A 55-year-old patient, G3Ab1P2 with a past medical history of treated hypertension and hypothyroidism referred to our urogynecology clinic with chief complaint about urinary incontinence as well as two-year prolonged and heavy menstrual bleeding. She reported being sexually active and a positive family history of uterine malignancy in her daughter and her sister that underwent TAH.
At that time, the medical history revealed mixed urinary incontinence accompanied by urge-predominant symptoms. In addition, the physical examination revealed stage 1 of pelvic organ prolapse in all three compartments and a positive cough stress test. Furthermore, the result of her transvaginal ultrasound (TVS) and endometrial biopsy were normal.
Papanicolaou smear test was also done and the result was reported as “negative for intraepithelial lesion or malignancy”. To relieve her urinary symptoms, an anticholinergic drug was prescribed and the she was asked to do follow-up check-ups in a month so that we could evaluate her menstrual bleeding pattern after the endometrial biopsy and track her response to anticholinergic drug.
Unfortunately, the patient did not come in for the follow-up visit. One year later, she referred to our hospital with chief complaint about heavy, prolonged menstrual bleeding and a permanently abnormal yellow discharge that could not be distinguished from its urinary or vaginal source. On examination, no pelvic mass was palpable. Mixed vaginal infection and uterine prolapse stage 1 were diagnosed.
The patient underwent a transvaginal ultrasound which indicated a 21*18 mm endometrioma cyst in the right ovary and a 32*18 mm tabular hypoechoic structure with hypervascular thick wall in the left adnexa separated from the left ovary suspected for the left fallopian tube pathology. For more assessment, magnetic resonance imaging (MRI) was requested.
MRI enhanced images of the pelvic cavity confirmed the small endometrioma in the right ovary and demonstrated a tubular left adnexa structure measuring 36*12 mm with thick rim wall enhancement without internal solid component, more suggestive of hematosalpinx, hydrosalpinx , or associated inflammatory process without any evidence of malignancy (Fig. 1A, C).
Focal hyperplasia without atypia with disordered proliferative endometrium was detected on hysteroscopy-D & C. Her abnormal lab test was hemoglobin 10.9 g/dL and ESR= 97.
Finally, the patient became a candidate for TAH – BSO due to the drug (Megestrol Acetate) -resistant abnormal vaginal bleeding, her abnormal vaginal bleeding, positive family history of malignancy, and abnormal vaginal discharge.
Before surgery, an urodynamic study was also done because of urgency-predominant mixed urinary incontinence and the patient’s inability to differentiate vaginal discharges from the leak of urine. The urodynamic study revealed normal findings.
Laparotomy revealed unusual left fallopian tube feature (Large, bulky, and vegetative feature), suspected to malignancy. Intraoperative frozen-section analysis of the left fallopian tube and ovary specimens detected the mass as a high-grade serous carcinoma of fallopian tube. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and partial omentectomy were performed. The definitive histopathological diagnosis was high-grade serous carcinoma of the left fallopian tube stage 2b (Fig. 2A, C).with omental involvement without any evidence of lymph-vascular invasion.
Based on post-surgery MRI findings which were normal, she became a candidate for six courses of adjuvant chemotherapy with carboplatin and paclitaxel followed by active surveillance. At the time of this report (one month after her surgery), she was receiving one course of chemotherapy without any major adverse effect.