CASE 3 Suspicious mass, ascites signal need for surgery
A 19-year-old gravida 1 para 0 seeks prenatal care at 17 weeks’ gestation, complaining of rapidly enlarging abdominal girth. The physical examination estimates gestational size to be considerably greater than dates, but US is consistent with a 17-week intrauterine pregnancy. Imaging also reveals a 12-cm heterogenous left adnexal mass and a large amount of ascites.
Surgery is clearly warranted, but how extensive should it be?
When a malignancy is detected, a thorough staging procedure may be justified, depending on gestational age, exposure, desires of the patient, and operative findings. A midline incision is preferred.
Pregnant and nonpregnant women with stage 1A or 1C epithelial ovarian cancer who undergo fertility-preserving surgery (with chemotherapy in selected patients) have a good prognosis and a high likelihood of achieving a subsequent normal pregnancy.15 The same is true for women with a malignant germ-cell tumor of the ovary, even when disease is advanced.16 However, careful surgical staging is necessary.
The most important consideration when deciding whether to continue the pregnancy is the need for adjuvant chemotherapy. Depending on the gestational age and diagnosis, a short delay (4 to 6 weeks) may be appropriate to allow the pregnancy to progress beyond the first trimester or to maturity.
In case 3, a laparotomy was performed at 19 weeks’ gestation via a midline incision, and approximately 5.3 L of ascites was evacuated. A large, nonadherent left ovarian tumor was removed. The right ovary appeared to be normal, as did the gravid uterus, which was minimally manipulated. The rest of the surgical exploration was normal, and the distal portion of the omentum was excised. The frozen-section diagnosis was a malignant stromal tumor. Final pathology showed an 18×13.5×8.8 cm, poorly differentiated, SertoliLeydig-cell tumor with heterologous elements in the form of mucinous epithelium. The omentum was negative for tumor.
Chemotherapy was initiated in the third trimester, based on the limited data available, with intravenous etoposide and platinum administered every 21 days. The patient received 3 cycles of chemotherapy prior to delivery.
At 37 weeks’ gestation, labor was successfully induced. After delivery, bleomycin was added to the chemotherapy regimen, and 3 additional courses with all 3 agents were administered. The patient was lost to follow-up shortly after completing chemotherapy.
Clearly, an informed discussion of the options with the patient is imperative before any surgery, especially when chemotherapy may be delayed. Pregnancy does not appear to alter the prognosis for the patient with an ovarian malignancy, and ovarian cancer has not been reported to metastasize to the fetus.
Integrating evidence and experience
Pregnant women have a very low rate of ovarian cancer
Leiserowitz GS, Xing G, Cress R, Brahmbhatt B, Dalrymple JL, Smith LH. Adnexal masses in pregnancy: how often are they malignant? Gynecol Oncol. 2006;101:315–321.
Ovarian malignancies are rare during pregnancy. When they do occur, they are likely to be early stage and to have a favorable outcome, according to this recent population-based study.
Using 3 large databases containing records on 4,846,505 California obstetric patients between 1991 and 1999, Leiserowitz and colleagues identified 9,375 women who had an ovarian mass associated with pregnancy. Of these, 87 had ovarian cancer and 115 had a low-malignant-potential (LMP) tumor, for a cancer occurrence rate of 0.93%, or 0.0179 per 1,000 deliveries. Thirty-four of the 87 cancers were germ-cell tumors.
Of the 87 ovarian cancers, 65.5% were localized, 6.9% regional, 23% remote, and 4.6% of unknown stage. The respective rates for LMP tumors were 81.7%, 7.8%, 4.4%, and 6.1%.
Women with malignant tumors were more likely than pregnant controls without cancer to undergo cesarean delivery, hysterectomy, transfusion, and prolonged hospitalization. These women did not, however, have a higher rate of adverse neonatal outcomes.
When cancer is advanced
Few data shed light on whether a pregnancy should continue when ovarian cancer is advanced.17 The definitive surgical approach must be highly individualized.
It is not always possible to make an accurate diagnosis based on a frozen section. In such a case, the pregnancy should be preserved until the time of definitive diagnosis. As always, the patient’s wishes and gestational age must be considered.
How factors besides malignancy can influence care
Most persistent adnexal masses move well out of the pelvis as pregnancy progresses. Occasionally, however, an ovarian tumor may be located in the posterior cul-de-sac even at term, a fact easily confirmed by examination or US.4,7 A tumor in the posterior cul-de-sac can obstruct delivery or rupture. When it has a benign cystic appearance on US, it may be decompressed via transvaginal aspiration. Otherwise, the best approach is cesarean section and concomitant management of the mass.