She barely walked properly; her belly was huge. She looked like she was 36 weeks pregnant. She was young; she looked in her mid-20s.
“How far pregnant are you, mam?
“Im not pregnant Dr”
Oopppsss… I should have started with an open question rather than assuming she was pregnant.
She had an ovarian mass - a growth from her ovary, which she noticed two months prior to her presentation to my clinic. She had no other symptoms other than abdominal discomfort. With a mass that huge, she got pretty full easily; hence she ate so little.
After taking a thorough medical history - nothing was significant. She was fairly healthy with no family history of cancer.
I ordered a few tests to help me plan treatment for her.
Ca125- 85 (a tumour marker to gauge the nature of an ovarian cyst/mass - the level of Ca 125 for a cancerous mass is usually around a few thousand).
CT scan - huge multiloculated right ovarian mass measuring 34x20x15cm.
After considering everything (her clinical history, family history, blood results and CT scan findings), I conquered that her mass was likely benign.
“Madam, from your tests, the ovarian growth is most likely non-cancerous. I proposed we take the affected ovary out (together with the mass).”
You may ask why I removed the entire ovary instead of the mass only. There was no right or wrong to this. Although from the tests, it seemed that the mass was benign - I could not rule out that the mass was borderline cancerous or cancerous. If this was the case, complete treatment required the removal of the entire ovary. In other words, if I had only performed a cystectomy (remove the mass only), and the mass was confirmed cancerous, a second surgery would be needed for the patient (to remove the rest of the ovary).
The patient agreed to the proposed procedure.
For this patient, I did a midline incision. A small one below the umbilicus. I took this decision because I knew the mass was mainly fluid. I then made a small incision on the mass itself - drained the fluid, making sure to avoid intraperitoneal spillage as much as
I could. Then, when more room was available, I performed salpingo-oophorectomy - removal of the mass together with the ovary.
The surgery went well, and she was discharged two days post-surgery.
After one week, the histopathological examination result was ready.
It was a benign mucinous cystadenoma - non-cancerous. I was relieved. The patient came to the clinic for a post-surgery review. She came to my clinic looking fine. I examined her wound, and all was well healed.
I hope you can learn something from the story above. Not all big ovarian masses are cancerous. The nature of surgery is very much dependent on the type of tumour. More extensive surgery means longer recovery time. Other gynaecologists may not have the same approach to this case. All patients' conditions are not the same and the treatment given should be tailored to individual needs.
For healthcare workers, especially aspiring OBGYNs you can refer to these articles for further reading
Greentop 62: Management of suspected ovarian masses in premenopausal women. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/ovarian-masses-in-premenopausal-women-management-of-suspected-green-top-guideline-no-62/
Management of the Adnexal Mass: Considerations for the Family Medicine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9294310/
**written consent has been obtained from the patient for the photos shown.
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