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A 62-Year-Old Woman With a Large Abdominal Mass

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 62-year-old nulligravida woman presented with a 10-month history of progressive abdominal distension and diffuse abdominal pain associated with a 25-kg weight gain. Results of upper endoscopy and colonoscopy performed 1 week prior to presentation were normal. She reported dyspnea on exertion but had no fevers or chills, nausea or vomiting, hematochezia, or change in the caliber or consistency of her stools. On physical examination, she had normal vital signs, no abnormalities on pelvic and rectal examination, and a large abdominal mass extending from the epigastrium to the pelvis. Laboratory testing showed a normal complete blood cell count, erythrocyte sedimentation rate, and comprehensive metabolic panel and normal levels of serum carcinoembryonic antigen (CEA), cancer antigen 125 (CA-125), and cancer antigen 19-9 (CA19-9). Computed tomography (CT) of her chest, abdomen, and pelvis revealed a large mass occupying the entire abdominal cavity (Figure 1).

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Mucinous ovarian carcinoma

D. Laparotomy with removal of mass

The key to the correct diagnosis is recognizing that a unilateral abdominal mass larger than 10 cm is characteristic of a primary ovarian neoplasm, for which complete surgical resection is the recommended treatment. A needle biopsy (choice A) may not provide adequate tissue to make an accurate diagnosis. Percutaneous drainage (choice B) is not recommended because this procedure may cause spillage of malignant cells into the abdomen. Diagnostic laparoscopy (choice C) would not remove the abdominal mass.

Mucinous ovarian tumors are categorized as benign, borderline, or malignant (mucinous ovarian carcinoma).1 Mucinous ovarian tumors are typically unilateral, multicystic, and large, with a mean size of 10 cm if benign; 16 cm if borderline, and 20 cm if malignant.2

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Article Information

Corresponding Author: Luigi Marano, MD, PhD, Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery and Neurosciences, University of Siena, Strada delle Scotte, 4, 53100 Siena, Italy (luigi.marano@unisi.it).

Published Online: December 19, 2022. doi:10.1001/jama.2022.23320

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share her information.

References
1.
WHO Classification of Tumours Editorial Board.  World Health Organisation Classification of Tumours of the Female Reproductive Organs. 5th ed. International Agency for Research on Cancer; 2022.
2.
Talia  KL , Parra-Herran  C , McCluggage  WG .  Ovarian mucinous and seromucinous neoplasms.   Histopathology. 2022;80(2):255-278.PubMedGoogle ScholarCrossref
3.
Mueller  JJ , Lajer  H , Mosgaard  BJ ,  et al.  International study of primary mucinous ovarian carcinomas managed at tertiary medical centers.   Int J Gynecol Cancer. 2018;28(5):915-924.PubMedGoogle ScholarCrossref
4.
Berek  JS , Kehoe  ST , Kumar  L , Friedlander  M .  Cancer of the ovary, fallopian tube, and peritoneum.   Int J Gynaecol Obstet. 2018;143(suppl 2):59-78. doi:10.1002/ijgo.12614PubMedGoogle ScholarCrossref
5.
Kurnit  KC , Frumovitz  M .  Primary mucinous ovarian cancer.   Int J Gynecol Cancer. Published online October 13, 2022. doi:10.1136/ijgc-2022-003806PubMedGoogle ScholarCrossref
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Köbel  M , Kang  EY .  The evolution of ovarian carcinoma subclassification.   Cancers (Basel). 2022;14(2):416. doi:10.3390/cancers14020416PubMedGoogle ScholarCrossref
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Lheureux  S , Braunstein  M , Oza  AM .  Epithelial ovarian cancer.   CA Cancer J Clin. 2019;69(4):280-304. doi:10.3322/caac.21559PubMedGoogle ScholarCrossref
8.
Xu  W , Rush  J , Rickett  K , Coward  JI .  Mucinous ovarian cancer.   Crit Rev Oncol Hematol. 2016;102:26-36. doi:10.1016/j.critrevonc.2016.03.015PubMedGoogle ScholarCrossref
9.
Craig  O , Salazar  C , Gorringe  KL .  Options for the treatment of mucinous ovarian carcinoma.   Curr Treat Options Oncol. 2021;22(12):114.PubMedGoogle ScholarCrossref
10.
Peres  LC , Cushing-Haugen  KL , Köbel  M ,  et al.  Invasive epithelial ovarian cancer survival by histotype and disease stage.   J Natl Cancer Inst. 2019;111(1):60-68. doi:10.1093/jnci/djy071PubMedGoogle ScholarCrossref
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