Author
Information
Vibha
More*, Shruti Panchbudhe*, Kimaya Mali
(* Assistant Professor, ** Professor, ***
Second year
Resident. Department of Obstetrics and Gynecology, Seth G. S. Medical College
& K.E.M. Hospital, Mumbai, India.)
Abstract
The incidence of ovarian carcinoma in pregnancy
is uncommon. A patient presented at 35 weeks with right sided ovarian mass
of 15×13×12 cm and gross ascites.
Emergency cesarean section was performed in view of primigravida with breech
presentation in labor with right salphingo-oophorectomy with infra-colic omentectomy. Histopathological examination of
right ovarian mass was suggestive of borderline serous papillary neoplasm.
Introduction
Epithelial ovarian
cancer during pregnancy is rare. Early detection of ovarian cancer has
increased with the use of routine prenatal ultrasonography. Epithelial cancers
are asymptomatic other than those symptoms induced mechanically by the size of
the tumor. Confusion of symptomatology with the physiologic changes associated
with the pregnant state also causes a delay in diagnosis. The majority of
ovarian cancers diagnosed during pregnancy are found at an early stage, with
maternal prognosis similar to that in the non-pregnant patient.
Case report
A 22
years old
woman, primigravida with 35 weeks of gestation was referred from a
private
hospital with right ovarian malignancy and gross ascites. She was registered at
that
private hospital at two months of pregnancy. Her routine ultrasonography at
eight weeks of gestation detected right ovarian mass measuring 9×8×11cm
and mild free fluid in the cul de sac.
Both arterial and venous flows were present with decreased resistance index of 0.3
in the right ovary on Doppler study. She had regular
antenatal visits and her only complaint was increased distension of abdomen from
the third
month of her pregnancy. Repeat ultrasonography was performed at 20 weeks of
gestation which was showed moderate ascites and a 9.8×6.8 cm sized isoechoic to hypoechoic lesion in right adnexa
with central cystic degeneration. The right ovary was not visualised separately
from the mass. Her CA 125 was 454.9 U/ml. Cytological examination
of her
peritoneal
fluid showed lymphocytes, neutrophils and plenty of reactive mesothelial
cells with no malignant cells. Serial ultrasonography of the abdomen showed
increasing ascites while size of ovarian mass remained
the same.
There was a slight increase in Ca 125 level to 469 U/ml.
She was referred
to us at 35
weeks of gestation with chief complaints of pain in abdomen with right ovarian
mass with gross ascites for further management. On examination
her vital
parameters were stable. Systemic examination was normal. Abdominal examination
revealed gross ascites due to which fundal height, presenting part and fetal
heart sound were not appreciated. On vaginal examination,
the cervix
was 2 cm dilated and 50% effaced,
the presenting
part was breech, fetal
membranes were intact, and show was seen. Fetal heart sounds were demonstrated on ultrasonography. An emergency lower segment
caesarean was done for primigravida with breech presentation in early labor. A
male fetus weight 1.5
kg was
delivered with Apgar score of 9/10. Around 8 to 10 L of pale yellow ascitic
fluid
was drained.
There was a
right sided ovarian mass measuring about 15×13×12 cm in size, which was firm in
consistency. Capsule of the ovarian mass was breached and externally there was
a fungating growth of about 5 cm above the surface of ovary. The fungating
growth was greyish brown in color, soft to firm in consistency,
and with
few yellowish white areas. There was also an intrauterine septum
with sub mucosal fibroid of around 5 cm on the posterior wall
of the uterus. In view of above intraoperative findings right
salphingo-oophorectomy with infra-colic omentectomy was done. Specimen was sent
for histopathology and peritoneal fluid was sent for cytology. Her post
operative course was uneventful. On day 2 postoperative her Ca 125 was 226 U/ml
and other tumor markers were within normal range .There were no malignant cell
detected on cytology of peritoneal fluid. Histopathological examination of the
right ovarian mass was suggestive of borderline serous papillary neoplasm and
there was no definite evidence of malignancy in the
omentum.
This diagnosis was confirmed at an oncology
center. According
to International Federation
of Gynaecology and obstetrics (FIGO) classification, the patient belonged to category stage1c. The patient was advised
only follow up visits.
Figure 1: Right ovarian mass (green
arrow), fibroid (yellow arrow), indentation on fundus due to septum (orange
arrow) and normal ovary (purple arrow).
Figure 2: Fungating growth on the
surface of the ovarian mass (arrow).
Figure 3: Omentum
with nodules.
Discussion
Epithelial cancers are
most common ovarian malignancies of which 75% are of serous type. Ovarian
cancers are associated with low parity and infertility.
The incidence of ovarian tumor is 1/556 during pregnancy.[1]
Approximately 3%
of women diagnosed with a malignancy of the reproductive tract will have a
coexisting pregnancy.[2] In first two decades of life,
almost 75% of ovarian tumors are of germ cell origin. Dysgerminoma is the most
common ovarian germ cell tumor that coexists with pregnancy, and constitutes
25-35% of all ovarian cancers.[3] Borderline ovarian tumors are tumors of low malignant potential
which are confined to the ovary, encountered most frequently between the ages
of 30-50 years and are associated with a good
prognosis. The histological types of ovarian cancers during pregnancy are
similar to those for non pregnant women in the corresponding reproductive-age
group as reported in several studies.[4]
Ovarian
cancers are usually asymptomatic. The vague digestive disturbances such as
flatulence, eructation and abdominal discomfort may precede other symptoms
by many months which have led to the well accepted statement "How many
early ovarian carcinomas have been nurtured in the sea of soda-bicarbonates".
Diagnostic delay is also due to confusion of symptomatology with the
physiologic changes associated with the pregnant state. An
ultrasonography is routinely performed for evaluating fetal status in pregnant
women, which also
helps in the early detection of an incidental ovarian tumor. With increased use
of routine prenatal ultrasonography, finding of
an adnexal mass in pregnancy is also increasing. In malignant tumors the
resistance index is usually low (< 0.4) and there is high peak velocity on
Doppler studies. CT and MRI can be used to
evaluate the tumor and the extent of its spread.
CA-125 higher than 35
U/ml is found in over 80% of non mucinous epithelial ovarian cancers.
During pregnancy,
surgical management of an adnexal mass creates a dilemma to gynecologists. In
case of an
adnexal mass greater than 6 cm in diameter, with a complex
structure, or ascites, surgical management is critical for obtaining a final
histological diagnosis and ruling out malignancy.[5]
In stage 1 low grade,
low risk abdominal hysterectomy with bilateral salphingo-oophorectomy is
appropriate. In patients who desire to preserve fertility, uterus and
contralateral ovary can be preserved in women with stage 1A, grade 1
to 2 disease. Careful monitoring of such patients is required, with routine periodic
pelvic examination and serum CA-125 levels.
References
1.
Hopkins MP, Duchon MA. Adnexal surgery in
pregnancy. J Reprod Med.1986; 31:1035–1037.
2.
Zanotti KS, Belinson JL, Kennedy AW. Treatment
of gynecologic cancers in pregnancy. Semin
Oncol. 2000;27:686–698.
3.
Dgani R, Shoham Z, Atar E, Zosmer A, Lancet M.
Ovarian carcinoma during pregnancy: a study of 23 cases in Israel between the
years 1960 and 1984. Gynecol Oncol. 1989;33:326–331.
4.
Behtash N, Karimi
Zarchi M,
Modares Gilani M, Ghaemmaghami F, Mousavi A, Ghotbizadeh F. Ovarian
carcinoma associated with pregnancy: a clinicopathologic analysis of 23 cases
and review of the literature. BMC Pregnancy Childbirth. 2008;8:3.
5.
Dudkiewicz J, Kowalski T, Grzonka D, Czarnecki
M. Ovarian tumors in pregnancy. Ginekol Pol. 2002;73:342–345.
Citation
More
V, Panchbudhe S, Mali K,
Satia M, Bang N. Borderline Serous
Papillary Neoplasm In A Term Pregnancy. JPGO Volume 1 Issue 4,
April 2014, available at: http://www.jpgo.org/2014/04/borderline-serous-papillary-neoplasm-in.html