57-year-old female with an ovarian mass for Investigation.

Background 

• Liver disease
  • Long history of untreated HCV
  • Now diagnosed with Childs Pugh B liver cirrhosis – albumin 20, bilirubin 64, platelets 57.
  • Recent admission with decompensation – severe hydrothorax treated with diuretics.
  • Antivirals recently commenced but not with curative intent.
  • Letters suggest gastro teams and gynae team all aware of both issues.

• Ovarian mass
  • Incidental finding although some abdominal discomfort
  • 7.7cm2 
  • Ca125 274 (could be elevated due to liver disease)

• Asthma
• PAF 

Discussion 

Should surgery proceed?

• Cirrhosis surgery risk score (http://www.vocalpennscore.com) suggests:
  • 30d mortality of 7%
  • 6/12 mortality 19%

• Phone call to gastroenterology team: 
  • High risk of haemorrhage (very difficult to control) with any abdominal surgery, especially laparoscopic, due to portal hypertension.
  • High risk of postoperative decompensation, encephalopathy, infection, and wound breakdown.
  • Patient requires urgent variceal banding, but this will worsen portal hypertension.
  • Delay of 2/12 to enable gastroscopy, ongoing antiviral treatment, anti-portal HTN treatment, repeat imaging, and possible mild improvement.

• General opinion at the meeting was that the real risks highlighted by the gastroenterologist superseded the theoretical risks of a delayed diagnosis of a possible ovarian cancer (patient unlikely to be a candidate for radical curative surgery or chemotherapy). See attached summary article.
• TIPS (or similar procedure) may be an option to offload portal hypertension prior to consideration for gynae surgery – for further discussion after 2/12 delay.