CASE PRESENTATION

Dr.Ramesh Sharma

Department of Obstetrics and Gynaecology.

IOM, TU Teaching Hospital.

HISTORY

41 year Para 3 lady, from Rukum Post TAH with ? BSO done 6 years back at

valley Hospital Presented to our centre with complaint of

Mass per abdomen – 1 year Abdominal pain and increase in size of mass for

last 5 months Loss of appetite for 5 months

HISTORY …CONTD.. Menstrual history- Post TAH Obstetric history- Para 3, all vaginal

deliveries at home Contraceptive history- none

HISTORY …CONTD.. Past history- TAH done 6 years back for

fibroid uterus The per operative finding revealed :

A mass around 3 ×3 cm arising from the intestine which was removed. Lumen not involved

Uterus was enlarged, tubes and ovaries not commented on

Histopathology. Separate mass removed from the intestine

shows leiomyoma with hyaline degeneration Endometrium: proliferative; Cervix: chronic

cervicitis Status of tubes and ovaries not mentioned

HISTORY …CONTD.. Personal history- non smoker, doesn’t

consume alcohol Family history – no family h/o malignancy

CLINICAL EXAMINATION

General condition- fair..thin built. Weight: 38 kg Vitals: stable Pallor, edema, dehydration, jaundice- nil No lymphadenopathy Breast, axilla : normal Chest- normal vesicular sounds all over

bilateral equal air entry CVS- S1 S2 M0

CLINICAL EXAMINATION..CONTD.. Per abdomen-

A huge mass(size 30 × 40 cm), solid, stony hard in consistency, bosselated, irregular, well defined margins in the upper and lateral parts, lower border could not be felt, non tender, immobile

No ascites

CLINICAL EXAMINATION..CONTD.. Vulval inspection- no abnormality

P/S- vault/vagina : normal

P/V Vaginal vault appeared normal Firm mass felt in anterior fornix Upper pole could not be reached

CLINICAL EXAMINATION..CONTD.. Per rectal examination:

Rectal mucosa free Anteriorly, hard mass felt

PROVISIONAL DIAGNOSIS

Ovarian tumor

INVESTIGATIONS

Hematology

Hb 10.8 gm%

Total Count 6110/ cu mm

Differential count N: 65 L:32 M:2 E:1

Platelets 3,48,000/cu mm

INVESTIGATIONS

Biochemistry

Na 146meq/l

K 4.5meq/l

RBS 4.1mmol/l

Urea 3.4mmol/l

Creatinine 73 µmol/l

Bilirubin T: 7µmol/l, D:1µmoml/l,

Protein 70 g/l

Albumin 36g/l

LDH 440U/l

SGOT 40U/l

SGPT 17U/l

ALP 215U/l

Coagulation Profile

BT 3 minutes

CT 5 minutes

PT 12 seconds (C:12 secs)

APTT 27 secs (C:27 secs)

Fibrinogen 330mg/dl (N: 200-400)

FDP D-dimers >200,<400 (N:<200)

INVESTIGATIONS

Serology

HBs Ag ELISA Non Reactive

HCV Ab ELISA Non Reactive

HIV 1-2 Ab ELISA Non Reactive

Tumor markers

CEA 6.2ng/ml (<4.7)

α- feto protein 10 ng/ml

CA-125 49 U/ml (<33.1)

β-HCG 55 mIU/ml (<7)

Urine RE/ME

Normal

IMAGING STUDIES

ULTRASONOGRAM OF ABDOMEN

Findings:

A large, solid mass seen in pelvis measuring approximately 173 ×153 mm suggestive of ovarian tumor.

Upper abdomen: no abnormality detected

CT ABDOMEN AND PELVIS

CT SCAN REPORT : 2068/1/12

Post hysterectomy status Huge (30x27x25cm)heterogeneously

enhancing mixed attenuation abdominopelvic mass with ovaries not separately identified from this mass –most likely malignant mass of ovarian origin ? side of origin.

Diffuse omental thickening and omental caking with small round enhancing nodule (17.5x15.6mm)in rectovesical pouch –s/o omental and peritoneal metastatic deposits

Poorly enhancing hypodense nodule(20.7x20.5mm) in right lobe of liver –s/o metastatic lesion

CT SCAN REPORT : 2068/1/12

Multiple mildly enhancing round and oval nodules in scanned part of both lungs,largest 21.5x20.4mm in size –s/o metastatic lesions.No pleural effusion

Bilateral mild hydronephrosis most likely secondary to ureteric compression by the above described mass

Mild ascites around lesion in pelvis No enlarged LN

BARIUM ENEMA

(3/2/068) (Colonoscopy was tried but not able to go beyond 80 cm so, advised for barium enema ) Soft tissue density (probably cystic) mass at

periumbilical region Fairly smooth outlined displacement of sigmoid

colon, ascending and transverse colon, more of sigmoid with mildly dilated sigmoid loop

CHEST X-RAY

USG GUIDED FNAC

(068/2/6) : mostly blood and few mesothelial cells

Repeat USG guided FNAC sent on 068/2/9 : same report

FINAL DIAGNOSIS

? Ovarian tumor with suspected metastasis to the liver and lungs

MANAGEMENT

Planned for Staging Laparotomy on Friday

THANK YOU!!