THE CASE FILES

Abstract

Figure 1.: Axial view showing the maximal diameter of the left ovary.FigureFigureFigureA 33-year-old obese woman was sent to the ED by her primary care physician with the complaint of severe abdominal pain for 10 hours. Her pain was associated with nausea and loss of appetite without vomiting. The patient had a past medical history significant for hypertension, and depression, which were treated with losartan-hydrochlorothiazide and paroxetine HCL, respectively. Her past medical history was also significant for untreated polycystic ovarian syndrome (PCOS). The patient denied ever having abdominal surgeries, but noted that her gynecologic history was significant for irregular menses. The patient's abdomen was severely tender in the left lower quadrant with voluntary guarding and abdominal masses which were palpable approximately three centimeters above the umbilicus bilaterally. Laboratory workup over the course of the visit included beta HCG, CBC with differential, CMP, lipase, lactic acid, urinary analysis, coagulation studies, and CA-125. Laboratory results were remarkable for elevated lactic acid of 3.1 and extremely high CA-125 at 675.9. CT imaging of abdomen and pelvis with IV contrast was performed, and revealed markedly enlarged cystic ovaries, the left measuring larger at 28 cm and the right at 21cm. The immediate diagnostic concern was ovarian cancer due to the elevated CA-125. The patient was discharged home with pain medication, and instructed to meet with a gynecologic oncologist for ovarian cyst removal and staging. With the small pool of research pertinent to this patient's history of untreated PCOS, perhaps there is a need for more research into a relation between PCOS and ovarian cancer. Occam's Razor PCOS diagnosis is considered after the exclusion of any other entities that would cause hyperandrogenism with menstrual dysregulation and polycystic ovaries. (J Clin Endocrinol Metab 2006;91[3]:781; Hum Reprod 2004;19[1]:41.) It's estimated that five to 10 percent of all women are affected by PCOS, and with this common syndrome comes an increased prevalence in comorbidities such as diabetes, hypertension, obesity, metabolic syndrome, and infertility. The prevalence of infertility is extremely high due to oligomenorrhea and amenorrhea, and usually leads to the workup and diagnosis of PCOS. (Obstet Gynecol 1996;88[4 Pt 1]:554; Gynecol Endocrinol 2013;29[2]:145.)Figure 2.: Coronal view showing bilateral polycystic ovaries.A clear correlation has been made between PCOS and endometrial cancer, but little evidence suggests a link between PCOS and ovarian cancer. (Hum Reprod Update 2001;7[6]:522; Folia Histochem Cytobiol 2009;47[5]:101; Gynecol Endocrinol 2005;20[4]:200; Reprod Biomed Online 2009;19[3]:398.) The most quoted paper advocating a relationship between PCOS and ovarian cancer showed a 2.5-fold increase in the risk of epithelial ovarian cancer in PCOS, going up to as high as 10.5-fold for women who were not treated with oral contraceptives. (Obstet Gynecol 1996;88[4 Pt 1]:554.) This study has been limited for interpretation due to its small sample size and not being the primary focus of the original study. A more recent study compared separately the risk of PCOS and its relations to endometrial, ovarian, and breast cancers, which originally showed on analysis that ovarian cancer was not significant (OR 1.41;95% CI,0.93-2.15 p<0.11), but further stratification of the population to include only women younger than 54 showed the risk became significantly elevated (OR 2.52; 95% CI 1.08-5.89, p<0.03). (Hum Reprod Update 2014;20[5]:748.) With PCOS affecting such a high percentage of women and this example of a possible malignant transformation in a patient of known PCOS, perhaps it warrants more studies to find an association that has eluded us so far. We must keep Occam's razor in mind before dismissing this patient's presentation as a separate occurrence of ovarian carcinoma.