A 72 Year Old Woman With Shortness of breath and Abdominal Swelling ...

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: 
Haemoglobin = 9.2 g/dL
CA-125 = 118 ku/L (normal <30ku/L)
Other routine blood work including liver function test and renal function was in normal range.

The Chest X ray shows An effusion on the right side and Ct scan of the abdomen and pelvis reveals a tumor on the left side and ascites.

Questions
• What is the likely diagnosis?
• How should this woman be further investigated?
• If the diagnosis is confirmed how should she be managed?

Answers And Discussion: 


• What is the likely diagnosis?
The most likely Diagnosis is Ovarian carcinoma
Discussion: The history and examination are suggestive of a right pleural effusion and ascites. Them 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.
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.

• How should this woman be further investigated?
To confirm the diagnosis the ovarian tissues should be obtained for pathology.

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 salpingoophorectomy
and to reduce all abdominal tumour deposits to a volume of less than 2 cm. This allows optimal effect of chemotherapy following surgery.

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

• The prognosis for ovarian cancer is poor, as most women present at stage 3 or 4.
• Staging and primary treatment is by laparotomy, total abdominal hysterectomy, bilateral salpingoophorectomy and debulking.
• Chemotherapy is often effective adjuvant therapy.
• Prior to any treatment this woman also needs drainage of her pleural effusion for symptomatic
• relief and optimization for anaesthetic.