A 55-year-old, frail-looking multiparous postmenopausal lady presented with the chief complaints of anorexia and easy fatigability for one month and abdominal distention, decreased urine output and constipation for the last 10 days. She also complained of mass coming out of the vagina for the last 10 days. There was no significant medical, family, psycho-social or past history. On clinical examination, except for the presence of bilateral pedal oedema, her general physical examination was unremarkable. On abdominal examination, she had tense ascites and no abdominal mass could be appreciated. Second-degree cervical descent, cystocele and rectocele were present on local examination (Fig. 1). On per-speculum examination, the cervix and vagina appeared healthy. On pelvic examination, all the fornices were full due to tense ascites and exact uterine size could not be made out. On per-rectal examination, rectal mucosa was free but a hard and fixed mass was felt anteriorly which was high-up in location.
All her routine blood investigations were within normal range except for decreased proteins [serum total proteins = 3.2 gm/dl (6–8.3 gm/dl), serum albumin = 1.8 gm/dl (3.5–5.5 gm/dl)] and raised serum lactate dehydrogenase (1068 U/ml, normal = 100–190 U/L). Biochemical investigations revealed raised levels of tumour markers such as cancer antigen-125 (CA-125) = 225.0 mIU/L (normal = 0–35 mIU/L) and carcinoembryonic antigen = 146.5 ng/ml (normal ≤ 3.4 ng/ml). The abdominal ultrasound (USG) showed the presence of gross ascites and a 10 × 9 × 8 cm solid cystic mass with increased vascularity and multiple septae in the lower abdomen. Uterus measured 6 × 2.5 × 1.5 cm with normal myometrial echotexture. Bilateral ovaries were not visualised. Contrast-enhanced computed tomography (CECT) abdomen revealed the presence of gross ascites with 10.2 × 10.7 × 12.5 cm solid-cystic mass arising from bilateral ovaries. It was extending to the pouch of Douglas (POD), abutting the rectum and sigmoid posteriorly and pelvic wall laterally with maintained fat planes. Hypodense soft tissue deposits likely metastasis were also reported in a subcapsular location in the liver (2.5 × 2 cm), pancreas (2.8 × 1.8 cm) and at the gastro-oesophageal junction (1 × 1 cm). A radiological diagnosis of ovarian neoplasm with metastasis was given. An ascitic fluid examination done for malignant cytology was suggestive of mucin secreting neoplasm. USG guided fine needle aspiration cytology, from the mass was reported as adenocarcinoma. Upper Gastrointestinal and lower Gastrointestinal endoscopies were unremarkable. Her Risk of malignancy index score was 2025; suggestive of malignancy. Using the International Ovarian Tumour Analysis ADNEX model various risks calculated were 42.8% for benign, 57.2% for malignant and 41% for borderline [1].
A preoperative diagnosis of FIGO stage IV ovarian carcinoma was made and she was planned for neoadjuvant chemotherapy followed by interval debulking and adjuvant chemotherapy. She received her first cycle of paclitaxel and carboplatin-based chemotherapy uneventfully. During her second cycle, while still admitted in the hospital, she reported an episode of sudden, unprovoked, spontaneous, painless gush of fluid coming out through her vagina while she was ambulating. On examination, she was hemodynamically stable and a firm to hard mass with restricted mobility could now be appreciated in the lower abdomen (Fig. 2). On per speculum examination, a defect measuring 3 × 3 cm was seen in the posterior vaginal wall 1 cm from the cervical os (Fig. 3). It had ragged and necrotic margins and fluid with mucus flakes was seen draining out through it. These findings were confirmed on vaginal examination.
The patient was now planned for an exploratory laparotomy on a semi-emergency basis in collaboration with gastro-surgeons. Per-operatively, there was minimal ascites along with left and right ovarian masses, irregular, solid-cystic and each measuring 9 × 6 × 4 cm. There were multiple metastatic omental deposits, the largest measuring 1 cm (Fig. 4). No tumour deposit was felt on the liver surface, stomach, spleen, colon, small intestine, pancreas, paracolic gutters or pouch of Douglas. No retroperitoneal or pelvic lymph nodes were palpated. A defect with necrotic margins was confirmed in the posterior vaginal wall which measured 3 × 3 cm (Fig. 5). A total abdominal hysterectomy with bilateral salpingo-oophorectomy with omentectomy with appendicectomy was performed. The posterior vaginal wall rent was repaired in two layers. An intra-abdominal drain was put in and left for 15 days postoperatively in order to avoid pressure impact on the repaired area in case of recurrence of ascites. The patient tolerated the procedure well.
Post-operative course
Mild leak per-vaginum continued postoperatively and stopped on the 3rd postoperative day. Stitch removal was done on day 10. The final histopathology report read as bilateral adnexal masses showing mucinous adenocarcinoma with tumour cells infiltrating the capsule along with multiple foci of tumour deposits in the omentum. No evidence of malignancy was seen in the specimen of uterus, cervix, fallopian tubes, appendix or the excisional biopsy taken from the margin of the defect in the posterior vaginal wall. Adjuvant chemotherapy with paclitaxel and carboplatin was started 3 weeks postoperatively and 4 cycles were given. Post chemotherapy, the patient appeared clinically well and radiologically tumour free with CA 125 level of 38 IU/ml for a follow-up period of 8 months. She is currently under follow up. There has been no adverse or unanticipated events till the date of follow-up.
