Case 6: Shortness of breath and abdominal pain

 

Case 6: Shortness of breath and abdominal pain

CASE 6: SHORTNESS OF BREATH AND ABDOMINAL PAIN

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 postmenopausal

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 generally 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.

INVESTIGATIONS

Normal range

Haemoglobin 9.2 g/dL 11.7–15.7 g/dL

Mean cell volume 82 fL 80–99 fL

White cell count 4.1×109/L 3.5–11×109/L

Platelets 197×109/L 150–440×109/L

Sodium 135 mmol/L 135–145 mmol/L

Potassium 4.0 mmol/L 3.5–5 mmol/L

Urea 5.1 mmol/L 2.5–6.7 mmol/L

Creatinine 89 mmol/L 70–120 mmol/L

Alanine transaminase 18 IU/L 5–35 IU/L

Aspartate transaminase 17 IU/L 5–35 IU/L

Alkaline phosphatase 78 IU/L 30–300 IU/L

Bilirubin 12 mmol/L 3–17 mmol/L

Albumin 30 g/L 35–50 g/L

CA-125 118 ku/L <30 ku/L

Chest X-ray and abdominal computerized tomography (CT) scan are shown in Figs. 6.1

and 6.2 respectively.100 Cases in Obstetrics and Gynaecology

14

Questions

• What is the likely diagnosis?

• How should this woman be further investigated?

• If the diagnosis is confirmed how should she be managed?

Figure 6.1 Chest X-ray.

Figure 6.2 Abdominal CT scan.Case 6: Shortness of breath and abdominal pain

15

ANSWER 6

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 tissue

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 dissection and omental resection are usually part of the procedure.

Prior to any treatment this woman also needs drainage of her pleural effusion for symptomatic relief and optimization for anaesthetic.

The prognosis for ovarian cancer is poor, as most women present at stage 3 or 4.

! Ovarian cancer staging and prognosis

Stage

Prognosis

(5-year

survival rate)

Stage 1

Confined to the

ovaries

1A One ovary affected, ovarian capsule is

intact

1B Both ovaries affected, ovarian capsules

intact

1C Ovarian capsule is ruptured, tumour on

ovarian surface or malignant cells

detected in ascites or peritoneal washings

90%

Stage 2

Pelvic spread

2A Extension or implantation into the uterus

and/or fallopian tubes (no malignant cells

in ascites/peritoneal washings)

2B Extension to another organ in the pelvis

(no malignant cells in ascites/peritoneal

washings)

2C As for 2A/B plus malignant cells in ascites/

peritoneal washings

65%

continued100 Cases in Obstetrics and Gynaecology

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! Ovarian cancer staging and prognosis – continued

Stage

Prognosis

(5-year

survival rate)

Stage 3

Peritoneal metastasis

outside the pelvis and/

or regional lymph

node metastasis

(includes liver capsule

metastasis)

3A Microscopic peritoneal metastasis beyond

the pelvis

3B Macroscopic peritoneal metastasis

beyond the pelvis (max. diameter 2 cm)

3C Macroscopic peritoneal metastasis

beyond the pelvis (max. diameter >2 cm)

and/or distant lymph node metastases

35%

Stage 4

Distant metastasis

beyond the peritoneal

cavity (or liver

parenchymal

metastasis)

20%

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.

• Neoadjuvant chemotherapy (preoperative chemotherapy to shrink the tumour

mass down so that debulking surgery is more likely to be successful) may also be

considered depending on the extent of disease on imaging.

• Chemotherapy is often effective adjuvant therapy.