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.