This document presents a case report of a 41-year-old female patient who presented with complaints of an abdominal mass, abdominal pain, weight loss, and loss of appetite. Imaging studies including ultrasound, CT scan, barium enema, and chest X-ray revealed a large pelvic mass likely originating from the ovaries with suspected metastasis to the liver and lungs. FNAC of the mass was non-diagnostic. The patient was scheduled for staging laparotomy to further evaluate the ovarian tumor and metastatic spread.

1. Case presentationDr.Ramesh SharmaDepartment of Obstetrics and Gynaecology.IOM, TU Teaching Hospital.

2. History 41 year Para 3 lady, from RukumPost TAH with ? BSO done 6 years back at valley HospitalPresented to our centre with complaint ofMass per abdomen – 1 yearAbdominal pain and increase in size of mass for last 5 monthsLoss of appetite for 5 months

3. History …contd..Menstrual history- Post TAHObstetric history- Para 3, all vaginal deliveries at homeContraceptive history- none

4. History …contd..Past history- TAH done 6 years back for fibroid uterusThe per operative finding revealed :A mass around 3 ×3 cm arising from the intestine which was removed. Lumen not involvedUterus was enlarged, tubes and ovaries not commented onHistopathology.Separate mass removed from the intestine shows leiomyoma with hyaline degenerationEndometrium: proliferative; Cervix: chronic cervicitisStatus of tubes and ovaries not mentioned

5. History …contd..Personal history- non smoker, doesn’t consume alcoholFamily history – no family h/o malignancy

6. Clinical examinationGeneral condition- fair..thin built.Weight: 38 kgVitals: stablePallor, edema, dehydration, jaundice- nilNo lymphadenopathyBreast, axilla : normalChest- normal vesicular sounds all overbilateral equal air entryCVS- S1 S2 M0

7. Clinical examination..contd..Per abdomen-A huge mass(size 30 × 40 cm), solid, stony hard in consistency, bosselated, irregular, well defined margins in the upper and lateral parts, lower border could not be felt, non tender, immobileNo ascites

10. Clinical examination..contd..Vulval inspection- no abnormalityP/S- vault/vagina : normalP/VVaginal vault appeared normalFirm mass felt in anterior fornixUpper pole could not be reached

11. Clinical examination..contd..Per rectal examination:Rectal mucosa freeAnteriorly, hard mass felt

12. Provisional diagnosisOvarian tumor

13. Investigations

14. Investigations

16. Investigations

17. Imaging studies

18. Ultrasonogram of abdomen

19. Findings:A large, solid mass seen in pelvis measuring approximately 173 ×153 mm suggestive of ovarian tumor.Upper abdomen: no abnormality detected

20. CT ABDOMEN and pelvis

41. CT scan report : 2068/1/12Post hysterectomy statusHuge (30x27x25cm)heterogeneously enhancing mixed attenuation abdominopelvic mass with ovaries not separately identified from this mass –most likely malignant mass of ovarian origin ? side of origin. Diffuse omental thickening and omental caking with small round enhancing nodule (17.5x15.6mm)in rectovesical pouch –s/o omental and peritoneal metastatic depositsPoorly enhancing hypodense nodule(20.7x20.5mm) in right lobe of liver –s/o metastatic lesion

42. CT scan report : 2068/1/12Multiple mildly enhancing round and oval nodules in scanned part of both lungs,largest 21.5x20.4mm in size –s/o metastatic lesions.No pleural effusionBilateral mild hydronephrosis most likely secondary to ureteric compression by the above described massMild ascites around lesion in pelvisNo enlarged LN

43. Barium enema (3/2/068) (Colonoscopy was tried but not able to go beyond 80 cm so, advised for barium enema )Soft tissue density (probably cystic) mass at periumbilical regionFairly smooth outlined displacement of sigmoid colon, ascending and transverse colon, more of sigmoid with mildly dilated sigmoid loop

48. Chest X-ray

52. USG guided FNAC(068/2/6) : mostly blood and few mesothelial cellsRepeat USG guided FNAC sent on 068/2/9 : same report

56. Final diagnosis? Ovarian tumor with suspected metastasis to the liver and lungs

57. managementPlanned for Staging Laparotomy on Friday

58. Thank you!!