Cancer Information Management

GYN Case 3 (Diagnosed and all treatment at the reporting facility)

X-Rays & Scans

01/17/2022 CT Abd/Pelvis/Chest: Small to moderate right pleural effusion with right lower lobe segment atelectasis. Mild to moderate ascites. Pericardial effusion. 22 x 10 cm fluid filled mass/cyst anterolateral aspect of liver. 10 cm left adnexal mass, possibly arising from the ovary, with numerous enlarged retroperitoneal lymph nodes, largest focus, worrisome for ovarian carcinoma with involvement of regional lymph nodes.

Laboratory Studies

01/18/2022 CA 125: 1258, elevated

Cytology

01/19/2022 FNA RLL: Pleural fluid: No malignant cells seen.

Surgery

06/14/2022 Surgery: BSO, hysterectomy, omentectomy; repair of umbilical hernia.

Operative Findings: Minimal disease in abdomen. Uterus slightly enlarged. Left ovary abnormal, consistent with cancer. No significant ascites is noted.

Pathological Reports

06/14/2022

Left ovary/Left fallopian tube: Serous carcinoma, grade 2, 7.8 cm, arising from ovary and extending to surface of fallopian tube. Right ovary/Right fallopian tube: negative. Uterus: negative. Omentum: negative. 0/2 pelvic lymph nodes positive and 1/2 para-aortic lymph nodes positive, 1.1 cm largest metastatic nodal deposit. No lymphovascular invasion. No malignant cells in ascites.

Discharge date: 06/17/2022

Outpatient Chemotherapy

07/08/2022 – 9/09/2022 (Hospital infusion center)

Chemotherapy: Carboplatin/Taxol.

Medical Oncologist Office Note

10/15/2022: Patient is status post hysterectomy and chemotherapy for ovarian cancer. Recent CT showed no abnormalities in chest, abdomen or pelvis. Patient has no evidence of disease at this time.

END