CASE PRESENTATION AND DISCUSSION ON ABDOMINAL MASS

OLIVER S.LEYSON

Surgery Resident

Department Of Surgery

Ospital Ng Maynila Medical Center

General Data

      6 mos, female from Sta Ana Manila

Chief Complaint

      Abdominal Mass

History of Present Illness

4 mos PTA -------------------------à    mother noted abdominal enlargement with               

                                                            abdominal mass, no change in bowel habits

                                                           (-) vomiting.  No consult done

                                                           No medications taken

                                                           no other symptom noted

2 weeks PTA ----------------------à   progression of abdominal   

                                                          enlargement,  poor suck,

                                                          Prompted  consult at private MD

                                                          advised consult OMMC

1 day PTA -----------------------  à   persistence of abdominal enlargement,

                                                          associated with vomiting refusal to feed                                                                          prompted consult OMMC

                                    Admitted

Past Medical History

      No previous hospitalization

Family History

      Unremarkable

Personal Social History

Gestation: patient was born to a 26 yo G1P1

            (+) prenatal check up at health center

            (+) intake of Multivitamins and Ferrous sulfate

            (-) maternal illness     (-) exposure to radiation

            (-) intake of teratogenic drugs

Delivery: delivered term via NSD at OMMC

            (-) fetomaternal complication

Neonatal- good suck, good cry, no retractions, no jaundice.

Immunization-  (+) BCG, (+) DPT2 (+) OPV2

Feeding-  Breastfed since birth up to present

Growth and development-  at par of age

Physical Examination

General: Awake, comfortable, poorly-nourished, fairly developed, not in cardio-

              respiratory distress

CR: 126/min RR: 40/min  T: 36.7C   BW: 6kgs

HC: 42 cms CC: 40 cm  AC: 48 cm  BL: 64 cm

HEENT: normocephalic, pink palpebral conjunctiva anicteric sclerae, (-) NAD

Chest and Lungs: Symmetrical chest expansion, no retraction,clear breath sounds.

Heart: Good heart tone,  normal rate regular rhythm no murmrur.

Abdomen: Globular, tensed shiny, bulging flank mass extendingto the anterior the

                 abdominal wall right measuring 10 x 10 cm solid, non hard, firm, non-

                 movable, non tender,

Extremities: grossly normal full equal pulses

Rectal Exam: no skin tags, no fissures, good sphincteric tone, no mass, no tenderness,

                       no bleeding, with yellowish stool on examining finger.

Salient Features       

-         6 mos old/ Female

-         gradually enlarging abdominal mass ( 6 mos duration)

-         abdominal mass 10x10cm, firm, non hard, non-movable extending to the right anterior abdominal wall

-         No change in bowel habits

-         Asymptomatic

-         Female

Algorithm for abdominal mass

Abdominal Mass

                      Extra-abdominal                           Intra-abdominal

                                                   Retroperitoneal                             Intraperitoneal

Clinical Diagnosis

Paraclinical diagnostic procedure:

•         Do I need a paraclinical diagnostic procedure?

•         Yes, because I’m not yet certain of my primary clinical diagnosis.

Goal

•         Identify the organ of origin and the extent of the tumor

PARACLINICAL DIAGNOSTIC PROCEDURE

            I have chosen CT scan of the abdomen as the procedure that would increase my degree of  certainty of my primary clinical diagnosis, because it can demonstrate the organ involved and the extent of the tumor comparable and cheeper than MRI and more sensitivity than that with the x-ray.  Ct scan is the most cost effective procedure for this patient

CT Scan result:

      Huge homogenous soft tissue mass

      Occupying the Right hemiabdomen and extends to the left

      displacing the bowels contralaterally and inferiorly.

      The liver is displaced superiorly and anteriorly

      Cystic component located inferior portion and measures about 10 x9 cm

      Both kidneys are functioning, displaced inferiorly more at the right, no hydronehprosis.   Spleen unremarkable, filled bowels compressed towards the left

Impression: Mass is retroperitoneal in location extra-renal, extra-hepatic

Retroperitoneal Mass

            Wilms Tumor                            Neuroblastoma             Teratoma

            We can readily rule out Wilms Tumor here in the CT scan result because of the extra renal in origin of the tumor.  Neuroblastoma cannot be totally ruled out because it’s the most common solid tumor in children, we can therefore say that with 90% degree of certainty the patient has teratoma.

Clinical Diagnosis

PARACLINICAL DIAGNOSTIC PROCEDURE:

•         The CT Scan  increased my degree of certainty to 90 % basing my decision both on pattern recognition and prevalence so I do not need further a paraclinical diagnostic procedure.

Pre Treatment  Diagnosis

            · Since the treatment to both of my primary and secondary clinical diagnosis are relatively the same, I will proceed now to Treatment Option.

Preoperative treatment goals

Complete extirpation of mass

Achieve locoregional and systemic control of the tumor

Treatment Options

            The most cost effective treatment surgical with chemotheraphy option because it achieves our goal of extirpation of the mass and locoregional and systemic control of the tumor.

Pre-op preparation

•          Informed consent                                                                                           

•          Psychosocial  support

•          Optimize patient’s health

            1. Maintain orogastric tube to decompress the stomach

            2. Adequate fluid resuscitation to correct hypovolemia & electrolyte                                  abnormalities

            3.  Preoperative antibiotics                          

•          Screen for any condition that will interfere with treatment

Operative technique

      Patient lying supine under GA

      Asepsis / antisepsis done

      Sterile drapes placed

      A transverse incision done up to the peritoneum

      Intra-operative findings noted

      Incision extended up to left upper quadrant

      Sharp & blunt dissection of the mass from the subhepatic area

       Transverse colon and duodenum dissected from the mass.

       Dissection carried up to the retroperitoneal area with electrocautery.

      Feeding vessels clamped and ligated

      Complete excision of mass

      complete gauze and instrument count

       colon reperitonealized

       abdominal closure

                              - Posterior rectus sheath with Vicryl 2.0

                              - Anterior rectus sheath with Vicryl 2.0

                              - Skin with Vicryl 5.0

      Dry sterile dressing

Intraoperative findings

      20 x 15 x 15 cm cystic mass with solid components noted at subhepatic area extending to the splenic flexure

      Mass was noted adherent to the transverse colon and to the right of the duodenum.

      It extends to the medial side of the right kidney.

        Mass weighed 2 kgs.

        On cut section we noted 500 cc of straw colored fluid which is loculated.

      Solid areas heterogenous with some fleshy and some fatty .area

Operation performed

Laparotomy, excision

Final Diagnosis

Retroperitoneal Teratoma

Histopathologic Diagnosis

Immature Teratoma Grade II

Post op Management:

•         Maintained on NPO

•         Adequate analgesia given

•         Antibiotics continued

•         Adequate pulmonary support

•         Monitoring of early complications

•         Start early Feeding as soon as the patient started to soil

•         Daily wound care given

•         Antibiotics given

Follow up plan

•         Continue medications at home

•         Continue daily wound care

•         Follow up after a week for start of chemotheraphy ( 6 cycles)

–        Bleomycin

–        Carboplatin

–        Etoposide

Aftermath of the patient

•         Achieved the following:

–        Resolution abdominal mass

–        Improved patients condition

–        Happy and contented with the outcome

–        No medicolegal suit