

--

--

30

--

--

10/30/03 12:10 PM

--

--

40.9

--

--

--

--

--

--

8.0

312

10/30/03 12:10 PM

--

2.2

--

--

--

--

--

--

--

--

--

10/30/03 12:10 PM

13

--

--

--

--

--

--

--

--

--

--



1. TEST INFORMATION: Carcinoembryonic Antigen The Diagnostic Products Corporation Immulite 2000 CEA chemiluminescent immunoenzymetric method was used. Results obtained with different assay methods or kits cannot be used interchangeably. Measurement of CEA has been shown to be clinically relevant in the management of patients with colorectal, breast, lung, prostatic, pancreatic, and ovarian carcinomas. Smokers may have slightly elevated levels of CEA. The CEA assay value, regardless of level, should not be interpreted as evidence for the presence or absence of malignant disease and is not recommended for use as a screening procedure to detect the presence of cancer in the general population.

2. TEST INFORMATION: Cancer Antigen 125 The Abbott AxSYM CA 125 immunoassay method was used. Results obtained with different assay methods or kits cannot be used interchangeably. The CA 125 assay is used as an aid in monitoring response to therapy for patients with epithelial ovarian cancer. Serial testing for patient CA 125 values should be used in conjunction with other clinical methods for monitoring ovarian cancer. Patients with confirmed ovarian carcinoma may have pretreatment CA 125 assay values in the same range as healthy individuals. Elevations may be observed in patients with nonmalignant disease. For these reasons, a CA 125 assay value, regardless of level, should not be interpreted as absolute evidence of the presence or absence of malignant disease.

 

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Surgical Pathology Report 11-5-03

 

SP CLINICAL HISTORY

Pelvic mass.

SP GROSS DESCRIPTION

This case consists of five specimens each received in their own container
labeled with the patient's name and medical record number.
Container one received fresh for frozen section labeled "left ovary and
tube". The 100.6 gram ovary is 8.2 x 6.6 x 3.9 cm. The light tan to pink
surface is nodular and cut sections reveal a rim of firm tan homogenous tissue
(0.6-1.3 cm) surrounding a central white cystic region (3.5 x 1.7 cm). There
is also a small firm white, well circumscribed nodule located 0.9 cm from the
ovarian capsular surface, the mass is 0.6 x 0.7 x 0.7 cm. A grossly normal
appearing portion of fallopian tube is attached to the specimen (5.2 cm in
length by 0.6 cm). Frozen section 1FA is resubmitted in cassette 1FA for
permanent. Cassette code: 1A - fallopian tube; 1B-1F - representative
sections of left ovary.
Container two is received fresh for frozen section labeled "right tube and
ovary". The 520 gram ovary is 16.0 x 10.0 x 8.5 cm. The surface is white to
light pink and nodular. A section of grossly normal fallopian tube is present
(10.5 cm in length and up to 2.0 cm in diameter). Sectioning reveals a cut
surface like fat from specimen number one, with a firm light tan rim of tissue
surrounding a central soft gelatinous tissue with areas of hemorrhage and
multiple firm white nodules. Frozen section 2FA is resubmitted for permanents
in cassette 2FA. Cassette code: 2A - fallopian tube; 2B-2I - representative
sections from right ovary.
Container three is received fresh for frozen section labeled "uterus". The
168 gram uterus is 11.5 cm from fundus to cervix, 6.5 cm from cornu to cornu
and 4.8 cm from anterior to posterior. The cervix is 3.6 cm in length by 2.6
cm with an abundant amount of white mucous. The endometrial cavity is 2.5 x
4.7 cm. The endometrium is 0.1 to 0.2 mm in thickness. The myometrium is tan
and firm throughout without evidence of tumors or other lesions, and is up to
2.3 cm in thickness. The serosal surface is light tan to brown and smooth.
Cassette code: 3A - posterior cervix; 3B - anterior cervix; 3C - fundus; 3D-3F
- representative sections of uterus.
Container four is received fresh for frozen section labeled "stomach - stitch
at proximal margin". The 186.4 gram specimen is 13.9 x 13.4 x 1.4 cm. A
portion of omentum is attached to the specimen (12.5 x 7.4 cm). The mucosal
surface of the stomach is light tan to brown. There are two areas of
ulceration. The first is 5.6 cm from the distal surgical margin and is 1.8 x
0.4 x 0.5 cm. The second area of ulceration is located 6.7 cm from the distal
surgical margin and measures 0.9 x 1.2 x 0.6 cm. Cut sections reveal a very
thick firm white gastric wall up to 1.1 cm thick. The serosal surface of the
stomach is light tan to pink and smooth. Frozen section 4FA is resubmitted in
cassette 4FA for permanents. Frozen section 4FB is resubmitted in cassette
4FB for permanents. Cassette code: 4A - distal surgical margin; 4B-4E -
representative sections from stomach, note 4D and 4E contain areas of mucosal
ulceration; 4F - five possible lymph nodes (0.3 x 0.4 x 0.7-1.2 x 0.6 x 0.3
cm).
Container five received with formalin labeled "appendix" is a 5.1 cm in length
by 1.6 cm in diameter vermiform appendix with moderate amounts of
periappendiceal fat. The surgical margin is inked green and representative
sections are submitted in cassette 5A.
------------------------

SP FROZEN SECTION DIAGNOSIS

Frozen section diagnosis
1FA - "Ovary, left, excision - carcinoma with signet ring cells"
2FA - "Ovary, right, excision - carcinoma with signet ring cells"
3FA - "Gross only"
4FA - "Stomach proximal margin excision - no tumor seen"
------------------------

SP MICROSCOPIC EXAMINATION

Sections from the stomach show two areas of ulceration. Both of these are
associated with poorly differentiated carcinoma. The carcinoma extends
through the muscular wall of the stomach. The tumor shows marked perineural
invasion. The distal and proximal surgical margins of the stomach are free of
neoplasm. Poorly differentiated carcinoma with prominent signet ring cells is
also seen in the left ovary, the right ovary, and the right fallopian tube.
The tumor is also present in the wall of the appendix. The hysterectomy
specimen is unremarkable.
------------------------

SP DIAGNOSIS

1. LEFT OVARY AND TUBE:
OVARY, LEFT, EXCISION - METASTATIC POORLY DIFFERENTIATED CARCINOMA.
FALLOPIAN TUBE, LEFT, EXCISION - NO PATHOLOGIC DIAGNOSIS.
\
2. RIGHT TUBE AND OVARY:
OVARY, RIGHT, EXCISION - METASTATIC POORLY DIFFERENTIATED CARCINOMA.
FALLOPIAN TUBE, RIGHT, EXCISION - METASTATIC POORLY DIFFERENTIATED
CARCINOMA.
\
3. UTERUS:
UTERUS, CERVIX, TAH/BSO - NO PATHOLOGIC DIAGNOSIS.
UTERUS, ENDOMETRIUM, TAH/BSO - INACTIVE PATTERN.
UTERUS, MYOMETRIUM, TAH/BSO - ADENOMYOSIS.
UTERUS, SEROSA, TAH/BSO - NO PATHOLOGIC DIAGNOSIS.
\
4. STOMACH:
STOMACH, GASTRECTOMY - ULCERATION WITH POORLY DIFFERENTIATED CARCINOMA
(T3N1M1).
LYMPH NODES, PERIGASTRIC, EXCISION - METASTATIC CARCINOMA (1/5).
\
5. APPENDIX, EXCISION - METASTATIC POORLY DIFFERENTIATED CARCINOMA.

 

 

 

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Admission H&P 10/30/02

CHIEF COMPLAINT: Referral secondary to pelvic mass and ultrasound revealing a 12 cm mass and a 3 cm mass per patient report.

HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old gravida 8, para 8-0-1-8, who comes in today secondary to referral for pelvic masses. She states six months ago she began noting abdominal bloating that increased over the past one month. In addition, she noted increased abdominal hardness. Six months ago, her bowel movements became looser and darker, although she denies hematochezia, melena, difficulty with urination, or hematuria. She notes no weight change, although occasional nausea and increasing tiredness, positive early satiety, no adenopathy.

She has a history of a crushed sternum while skiing when she was 30 years of age and has noted chest pain since then, although this increased in the past few months. It occurs q.d., lasts for one hour. Two times it
has radiated to her shoulder or her back. No associated diaphoresis, nausea, vomiting. It occurs while she is lying down and not with exertion. Her workup in the past has included several EKGs with all of them being normal, the most recent two years ago.

CURRENT MEDICATIONS: None.

ALLERGIES: Zithromax leads to hives.

PAST GYNECOLOGIC HISTORY: Last Pap smear this past Friday. She did undergo annual Pap smears, although skipped 2001. All have been normal with no abnormalities. Last mammogram last Friday, unknown results. All
mammograms in the past have been normal. Menarche at 13 years of age, regular cycles lasting for seven days. Last menstrual period five months ago with progression prior to her last menstrual period of increasingly
light periods.
PAST OBSTETRICAL HISTORY: Gravida 8, para 8-0-1-8, NSVD at term times eight with one SAB.


PAST MEDICAL HISTORY: Pneumonia three to four times with last episode three years ago, hospitalized for pneumonia treatment. PAST SURGICAL HISTORY: A left leg tumor at 18 that was benign. Foot surgery and hand
surgery.

FAMILY HISTORY: A Wilms tumor in a son that passed away at age 6. Thyroid cancer in a daughter. Mother with heart disease, father with strokes. No uterine, breast, colon, or ovarian cancer.

SOCIAL HISTORY: Married. No alcohol, tobacco, or recreational drugs. REVIEW OF SYSTEMS: No abnormal vaginal bleeding or discharges. Hot flashes times one.

IMAGING DATA: Outside ultrasound: Large right-sided mass with mixed echogenic pattern. Left side also has an abnormal-appearing smaller mass with a mixed echogenic appearance. Increased blood flow noted in right
mass. Uterus 10.2 x 6.1 x 4.3 cm. Right ovary 12.7 x 10.6 x 5.9 cm. Left ovary 6.5 x 5.6 x 5.9 cm. Performed on 10/25/2003.

PHYSICAL EXAMINATION: VITAL SIGNS: Height 170, weight 83.6, blood pressure 115/80, heart rate 80, T-current 37.2. GENERAL: Alert and oriented, well groomed, in no acute distress. CARDIOVASCULAR: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: Clear to auscultation bilaterally. NECK: No adenopathy or thyroid enlargement. GI: Soft, mildly obese, vague fullness in the suprapubic area. Groin: No adenopathy. PELVIC: Normal external genitalia, normal BUS. Speculum exam reveals well-estrogenized vaginal mucosa. The cervix is normal in appearance and parous. Bimanual exam reveals a regular, hard, enlarged mass, approximately 8 x 6 cm, in the midline that is mobile, mildly tender. Rectovaginal septum is free of disease.

ASSESSMENT AND PLAN:
A 53-year-old gravida 8, para 8-0-1-8, with bilateral pelvic masses and increasing chest pain of unknown etiology.

1. Preoperative workup. The patient is sent today for a chest x-ray, PA and lateral, a 12-lead EKG, a CBC with platelets, complete metabolic panel, PT, PTT, CA-125, CEA, and urine dip beta-HCG. In addition, she
has been scheduled for a stress echo through Cardiology on 10/31/2003.
2. Preoperative appointment. A preoperative appointment is scheduled 11/04/20033 to clear the patient for surgery. Stress echo to be obtained as above tomorrow, in addition to the chest x-ray to evaluate possible heart disease/worsening/unstable angina.
3. Pelvic masses. Labs as above, in addition to repeat ultrasound today in Radiology.
4. Surgery. The patient is scheduled for surgery for exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, staging/debulking, possible bowel resection, and reanastomosis. Risks, benefits, alternatives, and indications of the procedure were discussed with the patient and consent obtained.

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Operation Report   11/05/02

PREOPERATIVE DIAGNOSIS:       Ovarian mass.
POSTOPERATIVE DIAGNOSIS:      Metastatic gastric adenocarcinoma.

PROCEDURE PERFORMED:     1. Total abdominal hysterectomy and
                            bilateral salpingo-oophorectomy
                            performed by OB/GYN.
                         2. Subtotal gastrectomy with Billroth II
                            gastrojejunostomy performed by general surgery.
                         3. Appendectomy.

ANESTHESIA:              General anesthesia with endotracheal
                         intubation and spinal anesthesia.

INDICATIONS: The is a 53-year-old woman who was found to have bilateral ovarian masses. For this reason she was taken to the operating room today for an exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy. Intraoperative findings revealed massive bilateral ovaries. Bilateral adnexal masses, approximately 15 cm in greatest dimension and normal CA-125 and CEA. The patient underwent laparotomy revealing a right ovarian mass approximately 15 x 18 cm which was lobulated and solid, white and fibrous. The left ovary also had a 6 x 8 cm tumor. The uterus was normal sized. The ovaries, once removed, showed signet ring carcinoma, consistent with the GI primary, specifically gastric primary.

Upon extension of the incision, better palpation and inspection of the stomach, revealed approximately an 8 x 4 cm thickened greater curvature in the antrum of the stomach. This was consistent with a stomach primary
and the General Surgical Service was consulted intraoperatively.


The remainder of the abdomen was otherwise without evidence of intraperitoneal disease. A 1 cm node in the right para-aortic region was soft noted, but not suspicious. The remainder of the lymph nodes were not enlarged in the pelvis and the aortic area. Intraoperative pathology evaluation of these lesions revealed them to contain metastatic adenocarcinoma with signet-ring cell morphology consistent with metastatic gastric adenocarcinoma. For this reason the abdomen was thoroughly explored. There was appreciated a large antral mass involving the stomach. This mass was highly suspicious for adenocarcinoma of the stomach and consistent with the potential source of the patient's metastatic ovarian lesions.


The patient was found to have an incidentally found large antral mass involving the distal stomach that was freely mobile and eminently resectable. The patient had a near obstructing lesion involving the distal stomach and had the potential for significant gastrointestinal bleeding from this lesion. In addition, this
represented our only focus of disease. For this reason we felt it would be reasonable to proceed with resection should the family agree so. We went out and had a very extensive discussion with the patient's husband and, after explaining to him the situation, he strongly agreed that we needed to proceed with distal gastrectomy stating that he felt that this was what the patient would want also. For this reason we proceeded with this operation without obtaining informed consent.

FINDINGS: 1) Approximately 6 x 4 cm mass involving the antrum of the stomach just proximal to the pylorus but limited to the antrum of the stomach. 2) No evidence of suspicious periaortic, celiac, or other adenopathy within the abdomen. 3) No other evidence of intra-abdominal carcinoma. 4) Indurated, firm, enlarged appendix.

Condition good to the recovery room. Complications none.

Specimens: 1) Stomach to pathology. 2) Appendix to pathology.

Estimated blood loss was 50 cc.

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Discharge Summary

Discharge Summary         Adm Date:   11/05/03
                         Disc Date:   11/13/03
REASON FOR ADMISSION:
The patient is a 53-year-old female referred with a pelvic mass and a pelvic ultrasound that revealed a
12 cm mass on one ovary and a 3 cm mass on the other, according to the patient.

HISTORY: She is a 53-year-old, gravida 8, para 8, who secondary to this referral. She reported that six months prior to being evaluated on 10/30/2003, she began noting some abdominal bloating that had increased over the past month. She also felt that she noticed some increasing abdominal firmness. Approximately six months ago, her bowel movements became looser and darker, although she denied any melena, hematochezia, any dysuria, or hematuria. She also denied no weight change, although she has had occasional nausea, increasing
fatigue, and some early satiety. She was, therefore, scheduled to undergo an exploratory laparotomy with a total abdominal hysterectomy and bilateral salpingo-oophorectomy with staging, debulking, and possible
bowel resection and reanastomosis, depending on the pathology of these masses.

PAST MEDICAL HISTORY: 1. Crushed sternum while skiing when she was 30 years old and has had occasional chest pain since then. 2. Pneumonia times four, the last episode three years ago. 3. Eight pregnancies and eight births. She continues to have normal menstrual periods. She has had normal mammograms and normal Pap smears with the exception of her Pap smear skipped in 2001.

PAST SURGICAL HISTORY: 1. Tumor of her left leg that was removed at the age of 18 and was benign. 2. She has also had some foot surgery and hand surgery in the past.

MEDICATIONS: She is taking no medications.

ALLERGIES: She has a medication allergy to Zithromax which causes hives.


SOCIAL HISTORY: She is married with again eight children, the youngest which is 9. She denied any alcohol, tobacco, or illicit drug use.

REVIEW OF SYSTEMS: She denied any abnormal vaginal bleeding or discharge. Otherwise, review of systems is as noted above.

The outside ultrasound revealed a large right-sided mass and a smaller mass on the left ovary. The right mass was estimated to be approximately 12.5 x 10 x 6 cm. The left mass was 6 x 5 x 6 cm.

PHYSICAL EXAMINATION: VITAL SIGNS: She had a weight of 84 kilograms. Her blood pressure was 115/80, heart rate 80, and temperature 37.6.

GENERAL: She is a very alert, oriented, pleasant female in no acute distress. HEENT: Her pupils were equal, round, and reactive. Her sclerae were nonicteric. Her EOMs were intact. Her mucous membranes were pink and moist. NECK: Supple with no adenopathy or thyromegaly. LUNGS: Clear to auscultation bilaterally. HEART: Rate and regular were regular with no gallops, murmurs, or rubs. ABDOMEN: Soft and mildly obese with a vague fullness in the suprapubic area. She had no obvious femoral adenopathy bilaterally. PELVIC: was normal. Her bimanual exam revealed an irregular, hard, enlarged mass approximately 8 x 6 cm in the midline that was mobile and mildly tender.

HOSPITAL COURSE: Again, she was, therefore, scheduled to undergo exploratory laparotomy, TAH, and BSO. She was taken to the operating room on 11/05/2003. Intraoperatively, a specimen of one of these ovarian
masses revealed gastric adenocarcinoma. Therefore a general surgeon was consulted and entered the operating room to further assist in management of this unexpected finding. The patient's husband gave permission to
proceed to further explore her abdomen and look for and resect a gastric tumor. These masses bilaterally on her ovaries were found to be metastatic gastric CA. She also had an appendiceal mass. A subtotal gastrectomy with a Billroth II reanastomosis and also an appendectomy were performed in addition to the TAH-BSO as previously planned.

The patient had no intraoperative complications and was taken to the recovery room in stable condition. She was then transferred to the floor where she remained stable.

Her postoperative course was unremarkable. She began taking p.o. liquids when she began passing flatus on postoperative day six and tolerated this and was advanced to a post-gastrectomy diet. Her pain was controlled on an IV PCA until postoperative day seven when she was switched to oral Lortab. She was also given Vioxx q.d. for additional pain control. She had an epidural infusion early on with her PCA that also aided in her pain control in the immediate postoperative period. Again, the patient had no postoperative complications. Her wound continued to heal well, and her staples were removed on the day of discharge, postoperative day eight. She advanced to tolerating adequate amounts of liquids and p.o. intake. Her pain was controlled with Lortab and Vioxx, and she was ambulating well.

DISPOSITION: She will follow up with her OB/GYN in six weeks. She will follow up with the general surgeon in one week for postoperative evaluation. She was given continued wound care instructions. DISCHARGE MEDICATIONS: Vioxx 25 mg p.o. q.d. p.r.n. for pain, #30; Lortab 7.5 mg one to two p.o. q.4-6h. p.r.n. pain, #40. Activity: She was encouraged to continue ambulating, coughing, and deep breathing. She has an abdominal binder that she feels aids in her comfort while ambulating. She was cautioned to avoid any heavy lifting
greater than 20 to 30 pounds over the next four to six weeks. She was instructed to take an over-the-counter stool softener or Milk of Magnesia should she have difficulty with constipation following discharge from the
hospital from her narcotic use.

 

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Oncology Evaluation 11-26-03

 

IDENTIFYING INFORMATION
The patient is a 53-year-old woman with a recently resected stage IV gastric carcinoma who is referred to the Oncology Division for an opinion regarding the need for postoperative therapy. The history is obtained from the patient, her husband, and Hospital records.

HISTORY OF PRESENT ILLNESS   

This summer, she noted that she was "pudgy". When she was up against a cupboard, she noted that her abdomen was firm. She saw her gynecologist who detected a pelvic mass, concerning for an ovarian cancer.
Bilateral adnexal masses measuring 15 cm in the greatest dimension were noted. A CA-125 and CEA were normal.   

On November 5, an exploratory laparotomy revealed a 15 x 18 cm right-sided ovarian mass as well as a 6.0 x 8.0 cm left ovarian mass. The uterus appeared normal. Biopsy showed a signet ring carcinoma consistent with a GI primary. An 8.0 x 4.0 cm thickening in the greater curvature of the antrum was suggestive of a gastric primary.

A subtotal gastrectomy and appendectomy were performed. She recovered from surgery without difficulty, and her presurgical symptoms have resolved.

The pathology revealed a poorly differentiated carcinoma extending through the muscular wall of the stomach. There was perineural invasion. The proximal distal surgical margins were free, and signet ring cells were evident. One of five resected perigastric lymph nodes contained cancer. The appendix, both ovaries and both fallopian tubes contained metastatic poorly differentiated carcinoma. The uterus contained no cancer. The final stage was stage IV (T3 N1 M1).

She was presented at the Multidisciplinary Tumor Conference, where a discussion regarding the potential role of postoperative chemo/radiotherapy was discussed prompting this referral.

At the moment, she is feeling better. Her abdominal distension has improved, and she has had minimal difficulties after surgery. She has had no evidence of infection or bleeding, and no palpable abnormalities have been detected.

PAST MEDICAL HISTORY   

Surgeries:   

1. Removal, lower left leg benign tumor, 1967.
2. Left foot bunion surgery, 1994.
3. Repair, broken left hand, 1996.
4. Exploratory laparotomy with hysterectomy, appendectomy, bilateral salpingo-oophorectomy, and antrectomy, 2002.
5. Tonsillectomy.

Medical Illnesses: Pneumonia requiring hospitalization in 1988 and in 1997.

Injuries: She once had a crushed sternum in a skiing injury,

OB/GYN: She has had eight pregnancies and one miscarriage. She has eight children, and she has delivered twins.


Childhood Illnesses: No history of polio or rheumatic fever.

Allergies: She has had hives after azithromycin.   

Current Medications: Reglan, 1-2 tablets per day.

Habits: She does not use tobacco or alcohol. She wears seat belts. Before the events noted above, she walked two miles per day.

FAMILY HISTORY   

Her father died at age 74 of a stroke and her mother died at age 72 of a heart attack. She believes both of them may have had a malignancy, though the type is not known. She has four brothers and one sister who are alive and well. She had eight children (including 31-year-old twins). One son died at age 6 of a Wilm's tumor. A daughter, now 31, has recovered from thyroid cancer.

SOCIAL HISTORY   

She has been married to her current husband for 15 years. They have two genetic children together, and between the two of them, there are a total of 11 children. She is self-employed, cleaning model homes. Despite the disastrous events noted above, she notes she feels "at peace".
     
REVIEW OF SYSTEMS   

General: Negative except as noted in History of Present Illness.   
Skin: She notes some itching on her back at the site of an epidural anesthetic.
HEENT: She wears corrective lenses.   
Respiratory: She has noted occasional shortness of breath, but this has not changed of late.   
Cardiovascular: Because of vague chest discomfort, probably related to her previous crushed sternum, she had an echocardiogram done last month and this was normal.   
GI: See History of Present Illness. She has had some diarrhea since her surgery.
GU: Negative.   
Musculoskeletal: Negative.   
Neurologic: She has occasional dizziness when standing.
GYN: See History of Present Illness.

PHYSICAL EXAMINATION

General: She is a well-appearing woman who does not look acutely or chronically ill. She is articulate and intelligent.
Vital Signs: Weight is 75.7 kg, height 170 cm, temperature 37.1C, blood pressure 104/52, pulse 69, and respirations 14.
Skin: No suspicious lesions are seen.
Head: Normocephalic/atraumatic.
Eyes: The sclerae are non-icteric and the pupils respond appropriately to light. A funduscopic exam is benign.
Ears: The tympanic membranes are intact.
Nose/Mouth: No suspicious lesions are seen.
Neck: The thyroid is normal in size and the trachea is midline.
Lymphatic: There is no palpable lymphadenopathy.
Chest: The diaphragm descends symmetrically and the lung fields are clear to auscultation and percussion.
Breasts: Not examined.
Cardiovascular: The heart rate is regular. S1 and S2 are normal. There are no murmurs, rubs, clicks, or gallops.
Abdomen: Her incision is well healed. Her abdomen is soft and non-tender. There is no hepatosplenomegaly and there are no palpable abdominal masses.
Pelvic: Not examined.
Extremities: There is no peripheral edema.   
Neurologic exam: The mental status is normal. Cranial nerves II-XII are intact. The screening exam of the motor, sensory, and cerebellar systems is normal. The reflexes are 3+ and symmetric.

ASSESSMENT     

Poorly differentiated gastric carcinoma, stage IV (T3 N1 M1).

She presented with bilateral Krukenberg tumors. Ovarian carcinoma was suspected, but at the time of surgery, when the frozen section suggested otherwise, a primary gastric tumor was found. All disease has been resected, and the surgical margins are clear of disease. Still, she has metastatic disease to both ovaries, both fallopian tubes, and to the appendix. It stretches credibility to assume that she has had a curative resection. Her symptoms have improved since her surgery.

At the tumor conference, we talked about the pro's and con's of further therapy. Two disparate options were discussed. One option would be to offer no therapy as she is asymptomatic and no curative therapy for stage IV gastric cancer exists. The other option would be to be very aggressive considering her relative youth. This aggression would build on data published in the September 2001 New England Journal of Medicine suggesting that chemo and radiotherapy after curative resection of adenocarcinoma of stomach improves overall survival. In this study, no patients had metastatic disease. To draw the parallel, one would have to consider whole abdominal radiotherapy and its prohibitive toxicity.

I had a prolonged discussion with the patient and her husband regarding these different approaches. I also pointed out that as of yet, she had not yet been completely staged, and the possibility of, as of yet, undetected metastatic disease is possible.

PLAN   

I suggested that we perform scans of the thorax, abdomen, and pelvis in about two weeks. This will help complete her staging, as well as define her postoperative anatomy. They will consider the different approaches we have discussed, and we will go over them again when she returns.

 

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History and Physical 9-17-04:

I.D. & Chief Complaint:  The Patient is a 54-year-old woman who has a history of Stage IV gastric cancer who presents with difficulty eating secondary to efferent limb obstruction of her gastrojejunostomy. 

 

History of Present Illness:  The patient is a 54-year-old woman who in November of 2003 underwent exploratory laparotomy for presumed ovarian pathology.  She was found to have metastatic gastric cancer.  She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, subtotal gastrectomy with Billroth II gastrojejunostomy and appendectomy.  Pathology revealed a T3 N1 M1 adenocarcinoma of the stomach with metastatic disease both to her ovaries and appendix.  At that time she also had suspicious retroperitoneal adenopathy.  She recovered uneventfully and was discharged under the care of Dr. Oncologist from Medical Oncology.  No further treatment was given as the patient suffered from Stage IV disease and was clinically asymptomatic.  She has been followed since this time for disease progression.  She's undergone multiple CAT scans of both her chest, abdomen and pelvis that have failed to demonstrate disease progression.  Her most recent MRI scan, dated August of 2004, revealed no disease progression.  In fact, the MRI of the abdomen suggested the liver lesions previously presumed to be metastatic disease are that of simple cysts. 

 

Unfortunately, patient has developed symptoms of gastric outlet obstruction.  She did remarkably well from her initial surgery for approximately 6-7 months.  Over the last several months she has developed progressive difficulty eating.  She has been evaluated by multiple upper gastrointestinal radiographic procedures and endoscopies.  There have not been demonstrated to be evidence of recurrent disease at her gastrojejunostomy.  She has benign appearing stricture of her gastrojejunostomy.  This has been dilated on occasion with transient improvement in her symptoms.  Her most recent radiographic study in August suggested a possible gastric outlet obstruction or efferent limb syndrome.  There is no evidence of distal obstruction. 

 

Patient has been placed on nasoenteric tube feeds, which has resulted in an arrest of her weight loss and failure.  She's actually, clinically, feeling quite well.  She is considerably troubled by the presence of the nasoenteric feeding tube with regard to symptoms involving her ear, sinuses and throat pain.  She also awakens at nighttime with difficulty breathing because of the presence in the tube in her throat.  She has presented to me for consideration of surgical jejunostomy and evaluation as the cause of her difficulties eating. 

 

Past Medical History:     Significant for sternal trauma from a skiing accident.  She has a history of previous pneumonia.  She has a history of multiple normal pregnancies. 

 

Past Surgical History:     Number one; as above.  Number two; benign left leg tumor.  Number three; foot surgery and hand surgery in the past.

 

Medications:  She is allergic to Zithromax and is currently not taking any medications.

 

Social History:  Significant for the fact that she is married with eight children.  She denies alcohol, tobacco or drug use.

 

Review of Systems:  Constitutional symptoms; none.  Eyes; none.  Ears, nose and throat; none.  Heart; none.  Lungs; none.  Stomach and intestines; none.  Kidneys and bladder; none.  Musculoskeletal review; none.  Skin; none.  Brains and Nerves; none.  Glands; none.  Breasts; none.

 

Physical Examination:  On physical examination she is a well-developed, well-nourished woman in no apparent distress.  She weighs 111 pounds.  Her temperature is 98.3 degrees.  Her blood pressure is 80/50 and her heart rate was 86.  Her HEENT exam reveals a normocephalic atraumatic cranium.  Her extraocular movements are intact.  Her mucus membranes are pink and moist without lesions.  Her neck is supple with a midline trachea and no palpable adenopathy.  Her chest is clear to auscultation.  Her cardiac exam is regular rate and rhythm.  Her back is without costovertebral angle tenderness.  Her abdominal exam reveals a well healed incision without evidence of hernia.  She has no palpable hernias.  She has no hepatosplenomegaly and no palpable masses.  Her groin exam reveals no hernias.  Her genitourinary and rectal exams were deferred.  Her extremities were without cyanosis, clubbing or edema.  Neurologically she is intact to both motor and sensation. 

 

Summary:

The Patient is a 54-year-old woman with a history of Stage IV gastric cancer diagnosed 9 months ago.  She presents with symptoms of gastric outlet obstruction or efferent limb syndrome.  This is presumably secondary to anastomotic stricturing of her previous Billroth II gastrojejunostomy.  This has necessitated placement of a nasoenteric feeding tube for enteral nutrition.  She presents for further evaluation as the cause of her upper gastrointestinal symptoms, as well as consideration of surgical jejunostomy. 

 

Patient suffers from Stage IV gastric cancer.  At this time, she has no radiographic evidence of progressive disease.  This has been well documented over the last several months with multiple CAT scans and most recently an MRI scan.  She does not have evidence of an anastomotic recurrence, as measured by endoscopy in the last two months.  She has not been treated for metastatic gastric cancer with adjuvant chemotherapy or radiation treatment.

 

At this time, it is difficult to ascertain whether her failure to thrive is a function of progression of her disease that is not apparent radiographically or a benign stricture of her gastrojejunostomy.  Regardless of the etiology, her symptoms have progressed to the point that she requires entero nutrition.  For this reason, I do think it's reasonable to consider her for placement of a surgical jejunostomy.  I have purposed to her a plan of diagnostic laparoscopy to stage her disease and to ascertain the extent of disease progression.  If technically feasible and safe, a surgical jejunostomy would then be performed. 

 

The principal issue then remains whether or not her gastrojejunal anastomotic issues are those of recurrent cancer or of a more benign behaving but disabling gastrojejunal anastomotic stricture.  With this in mind, I have presented the patient the option of surgical revision of her Billroth II two way roux-en-y gastrojejunostomy in the event that she does not have any evidence of significant disease burden within her abdomen.  We've discussed this now on at least three occasions with her family present.  I've told them that this represents a significant operation especially in the setting of metastatic gastric cancer.  However, if it were technically feasible and safe it could mean the difference between her eating and not eating.  If we could revise this anastomosis with sufficiently low morbidity we could dramatically improve her quality of life.  I've mentioned to her that this would only seem reasonable if her disease burden were marginal at best.  Clearly, if she had metastatic disease locally present within the upper abdomen this would not be technically wise.  With this in mind, I have offered to her surgical revision at the same setting as diagnostic laparoscopy and placement of a surgical feeding tube. 

 

The nature of her problem, as well as the rationale, risks and alternatives to this treatment plan were discussed with both she and several family members including her husband and they have agreed to proceed.  They have been given ample opportunity to discuss this treatment plan and to consider the alternatives to treatment.  After having a period of time for discussion and having their questions answered they wish to proceed.   She will be scheduled for surgery within the next week or two. 

 

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Operative Report 9-26-04:

 

PREOPERATIVE DIAGNOSIS:       Stage IV gastric cancer.

POSTOPERATIVE DIAGNOSIS:      Same.

 

OPERATION PERFORMED:          1.  Diagnostic laparoscopy.

                              2.  Feeding jejunostomy.

 

ANESTHESIA:                   General with endotracheal intubation.

 

COMPLICATIONS:  None.  SPECIMENS:  None.  SPONGE AND NEEDLE COUNT:

Correct times two.  ESTIMATED BLOOD LOSS:  Approximately 15 cc.

 

INDICATIONS:  Patient is a 54-year-old woman who 10 months ago underwent an exploratory laparotomy for metastatic gastric cancer.  She did well for approximately seven months, and over the last few months had developed symptoms of gastric outlet obstruction.  This had progressed to the point that she was unable to eat or drink.  She was requiring enteral tube feeds to maintain nutritional support and had failure to thrive.  Radiographic studies failed to demonstrate a progression of her disease.  She was advised that she could likely suffer from an efferent outlet obstruction or progression of her disease.

 

We recommended to her a plan of diagnostic laparoscopy to better stage her disease and assess whether or not she would be a candidate for revision of her gastrojejunostomy to a Roux-en-Y gastrojejunostomy with the hopes of alleviating her efferent outlet obstruction.  The nature of her problem, as well as the rational risks and alternatives to this treatment plan were discussed with her and her family on several occasions, and they agreed to proceed after offering written informed consent.

 

FINDINGS:  Extensive carcinomatosis involving visceral and parietal peritoneal surfaces.  She had a large tumor mass occupying the omentum and transverse colon in the vicinity of her gastrojejunostomy likely serving as the cause of her efferent outlet obstruction.  Because of the extent of her disease, she was not felt to be a candidate for revision of her gastrojejunostomy, and for this reason a feeding jejunostomy was performed.

 

PROCEDURE:  The patient was brought to the operating suite where she was placed under general anesthesia with endotracheal intubation.  Her abdomen was then prepped and draped in the usual sterile fashion.

 

We gained access to the abdomen by an open technique through a 10-mm incision centered in the left mid abdomen.  Through this, a 10-mm trocar was placed, and the abdomen was inspected and found to contain no evidence of hollow viscus injury.  Two additional 5-mm working ports were then placed under direct visualization into the peritoneal cavity.

 

We then thoroughly explored the abdomen.  Of note, there was extensive carcinomatosis involving both visceral and parietal peritoneal surfaces.  Most of these nodules were not more than 5 mm to 1 cm in size, but nevertheless involved both the hollow visceral peritoneum and the parietal peritoneal surfaces.  In addition, there was extensive omental involvement and tumor caking on the inferior aspect of her incision.  There was a large firm mass in the vicinity of the gastrojejunostomy, likely contributing to her gastric outlet obstruction.

 

Because of the extensive nature of her disease and per discretion with both the patient and the family preoperatively, we elected to not proceed with revision of her gastrojejunostomy, but rather to place a feeding jejunostomy.

 

The small bowel seen emanating from the gastrojejunostomy was grasped with a 5-mm grasper and a 10-mm trocar site was incised 4 cm in length.  We then placed a feeding jejunostomy through a separate stab incision in the abdominal wall and into the small bowel in a tunneled Witzel type fashion.  The small bowel was then anchored to the parietal peritoneum with several #3-0 silk pop-offs to prevent axial rotation on the axis of the feeding tube.  The feeding tube was secured in place with a #2-0 nylon suture.

 

The peritoneum was closed with a #3-0 Vicryl, and the fascial defect was closed with an #0 PDS.  Interrupted Vicryl was used to reapproximate Scarpa's fascia, and a #4-0 Monocryl subcuticular stitch was used to close the skin as well as closing the skin of the two 5-mm trocar sites.  The patient was then extubated and brought to the recovery room in satisfactory condition.

 

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Discharge Summary 9-27-04:

Status post jejunostomy tube placement.

 

HISTORY:  The patient is a 54-year-old female with a history of stage IV gastric cancer who had difficulty eating secondary to efferent obstruction of her gastrojejunostomy.  On repeat MRIs there was no demonstration of progression of her disease, however, the patient developed symptoms of gastric outlet obstruction since her initial surgery six to seven months ago.  She had progressive difficulty eating, with vomiting about every 36 hours and so a Dobbhoff tube was placed.  She was unable to tolerate the Dobbhoff tube and requested to have a surgical jejunostomy and possible revision of her gastrojejunostomy in hope that there was just an anastomotic stricturing.

 

HOSPITAL COURSE:  On the date of proposed surgery, the patient had a preoperative potassium of 2.8.  Surgery was delayed and the patient received a total of 80 mg IV potassium and 40 mg p.o. potassium.  On the next morning, the patient's potassium was 3.5 and we proceeded to OR for surgery.  Upon laparoscopy, the patient had carcinomatosis and it was decided to proceed with a jejunostomy tube placement without revising the previous gastrojejunostomy anastomosis.  The patient tolerated the procedure well and on postoperative day one, the patient was started on Promote tube feeds at 20 ml/hr with ramping to 70 ml/hr times 24 hours per Nutrition's recommendations. The patient, per Nutrition, needed to have 1750 kcals per day and a tube feed schedule was proposed.  The patient was ready for discharge, tolerating her tube feeds at 60 ml/hr the entire day.

 

DISPOSITION:  The patient was discharged to home with Home Health Service to come to see her.  She is on J-tube feeding at 70 ml/hr times 24 hours and then will increase. 

 

DISCHARGE MEDICATIONS:  She was also given Tylenol either 650 mg p.r. or crushed and put down her J-tube q.4h. for pain. She is to follow up in one week.  She was sent home with supplies.  She was instructed to call a physician if she experienced increased pain, discharge, or bleeding from her incision site, or other problems.  It was also discussed whether to begin her on octreotide to reduce her gastric secretions because she is currently vomiting them every 36 hours.  However, it requires twice a day IV dosages to find the correct dose before it can be switched to once a month IV injection.  This can be discussed at the next appointment.

 

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Post Operative office visit 10-7-04:

Patient is doing well.  She's gained about 5 pounds since discharge.  She is giving herself tube feeds at nighttime and is trying to supplement her diet, as best she can, orally during the day.  Her tube appears secure.  She's had a variety of questions that have been answered today.  I've asked her to follow up in three weeks.  I've encouraged her to try and eat. 

 

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Post Operative office visit 10-28-04:

Patient presents today for continued care.  She's had evolving problems with nausea and vomiting.  She's also having some difficulties with abdominal bloating and pain related to her tube feeds.  Her blood pressure today is 85/51 with a heart rate of 100.  Her weight is down to 101 pounds.  It is clear that patient is approaching a terminal state with regard to her wide spread metastatic gastric cancer.  We've had an extensive discussion with her today with regard to instituting Hospice type care.  After this discussion we've come up with the following plan.  We will first place an indwelling catheter for intravenous fluids.  We will arrange, with the assistance of our Social Services, to have the Home Health people come and give her a liter or two of fluid a day.  This will also allow us access for intravenous antiemetics.  In addition, we will encourage her to continue on with her tube feeds.  We will also arrange for her to be visited by the Home Hospice people for a home assessment.  This will be, at the very least, to initiate discussions with she and her family about end of life issues.  We've spent a great deal of time with patient today discussing these and she agrees with this plan.  We will also check her electrolytes to make sure her potassium does not need to be addressed. 

 

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