Case Presentation

A 64-year-old postmenopausal female was admitted to our hospital with lower abdominal pain for 3 months and vaginal bleeding for 21 days. Her physical examination revealed the existence of a lower abdominal mass about the size of 8-9cm in diameter on deep palpation, closely related to the uterus. Obvious tenderness and rebound pain were complained about. Shifting dullness was positive and a small amount of blood clot was seen in the vagina. The abdominal computed tomography (CT) showed a cystic and solid mass in the right annex and a cystic mass in the left annex with a large amount of ascites. The magnetic resonance imaging (MRI) confirmed the same finding of bilateral masses, with thickened and dense peritoneum and mesentery (Fig.1). No obviously abnormal imaging performance in the upper digestive tract, liver, pancreas or kidney. Laboratory tests showed an elevated AFP level of 3630ng/ml (normal <10), CA 125 level of 337.9 U/ml (normal <35) and HE4 level of 142.7pmol/L (normal <81.9). She had a cesarean section 26 years ago and had no family history of any malignancy.
A maximal debulking surgery was arranged under the impression of ovarian cancer on April 20th, 2015. During the surgery, a right ovarian tumor of 9×7×4 cm and a left one of 3.3×3×1.5 cm were discovered with direct invasion to the pelvic peritoneum, uterus, rectum and mesentery. Multiple solid nodules of 2-3 cm in diameter were palpable in the omentum. A contracted tumor tissue about 6×6×8 cm in size was found in the sigmoid colon mesentery. A 10 cm section of colorectum presented significant stiffness, thickening, edema and flatulence, with fixed adhesion to the uterus posterior wall. Radical surgery was performed, including a total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, appendectomy and pelvic floor peritoneum resection. Additionally, a partial colorectal resection and end-to-end anastomosis were performed and an ileostomy was created. The postoperative pathological results suggested a poorly differentiated adenocarcinoma displaying a hepatoid pattern without yolk sac tumor-like areas. The omentum mass, pelvic peritoneum, rectal and appendiceal mesentery were positive for malignancy and malignant cells were seen in ascites. All the resected pelvic lymph nodes were negative. The final diagnosis was HCO of stage IIIC.
One month after the surgery, the AFP level of our patient decreased from 3630 ng/ml to 158.5 ng/ml. Then she was treated with combined chemotherapy of paclitaxel and carboplatin for 9 courses until May 11th, 2016. The response was satisfactory and her serum AFP level returned to within the normal range.
The patient was disease-free for about two years, confirmed by MRI and stable serum AFP level. However, in March 2017, she onset with the symptoms of intestinal obstruction, and her serum AFP was gradually elevated. Her pelvic MRI revealed pelvic effusion and metastasis in the omentum, peritoneum and mesenteric nodules. Recurrence of ovarian cancer was considered but we applied palliative treatment instead of the aggressive one due to the high risk of surgery. Chemotherapy was administrated with paclitaxel and carboplatin. The patient’s AFP level did decrease after the course but the chemotherapy was terminated after the third course of administration on October 12th, 2017 because of the severe adverse reaction (IV-degree myelosuppression). On November 20th, 2017, the chest and abdominal CT revealed pleural effusion and a large amount of peritoneal effusion with multiple small nodules in the peritoneum and swollen retroperitoneal lymph nodes. In spite of comprehensive supportive treatment, the patient died of cachexia and multiple organ failure in early 2018, about 3 years after the initial diagnosis.
The patient’s diagnosis, treatment, follow-up, and outcome are presented in chronological order in Table 1. Figure 2 depicts the whole course of disease monitoring using AFP, CA125, and HE4 values.