1.

CASE REPORT

1.1 Patient Identity

Name : Mrs. Ni Putu Candra
Age : 33 years old
Address : Bima, Mataram
Medical Record Number : 0001698991
Hospital Admission : July 18th 2018

1.2 Anamnesis
Referred from : Mataram District Hospital
Chief complaint : Severe headache and blurred vision

Anamnesis:
P1A1 (YC 4 y.o.) was referred from Mataram District Hospital with severe
headache and blurred vision since 2 weeks prior to admission. The patient had a
brain metastases due to gestational trophoblastic neoplasia with a history of
curretage for hydatiform mole underwent on August 1st 2016. On September 1st
2016, she underwent another curretage due to vaginal bleeding which was later
found to be caused by squamous cell carcinoma. The patient finally underwent total
abdominal hysterectomy and was found to have choriocarcinoma, was treated with
MTX chemotherapy, and diagnosed with resistant gestational trophoblastic
neoplasia. She underwent the 1st through 3rd EMCO chemotherapy in October until
December 2016 and then 1st EMCO consolidation in January 2017. BhCG level was
found to be high in September 2017. Underwent the first and second cycle of TP in
February to March 2018, with TP consolidation underwent in March-April 2018.
She was then observed for 3 months until in July 2018 she was found to have a high
level of BhCG and with a symptom of severe headache, and was admitted to Hasan
Sadikin General Hospital.
There was no vaginal bleeding. No abdominal mass was found upon
physical examination. The patient was able to urinate and defecate normally.
1.3 Obstetric History

Marriage : married once, 28 years old

Menarche : 14 years old

ECOG scale :2
Karnofsky : 70%

1.4 Vital signs

General condition : Compos mentis
Blood Pressure : 130/90 mmHg
Heart Rate : 96 x/min
Respiratory Rate : 22 x/min
Temperature : 36,8oC
Cor : Heart rate regular, murmur (-) gallop (-)
Lung : Vesicular breath sound, right=left, Ronkhi -/-,
Wheezing -/-
Reflex : Physiologic reflex (+/+)
Edema : -/-
Spleen and liver : within normal limits

1.5 Abdominal Examination

Observation : shape was flat
Palpation : soft, no pain, no ascites, no mass palpated

1.6 External Genitalia Examination

Within normal limits

1.7 Inspeculo Examination

Fluxus (-)
Fluor (-)
Vaginal stump : within normal limits

FIGO score : 11

1.8 Internal Examination

Vulva / vagina : within normal limits
Portio : within normal limits
Ostia : within normal limits

1.9 Laboratory Findings (July 18th 2018) :

Variable Result

Hematology

Hemoglobin 12 g/dL

PCV 35.8 %

Leukocyte 9,070 /mm3

PC 259,000

Blood Chemical

SGOT 19 U/L

SGPT 20 U/L

Ureum 35 mg/dL

Creatinine 0.88 mg/dL

Electrolyte

Na 145 mEq/L

K 3.5 mEq/L
1.10 Chest X-Ray

- February 12nd 2018 : Intrapulmonal metastasis (+)

- July 11th 2018 : Intrapulmonal metastasis (-), cardiomegaly (-)

1.11 Head CT-Scan (July 16th 2018)

Conclusion : Intracranial metastases temporal SR

1.12 Histpathology Result
- Curretage (August 1st 2016) : missed abortion
- Curretage (September 1st 2016) : squamous cell carcinoma
- Total abdominal hysterectomy (September 2016) : choriocarcinoma

1.13 Abdominal Ultrasonography (July 16th 2018)

Conclusion :
 Fatty liver
 No solid/ cystic mass on uterus, color flow (-), residive mass (-)
 Other organ within normal limit

1.14 Neurology Consultation (July 19th 2018)

Diagnosis :
 Secondary headache due to space occupying lesion
 Space occupying lesion due to suspected metastases of choriocarcinoma
stage

Treatment :
 Dexamethason 3x2 amp IV tapering off / 3 days
 Omeprazol 2x1 amp IV
 Consult to neurosurgery department
1.15 Consultant Assessment (July 20th 2018)
Diagnosis:
 Choriocarcinoma stage IV FIGO score 11 (high risk); post methotrexate
chemotherapy; post EMCO consolidation II; post TP consolidation II; post
total abdominal hysterectomy; brain metastases

Management:
 Craniotomy tumor removal or intrathecal chemotheraphy

1.16 Neurosurgery Consultation (July 21st 2018)

Diagnosis:
 Supratentorial space occupying lesion due to suspected metastases of
choriocarcinoma stage IV post chemotheraphy and hysterectomy
Management:
 Plan for elective craniotomy tumor removal
1.17 CT-Scan (July 26th 2018)
Conclusion:
 Solid mass with perifocal edema on surrounding on cortical subcortical left
temporal lobe, which deviate left lateral ventricle to right
 Intracranial metastase
Pre Operative Clinical Photo of Patient :
1.18 Craniotomy (August 3rd 2018)
Patient underwent Craniotomy surgery performed by neurosurgery
departement and histopathology result was Carcinoma metastatic e/r Left Temporal

Surgery Report :
Specimen :

Histopathology result :
Post Operative Clinical Photo of Patient :
1.19 Post-Operative Managements
 Chemotherapy high dose MTX

Management Recommendations According to PNPK

 High risk TTG has one of the following characteristics:

 High risk Hammond

 TTG (FIGO) with a WHO risk value of > 7
 EMA / CO (etoposide, methotrexate, actinomycin D and
cyclophosphamide and oncovin / vincristine) are the first line
combination chemotherapy Regiments commonly used in high-risk
TTG patients.
 In randomized clinical trials, this Regiment is still rare compared to
other combination Regiments
 Patients with FIGO score> 7 must be treated using multi-agent
chemotherapy, and most of the Trophoblast Management Center now
uses a combination of EMA / CO because it has high effectiveness,
simple to administer and is relatively non-toxic.
 SCHEME OF CHEMOTHERAPY EMACO HIGH DOSE

Day Time no Regiment

I 05.00 1 0.9% physiological NaCl 1 lt + KCl 20mMol, finish in 2 hours
08.00 2 Allopurinol tab 100 mg P.O and check urine pH
08.00 3 NaHCO31.4%, 500 mL finish in 30 minutes
08.30 4 Ondansentron 1 amp iv (anti-emetic) and Metylprednisolone
125 mg iv (anti-allergic)
09.00 5 Etoposide 100 mg / m2 in 500 cc NaCl 0.9% is discharged in 30
minutesActinomycin D 1 flacon (0.5 mg) given IV

SCHEME
10.00 6OF Methotrexate
CHEMOTHERAPY 500 mg / m2 EMACO HIGH
in 1000 ml finish in 12DOSE
hours
22.00 7 Methotrexate 500 mg / m2 in 1000 ml finish in 12 hours

Day Time no Regiment

II 10.00 1 Folinic acid 10 mg IM (24 hours after MTX)
12.00 2 Allopurinol tab 100mg P.O and check urinary pH
3 Etoposide 100 mg/m2 in 500 cc

12.30 4 NaCl 0.9% finish in 30 minutes

16.00 5 Hidration during chemo per-oral and i.v for 3 liter in 24 hours
20.00 6 check urinary pH
SCHEME
00.00 7OF CHEMOTHERAPY
Allopurinol EMACO
tab 100mg P.O and HIGH
check urinary pH DOSE

Day Time no Regiment

III 04.00 1 Allopurinol tab 100mg P.O and check urinary pH
08.00 2 Check urinary pH
10.00 3 Erbanfol 10 mg IM (24 hours after MTX)
12.00 4 Allopurinol tab 100mg P.O and check urinary pH
16.00 5 Check urinary pH
20.00 6 Allopurinol tab 100mg P.O and check urinary pH
00.00 7 Check urinary pH
 SCHEME OF KEMOTERAPI EMACO HIGH DOSE

Day Time no Regiment

IV 04.00 1 Allopurinol tab 100mg P.O and Check urinary pH
08.00 2 Check urinary pH
10.00 3 Erbanfol 10 mg IM (24 hours after MTX)
12.00 4 Allopurinol tab 100mg P.O Check urinary pH
16.00 5 Check urinary pH
20.00 6 Allopurinol tab 100mg P.O Check urinary pH
SCHEME
00.00 7 OF KEMOTERAPI
Check urinary pH EMACO HIGH DOSE

Day Time no Regiment

VIII Vincristine 1 vial (1 mg) Intravena

Cyclophosphamide 600 mg (3 vial @200 mg) dissolved in

500cc NaCl 0.9% infused for 12 hours
IX Methotrexate intrathecal 12,5 mg accompanied by folinic acid
15 mg Per oral
Join with TS Neurologic department for administration of
intrathecal chemotherapy
1.20 Conference Conclusion (August 31st 2018)
 Methotrexate intrathecal 12.5 mg given by Neurologist and the
cerebroliquid will be sent to laboratorium to measure intracerebral BHCG
 Before intrathecal methotexate given, check the BHCG serum
 Join conference with neurologists will be held
 Monitoring urinary pH, follow up every 2 weeks
1.21 Care Plan Timeline
• August 14th 2018
 BHCG 398.3 mIU/mL

• August 24th 2018

 BHCG 5700 mIU/mL

• August 29th 2018

 Chemotherapy EMACO high dose and chemotherapy MTX intrathecal
12.5 mg I

• September 12th 2018

 BHCG 28.5 mIU/mL

• October 2nd 2018

 BHCG 40 mIU/mL

• October 4th 2018

 Chemotherapy EMACO high dose and chemotherapy MTX intrathecal
12.5 mg II

• October 16th 2018

 BHCG 14.2 mIU/mL

• October 25th 2018

 Chemotherapy EMACO high dose and chemotherapy MTX
intrathecal III

• November 2nd 2018

 BHCG LCS 7.8 mIU/mL
 BHCG Serum 16.7 mIU/mL

• November 8th 2018

 BHCG 6.6 mIU/mL

• November 14th 2018

 Chemotherapy EMACO high dose IV chemotherapy MTX
intrathecal IV
• November 26th 2018
 BHCG LCS : 7,2 mIU/mL
• Desember 3th 2018
 BHCG Serum : 17,6 mIU/mL
• Desember 6th 2018
 Chemotherapy EMACO high dose V chemotherapy MTX
intrathecal V
• Desember 14th 2018
 BHCG LCS : 2.5
 BHCG Serum : 30.6
• Desember 18th 2018
 BHCG Serum : 7.5