Mixed Germ Cell Tumour of Ovary WTH Chemotherapy Side Effect

Introduction: Mixed germ cell tumour is a very rare type of aggressive cancer, consisting of more than one type of germ cell components. The most common component reported was dysgerminoma, followed by endodermal sinus tumour, teratoma, choriocarcinoma and embryonal carcinoma respectively. This study focuses on the combination of dysgerminoma and endodermal sinus tumour (yolk sac tumour) along with the hearing loss as the side effect of chemotherapy. Clinical Findings: Pain in the lower abdomen (lump is visible and has occupied hypogastrium along with bilateral iliac region extending 2-3 cm above the umbilicus), backache, fever (100.6 °F). Later after the third chemo cycle, it was found that the patient has progressive mild hearing loss. Diagnostic Evaluation: HB= 9.7gm%, TLC= 10300/cumm, PLT= 5,49 lakhs/cumm, CA 125= 909 U/ML. Histopathology Report: Ascitic fluid along with thirteen containers containing right ovarian mass, Case Study Biswas et al.; JPRI, 33(59B): 766-773, 2021; Article no.JPRI.78442 767 right ovary with mass, right fallopian tube, bowel deposits as well as residual nodules and pelvic deposits were sent of which, the reports indicated mixed germ cell tumour of the ovary. Therapeutic Intervention: Packed red blood cells transfusion, Pre-chemo and post-chemo hydration, Pre-chemo and post-chemo drugs, BEP Chemotherapy (Bleomycin, Etoposide, Cisplatin). Conclusion: My patient aged 11 years old female was admitted to Gynaecology Ward No – 16, AVBRH on 27/12/2020 for the first cycle of chemotherapy with the complaints of lower abdominal pain, backache and fever. The patient was diagnosed as the case of mixed germ cell tumour, further had mild hearing loss as the side effect of chemotherapy The patient is on chemo and is advised for follow up care once a month.


INTRODUCTION
Germ cell tumours by name suggest that it is the tumours of the egg cell in females and sperm cells in males. Mixed germ cell tumour is termed so, because of its characteristics of involving at least more than one type of germ cell tumours. To date, the most common combination of mixed germ cells reported is dysgerminoma and endodermal sinus tumour [1], whereas the rarest counts embryonal carcinoma and immature teratoma [2]. It is primarily found in children and adolescent.
Among ovarian cancer, it is reported to be the second most common type of tumours constituting about 15-20%; of which, about 3% are the malignant ones [3]. Usually, the book picture depicts that mixed germ cell tumours have symptoms of abdominal pain, constipation, lump over lower abdomen or back, puberty is attained at a very young age and severe pain [4].

Patient Identification
A female child of 11 years from Pusad, Yavatmal was admitted to Gynaecology Ward No -16, AVBRH on 27/12/2020 diagnosed as the case of mixed germ cell tumour on 04/01/2021. She weighs 30 Kgs with a height of 150 cms.

Family History
My patient's family comprises four members. She was diagnosed to have mixed germ cell tumours with no abnormal genetic history from her parents. The parents had a non-consanguineous type of marriage. Except for the patient admitted to the hospital, other family members don't have any complaints regarding their health. The family belongs to a middle class family, hence the nursing interventions were framed accordingly, along with helping their healthcare expenses by connecting them with health schemes via hospital's social worker.

Past Medical History
My patient has a history of fever 15 days before the admission, which the patient's parents reported as typhoid (document not available for the diagnosis of typhoid) and treated it at home. Tumour board discussion was done on 30/12/2020 and later her histopathological report confirmed to have mixed germ cell tumour on 04/01/2021. Till that duration, she was admitted to the hospital from time to time for the packed red blood cells transfusion.

Past Interventions and Outcome
Abdominal pain being the chief complaint of the patient, was suspected to have right ovarian mass from ultrasonography report, which was later diagnosed as mixed germ cell tumour through the histopathological report on 04/01/2021. Also, the patient had a 9.7gm% haemoglobin level at the time of admission, for which 2 units of packed red blood cells was transfused in corresponding days, which was found effective as the Hb% was noted as 13.2 gm% on 31/12/2020 from 9.7 gm% on 27/12/2020.

Present Medical History
The patient was brought to AVBRH on 27 December 2020 by her parents with complaints of lower abdominal pain, backache and fever for which she was admitted to Gynaecology Ward No -16. She was a case of ovarian tumour and her haemoglobin level at the time of admission was 9.7 gm%. The child was weak and did not attain menarche to date.

Physical examination
It was found that the patient had right ovarian mass from ultrasonography, on thorough examination from head to foot, a visible lump was noted over the lower abdomen, on further palpation it was found to occupy the hypogastrium region and bilaterally iliac region extending 2-3cm above the umbilicus. The child is thin, weak and has dull look. She is well oriented with the date, time, place and is cooperative.

Histopathology report
Ascitic fluid along with thirteen containers containing right ovarian mass, right ovary with mass, right fallopian tube, bowel deposits as well as residual nodules and pelvic deposits were sent of which, the reports indicated features suggestive of mixed germ cell tumour of the ovary.

Audiogram report
Right ear: Mild conductive hearing loss, Left ear: Mild sensorineural hearing loss, as depicted in the Picture 1.

MANAGEMENT
Unlike other cases, surgeries were done before as an emergency, to remove the ascitic fluid. Hence, chemotherapy was followed after the surgical management. Also, the patient didn't receive radiation therapy.

Surgical Management
The patient underwent her first surgery ever on 30/12/2021 as an, after consulting responsible physicians and paediatricians. The patient was prepared with antibiotic coverage for Pigtail procedure in order to drain around 500ml of ascitic fluid from peritoneal cavity. Intra-operative notes: During the procedure a yellow-white lump mass of irregular, friable with solid consistency, and haemorrhagic yet necrotic areas were seen and palpated. Hence, further surgeries were carried out on need based. As a result, the patient had exploratory laparotomy with right ovarian mass removal with right sided salpingectomy with infra-colic omentectomy with partial supra-colic omentectomy with peritoneal biopsy. Meanwhile, the required samples were collected in 13 containers according to the protocol and was sent for histopathological examination. . Side-effects of chemotherapy: As chemotherapy has numerous side effects, of which hearing loss is accounted to be rare but inevitable due to long term use chemotherapy drugs, especially in minor age group population [5]. After the third cycle of chemotherapy, it was found that the patient had the difficulty to hear distant things or person. Hence as per the suspicion, Rinne and Weber tests was performed, of which the report is depicted in picture 1. It was suggestive that the precipitating amount of chemotherapy, especially in such a young age may be the causative factor [5].

Nursing Management
This case belonged to medical, surgical, oncology, gynaecology as well as paediatrics concerned department, therefore nursing care played a vital role in every aspect, which is framed below accordingly: 3. To provide symptomatic pain relief. 3. To provide the patient with a healthy diet in order to cope up with daily activities. 3. To prepare the patient for the surgery.     1. To hydrate the body of the patient.

Post-operative
2. Advice the patient to perform deep breathing and leg exercises like early walking.
2. To reduce the chances of blood clots and infections in the chest. 3.Explain the need of family assisted care to the family members.
3.To carry out day to day activity and avoid any further injuries.

Follow-Up Care
The patient is advised to visit the hospital on Thursdays in case of emergency. She has been prescribed to take:  Tablet Pantoprazole 40 mg OD x 7 days,  Tablet Paracetamol 500 mg BD x 7 days (SOS),  Tablet Chymoral forte BD x 1 month,  Tablet Limcee OD x 1 month,  Protein powder 2tbsp BD x 1 month.
The patient was also advised: 1. To take adequate rest to avoid exhaustion, 2. To drink plenty of oral fluids to keep the body hydrated, 3. To eat high iron and fibre rich diet to enhance the haemoglobin level and immunity of the body, 4. To perform deep breathing and leg exercises or early walking as it reduces the probability of blood clots and infections in the chest. The radiation therapy does not only impair the growth of uterus but also increases the chances of depletion of the ovarian follicles. Contrastingly, salpingo-oophorectomy reduces the risks of developing ovarian cancer among women aged 35 to 40 years by 85% -95% [10,11,12,13,14] and it is usually recommended to perform after the mother is done with childbearing [14,15], whereas, my patient is underaged, i.e., didn't even attain menarche and has been diagnosed with mild hearing loss of both ears being the side effect of chemotherapy. Thereby, claiming to be an exceptional case.

Follow-Up Investigations
Overall, the above discussed studies provide a contradictory conclusion regarding the effect of treatment and recovery rates. Hence, the care of the patient should not only be limited to the medical or surgical management, but should also focus on psychological aspects of the patient as well as their caregiver. The willpower of the patient plays a major role in the recovery, therefore non-pharmacological therapies should also be prioritized by providing a positive and motivating atmosphere to the patient. It is also observed that cancer rehabilitation helps the patients to interact with people of similar diagnosis, which makes them enthusiastic and determined to live a quality life.

CONCLUSION
A female patient aged 11 years old from Pusad, Yavatmal was admitted to Gynaecology Ward No -16, AVBRH on 27 December 2020 with chief complaints of lower abdominal pain, backache and fever from 3 days. She is diagnosed as the case of mixed germ cell tumour through the histopathological report on 04/01/2021. As soon as the patient was admitted to AVBR hospital, all the required investigations were done and appropriate treatments were started. The patient is on symptomatic treatment and underwent surgeries as well, which is helping her to relieve the complaints. Since then, she has been readmitted for chemo cycles. Recently, the patient had been diagnosed with mild hearing loss associated with chemotherapy as side effect. The patient and her family underwent psychological stress, which was resolved to an extent by being an active listener and providing proper counselling.

CONSENT
Informed consent was obtained from the patient's parents.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).