A 70 year-old woman has been admitted with shortness of breath. On further questioning she says she has been unwell for about 8 weeks. She has decreased appetite and nausea when she eats. She has lost weight but her abdomen feels swollen. She has generalized dull abdominal pain and constipation, which is unusual for her. There are no urinary symptoms. She has always been healthy with no previous hospital admissions. She is a widow and did not have any children. Her periods stopped at 52 years and she has had no post- menopausal bleeding. She has never taken hormone-replacement therapy. Examination She appears pale and breathless on talking. Chest expansion is reduced on the right side, with dullness to percussion and decreased air entry at the right base. The abdomen is gen- erally distended with shifting dullness. There is a mass arising from the pelvis. Speculum examination is normal, but on bimanual palpation there is a fixed left iliac fossa mass of about 10 cm diameter. Haemoglobin 9.2 g/dL, Mean cell volume 82 fL, White cell count 4100, Platelets 197, Sodium 135, Potassium 4, Urea 5.1, Urea Creatinine 89, Alanine transaminase 18, Aspartate transaminase 17, Alkaline phosphatase 78, Bilirubin 12, Albumin 30, CA-125 118. 1. What is the likely diagnosis? 2. How should this woman be further investigated? 3. If the diagnosis is confirmed how should she be managed?

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It is mostly epithelial ovarian cancer and showing the local as well as distant spread to lungs with raised tumour marker CA125 . The h/o in favour are 1)Nulliparity 2)Long (52yrs) unopposed ovulation. 3) Age 70 yrs. 4) Mass arising from pelvis. FNAC to type the malignancy and than chemotherapy SOS debulking surgery if required.

,possible Diagnosis 1. Kidney failure ? acute ? chronic 2.Pleural effusion Rt side ? cause ? Pneumonia ? Koch's ? CA lung 3. Hyperbilirubinemia ? obstructive 4.Ascites ? cause 5. Class 4 dyspnoea due to mod to severe Pleural effusion ,?renal failure with metabolic acidosis , ?CCF ,?ACS ( unlikely as per history) 6.Anaemia ? low intake ,? on going bleeding. 7. Lump of unknown etiology in Lt illiac fossa. INVESTIGATIONS Peripheral smear to look for cause of anaemia,Urine analysis, ECG ,echo,HRCT chest, USG abdomen for kidney size & Lt illiac fossa mass,& liver pathology .ascitic fluid analysis, pleural fluid analysis . ABG for metabolic acidosis for kidney failure. therapeutic & diagnostic pleural tapping. rest treat as per symptoms & as per investigations .

Ovarian carcinoma with lung metastasis with pleural effusion. There is transcoelomic spread to liver causing jaundice.Do cytological examination of ascitic and pleural fluid.Tvs will give you idea about primary. Patient should be posted for pleural tapping paracentasis will relieve respiratory symptoms .Chemotherapy should be managed.

it is most probably Epithelial ovarian ca,with metastasis in lung,mysentry and liver,ct abdomen with pet scan for staging and spread,pleural tapping and pleural fluid cytology,though the ca spread is advanced,debulking surgery may give her some time.

Advanced ovarian carcinoma. Should be treated by palliative measures. Tapping pleural and peritoneal fluid might relieve her of breathlessness. Looking at RFT and LFT , chemotherapy may worsen her health. Though tapping of fluid give temporary relief. Surgery is out of question.

Thanks to all friend participants for keeping your views regarding the case, special thanks to Dr. Devkripa Banerjee, Dr. Ashok Avachat, Dr. Abhishek Laybhay, Dr. Fahad Abdul Majeed, Dr. Vijay Gupta and Dr. Neethika Raghuwanshi.

always welcome dr ahirwar sir
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Suspected to be a case of ca lung secondary to abdomen with ascites and undefined lump in lt iliac fossa probably colorectal. Adv USG of whole abdomen Ascitic fluid examination .

She is a case of rt sided pleural effusion due to Ca lung secondary in abdomen Ct abdomen chest plural & ascitic tapping cytopath study FNAC of abd mass will lead to diagnosis

ca colon with metastatic lesion in lung. biopsy of pleural exudate can confirm dx. HRCT required for this. tt accordingly. ..

Pleural effusion with metastasis from ovarian cancer. Needs further investigation and evaluation to conclude and line of treatment .

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