HIGH-GRADE
PAPILLARY SEROUS
CARCINOMA
GROUP UV GULLAS COLLEGE OF MEDICINE
CLERKS
Objectives of the Case Study
1. To discuss a case of a patient presenting with HIGH-GRADE
PAPILLARY SEROUS CARCINOMA
2. To know the differential diagnoses of patients presenting with
such condition.
3. To discuss the Pathophysiology and Clinical Presentation of the
disease
4. To discuss the diagnostic and therapeutic approaches of patient.
01
Patient’s
Profile
I. GENERAL DATA
L.M.M
79 years old, married
Filipino,
Filipino,Catholic,
Catholic,born
bornon
onseptember
september
23, 1943
23, 1943
From Samboan, Cebu City
II. Chief Complaint
ABDOMINAL
ENLARGEMENT
III. Past Medical History
Past medical and surgical history:
• Diagnosed case of Invasive Ductal Ca, (2014)
• Known Diabetic
• Known Hypertensive
• No history of Hypertension, DM, Asthma, Cancer or any
heredofamilial diseases on maternal and paternal side.
IV. Gynecologic History
● Menarche: 14 years of age
● Duration: 4-5 days
● Pads: 3-4 pads per day
● Associated with Dysmenorrhea with ps of 6/10, no
medication taken.
IV. Gynecologic History
● Coitarche: 21 years of age
● Partner: 1 sexual partner
● Contraceptives: None
● Pap Smear: None
● STIs: No history and no screening done
V. Obstetrical History
PREGN YEAR MODE GEST SE PREGN COMPLICATIONS/O
ANCY OF OF AT X ANCY UTCOMES
ORDER DELIV DELIV ION OUTCO
ERY ERY COMPL ME
ETED
G1 1964 STILL - DEAD 9 MONTHS
BIRTH
G2 1968 NSD TERM MAL LIVE -
E
G3 1977 NSD TERM FEM LIVE -
ALE
G4 1979 STILL - DEAD 8 MONTHS
BIRTH
G5 1980 NSD TERM FEM LIVE -
ALE
VI. Personal and Social History
● Vendor
● Non-smoker, non-alcoholic and denies use of illicit drugs
IX. History of Present Illness
● 5 months prior to admission, patient noted an onset of increase in abdominal
5 months size associated with changes in bowel movement. No medication nor
consultation done.
Prior to
● 3 month prior to admission, patient consulted at OPD and was prescribed
Admission
for lab, ultrasound was done which shows massive ascites.
● 2 months prior to admission, patient consulted a private OB and was
advised for endometrial biopsy and results showed malignancy.
● Patient was later advised for surgical management of the malignancy hence
came to our institution.
DIAGNOSTIC MODALITIES
ULTRASOUND
REMARKS:
(02/02/2023) ● The uterus is anteverted with irregular contour and homogeneous
myometrium. The endometrium is markedly thickened and
heterogeneous demonstrating minimal color on color flow
mapping( colour score 2 ). The endometrial midline is not defined.
The endometrial interface is intact.
● IETA TERMS:
● Echogenicity: non-uniform
● Endometrial midline: not defined
● Endomyometrial interface: regular
● Intracavity fluid: low-level echoes
● Color score: score 2 ( minimal color )
● Vascular pattern: scattered vessels
DIAGNOSTIC MODALITIES
● The cervix contains nabothian cyst. It is dilated to 1.1 cm by
ULTRASOUND
(02/02/2023) heterogeneous structures continuous with endometrial mass.
● The myometrial wall appears markedly thinned out.
● Anterior to uterus is a heterogeneous structure measuring 2.9 x 3.4 x
2.4 cm probably representing a metastatic lesion.
● Both ovaries are not visualized in this scan.
● There is moderated ascites noted.
Impression:
Enlarged anteverted uterus with markedly thickened endometrium, as
described.
Consider an endometrial pathology with extension to the cervix.
Consider a metastatic lesion, anterior to the uterus.
DIAGNOSTIC MODALITIES
ULTRASOUND Not visualized ovaries
(02/02/2022) Moderate ascites noted
X. Review of Systems
General: (-)weight change, (-) fever, (-) weakness
Skin: (-) lesions, (-) itching, (-) bruising, (-) rashes
Head: (-) headache
Eyes: (-) blurring of vision, (-) visual loss
ENT: (-) ear pain, (-) tinnitus, (-) vertigo, (-) nosebleed, (-) sore throat
Neck: (-) stiffness, (-) lumps
X. Review of Systems
Respiratory: (-) cough, (-) sputum, (-) shortness of breath,
Cardiovascular: (-) chest pain, (-) palpitations, (-) orthopnea
Gastrointestinal: (-) vomiting, (-) diarrhea, (-) hematochezia,
(-) loss of appetite
Genitourinary: (-) frequency, (-) dysuria, (-) hematuria
X. Review of Systems
Musculoskeletal: (-) muscle pain, (-) joint pain
Psychiatric: (-) history of depression or psychiatric disorders
Neurologic: (-) fainting, (-) seizure, (-) motor or sensory loss
Hematologic: (-) bruising, (-) adenopathy
Endocrine: (-) temperature intolerance, (-) polyuria, (-) polydipsia
Allergic/Immuno: (-) urticaria, (-) hay fever
X. Physical Examination
GENERAL: awake, responsive, cooperative, not in respiratory distress.
Vital Signs:
● Temperature: 36.7 oC
● Blood pressure: 120/80 mmHg
● Heart rate: 83 bpm
● Respiratory rate: 19 cpm
● O2 sat: 99 % at room air
XI. Physical Examination
SKIN: no jaundice, warm to touch with good skin
turgor
HEENT: pink palpebral conjunctiva, anicteric sclerae,
thyroid is not enlarged, no lymphadenopathies
CHEST AND LUNGS: equal chest expansion, clear breath
sounds on all lung field, no rales and no
XI. Physical Examination
BREAST: Symmetric, no skin dimpling, non-tender, no mass,
no lumps, no discharge
CARDIOVASCULAR: PMI at the 5th ICS, regular rate and
rhythm, distinct heart sounds, no murmurs,
heaves or thrills
ABDOMEN: Flabby, normoactive bowel sounds, nontender,
EXTREMITIES: full range of motion on all extremities, no
deformities, no fractures, no edema.
XI. Physical Examination
Bimanual Pelvic Examination
● Introitus - parous
● Cervix - closed cervix, smooth
● Uterus - small
● Adnexa - non tender adnexa, no palpable mass
● Discharge - none
XII. Salient Features
● 79 years old
● Bloating.
● Pelvic or abdominal pain.
● Abdominal Enlargement
Primary Impression
1. G5P3 (3012)
2. High grade papillary serous carcinoma, Stage 4A
3. S/P Endometrial biopsy (02/14/2023, CDUH)
4. S/P Neoadjuvant chemotherapy x 3 cycles (03/30/2023,
PSH)
02
CASE
DISCUSSION
incidences
● High-grade serous carcinoma tends to grow quickly. It is often
diagnosed in advanced stages (Stage III or IV), meaning that the
cancer cells have already spread outside of the ovaries. Recent
studies have shown that high-grade serous carcinomas that begin
with a primary tumour in the fallopian tubes take an average of
6.5 years to reach the ovaries, after which they spread to other
areas quite quickly.
incidences
Advanced stage carcinomas generally spread to the peritoneum (the
lining of the organs of the pelvis and abdomen) first, and can lead to
fluid buildup in the peritoneal cavity — a condition called ascites,
which can cause abdominal bloating, and in some cases is the first
noticeable symptom of presence of ovarian cancer. Early stage high-
grade serous carcinoma often does not cause any noticeable signs or
symptoms, thus the cancer is often diagnosed at more advanced
stages.
incidences
Once they do appear, signs and symptoms of ovarian cancer can
include the following:
Bloating
Pelvic or abdominal pain
Difficulty eating or feeling full quickly
Urinary symptoms (urgency or frequency)
epidemiology
● Accounts for majority of ovarian carcinoma diagnoses and related deaths
● Affects women disproportionately in western nations
● Increased risk in Caucasian as compared with African American women
● Decreased risk with several menstrual and reproductive factors:
● Parity
● Later age at menarche
● Earlier age of menopause
● Oral contraceptive use
● Increased risk with oestrogen only hormonal therapy, combined oestrogen and
progestin regimens
Pathophysiology
● Hereditary predisposition in 15 - 20% of cases involving BRCA genes:
● BRCA1 germline mutations cause 50% lifetime risk of ovarian cancer at average age of ~50 years
● BRCA2 germline mutations causes lower lifetime risk (10 - 35%) at a later age (average ~55 years)
● Associated with homologous recombination defects
● Hereditary predisposition in 6% of women with Fanconi anemia
● A significant proportion arise in the fallopian tube and spread to the ovaries and peritoneum
Diagnostics
Diagnostic Modalities
● Routine tests:
○ Pregnancy test
○ Complete blood count and Coagulation profile
○ Thyroid function tests and prolactin test
○ Pap smear
○ Screening for STI
○ Serum ferritin
● Imaging studies
○ Transvaginal sonography
● Endometrial biopsy
● Hysteroscopy
Complete Blood 04/20 04/21
Count
WBC 16.92 H 15.59 H
RBC 2.76 L 3.23 L
Laboratories
Hgb 81.00 L 95.00 L
Hct 24.30 L 28.50 L
Platelet count 69.00 L 66 L
Neutrophils 74.50 H 76.90 H
Lymphocyte 17.00 L 15.50 L
Monocyte 7.90 6.00
Eosinophil 0.20 L 1.20 L
Basophil 0.30 0.40
Blood Chemistry 06/20 06/21
BUN 33.0 H 27.00 H
Laboratories
Crea 1.53 H 1.23 H
Na 141.30 138.30
K 4.26 3.98
Cl 106.10 107.50 H
Ca 1.30 1.29
Pictures of the speciment
Treatment and
Management
TREATMENT
● General management:
● Standard first-line treatment for high-grade serous ovarian carcinoma typically
consists of debulking surgery — otherwise known as cytoreductive surgery —
which involves removal of as much of the tumor as possible, followed by
intravenous paclitaxel/platinum-based chemotherapy, and often subsequent
maintenance therapy.
● Specific treatment for the patient:
● Total abdominal hysterectomy with bilateral salpingo-oophorectomy, infracolic
omentectomy, BLND on Wednesday (04/19/2023- second case)
● With 4 units PRBC at bloodbank
TREATMENT
IM pulmo:
● For incentive spirometry 10x every hour on waking hours only
● Continue maintenance medications
● Losartan 50 mg tab, 1 tab OD
● Metformin 500 mg tab, 1 tab BID
● CBG monitoring TID premeal and at bedtime
Definitive plan:
● Neoadjuvant chemotherapy (Done), Tumor Debulking, Adjuvant chemotherapy then
Brachytherapy.
Final Diagnosis
G5P3 3023: HIGH GRADE PAPILLARY SEROUS
CARCINOMA STAGE 4A.
HYPERTENSIVE CARDIOVASCULAR DISEASE:
LV DYSFUNCTION
DIABETES MELLITUS TYPE 2
MODERATE ANEMIA SECONDARY TO ACUTE
BLOOD LOSS
ACUTE KIDNEY INJURY
Thank
you!
