Ovarian Dysgerminoma Complicating Pregnancy: A Case Report and Review of Management Strategies

doi:10.21203/rs.3.rs-3968466/v1

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Case Report

Ovarian Dysgerminoma Complicating Pregnancy: A Case Report and Review of Management Strategies

https://doi.org/10.21203/rs.3.rs-3968466/v1

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Background: Ovarian dysgerminoma is a rare germ cell tumor that is uniquely challenging to diagnoseduring pregnancy. This case report illustrates the complexity of managing such a condition in a pregnant patient, with a focus on clinical presentation, diagnostic workup, therapeutic options, and patient outcomes.

Case Presentation: A 25-year-old woman, G6P4+1, presented with an 8-month history of amenorrhea and a 2-month history of progressively worsening lower abdominal pain, urine retention, and abdominal distension at 35 weeks of gestation. Upon examination, she was found to have an ovarian mass extending to the cervix. After a multidisciplinary discussion, a lower segment cesarean section was performed to deliver a live female infant, after which the ovarian mass was resected, which was later confirmed to be dysgerminoma with a yolk sac tumor. Diagnosis was established using ultrasound and supported by laboratory findings. The patient underwent surgery due to worsening symptoms, reflecting the urgent need for intervention. Postoperative management was complicated by the patient's refusal to continue with recommended chemotherapy. The patient initially recovered but later developed sudden abdominal distension and sought medical care at a rural facility. Despite the initial treatment, she experienced complications and tragically she passed away.

Conclusion: This case study underscores the importance of a thorough diagnostic approach, timely intervention, and the need for adherence to postoperative chemotherapy in the management of ovarian dysgerminoma during pregnancy. The findings also highlight the necessity of patient education and the potential impact of patient autonomy on treatment outcomes.

Surgical Obstetrics & Gynecology

Ovarian dysgerminoma

Pregnancy

Cesarean section

Chemotherapy

Patient outcomes

Case report.

This case report describes a rare type of tumor called ovarian dysgerminoma that was found in a pregnant woman. The report discusses the challenges faced in managing this condition during pregnancy, including how it was diagnosed, the treatment options considered, and the outcome for the patient.

In this case, a 25-year-old woman who was pregnant presented with a history of not having her disease for 8 months and experiencing increasing lower abdominal pain, difficulty urinating, and a swollen abdomen at 35 weeks of pregnancy. Upon examination, it was discovered that she had a mass in her ovary that extended to the cervix. After consultation with a team of doctors, a cesarean section was performed to deliver a healthy baby girl and remove the ovarian mass. The mass was later confirmed to be a dysgerminoma with a yolk sac tumor.

The diagnosis was made using ultrasound and laboratory tests. The patient underwent surgery because her symptoms worsened, and she required immediate intervention. However, the patient refused to follow the recommended chemotherapy after surgery. Although she initially recovered, she later developed sudden swelling in her abdomen and sought medical help at a rural facility. Unfortunately, despite initial treatment, she experienced complications and died.

This case study emphasizes the importance of a thorough diagnostic approach, timely intervention, and adherence to postoperative chemotherapy for managing ovarian dysgerminoma during pregnancy. These findings highlight the need for healthcare providers to consider these factors to improve outcomes for patients with this condition.

Ovarian malignancies during pregnancy, such as dysgerminomas and yolk sac tumors, are infrequent but critical conditions that can significantly impact maternal and fetal health. Dysgerminomas are rare malignant germ cell tumors that commonly present in women under the age of thirty and are typically unilateral with a favorable prognosis when detected early.¹ Despite their rarity, with an age-adjusted incidence rate reported in the literature, dysgerminomas account for a notable portion of ovarian malignant germ cell tumors (OMGCTs).²Here, we report a rare case in which a 25-year-old pregnant patient presented with a 2-week history of acute abdominal pain and distention.

A 25-year-old woman with a history of amenorrhea for 8 months, G6P4+1 (gravida 6, para 4 with 1 abortion), was pregnant at 35 weeks, and her last delivery was 2 years prior. She was referred to us from another hospital as a patient with a left ovarian mass. She presented to our facility with complaints of lower abdominal pain, which had been ongoing for 2 months but worsened significantly in the last 2 weeks. The pain was described as dull aching in nature with the feeling of heaviness, initially intermittent but progressing to continuous pain in the last 2 weeks and radiating to the perianal region. The pain was not relieved by painkillers. The patient also experienced urine retention, constipation, and abdominal distension.

Upon arrival, the patient was conscious, oriented, pale, in pain, and had bilateral lower limb edema. There were no signs of jaundice or cyanosis. Her vital signs on admission included a blood pressure of 120/80 mmHg, a pulse rate of 126 beats per minute, a fetal heart rate of 166 beats per minute, and an oxygen saturation (SpO2) of 95%. Lung auscultation revealed good air entry and normal heart sounds. Abdominal examination revealed more prominent generalized abdominal distension on the left lower abdomen with a gravid uterus at the 36-week fundal level and a cephalic pelvic grip. On vaginal examination, the cervix was displaced and contracted upward and laterally.

Diagnosis

Ultrasound (US) revealed a single viable fetus and a large left ovarian mass extending to the cervix. The laboratory test results were as follows: HB=10 g/dL, WBC=9 × 10^9/L, platelet=280 × 10^9/L, creatinine=0.4 mg/dL, ALT=16 U/L, and AST=25 U/L. MRI was recommended for patients to confirm the diagnosis of ovarian dysgerminoma and assess the extent of the disease. However, despite two attempts, MRI could not be performed due to the movement of the baby.

Management

Due to the worsening of the patient’s abdominal pain, a decision was made to terminate the pregnancy. Dexamethasone (6 mg) was administered intramuscularly for 2 days, and painkillers were provided. We performed a lower segment cesarean section (LSCS) in which a live female baby weighing 2.2 kg was delivered. During the surgical procedure, the mass ruptured, and its capsule was attached to the colon and rectum (Figure 1). Multiple adhesion bands were released from the colon and rectum (Figure 2). Following dissection, diffuse venous bleeding in the Douglas pouch was noted near the left ureter, and to avoid injury to vital structures and to control bleeding, we packed the pelvis with multiple gauzes for a second look 2 days later. Additionally, the lymph nodes and right ovary and tube were examined. A pelvic drain was placed, and the abdominal wall was closed in layers with good hemostasis. Histopathological samples were subsequently sent for further analysis. The patient's general condition was good and stable, and she was feeling well, passing through her flatus and stool. She was discharged home in satisfactory condition and advised to follow up for further care.

Follow-up and Outcomes:

After the histopathology results were obtained 3 weeks later, confirming the presence of dysgerminoma with a yolk sac tumor, the patient was referred to an oncology center for chemotherapy. She underwent one cycle of chemotherapy; however, her condition declined to continue with the remaining cycles. She returned home approximately 1 month later; she developed sudden abdominal distension. After seeking medical attention, she went to a rural medical center that was far from our hospital. Unfortunately, she experienced complications at that facility, and tragically, she passed away.

Globally, the incidence of ovarian germ cell tumors (OGCTs) varies, with these tumors being the primary ovarian malignancy affecting girls and young women.³ OCTs account for a significant percentage of all ovarian tumors according to demographic data, and while specific incidence rates during pregnancy are not as well documented, OGCTs remain one of the most common ovarian neoplasms encountered during pregnancy.⁴

The clinical presentation of ovarian dysgerminoma during pregnancy can be challenging to diagnose due to overlapping symptoms with normal pregnancy-related changes and other obstetric complications. In the present case, the patient's symptoms of abdominal pain, distension, and urinary retention were consistent with the common presentation of ovarian dysgerminoma, which can include abdominal discomfort and a palpable pelvic mass.⁵ Such symptoms necessitate a thorough diagnostic workup to differentiate them from other potential causes.

The diagnosis of ovarian dysgerminoma in pregnant patients often relies on a combination of ultrasound imaging and laboratory tests, with ultrasound being a critical tool for identifying the ovarian mass. In some cases, a second diagnostic test, such as MRI, may be recommended to confirm the diagnosis and to determine the extent of the disease.⁶ However, the distinctive features of dysgerminomas on imaging and the presence of a pelvic mass on clinical examination can guide the diagnostic process.⁷

The management of ovarian dysgerminoma during pregnancy presents unique challenges that require a multidisciplinary approach.. Although the incidence of ovarian dysgerminoma during pregnancy is low, with an estimated 0.2 to 1 per 1,000,000 pregnancies, this condition demands prompt and careful management due to its potential for rapid progression and complications.⁸

Therapeutic options for ovarian dysgerminoma during pregnancy include surgery and chemotherapy.⁹ The timing of surgery and the use of chemotherapy must be carefully considered to balance the need to treat the malignancy against the potential risks to the fetus. Chemotherapy, particularly with platinum-based agents, is the cornerstone of treatment for dysgerminoma. It can be administered during pregnancy after careful consideration of the gestational age and potential risks to the fetus.⁶

In the present case, the patient's worsening abdominal pain and identification of a large ovarian mass necessitated immediate surgical intervention. The decision to perform a lower segment cesarean section (LSCS) followed by resection of the ruptured ovarian mass highlights the complexity of balancing the urgency of maternal treatment with fetal considerations. The procedure is complicated by diffuse venous bleeding, emphasizing the risk of major postoperative complications associated with ovarian mass resection, such as hemorrhage and injury to surrounding structures.¹⁰ Despite these risks, the patient's postoperative period was stable, which is a testament to the surgical team's expertise and careful intraoperative management.

Postoperatively, the patient's refusal to complete the recommended cycles of chemotherapy underscores the importance of patient education and consent in the management of cancer during pregnancy. While chemotherapy for dysgerminoma can be safely administered during pregnancy, patient autonomy and decision-making play crucial roles in the treatment trajectory.⁶

The tragic outcome of this patient, following her decision to discontinue chemotherapy, highlights the critical nature of follow-up care for oncology patients. The sudden development of abdominal distension and subsequent complications after medical attention are sought at a rural facility further indicate the need for close monitoring and easily accessible care posttreatment, especially in patients who choose not to adhere to the standard protocol.⁹

In conclusion, the management of ovarian dysgerminoma during pregnancy requires a multidisciplinary approach, with a focus on timely diagnosis and a balance between effective cancer treatment and fetal safety. The case presented aligns with the reported literature in terms of clinical presentation, diagnostic challenges, and therapeutic strategies, although the outcome was unfortunately affected by the patient's decision to discontinue recommended therapy.

Acknowledgments

Not applicable.

Consent for Publication

Informed consent was not obtained because the patient died, and we could not access the patient’s next of kin.

Disclosure

The authors report no conflicts of interest related to this work.

Funding

The authors received no funding for the case report.

Data availability

Data openly available in a public repository with a DOI: https://doi.org/10.6084/m9.figshare.25241752

Authors' contributions

MG contributed to the study conception, HR to the study design, MA to the study interpretation, and HJ to the study drafting or substantive revision. All the authors approved the submitted version, taking personal accountability for their contributions and ensuring thorough investigation and resolution of any accuracy or integrity concerns.

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Ovarian Dysgerminoma Complicating Pregnancy: A Case Report and Review of Management Strategies

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