Ovarian Cancer Despite Previous Oophorectomy in Liver Transplant Patient

Abstract

Introduction: Paracentesis is the initial procedure to determine the etiology of ascites. Ascites is most commonly a result of increased portal pressure; however, other less common considerations include malignancies, which account for 7-10% of cases. We present an unusual case of ovarian cancer causing malignant ascites despite a previous oophorectomy. Case Report: A 70-year-old female with hepatitis C cirrhosis status post orthotopic liver transplantation 18 years prior to presentation and total abdominal hysterectomy with bilateral salpingooophorectomy (TAHBSO) 16 years prior, presented with new abdominal distention, shortness of breath, decreased appetite, and fatigue for 1 month. Physical examination was remarkable for abdominal distention and flank dullness. Right upper quadrant ultrasound was normal and showed no cirrhosis. A doppler ultrasound of the portal vessels showed no obvious clot. A paracentesis was performed with serum-ascites albumin gradient (SAAG) of 0.4, total protein of 3300 mg/dL, and cytology revealing adenocarcinoma. EGD and colonoscopy were negative for a primary source of cancer. An MRI of the abdomen/pelvis revealed a pelvic mass and omental thickening that was most consistent with a primary ovarian tumor despite the patient having a previous TAHBSO. She underwent resection of the pelvic mass, omentectomy, left ureterolysis, and radical dissection with suboptimal cytoreduction. Pathology showed clear cell carcinoma. Her post-operative course was complicated by a cardiac event. Despite aggressive care strategies, this led to respiratory failure and death. Discussion: Peritoneal fluid analysis is indispensable in diagnosing the etiology of ascites. In the setting of a low SAAG and elevated total protein, de novo and recurrent malignancies need to be included in the differential. This is amplified in the setting of previous transplant, as malignancy is a leading cause of death in liver transplant patients on immunosuppression. As our case typifies, this includes ovarian malignancies in all females, despite their previous gynecologic surgeries.Figure 1: Imaging shows multiloculated cystic mass with septations and solid components within the left pelvis.