Metastatic Ovarian Clear Cell Carcinoma in the Context of In
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Adnexal masses are routinely encountered in the clinical practice. However, adnexal masses during pregnancy are incidental findings and usually resolve spontaneously or can be managed conservatively during pregnancy due to their benign nature. Ovarian malignancy is a rare event to occur during pregnancy. Only a few cases of ovarian clear cell carcinoma (OCCC), a subtype of epithelial ovarian cancers, have been reported in pregnancy and all of which have undergone cystectomy or pregnancy termination prior to the last trimester of pregnancy.

This case presents a 38-year-old Asian G2P1001 female who delivered by cesarean section (CS) at 32 weeks gestation for pre-eclampsia with severe features with uncontrollable blood pressures. Her pregnancy was further complicated by a known right ovarian mass, history of endometriosis which was managed conservatively, as well as infertility. Both first and second pregnancies were conceived via in vitro fertilization by frozen embryo transfer. Her first pregnancy was otherwise uncomplicated, however resulted in primary CS for nonreassuring fetal heart tracing. No pelvic pathology was noted during that CS. The patient was first diagnosed with a right ovarian mass during her second pregnancy while on IVF treatment. The patient declined the option of removing the mass due to possibility of damaging the nearby ovarian tissue during removal of the mass and thus worsening her infertility. The IVF treatment was successful. The transvaginal ultrasonography performed during the early pregnancy suspected the right ovarian mass as endometrioma or desmoid tumor .

The mass was kept under surveillance by performing periodic ultrasound imaging. Due to the change in mass characteristics and increase in size, the patient was referred to a Gynecologic Oncologist during the second trimester. Considering the high risk pregnancy, recommendation was made to follow the mass with sequential ultrasound with the removal of the mass at the time of repeat CS as long as the mass did not change in size or configuration during the pregnancy and patient remained asymptomatic. Unfortunately, the patient developed pre-eclampsia with severe features at 32 weeks of gestation. Upon admission, she was given magnesium sulfate infusion for seizure prophylaxis and corticosteroids for fetal lung maturity. The Maternal-Fetal-Medicine specialists recommended delivery at thirty-four weeks of gestation unless there were new signs of maternal or fetal instability. However, three days after the admission, she underwent an emergency cesarean section due to recurrent severe blood pressure changes which were unresponsive to intravenous antihypertensive medications.

During cesarean section, extensive adhesions were noted at the level of adipose tissue, rectus muscle, and anterior surface of the uterus, which were densely adhered to each other and to the anterior abdominal wall. With limited visualization of the lower uterine segment, a classical vertical uterine incision was performed. The fetus was delivered without difficulty. The uterus was exteriorized and closed in layers. At this point, the right ovarian mass was visualized, the surface of which was friable and hemorrhagic. Two units of each packed red blood cells, fresh frozen plasma, and cryoprecipitate were administered. Antibiotics were reduced due to prolonged surgical time. With extensive lysis of adhesions and uterine packing, the surgeons successfully ligated the uterine pedicle and the infundibulopelvic ligament to remove the large ovarian mass.

The pathological examination of the resected specimen revealed an ovarian mass with attached intact fallopian tube, weighing 63 g and measuring 14.0 × 10.5 × 3.0 cm
The external surface of ovarian mass was smooth, hemorrhagic but without any excrescences. The serial sectioning revealed multiple cystic lesions filled with clear to yellow fluid as well as necrotic material overall occupying 80% of the ovarian mass. Microscopically, the viable ovarian tissue demonstrated tubulocystic and papillary architecture along with focal areas of solid sheets of tumor cells displaying the clear cytoplasm.

In summary, the case emphasizes the importance of close imaging surveillance for all masses diagnosed during the pregnancy in particular with a background of other risk factors such as endometriosis, East Asian ethnicity and IVF. The gravid females who undergo fertility treatment with a pre-existing ovarian mass and underlying endometriosis require close monitoring and early surgical management since they are at risk for rapid growth and malignant transformation.