History
A 72-year-old woman has been admitted with shortness of breath. On further questioning she says she has been unwell for about 8 weeks. She has decreased appetite and nausea when she eats. She has lost weight but her abdomen feels swollen. She has generalized dull abdominal pain and constipation, which is unusual for her. There are no urinary symptoms. She has always been healthy with no previous hospital admissions. She is a widow and did not have any children. Her periods stopped at 52 years and she has had no post-menopausal bleeding. She has never taken hormone-replacement therapy.
Examination
She appears pale and breathless on talking. Chest expansion is reduced on the right side, with dullness to percussion and decreased air entry at the right base. The abdomen is gen-erally distended with shifting dullness. There is a mass arising from the pelvis. Speculum examination is normal, but on bimanual palpation there is a fixed left iliac fossa mass of about 10 cm diameter.
Questions
• What is the likely diagnosis?
• How should this woman be further investigated?
• If the diagnosis is confirmed how should she be managed?
Medicine
The history and examination are suggestive of a right pleural effusion and ascites. The presence of a pelvic mass would suggest that this is due to an ovarian or bowel problem. The chest X-ray confirms the effusion, and the CT shows a left-sided pelvic tumour and ascites. There are also solid areas in the anterior abdominal wall that represent omental infiltration by the tumour.
CA-125 is a non-specific marker for ovarian carcinoma. The diagnosis is therefore likely to be that of ovarian cancer which commonly presents with systemic symptoms when metastatic disease is already evident. Confirmation of the diagnosis and management The surgical aphorism ‘there is no diagnosis without a surgical diagnosis’ means that tis-sue needs to be obtained to confirm the diagnosis. Laparotomy should be performed with three objectives:
1 obtaining tissue for diagnosis
2 staging the disease according to the extent of tissue involvement
3 primary debulking – to perform a total abdominal hysterectomy and bilateral salping-oophorectomy and to reduce all abdominal tumour deposits to a volume of less than 2 cm. This allows optimal effect of chemotherapy following surgery. Lymph node dis-section and omental resection are usually part of the procedure. Prior to any treatment this woman also needs drainage of her pleural effusion for symp-tomatic relief and optimization for anaesthetic.
The prognosis for ovarian cancer is poor, as most women present at stage 3 or 4.
KEY POINTS
• CA-125 is a non-specific marker for ovarian cancer.
• Ovarian cancer commonly presents late (stage 3/4) and prognosis is poor.
• Staging and primary treatment is by laparotomy, total abdominal hysterectomy, bilateral
salpingoophorectomy and debulking.
• Chemotherapy is often effective adjuvant therapy.
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