Case 12 A 57-year-old woman with abdominal swelling and vague abdominal pain

 Case 12 A 57-year-old woman with abdominal

swelling and vague abdominal pain

Mrs Rachel Simpson is a 57-year-old woman presenting with

some abdominal swelling and vague abdominal pain. She

noticed early in the year that she was putting on weight and

her clothes were getting tighter round her waist. This was

not unusual for her over Christmas and New Year but

despite trying to diet, the swelling was now noticeable to

her partner and a close friend had commented on it.

She is now very concerned as she finds she is unable to

eat a full meal as she soon feels full up and uncomfortable.

The same friend has long-standing irritable bowel syndrome

and thinks Mrs Simpson has similar symptoms, especially the

bloating. Mrs Simpson is very anxious as her brother died 10

years earlier from bowel cancer

What differential diagnoses

immediately come to mind?

• Ovarian cyst

• Ovarian cancer

• Bowel cancer

• Ascites

What would you like to elicit from

the history?

Presenting complaint

• Details of abdominal pain

• Gastrointestinal symptoms including constipation or

other change in bowel habit, rectal bleeding or bloating

• Weight gain

Associated symptoms

• Symptoms of pressure on bladder (urinary frequency

or incontinence)

• Symptoms associated with pressure on gastrointestinal

tract (early satiety, reflux, heartburn)

• Symptoms of anaemia (tiredness)

Menstrual history

Age at menopause.

Obstetric history

Parity, type of deliveries and any complications.

Family history

History of cancer, particularly endometrial, colon or

breast.

Mrs Simpson tells you that she thinks her last period was 7

years ago and she has had no bleeding since. She has no

children and although she and her husband were

investigated in her late twenties for primary infertility, no

cause was found. She has had problems with constipation

recently but no per rectum bleeding. She has been taking a

laxative which she bought over-the-counter. However, this

has aggravated the feeling of lower abdominal discomfort

and made her feel generally unwell. There is no family

history of endometrial or breast cancer but her brother was

diagnosed with bowel cancer at age 62.

What would you look for on

physical examination?

General examination

Pallor and cahexia are uncommon and even with

advanced disease there may be little or nothing to find

on general examination.

Abdominal examination

A distinct pelvic mass may be palpable above the pubic

symphysis. The size of a mass arising from the pelvis is

measured and stated relative to a pregnant uterus. A

benign mass will tend to be well - defined, smooth and

regular and may be mobile. A malignant mass will tend

to be irregular, difficult to define and may be fixed. There

may be abdominal spread and omental involvement may

be detected as an irregular ill - defined mass in the upper

or mid abdomen. There may be ascites causing distension with shifting dullness and a fluid thrill.

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.88 Part 2: Cases

PART 2: CASES

Pelvic examination

Bimanual examination. The uterus is likely to be small in

a postmenopausal woman and can be felt separately but

may become involved in a malignant mass. Feel on either

side of the uterine body for adnexal masses. A malignant

mass may be felt separately but may fill the pelvis giving

an indistinct impression of thickening and induration.

To summarize your findings so far, Mrs Simpson is a

57-year-old para 0 + 0 with a 6-month history of increasing

abdominal swelling and vague lower abdominal pain. On

examination, her BMI is 28, and there are obvious abnormal

findings, with generalized distension associated with shifting

dullness and a fluid thrill. There is an irregular firm swelling

in her upper abdomen which is difficult to define and

nodular fixed mass in her lower abdomen. Pelvic

examination is difficult as she is nulliparous and

postmenopausal. She cannot tolerate a speculum and, on

one finger vaginal examination, she has a craggy fixed mass

which cannot be distinguished in origin.

What do you do next?

Serum sample for CA125

Serum CA125 is often used in the investigation of women

with a pelvic mass to identify ovarian cancer.

Ultrasound scan of her abdomen and pelvis

Ultrasound scan of the abdomen and pelvis will identify

the mass. Important features that are suggestive of malignancy are used to calculate a risk of malignancy score (see

below). These include the structure of the cyst in terms

of cystic or solid, presence of ascites and disease beyond

the pelvis.

What other investigations would

you recommend?

• Full blood count (FBC) to check for iron deficiency

anaemia

• Urea and electrolytes (U & E) to check renal function

• Liver function test (LFT) to check for evidence of liver

involvement. Low albumin may be seen with ascites.

Her CA125 level is 437IU/mL (upper limit of normal is 30IU/

mL) (Box 12.1).

Her ultrasound report shows a slightly bulky uterus with a thin

regular endometrium. Neither ovary can be identified separate

to a large complex mass filling the pelvis. There are multiple

locules and solid areas and there is free fluid in the abdomen.

Her FBC, U&E and LFT are all with in the normal range.

What would you do next?

Risk of Malignancy Index scoring system

Risk of Malignancy Index (RMI) is used to calculate a

score based on CA125 level, menopausal status and a

score of the features identified on ultrasound. The score

is used to predict the likelihood of an ovarian mass being

malignant and appropriate referral for management

(Table 12.1 ).

RMI ultrasounds score menopausal score

CA IU mL

= ×

× 125( )

Box 12.1 CA125

• Glycoprotein antigen

• Serum level raised in 80% of women with ovarian

cancer but only 50% of women with stage I disease

• Used in detecting and monitoring epithelial ovarian

tumours

• May also be raised with other malignancies (colon,

pancreas, breast, lung)

• Also with benign conditions (menstruation,

endometriosis, pelvic inflammatory disease, liver disease,

recent surgery, effusions)

Table 12.1 Risk of Malignancy Index (RMI) scoring system.

Feature RMI 2 score

Ultrasound findings:

• Multiloculated cyst 0 = none

• Contains solid areas 1 = Only 1 feature present

• Both ovaries involved 4 = ≥2 features present

• Ascites present

• Intra-abdominal spread

identified

Menopausal status Premenopausal = 1

Postmenopausal = 4

CA125 IU/mL

KEY POINT

Women with an RMI score >200 should be referred to the

gynaecology oncology service.Case 12 89

PART 2: CASES

Now calculate the RMI (using RMI 2 score) for

Mrs Simpson

Calculation of RMI ultrasound score menopausal

score CA I

= ×

× 125( ) U mL

4 4 37 × ×

6992

Now review your differential diagnoses

1 Ovarian cyst. Unlikely because of her RMI score which

greatly exceeds 200.

2 Endometriomas. These have a complex structure with

solid elements and cause a modest rise in CA125 because

of peritoneal involvement. This may be considered in

premenopausal women but would not be expected as a

new finding in a postmenopausal woman.

3 Ovarian cancer. This is the most likely cause so far

based on her results and RMI score. No further imaging

is required but you may consider a CT scan of her

abdomen and pelvis for more information on the extent

of metastatic disease such as omental involvement and

peritoneal disease.

4 Bowel cancer. Although initially plausible, this is

unlikely given the high risk of ovarian malignancy.

However, the features of metastatic bowel cancer can be

very similar to ovarian cancer and histology may be necessary to establish the diagnosis. She has a history of a

first degree relative with bowel cancer but this does not

put her at high risk of a genetic cause (Box 12.2 ).

5 Ascites. This has been found on her scan and is most

likely caused by her advanced ovarian cancer and not a

Box 12.2 Ovarian cancer and high risk groups

Only 5–10% of ovarian cancers are familial. High risk

families for ovarian cancer have:

• Two or more first degree relatives with ovarian cancer

• One relative with ovarian cancer and one with breast

cancer before age 50

• One relative with ovarian cancer and two with breast

cancer diagnosed before age 60

• Known carrier of BRCA1 or BRCA2

• Three or more family members with colon cancer, or

two with colon and one with gastric, ovarian,

endometrial, urinary tract or small bowel cancer in two

generations

• An individual with both primary ovarian and breast

cancer

non - malignant cause. In uncertain cases, ascetic tap is

performed for cytology and biochemistry.

What treatment options would you

offer this patient?

The likelihood of malignancy and treatment plan needs

to be discussed with Mrs Simpson. At this stage, she

needs to be discussed at the gynaecology oncology

multidisciplinary team meeting. The main stay of treatment is surgery and chemotherapy.

Surgery

Most women with ovarian cancer will require a laparotomy to establish the diagnosis, stage the extent of disease

(Table 12.2 ) and to reduce the tumour bulk. Most

women present with advanced disease (FIGO stage III or

IV) and complete tumour clearance may not be possible.

However, optimal debulking of tumour will improve the

response to chemotherapy and prolong survival.

Laparotomy should include peritoneal cytology of any

free fluid or washings, hysterectomy, bilateral salpingo -

ophorectomy and omentectomy. The peritoneum, liver,

spleen, appendix, retroperitoneal lymph nodes and the

diaphragmatic surface need to be inspected or palpated

for evidence of spread.

Mrs Simpson undergoes a laparotomy. She is found to have

bilateral complex ovarian masses which are adherent to her

uterus. Free fluid in her pelvis is aspirated and sent for

cytology. Her omentum contains nodules of tumour and

there are fine seedlings over her pelvic and abdominal

peritoneum. Her liver and spleen are normal and there is no

nodal enlargement in the pelvis or para-aortic nodes. A total

abdominal hysterectomy, bilateral salpingo-oophorectomy

and infracolic omentectomy are performed. At the end of

the procedure the only residual disease is the ‘sago

seedlings’ on her peritoneum.

Histology confirms a moderately differentiated serous

cystadenocarcinoma of ovarian origin with involvement of

the omentum. This is FIGO stage IIIc.

Chemotherapy

Women with disease other than FIGO stage Ia will

require chemotherapy in addition to surgery (adjuvant

chemotherapy). Chemotherapy should include a platinum agent in combination with paclitaxel or as a single

agent if the patient is unfit or unwilling to have combination treatment. Mrs Simpson needs information on her

likely response to chemotherapy and possible adverse90 Part 2: Cases

PART 2: CASES

CASE REVIEW

This postmenopausal woman presents with increasing

abdominal swelling and vague lower abdominal pain. The

presenting symptoms of ovarian cancer are non - specific

and there is no one typical symptom. However, her age,

nulliparity and clinical findings of ascites and an irregular

pelvic mass are very suggestive of ovarian cancer. Ovarian

cancer is rare under the age of 30. The incidence increases

with age, with peak prevalence in women in their fifties.

Although this patient has a family history of bowel cancer

in a first degree relative, this does not meet the criteria of

a high risk family history.

The use of a RMI is useful in determining appropriate

referral and is based on menopausal status, CA125 tumour

marker level and ultrasound scan findings. Abdominal and

pelvic ultrasound are the most important imaging investigations at this stage. As is often the case, ovarian cancer is

often advanced before the patient presents with symptoms.

Epithelial tumours account for over 90% of all ovarian

cancers and are usually associated with an increased CA125

although less often with FIGO stage I disease. Spread is

often within the peritoneal cavity, and peritoneal and

omental disease and ascites may be apparent on clinical

examination or imaging.

First line treatment involves cytoreductive surgery

with the aim of removing, or at least optimally debulking

the tumour and chemotherapy. Optimal surgery will

include a total abdominal hysterectomy, bilateral salpingo - oophorectomy and omentectomy. First line chemotherapy should be a combination of carboplatin and

a taxane. Survival is related to the stage of disease at

presentation. However, most women present with

advanced disease when the 5 - year survival is only 10 –

15% and most women will develop recurrent disease

within 2 years.

Table 12.2 FIGO (International Federation of Gynaecology and Obstetrics) staging of ovarian cancer and 5-year survival.

Stage Findings 5-year survival

I Confined to one or both ovaries

Ia Limited to a single ovary 90%

Ib Limited to both ovaries 85%

Ic One or both ovaries with surface tumour or ruptured capsule; malignant ascites or washings 80%

II Extension to other pelvic structures

IIa Extension to uterus or tubes 70%

IIb Extension to other pelvic tissues 64%

IIc As IIa or but with surface tumour or ruptured capsule; malignant ascites or washings

III Peritoneal implants outside the pelvis or positive retroperitoneal nodes

IIIa Microscopic seedlings of peritoneum 59%

IIIb Peritoneal implants <2cm 40%

IIIc Peritoneal implants >2cm or positive retroperitoneal nodes 29%

IV Distant metastasis including liver or pleural fluid 17%

effects when deciding on treatment. Cure is unlikely and

the aim is to achieve remission from the disease.

Mrs Simpson decides on a combination of carboplatin and

paclitaxel. She has six pulses of treatment. She is able to

cope with the expected side-effects of nausea and vomiting

with prophylactic antiemetics. She experiences complete hair

loss during her treatment. At the end of her treatment, she

has no clinical evidence of disease and her CA125 level has

fallen to 10IU/L.

This is a complete clinical and biochemical response.

However, she is likely to develop recurrence of her disease

with in 6–36 months and is followed up in a multidisciplinary

clinic. Follow-up provides reassurance and may identify

recurrence. In the case of recurrence, chemotherapy may be

used with the aim of palliating symptoms.Case 12 91

PART 2: CASES

KEY POINTS

• Pregnancy should be excluded in young women with a

pelvic mass

• Benign pelvic masses such as benign ovarian cysts and

fibroids are usually identified in premenopausal women

• Ovarian cancer should be considered in postmenopausal

women with a pelvic mass

• CA125 and ultrasound are the most useful baseline

investigations

• The aim of surgery is to make a diagnosis, stage the

disease and to debulk the tumour as much as possible

• Except for very early stage disease (FIGO stage Ia), women

will require combined chemotherapy