Gyn case

1. Case presentation Dr.Ramesh Sharma Department of Obstetrics and Gynaecology . IOM, TU Teaching Hospital.

2. 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

3. History … contd.. Menstrual history- Post TAH Obstetric history- Para 3, all vaginal deliveries at home Contraceptive history- none

4. 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

5. History … contd.. Personal history- non smoker, doesn’t consume alcohol Family history – no family h/o malignancy

6. 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

7. 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

8. 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

9. Clinical examination.. contd.. Per rectal examination: Rectal mucosa free Anteriorly , hard mass felt

10. Provisional diagnosis Ovarian tumor

11. 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

12. Investigations Biochemistry Na 146meq/l K 4.5meq/l RBS 4.1mmol/l Urea 3.4mmol/l Creatinine 73 µ mol/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

13. 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)

14. 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

15. Imaging studies

16. Ultrasonogram of abdomen

17. Findings: A large, solid mass seen in pelvis measuring approximately 173 ×153 mm suggestive of ovarian tumor. Upper abdomen: no abnormality detected

18. CT ABDOMEN and pelvis

19. 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

20. 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

21. 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

22. Chest X-ray

23. USG guided FNAC (068/2/6) : mostly blood and few mesothelial cells Repeat USG guided FNAC sent on 068/2/9 : same report

24. Final diagnosis ? Ovarian tumor with suspected metastasis to the liver and lungs

25. management Planned for Staging Laparotomy on Friday

26. Thank you!!