1. Case presentation Dr.Ramesh Sharma Department of Obstetrics and Gynaecology. IOM, TU Teaching Hospital.

2. History 41 year Para 3 lady, from Rukum Post TAH with ? BSO done 6 years back at valley Hospital Presented to our centre with complaint of Mass per abdomen – 1 year Abdominal pain and increase in size of mass for last 5 months Loss of appetite for 5 months

3. History …contd.. Menstrual history- Post TAH Obstetric history- Para 3, all vaginal deliveries at home Contraceptive history- none

4. History …contd.. Past history- TAH done 6 years back for fibroid uterus The per operative finding revealed : A mass around 3 ×3 cm arising from the intestine which was removed. Lumen not involved Uterus was enlarged, tubes and ovaries not commented on Histopathology. Separate mass removed from the intestine shows leiomyoma with hyaline degeneration Endometrium: proliferative; Cervix: chronic cervicitis Status of tubes and ovaries not mentioned

5. History …contd.. Personal history- non smoker, doesn’t consume alcohol Family history – no family h/o malignancy

6. Clinical examination General condition- fair..thin built. Weight: 38 kg Vitals: stable Pallor, edema, dehydration, jaundice- nil No lymphadenopathy Breast, axilla : normal Chest- normal vesicular sounds all over bilateral equal air entry CVS- S1 S2 M0

7. Clinical examination..contd.. Per abdomen- A huge mass(size 30 × 40 cm), solid, stony hard in consistency, bosselated, irregular, well defined margins in the upper and lateral parts, lower border could not be felt, non tender, immobile No ascites

10. Clinical examination..contd.. Vulval inspection- no abnormality P/S- vault/vagina : normal P/V Vaginal vault appeared normal Firm mass felt in anterior fornix Upper pole could not be reached

11. Clinical examination..contd.. Per rectal examination: Rectal mucosa free Anteriorly, hard mass felt

12. Provisional diagnosis Ovarian tumor

13. Investigations

14. Investigations

16. Investigations

17. Imaging studies

18. Ultrasonogram of abdomen

19. Findings: A large, solid mass seen in pelvis measuring approximately 173 ×153 mm suggestive of ovarian tumor. Upper abdomen: no abnormality detected

20. CT ABDOMEN and pelvis

41. CT scan report : 2068/1/12 Post hysterectomy status Huge (30x27x25cm)heterogeneously enhancing mixed attenuation abdominopelvic mass with ovaries not separately identified from this mass –most likely malignant mass of ovarian origin ? side of origin. Diffuse omental thickening and omental caking with small round enhancing nodule (17.5x15.6mm)in rectovesical pouch –s/o omental and peritoneal metastatic deposits Poorly enhancing hypodense nodule(20.7x20.5mm) in right lobe of liver –s/o metastatic lesion

42. CT scan report : 2068/1/12 Multiple mildly enhancing round and oval nodules in scanned part of both lungs,largest 21.5x20.4mm in size –s/o metastatic lesions.No pleural effusion Bilateral mild hydronephrosis most likely secondary to ureteric compression by the above described mass Mild ascites around lesion in pelvis No enlarged LN

43. Barium enema (3/2/068) (Colonoscopy was tried but not able to go beyond 80 cm so, advised for barium enema ) Soft tissue density (probably cystic) mass at periumbilical region Fairly smooth outlined displacement of sigmoid colon, ascending and transverse colon, more of sigmoid with mildly dilated sigmoid loop

48. Chest X-ray

52. USG guided FNAC (068/2/6) : mostly blood and few mesothelial cells Repeat USG guided FNAC sent on 068/2/9 : same report

56. Final diagnosis ? Ovarian tumor with suspected metastasis to the liver and lungs

57. management Planned for Staging Laparotomy on Friday

58. Thank you!!