Scribd Logo
Upload

Welcome to Scribd!

  • 5 views

    Isolated Abdominal Wall Metastasis From Ovarian Cancer

    Uploaded by

    juhi
    The document describes a case of a 52-year-old female patient who presented with abdominal discomfort and lower limb weakness. She had a history of total abdominal hysterectomy and bilateral salpingo-oophorectomy for what was reported as a benign ovarian cyst. Imaging showed a mass in the abdominal wall. Biopsy of the mass revealed metastatic adenocarcinoma suggestive of a mullerian primary. The document discusses this case and considers whether the original ovarian cyst was misdiagnosed or if this represents true abdominal wall metastasis from ovarian cancer.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Isolated Abdominal Wall Metastasis From Ovarian Cancer

    Uploaded by

    juhi
    5 views17 pages
    The document describes a case of a 52-year-old female patient who presented with abdominal discomfort and lower limb weakness. She had a history of total abdominal hysterectomy and bilateral salpingo-oophorectomy for what was reported as a benign ovarian cyst. Imaging showed a mass in the abdominal wall. Biopsy of the mass revealed metastatic adenocarcinoma suggestive of a mullerian primary. The document discusses this case and considers whether the original ovarian cyst was misdiagnosed or if this represents true abdominal wall metastasis from ovarian cancer.

    Original Title

    Isolated Abdominal wall metastasis from ovarian cancer (1) (1)

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document describes a case of a 52-year-old female patient who presented with abdominal discomfort and lower limb weakness. She had a history of total abdominal hysterectomy and bilateral salpingo-oophorectomy for what was reported as a benign ovarian cyst. Imaging showed a mass in the abdominal wall. Biopsy of the mass revealed metastatic adenocarcinoma suggestive of a mullerian primary. The document discusses this case and considers whether the original ovarian cyst was misdiagnosed or if this represents true abdominal wall metastasis from ovarian cancer.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    5 views17 pages

    Isolated Abdominal Wall Metastasis From Ovarian Cancer

    Uploaded by

    juhi
    The document describes a case of a 52-year-old female patient who presented with abdominal discomfort and lower limb weakness. She had a history of total abdominal hysterectomy and bilateral salpingo-oophorectomy for what was reported as a benign ovarian cyst. Imaging showed a mass in the abdominal wall. Biopsy of the mass revealed metastatic adenocarcinoma suggestive of a mullerian primary. The document discusses this case and considers whether the original ovarian cyst was misdiagnosed or if this represents true abdominal wall metastasis from ovarian cancer.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 17

    ISOLATED ABDOMINAL WALL METASTASIS

    FROM OVARIAN CANCER


    By Dr RADHIKA GOPAKUMAR
    Moderator : Dr Shripad Hebbar
    Chief complaints

     Mrs X, a 52 year old female patient


     Hailing from Udupi
     Middle socio economic status
     S/P Total abdominal hysterectomy with bilateral salpingo oophorectomy(TAH and BSO)
    and partial omentectomy, came with bilateral lower limb weakness and pain radiating to
    both flanks and back, abdominal discomfort since 15 days
    History of presenting illness
     On routine health checkup at a local hospital, USG abdomen (July 23 rd 2020) showed
    Uterus 8 x 4.6 x 3.5 cm, small posterior wall fibroid 8 x 9 mm , right ovarian cyst 73 x 78
    x 55 mm with turbid fluid with internal septations and an echogenic lesion (?calcific) in
    cyst wall. Left ovary – normal .
     She was advised ovarian cystectomy initially, but lost to follow-up.
     She developed amenorrhea of 6 months duration (April to September 2022) followed by
    bleed P/V of 20 days duration in October 2022.
     USG abdomen and pelvis (September 19th 2022) showed Uterus anteverted 8 x 4 x 3.2
    cm , ET – 7 mm, a large right abdominopelvic adnexal cyst of 15.6 x 13 x 9.6 cm in size
    with multiple septations and internal echoes displacing bowel loops laterally , bilateral
    ovaries – not visualized and umbilical hernia of 1.2 cm with omental fat as content.
    History of presenting illness
     CECT (A and P)(October 6th 2022) showed a right
    abdominopelvic adnexal lesion of 11 x 13.6 x 16 cm)
     MRI (A and P)(October 8th 2022) showed a right ovarian
    complex multiloculated cyst 17 x 14 cm adhered to peritoneum
    and bowel loops, attached to right cornual end of uterine
    fundus)
     She underwent TAH with BSO and partial omentectomy on
    October 2022 at KIMS, Hubli. Post operative period was
    uneventful. Ascitic fluid sent for analysis showed features
    suspicious of malignancy.

    MRI abdomen and pelvis


    History of presenting illness
     Specimen sent for HPE was reported as atrophic
    endometrium and benign mucinous cystadenoma of right
    ovary .
     She was asymptomatic since discharge (October 2022) for
    8 months. Presently she developed bilateral lower limb
    weakness and pain radiating to both flanks and back,lower
    abdominal discomfort since 15 days.
     She had consulted a gynecologist at outside hospital 2
    weeks back.
     Ultrasound abdomen with pelvis(A and P) showed (5 th
    July 2023) irregular hypoechoic area 7 x 5.5 cm within
    deep layers of abdominal wall in midline of hypogastrium
    at site of previous surgery.
    ? Inflammatory mass ?neoplasm- involving soft tissue planes
    including muscular planes extending upto pubic and inguinal
    areas, uterus and adnexa were not visualized. USG abdomen and pelvis
    History of presenting illness
     MRI (A and P) showed an ill defined infiltrative
    enhancing lesion 7 x 9.1 x 7.5 cm involving lower
    abdominal wall (rectus abdominus muscle extending
    into subcutaneous space along surgical scar)
    Posteriorly extending upto the pre-vesical space with loss of
    fat planes with anterior wall of bladder. Laterally upto
    inguinal region and along pelvic walls, predominantly on
    left side - aggressive fibromatosis , endometriosis were
    suspected

    MRI abdomen and pelvis


    History of presenting illness
     On neurology and orthopaedics evaluation at Tejasvini hospital, Mangalore – MRI lumbar
    spine showed (18/07/2023) altered signal intensity lesions in L3, L4, L5 vertebral bodies ,
    sacrum, left iliac bone and right femur. Multiple enlarged abdominal retroperitoneal
    pre/para aortic nodes were noted likely metastasis with D/D being lymphoma, large lesion
    was partially visualized in prevesical space involving muscular and subcutaneous space of
    anterior abdominal wall.
     She was given symptomatic treatment. She came to Kasturba Hospital for second opinion
    on 23rd July 2023.
     No white discharge or bleeding P/V, burning micturition, stress urinary incontinence or
    dysuria.
     No history of nausea, dyspepsia, post meal distension, loss of appetite, weight loss or
    constipation.
    Past History
     Menstrual History: Post TAH with BSO and partial omentectomy
     Obstetric History: P2L2Ab1, previous 2 LSCS, LCB – 17 years, sterilized
     Family History : Nil gynecological malignancy in family.
     Surgical History: s/p TAH and BSO with partial omentectomy (October 2022) Sterilised 17
    years back.
     Medical History: Nil comorbidities
    Examination
     General condition – fair
    Moderately built and nourished
    Height: 160 cm, Weight : 51 kg, BMI – 19.9 kg/m2
    Afebrile, PR: 70 bpm, BP: 110/70 mm Hg,
    No pallor, icterus, cyanosis, lymphadenopathy or pedal edema
     Breast and Thyroid – clinically normal
     CVS: S1 S2+
     RS: NVBS

     Per abdomen:
    Inspection –
    Abdomen appears distended
    No scars or sinuses
    Midline vertical scar wound healthy
    Palpation : Large diffuse swelling in suprapubic and pubic region
     P/S and P/V- Vault healthy
    Evaluation
     Lab investigations:
    HbA1c – 5.3%, RBS – 123 mg/dl
    Hemoglobin – 11 g/dl, Platelet count – 203 x 1000/microlilter
    Total count – 13.9 x 10000/microliter
    TSH – 2.3 microIU/mL
    URE- WBC -11.5/hpf, RBC- 78.5/hpf, yeast- 22.3/ hpf
    HbsAg and HIV – NR
    PT- 11 sec, INR – 0.97 , APTT – 27.8 sec
    Urea/creatinine/uric acid – 14/0.48/3 mg/dl
    Sodium/potassium/chloride – 130.1/4.2/93.2 mmol/L
    Total /Direct Bilirubin – 0.79/0.31 mg/dl
    AST/ALT/ALP – 44.6 /126/33.1
    CEA - 33.1 ng/dl , CA 19.9 - < 02 U/mL , CA 125 – 1200 U/mL
    Evaluation

     TVS done showed a well defined mass 5.5 x 2 x 4 cm arising from anterior abdominal
    wall, uterus and ovaries not visualized.
     Interventional radiology consultation was sought and ultrasound guided trucut biopsy from
    abdominal mass taken – she was discharged and advised for review with report. Recently,
    biopsy has been reported with features of metastatic adenocarcinoma with immune profile
    suggestive of mullerian primary (CK7 and PAX8 positive).
     Medical oncology consultation was sought in view of abdominal mass – review is
    ongoing .
    Treatment plan
    Based on trucut biopsy report of abdominal mass, medical oncology review ,
    further evaluation (to look for any further sites of metastasis) and treatment
    plan would be decided.

    Diagnosis

    P2L2Ab1 with previous 2 LSCS S/P TAH with BSO and partial omentectomy with abdominal
    wall metastasis from ovarian cancer
    Things to ponder

     Based on the HPE report of specimen sent post TAH with BSO and partial omentectomy in
    October 2022 – was the right ovarian cyst really benign mucinous cystadenoma ?
     Is the abdominal wall mass presently fibromatosis or metastasis from ovarian neoplasm ?
    Similar studies

     In a case report (2019), a 50 year old female


    had underwent TAH 10 years ago for uterine
    fibroid (2009)
     She presented at Maternity and child welfare
    hospital, Delhi (2019) with ulcerated
    swelling over left lower abdominal wall post
    optimal cytoreduction (BSO , total
    omentectomy, pelvic and para-aortic lymph
    node dissection done 18 months ago).
     Wide local excision of abdominal wall mass
    - histopathology confirmed metastatic
    endometroid cancer of ovary. All margins
    were negative. She received 6 cycles of
    Choudhary D, Sharma G, Singh T, Chishi N, Garg PK. Isolated abdominal wall metastasis in early ovarian cancer: a chemotherapy.
    true systemic metastasis or local tumour cells implantation. J Obstet Gynaecol. 2019 Jul;39(5):724-726. doi:
    10.1080/01443615.2019.1578734. Epub 2019 Apr 22. PMID: 31010379.
    Similar case reports
     Three cases of abdominal wall metastases from ovarian cancer after laparoscopy were reported.
     One patient had an implant of serous papillary carcinoma of low malignant potential at the trocar
    site after laparoscopic left salpingooophorectomy and right ovarian biopsy. She was treated with
    cyclophosphamide and cisplatin.
     Other 2 patients were referred following laparoscopy wherein Ascites drained and samples taken
    from pelvic carcinomatosis(Poorly differentiated and serous papillary carcinoma seen in HPE).
    They presented with palpable subcutaneous masses upto 8 cm at trocar site. Staging laparotomy
    and optimal debulking followed by carboplatin and cyclophosphamide commenced
     Laparoscopic surgery is inappropriate in patients with malignant ascites or when preoperative
    findings are suggestive of ovarian cancer.

    Gleeson NC, Nicosia SV, Mark JE, Hoffman MS, Cavanagh D. Abdominal wall
    metastases from ovarian cancer after laparoscopy. Am J Obstet Gynecol. 1993
    Sep;169(3):522-3. doi: 10.1016/0002-9378(93)90611-l. PMID: 8018126.
    Similar case reports
    .
     Ataseven et al have studied the impact of Abdominal wall metastasis (AWM) from ovarian cancer
    on prognosis and survival (Ataseven et al. 2016).
     They reported FIGO stage IV cancers with only AWM had better overall survival then FIGO stage
    IV cancers with other distal metastasis.
     Overall survival in stage IV B AWM was similar to stage IIIC. So according to Atasevan , AWM
    should be classified as stage IIIC than stage IVB.

    Ataseven B, du Bois A, Harter P, Prader S, Grimm C, Kurzeder C, Schneider S, Heikaus S, Kahl A, Traut A,
    Heitz F. Impact of Abdominal Wall Metastases on Prognosis in Epithelial Ovarian Cancer. Int J Gynecol Cancer.
    2016 Nov;26(9):1594-1600. doi: 10.1097/IGC.0000000000000826. PMID: 27654263.
    Thank you

    You might also like