CASE PRESENTATION OF

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• CASE PRESENTATION OF
• RECURRENT ABDOMINO PELVIC MASS
• DR. BUSHRA RAHIM
• PGT-IV, GYNAE/OBS UNIT II
• HOLY FAMILY HOSPITAL
• RAWALPINDI

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PATIENT PROFILE

• Name XYZ
• Age 14 years
• Marital Status Unmarried
• Occupation Student of 7th Class
• Resident of Taxilla
• Date of admission 19-02-2015
• Mode of admission OPD

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PRESENTING COMPLAINTS

• Abdominal distension 04 months
• Lower abdominal pain 01 month

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HISTORY OF PRESENTING COMPLAINTS

• Abdominal distension gradually progressing
• Lower abdominal pain mild and non radiating
• Weight loss
• No history of anorexia, bowel and urinary
  complaints

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PAST SURGICAL HISTORY

• Patient had two operative procedures
• 1st Laparotomy / Appendectomy in Jan, 2014 in
  SU-II, HFH
• Incidental finding was right ovarian cyst
• Appendectomy and cystectomy done
• Histopathology revealed inflamed appendix and
  mature teratoma

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PAST SURGICAL HISTORY

• 2nd Laparotomy
• Done in private hospital by general surgeon for
  torsion of ovarian cyst in June 2014
• On discharge slip no operative findings were
  documented

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MENSTRUAL HISTORY

• Menarche 14 yrs
• Menstruated only once for 07 days
• LMP 03-01-2015

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• FAMILY HISTORY
• Not significant
• PERSONAL HISTORY
• Non smoker, non addict, normal sleep and appetite

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SOCIO-ECONOMIC HISTORY

• Lower socio-economic status
• Father is a laborer

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EXAMINATION

• GENERAL PHYSICAL EXAMINATION
• Pulse 84/min
• B.P. 120/80 mmHg
• Temperature 98 F
• Thyroid Lymph Nodes
• Pallor

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SYSTEMIC EXAMINATION

• Unremarkable

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• ABDOMINAL EXAMINATION
• INSPECTION
• Grid iron and Pfannenstiel scar mark
• PALPATION
• Mass of 34 cm
• Firm, fixed, non tender
• Arising from pelvis
• Irregular margins

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INVESTIGATIONS

• Blood group O
• Rh Factor Positive
• Hb 10.9 g/dl
• Platelet count 234,000/mm3
• Viral serology Negative
• RBS 78mg/dl
• LFTs / RFTs Normal
• Urine R/E Clear

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TUMOR MARKERS

• CA-125 175 mIU / ml (ref. range lt35 mIU)
• Beta hCG 0.27 mIU/ml (ref. range lt2.5 mIU)
• ?lpha feto protein 170 ng/ml (ref. range lt31
  mIU)
• LDH 391 u/l (ref. range lt2.5 mIU)

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ULTRASOUND

• A heterogeneous solid mass with few areas of
  cystic degeneration
• Ovaries not separately visualized
• Uterus normal looking

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CT SCAN

• A heterogeneously lobulated multiseptated mass
  measuring 14072100 mm
• Compressing bladder
• Abutting anterior abdominal wall
• Pushing uterus posteriorly
• Right ovary not visualized
• Left ovary normal

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DIFFERENTIAL DIAGNOSIS

• Malignant ovarian tumors
• Benign ovarian tumors
• Uterine fibroids
• Retroperitoneal mass

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COUNSELLING OF PARENTS

• Conservative surgery
• Chances of second laparotomy
• Need for adjuvant chemotherapy
• Prospects of future fertility

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PROCEDURE

• Exploratory laparotomy on 02-03-15
• Mid line incision
• No ascites
• Peritoneal washings sent for cytology
• Huge firm vascular right sided ovarian mass
• Intact capsule
• Omentum stretched over the mass

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PROCEDURE CONT.

• Uterus nulliparous size
• Left ovary and tube normal looking
• Liver surface smooth

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PROCEDURE CONT

• Rt ovarian mass removed
• Ovarian mass sent for histopathology
• Omental biopsy taken and sent for histopathology
• Biopsy from contralateral ovary taken

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POST OP RECOVERY

• Smooth and uneventful

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HISTOPATHOLOGY REPORT

• Right ovarian mass Immature teratoma
• Omental Biopsy Non specific inflammation
• Peritoneal fluid Negative for malignant cells
• Biopsy of left ovary Unremarkable

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REFERRAL

• Patient referred to NORI hospital for oncologist
  opinion
• BEP regimen
• Three courses of chemotherapy till now

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