CASE STUDY. Presented by: Jessica Pizzo. CFCC Sonography student Class of 2018

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Sherilyn Harper
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1 CASE STUDY Presented by: Jessica Pizzo CFCC Sonography student Class of 2018

2 Case Presentation April 4, yr old woman presented to ED with lower abdominal pain & swelling, along with constipation. Prior History Patient stated she had a partial hysterectomy in 1979 due to a history of very large ovarian cysts but that she still retained her right ovary. Methods Standard transabdominal & transvaginal ultrasound scans were ordered and completed per NHRMC pelvic protocol using a GE Logic 9 machine.

3 Transabdominal view Transvaginal view Sagittal Midline Sagittal Midline Only bowel, free fluid, and the bladder were visualized More free fluid and bowel visualized

4 Transvaginal view Sagittal LEFT adnexa Sagittal RIGHT adnexa Nothing visualized Right Ovary seen with cystic appearing structures

5 Transvaginal view Transverse Right Ovary Right Ovary seen with complex cystic & solid features

6 Transvaginal view Transverse Right Ovary Right Ovary seen with complex cystic & solid features, possible papillary projections?

7 Transvaginal view Sagittal Right Ovary Right Ovary with color doppler

8 Transvaginal view Sagittal Right Ovary Sagittal Right Ovary Right Ovary positive for Venous flow Right Ovary positive for Arterial flow

9 Other notes The patient s ovary measured: 4.9 x 4.6 x 2.5 cm This could be considered slightly enlarged since the average ovarian size in an adult is: 2.5-5cm x 1.5-3cm x cm A woman who has been in menopause for several decades typically should have ovaries much smaller than that.

10 Differentials Due to the complexity of the structures, several diagnoses could be possible: Endometrioid Adenocarcinoma Serous Ovarian Cystadenocarcinoma Clear Cell carcinoma Kruckenberg s tumor

11 Radiologist Report The uterus is not visualized, nor is the left ovary. The right ovary appears complex with multiple physiologic cysts & follicles versus a single cystic and solid lesion within the right ovary. I would suggest a 6-wk follow-up to ensure resolution of the area of complexity as described.

The CT scan also showed the Ovarian mass that was seen on ultrasound, along with

12 Patient Follow Up Our patient also had a CT scan with contrast and it revealed a tumor near the rectosigmoid colon. The CT scan also showed the Ovarian mass that was seen on ultrasound, along with Hepatic Metastases, Pulmonary nodules, Pleural effusion, solid splenic lesions, and enlarged lymphnodes. She was given a diagnosis of Stage 4 Colon Cancer

13 Patient Follow Up After all imaging was done, she was sent to an Endoscopist in the hospital where she received a flexible sigmoidoscopy. The Endoscopist did visualize an obstruction in the sigmoid colon area. He tried to protrude through the mass to place a colonic decompression stent, in which he was unable to do so.

14 Patient Follow Up The next day (April 5, 2017) she was moved to the Critical care unit and became hypotensive, tachycardic, with worsening metabolic (lactic) acidosis and progressive renal insufficiency. She had Septic shock, acute renal failure, acute hypoxemic respiratory failure, abdominal perforation/ peritonitis status POST exploratory laparotomy/colectomy with anemia due to blood loss. After becoming Code Blue several times, her family decided to sign a DNR. She expired shortly after at 7:52am on April 6 th Just 3 days before her 57 th birthday

15 Patient Follow Up The only Ovarian diagnosis able to be found on her paperwork stated: Carcinomatosis Ovarian Mass which means: a condition in which multiple carcinomas develop simultaneously usually after dissemination from a primary source. In her case, Colon cancer.

16 Learning Opportunity Many ovarian malignancies can be indistinguishable from their benign counterparts. It s best to also order an abdomen complete/ct when suspecting Malignant ovarian masses in order to look for ascites, mets, nodules, or pleural effusion. Also, many cancers can spread to the ovary and MIMIC primary ovarian tumors, when in fact, the symptoms are NOT Ovarian in origin but are being caused by a malignancy elsewhere. There is an informative article online called Colon cancer in Ovaries vs. Ovarian cancer by Dr. Richard Reichert. It stated that Colon cancer is one of the most (if not THE most) common cancers to metastasize to the ovaries. It often appears indistinguishable from primary ovarian cancers and is COMMONLY misdiagnosed as an Endometrioid or Mucinous carcinoma. A patient who has been diagnosed with primary ovarian carcinoma of the Endometrioid or Mucinous type involving BOTH ovaries and extending into any other tissue beyond the ovary should get a Second opinion. If the patient has a known history of colon cancer, then an expert second opinion is warranted even if only one ovary is involved. An additional red flag is the finding of metastases in the LIVER, which is typical of metastatic colon cancer and almost unheard of for metastatic ovarian cancer.

Sarah Burton. Lead Gynae Oncology Nurse Specialist Cancer Care Cymru

Sarah Burton. Lead Gynae Oncology Nurse Specialist Cancer Care Cymru Sarah Burton Lead Gynae Oncology Nurse Specialist Cancer Care Cymru Gynaecological Cancers Cervical Cancers Risk factors Presentation Early sexual activity Multiple sexual partners Smoking Human Papiloma