Obgyn · Year 3 · from Obgyn

Case 2: Complex Ovarian Mass in a Postmenopausal Woman

Patient Demographics

• Age: 62 years
• Sex: Female
• Occupation: Retired schoolteacher

Chief Complaint

"I've been feeling bloated and my pants don't fit anymore."

History of Present Illness

The patient reports 3 months of progressive abdominal bloating, early satiety, and a 10-pound unintentional weight loss. She initially attributed symptoms to digestive issues but they have progressively worsened. She now feels full after eating only small amounts and has noticed her abdomen is larger despite losing weight. She denies vaginal bleeding, pelvic pain, or changes in bowel or bladder function. She has not seen a gynecologist in 5 years.

Gynecologic History

• Menarche: Age 11
• Menopause: Age 52
• No hormone replacement therapy
• Prior pregnancies: G2P2
• Last Pap smear: 5 years ago (normal)
• No history of abnormal Pap smears

Past Medical History

• Hypertension (on lisinopril)
• Hyperlipidemia (on atorvastatin)
• Prior cholecystectomy

Family History

• Mother: Breast cancer at age 68
• Sister: Ovarian cancer at age 58 (deceased)
• Maternal aunt: Breast cancer at age 55

Physical Examination

• Vital Signs: BP 138/82, HR 78, Weight 155 lbs (down from 165 lbs 3 months ago)
• General: Thin-appearing woman in no acute distress
• Abdomen: Distended, firm, palpable mass extending from pelvis to umbilicus, shifting dullness present (ascites), non-tender
• Pelvic: Cervix atrophic, uterus obscured by mass, large pelvic mass filling pelvis and extending into abdomen, fixed

Concerning Features

• Postmenopausal with new pelvic mass
• Symptoms classic for ovarian cancer (bloating, early satiety, weight loss)
• Ascites present
• Fixed, large mass
• Strong family history of breast and ovarian cancer

Diagnostic Workup

Laboratory Studies:

Transvaginal and Transabdominal Ultrasound:

• Large complex pelvic mass (12 cm) with solid and cystic components
• Thick septations (>3 mm)
• Papillary projections into cyst
• Internal vascularity on Doppler
• Moderate ascites
• Right ovary not separately visualized (mass arising from right adnexa)
• Left ovary: Atrophic, normal

CT Abdomen/Pelvis:

• 12 cm complex right ovarian mass
• Moderate ascites
• Omental thickening (omental caking) - suspicious for peritoneal carcinomatosis
• Enlarged para-aortic lymph nodes (up to 2 cm)
• No liver metastases
• No hydronephrosis

Diagnosis

Suspected Ovarian Malignancy (High-Grade Serous Carcinoma)

• Postmenopausal with complex adnexal mass
• Markedly elevated CA-125
• Suspicious imaging features (solid components, papillary projections, ascites)
• Omental caking suggesting advanced disease
• Strong family history suggesting possible hereditary cancer syndrome

Referral to Gynecologic Oncology

Indication for Oncology Referral:

• Postmenopausal patient with:
• Elevated CA-125
• Complex mass with solid components
• Ascites
• Imaging suggestive of metastatic disease

Benefit of Subspecialty Care:

• Gynecologic oncologists achieve better surgical outcomes
• Complete cytoreduction improves survival

Surgical Planning

Preoperative:

• Genetic counseling and BRCA testing initiated
• Paracentesis for symptom relief (4 L ascitic fluid removed)
• Cytology of ascites: Positive for adenocarcinoma
• Bowel prep administered
• Discussed goal of optimal debulking

Surgical Treatment: Exploratory Laparotomy and Tumor Debulking

Operative Findings:

• Moderate ascites
• 14 cm right ovarian mass with capsular rupture
• Omental carcinomatosis
• Diaphragm implants bilaterally
• Para-aortic lymphadenopathy
• No liver or splenic involvement
• Bowel serosa implants (superficial)

Procedure Performed:

• Total abdominal hysterectomy
• Bilateral salpingo-oophorectomy
• Total omentectomy
• Para-aortic and pelvic lymphadenectomy
• Peritoneal stripping from diaphragm
• Appendectomy

Outcome:

• Optimal debulking achieved (residual disease <1 cm)

Final Pathology

• High-grade serous carcinoma of the ovary
• FIGO Stage IIIC (peritoneal metastases >2 cm outside pelvis + positive lymph nodes)
• Fallopian tube epithelium with STIC (serous tubal intraepithelial carcinoma) - suggesting tubal origin

BRCA Testing Result

• BRCA1 pathogenic mutation detected
• Family members counseled regarding testing

Adjuvant Treatment

• Intravenous chemotherapy: Carboplatin + Paclitaxel x 6 cycles
• Maintenance therapy: PARP inhibitor (olaparib) given BRCA1 mutation

Prognosis

• Stage IIIC with optimal debulking: ~40% 5-year survival
• BRCA1 mutation: More favorable response to platinum chemotherapy and PARP inhibitors

Teaching Points

• Ovarian cancer classically presents with vague symptoms (bloating, early satiety, weight loss)
• 75% of ovarian cancers are diagnosed at advanced stage
• Postmenopausal patient with elevated CA-125 and complex mass has high malignancy risk
• Referral to gynecologic oncology improves outcomes
• BRCA mutations increase ovarian cancer risk significantly
• High-grade serous carcinoma often originates from the fallopian tube

Clinical Image

Image Description: Axial CT image of the abdomen/pelvis demonstrating a large complex ovarian mass with solid and cystic components, moderate ascites, and omental thickening (omental caking) consistent with peritoneal carcinomatosis in a patient with advanced ovarian cancer.

Attribution: Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0.

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