Presentation
Bloating and abdominal pain. Rule out appendicitis/diverticulitis.
Patient Data
There is a large heterogeneous mass posterior to the body of an anteverted uterus and cervix and inseparable from them. The mass measures approximately 9 x 5 x 8 cm. There is significant stranding surrounding the mass and also within the peritoneum of the lower abdomen extending to the level of kidneys superiorly. The sigmoid is closely related to this inflammatory changes with the deep pelvis and demonstrates wall thickening which could be reactive at this region. The mass cannot be confidently separated from the anterior wall of the proximal cecum. No upstream bowel obstruction. There is a 1 cm cyst in the left adnexa, likely ovarian in origin. However, both ovaries are not confidently identified. Likely calcified uterine intramural fibroid.
There are scattered peritoneal deposits and omental caking with large deposits along the mesentery of the descending colon and distal transverse colon. There is thickening of the presacral fascia, which could be due to small amount of free fluid.
Peritoneal deposits attached to the inferior edge of segment 6, measuring 2.5 x 2.1 cm.
An implant within the splenic hilum measuring 2.5 x 2.6 cm. Further medially and inferiorly there is another implant that measures 3.6 x 3.0 cm.
The gallbladder is thin-walled and contains a couple of peripherally calcified calculi. No biliary tree dilatation.
Bilateral simple cortical cysts.
Likely prior sleeve gastrectomy. No convincing signs of diverticulitis or appendicitis.
Mild left convex scoliosis of the spine. No aggressive destructive changes.
Fat containing periumbilical hernia.
Subsequent ultrasound images (not shown) performed the same day demonstrated a vascular mass lesion abutting the uterus.
Case Discussion
In the context of a high suspicion for a gynecological neoplasm, CA-125 marker was drawn the same day; it came back at a level of 1326 U/mL. Approximately 10 days later, the CA-125 level had increased to 1910 U/mL.
Our patient went on to have a biopsy of one of the left upper quadrant peritoneal implants, whose immunohistochemistry revealed the following:
- PAX8, Wt-1, CK-7: diffusely positive
- p16: abnormal, overexpressed
- p53: abnormal, overexpressed
- estrogen receptors: positive, moderate to strong intensity in >90% of tumor cells
- progesterone receptors: weakly positive in rare tumor cells
- GATA3: focally positive, weak
- CK-20, TTF1, napsin, D2-40, calretinin: negative
The immunoprofile is in keeping with the diagnosis of high grade Mullerian carcinoma. In view of the Wt1 positivity, the possibility of a high grade serous carcinoma of tubo-ovarian primary is favored over that of an endometrial primary.
Two weeks later, our patient underwent TAH, BSO and omentectomy with debulking.
Histopathological studies of specimens from the debulking pouch of douglas, uterus, fallopian tubes, ovaries + cervix, omentum, stomach, and splenic flexure confirm high grade serous carcinoma.
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