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!!
