Saint Louis University School of Medicine St. Louis, MO
Soumojit Ghosh, MD, Elie Ghoulam, MD, Samuel Burton, MD, Kamran Qureshi, MD; Saint Louis University School of Medicine, St. Louis, MO
Introduction: Risk-reducing surgery, such as mastectomy, hysterectomy (TAH) and bilateral salpino-oopherectomy (BSO) are often performed in women with BRCA gene mutation to prevent breast, ovarian and tubal cancers. In addition, BRCA mutation carriers have a 1.3% higher risk for peritoneal carcinomatosis (PC) than the general population. However, PC after risk-reducing surgery, is possible, but rare. We report a case of peritoneal carcinomatosis 10 years after prophylactic BSO.
Methods: A 57-year-old female with BRCA1 mutation presented with 3 weeks of progressive abdominal pain and distention. She had previously undergone risk-reducing surgery with prophylactic bilateral mastectomy and TAH-BSO (age 47). Family history was notable for ovarian cancer in her mother and sister, and breast cancer in her cousin. On admission, she was tachycardic, afebrile and normotensive. Physical exam revealed a distended abdomen with diffuse dullness to percussion and mild guarding. Lab workup including a CMP and CBC were within normal limits. A CT abdomen/pelvis revealed large volume ascites with loculations, peritoneal thickening and enhancement, and omental fat stranding [figure A]. A diagnostic and large volumeparacentesis was done. Ascitic fluid labsrevealed 1,577 WBCs (290 PMNs, 8% mesothelial cells) and a SAAG of 0.6. She was started on ciprofloxacin, albumin, furosemide and spironolactone. Ascitic fluid cytology came back positive for peritoneal adenocarcinoma. She completed chemotherapy followed by exploratory laparotomy with partial omentectomy and debulking of the high-grade serous adenocarcinoma. Discussion: Peritoneal carcinomatosis is an aggressive and difficult malignancy to diagnose at an early stage due to the absence of a screening test and anatomic location. It is theorized that PC after BSO occurs due to the shedding and seeding of pre-cancerous tubal or ovarian epithelial cells into the peritoneal cavity prior to or during their removal. Although prophylactic BSO significantly lowers the risk of ovarian and tubal cancer, in BRCA mutation carriers, there is still a potential risk of PC due to the possibility of pre-cancerous cells that have already shed into the abdominal cavity. Given that BSO removes the source of pre-cancerous epithelial cells, most PC cases occurs within 4 years of surgery. Our case demonstrates the importance to consider PC if a BRCA mutation carrier presents with ascites of unknown origin irrespective of when risk-reducing surgery was performed.
Figure A: CT abdomen/pelvis revealing diffuse, loculated ascites and peritoneal thickening and enhancement
Disclosures: Soumojit Ghosh indicated no relevant financial relationships. Elie Ghoulam indicated no relevant financial relationships. Samuel Burton indicated no relevant financial relationships. Kamran Qureshi indicated no relevant financial relationships.