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Diagnostic Challenges in Patients With Tumors

CASE 3. NORMAL-SIZED OVARIAN CANCER DETECTED BY COLOR DOPPLER ULTRASOUND USING A MICROBUBBLE CONTRAST AGENT

Fukuoka University Medical School, Fukuoka, Japan

A 58-year-old postmenopausal woman first visited our gynecologic clinic with a high serum CA 19-9 value (3,483 U/mL) owing to an unknown cause. The serum CA-125 value was 28 U/mL (normal level, < 35 U/mL). In her previous clinical examinations, no evidence of a tumor was found on chest or abdominal computed tomography scans, abdominal ultrasound, or gallium-67 scintigraphy. The patient had no history of any gynecologic disorders. A bimanual vaginal examination revealed a normal uterus without any adnexal enlargement. Both ovaries were confirmed to be of normal size, and a small cyst measuring 24 x 20 mm in size was detected in the left ovary by transvaginal gray-scale ultrasound. Magnetic resonance imaging showed a small cyst, 26 x 21 mm in size, in her left ovary (Fig 1, arrow; T2-weighted image). Transvaginal color Doppler ultrasound (CDU) showed no detectable blood flow in both the normal-sized ovaries (Fig 2A, arrowheads; the left ovary). However, a dramatic blood flow (Fig 2B, arrow) was detected within the left ovary by CDU 20 seconds after the intravenous bolus injection of a microbubble ultrasound contrast-agent, Levovist (Schering AG, Berlin, Germany), at a concentration of 300 mg/mL. In addition, the intraovarian vessels showed a low-resistance to the blood flow (resistance index; 0.31, and pulsatility index; 0.28), thus suggesting a malignant lesion within the ovary.^1–4 In postmenopausal woman, because an ovarian malignancy may be suggested if a vascular-rich lesion in the ovary is identified by diagnostic imaging, a laparotomy was performed for this patient. A normal-sized ovarian cancer was found (Fig 3). A bilateral salpingo-oophorectomy, total abdominal hysterectomy, partial omentectomy, pelvic lymph node dissections, and para-aortic lymph node sampling were then performed during this surgery. The carcinoma was confined to the normal-sized ovaries (left, 3.8 x 2. 8 cm; right, 3.5 x 2.7 cm), and a histopathologic examination showed a stage I mucinous cystadenocarcinoma of the ovary (Fig 4, hematoxylin and eosin staining, x3), without any extraovarian spread or metastasis. The serum CA 19–9 level remarkably decreased to a normal level (30 U/mL) by 4 weeks after surgery.

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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The authors indicated no potential conflicts of interest.

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