CASE REPORT

Diagnosis: Peritoneal Carcinosis - HA

In April 1978, a thirty-year-old woman experienced pain and swelling in the abdomen, and presented to Elisabeth-Krankenhaus (EKH) in Kassel, Germany. Medical examination revealed a high sedimentation, anemia, ascites in abdomen, and urinary infection. The patient was discharged from EKH on April 26, 1978, and re-hospitalized on April 28, 1978 at the Stadtkrankenhaus Kassel (SKHK) after a persisting swelling in the abdomen. Pathological examination of ascites withdrawn by puncture revealed non-specific tumoral cells. The results of the medical examination at SKHK were as follows: a slight swelling was present in the middle lobe of the thyroid. Arterial blood pressure was 100/60 mm Hg, and heart rate was 100 beats/min. The abdomen skin was extremely tight due to the presence of ascites. The patient experienced extreme pain due to the pressure in the abdomen. The liver and the spleen could not be palpated due to ascites. EKG was found to be normal. Laparoscopy revealed abundant ascites, many hepatic tumors ranging in size from a pinhead to a pea size (about 2mm - 8mm range). Many tumors of various sizes were also observed on the stomach, intestine, parietal peritoneum, ligamentum, and pelvis. The site of the primary tumor could not be exactly located, but it was thought to be pancreas. Finally the patient was diagnosed with wide spread peritoneal carcinosis. The medical report issued on May 10, 1978 ( Appendix HA1 ) stated the diagnosis as: "Ausgeprägte Peritonealcarcinose mit Befall sämtlicher Organe. Primär-tumor nicht sicher nachweisbar, möglicherweise vom Pankreas ausgehend. Im Unterbauch kein Hinweis auf Ovarialcysten. Ascites wird zur Untersuchung eingeschickt." (Translation by Google's online translation service: Pronounced Peritonealcarcinose with infestation of all organs. Primary tumor not surely demonstrable, possibly outgoing from the Pankreas. In the hypogastric region no reference to Ovarialcysten. Ascites is returned for investigation.) Following this diagnosis the patient was discharged on May 10, 1978 with no recommendation of any therapy.

A few days later the patient was flown back to Turkey to spend her remaining days. The medical condition of the patient deteriorated, and she was hospitalized at Social Security Hospital in Balikesir (Turkey) on May 27, 1978. Symptomatic therapy was applied, but since no amelioration of the medical condition could be provided, she was discharged from that hospital too on June 3, 1978.

The husband of the patient presented to Dr. Ozel on June 5, 1978 with the previous medical reports. The patient did not accompany him because of her poor medical condition. She was tested with N.O.I. injections in Balikesir. 0.3 mL dose of NOI caused a fever of 38.2^o C. She was then placed on a regular regimen with 0.3cc daily dose of NOI to be given six days a week. It was recommended to adjust the dosage according to daily fevers.

The patient presented to Dr. Ozel on 20 September 1978. On examination there was ascites in the abdomen. The right and the middle liver lobes were palpated to overpass the costal site by 6 and 3 cm respectively. The liver was palpated to be hard and rough. Abdomen skin was felt to be soft and under no pressure from the ascites. Arterial blood pressure was 120/80 mm Hg. 0.4 cc of NOI was causing a fever of about 38^o C. The patient was recommended to continue the regular treatment.

The patient presented to Dr. Ozel on 10 December 1978. She was experiencing no fever after NOI injections for the last four days. On examination, there was no ascites in the abdomen. The liver was palpated to pass the costal site by 2cm. The patient was experiencing no pain whatsoever. Arterial blood pressure was 120/80 mm Hg, and heart rate was 72/min. She was then started on a maintenance regimen with 0.4cc dose of NOI to be given at two-day intervals for the first two months, and then, 0.4 cc dose of NOI to be given at weekly intervals for another four months.

In August 1979 the patient went back to Germany. The same year she underwent an ovarian surgery at SKHK. No sign of malignancy was observed at the surgery.

In 1987, upon the request of Dr. Ozel, the patient presented to SKHK (of which the name was changed to Stadtische Kliniken Kassel) and underwent a medical examination from March 15, until April 1. No sign of the previous peritoneal-carcinosis existed. It is stated in the medical report issued on 21 May 1987 ( Appendix HA2 ) that the diagnosis of "peritoneal carcinosis" made in 1978 should have been wrong, and the diagnosis should have been "peritoneal tuberculosis," since the latter disease may have been gone away without any special treatment.

The patient has been in remission since 1979.