Serous ovarian carcinoma in pregnancy.

The diagnosis of ovarian carcinoma in pregnancy is rare (incidence of 0.018–0.073/1000 pregnancies). Its rarity is reflected by a paucity of cases reported in the literature. The present report concerns a case of advanced serous ovarian carcinoma in a full-term pregnancy. This was an incidental finding discovered during an emergency caesarean section for presumed fetal distress. The majority of ovarian carcinomas diagnosed in pregnancy present at early stages, are associated with a good prognosis and are non-epithelial type tumours. Advanced epithelial ovarian carcinoma diagnosed in pregnancy however is associated with a poor prognosis. Case reporting should certainly contain detailed information on clinicopathological variables and treatment regimens. Longer-term maternal and neonatal outcomes are more difficult to substantiate in case reporting. The authors therefore feel that data centralisation would be beneficial in identifying optimal management strategies in these rare tumours and in other malignant tumours diagnosed and treated during pregnancy.

The occurrence of ovarian carcinoma in pregnancy is uncommon. However, as increased maternal age at first pregnancy becomes more common, we anticipate a concurrent rise in the incidence of ovarian carcinoma in pregnancy. Obstetricians are therefore more likely to encounter such pathology more frequently in the future. Case presentation A 38-year-old multiparous caucasian woman presented in early labour at 41 weeks gestation. She was otherwise medically fit and well with no relevant family history. At 18 months prior to presentation, an emergency caesarean section was performed for a suboptimal cardiotocograph (CTG) following induction of labour at 39 weeks of monochorionic diamniotic twins. At the time of caesarean section the peritoneum overlying the anterior uterus was documented as being abnormally thickened and friable, with thickening extending towards the uterovesical fold. A diagnosis of probable endometriosis was made at this time. In her subsequent pregnancy a further emergency caesarean section was performed at 41 weeks gestation, again in early labour, for a suboptimal CTG. Her antenatal period was otherwise uneventful. Four abdominal ultrasound scans performed at 10, 12, 15 and 20 weeks gestation were reported as being normal. At caesarean section approximately 500 ml of free fluid was noted on opening the peritoneal cavity. A left ovarian mass, omental, peritoneal and diaphragmatic seedlings were noted. A gynaecological oncologist was requested to attend and a left ovarian biopsy, omental biopsy and ascitic fluid were sent for histological and cytological examination. She delivered a live, healthy, baby boy of 3986 g and made good recovery in the immediate postoperative period. The patient was informed at this time that her likely diagnosis was ovarian carcinoma. The placenta was noted as being macroscopically “normal”. Ascitic cytology confirmed the presence of numerous groups of cells derived from a serous papillary carcinoma. Left ovarian histology confirmed a moderately differentiated serous papillary ovarian carcinoma with multiple deposits noted in the omentum. The cancer antigen 125 (CA-125) level in the immediate postoperative period was 158 KU/litre. The patient was seen postoperatively and further management options including completion surgery or chemotherapy were discussed. The patient requested further surgery and a repeat laparotomy was performed 39 days after her caesarean section. At laparotomy a total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and infracolic omentectomy was performed. Significant disease progression was noted at laparotomy, including bilateral cystic solid ovarian tumours, miliary disease over the parietal and visceral peritoneum, with tumour deposits noted on the bowel serosa, liver surface and diaphragm. Surgical debulking to <2 cm disease residuum was achieved. Histology confirmed bilateral mixed serous and endometrioid ovarian carcinoma, Federation Internationale de Gynecologie et d’Obstetrique (FIGO) scale stage 3c. Adjuvant carboplatin and paclitaxel were administered with excellent response. Outcome and follow-up At 13 months the CA-125 level has normalised and a CT scan has revealed no persistent disease.

Malignant ovarian tumours diagnosed during pregnancy are rare, with the relative paucity of published reports in the literature reflecting the rarity of this condition. Germ cell tumours have been reported as more prevalent than other histological types of ovarian carcinoma diagnosed during pregnancy,1 and ovarian epithelial tumours diagnosed during pregnancy are reported in the majority to be tumours of low malignant potential, which are findings consistent with the age-matched, non-pregnant setting.1,2 Epithelial ovarian malignancy in itself is reported to occur in 1:12 000 to 1:50 000 pregnancies.3 Primary carcinoma of the ovary occurs more commonly in women of low parity in the latter half of their reproductive years. Patients with maternal ovarian cancer have been previously noted as significantly older than those with benign tumours or tumours of low malignant potential.1,4 Notably our patient was 38 years of age. Women in the developed world are increasingly likely to delay the onset of first pregnancy. In the UK, the birth rate in women over 30 years of age has doubled, and there has been a threefold increase in women over 40 years.5 It is uncertain whether ovarian cancer associated with pregnancy is increasing,2 yet as childbearing among older patients increases, so likely will the incidence of cancer in pregnancy. Despite having four US scans performed prior to 20 weeks gestation no adnexal mass was detected in our case. Standard antenatal practice in the UK is to offer an early ultrasound scan to determine gestational age and to detect multiple pregnancies in order to ensure consistency of gestational age assessments, improve the performance of mid-trimester serum screening for Down syndrome and reduce the need for induction of labour after 41 weeks.6 Examination of the adnexae however is not routine. Certainly in older patients we suggest that, in addition to gestational dating, routine examination of the adnexae should be considered. Like in this case, prior studies report that most pregnant women found to have an adnexal mass during pregnancy are asymptomatic1,7 and that the majority of masses are detected incidentally by routine pelvic or ultrasound examinations.1 Detection at delivery by caesarean section is reported as being much less common with five prior publications1,4,7–9 dated from 1963 to 2007 reporting only 10 cases. Detection at caesarean section does however emphasise the importance of thorough abdominopelvic review at the time of surgery.8 When a suspicious adnexal mass is detected in the antenatal period however, MRI would be preferential to CT as there is presently no good evidence examining the association between CT scanning and adverse pregnancy outcome.10 Clinicopathological survival prognosticators in epithelial ovarian cancer include FIGO stage, histological grade, and the extent of residual disease following tumour-debulking surgery. The majority of ovarian cancers diagnosed during pregnancy are reported as being found at an early stage,1,3 with maternal prognosis regarding stage reported to be similar to that in the non-pregnant patient.4,7 There is, however, no evidence that pregnancy itself adversely affects the survival of patients with epithelial ovarian carcinoma, nor is there evidence that pregnancy serves a beneficial effect on the disease process. CA-125 levels may be raised in pregnancy. In this case only a low level rise was identified in the immediate postnatal period. Prior reports on ovarian cancer detected during pregnancy have been inconsistent in their reporting of CA-125 levels so no real inferences can be made regarding the value of CA-125 in maternal epithelial ovarian cancer.10 The diagnosis of epithelial ovarian cancer during pregnancy is a rare event. There is a suggestion that, despite its rarity, the incidence may be increased in the older patients who are pregnant. Childbearing among older patients is increasing and it is therefore likely that the incidence of cancer in pregnancy will also increase. There are currently no definitive guidelines in the literature regarding the management of epithelial ovarian cancer presenting during pregnancy. The paucity of data in the literature unfortunately makes it difficult to assess the true outcome of treatments. Case reporting should certainly contain detailed information on clinicopathological variables and treatment regimens. Longer-term maternal and neonatal outcomes are more difficult to substantiate in case reporting. The authors therefore feel that data centralisation would be beneficial in identifying optimal management strategies in these rare tumours and in other malignant tumours diagnosed and treated during pregnancy. Learning points The diagnosis of epithelial ovarian cancer during pregnancy is a rare event. Childbearing among older patients is increasing and it is therefore likely that the incidence of cancer in pregnancy will also increase; epithelial ovarian carcinoma is one such example. Centralisation of data would be beneficial in identifying optimal management strategies in malignant tumours diagnosed and treated during pregnancy. Footnotes Competing interests: None. Patient consent: Patient/guardian consent was obtained for publication.

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