A patient who will be referred to as Ms. L in this case study was 34 years old when she presented to the emergency department in January 2012 with severe pain in the right lower quadrant that radiated to her back.
She also reported a feeling of pressure when voiding but no dysuria, urinary frequency, or hematuria. Ms. L denied melena and diarrhea. She also denied fevers, chills, and night sweats. She rated the pain as 10/10 in severity.
On further questioning, the patient described the pain as cyclic in nature, occurring every four to six weeks over the previous 18 months. Although she was taking oxycodone hydrochloride with acetaminophen 10 mg every four hours, the pain persisted, prompting her visit to the emergency department.
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1. HISTORY
Ms. L was gravida 3, para 3. She had a history of multiple abdominal and pelvic surgeries, including Cesarean sections in 2002, 2005, and 2008, and an endometrial ablation and dilation and curettage (D&C) in 2008. She underwent a hysterectomy in 2009 due to abnormal uterine bleeding.
A bilateral salpingo-oophorectomy was performed later that year. Ms. L had complications after each of these surgeries, which led to additional surgeries including hernia repair, partial cystectomy, adhesiolysis, and a transureteroureterostomy due to ureteral strictures and injury. She had chronic urinary tract infections.
Ms. L reported that she had previously been evaluated for her ongoing pain, but because of her many surgeries and subsequent complications, she was advised that additional surgeries were not in her best interest.
2. EXAM AND TESTS
Initial examination in the emergency department revealed the following: temperature 36.9°C, pulse 98, respirations 18, blood pressure 131/78, oxygen saturation 96% on room air.
General: The patient appeared to be in no acute distress. Head: normocephalic, atraumatic. Pupils: PERRLA (pupils equal, round,reactive to light and accommodation). Lungs: clear to auscultation. Heart: regular rate and rhythm without murmur. Abdomen: obese and soft with mild tenderness in the right lower quadrant. No rebound or guarding. Good bowel sounds. Extremities: no edema, clubbing, or cyanosis. Skin: no rash. Neurologic: alert and oriented x 3. Cranial nerves II-VII grossly intact.
Initial testing included laboratory studies: complete blood count, urinalysis, basic metabolic panel (BMP), and liver function tests (LFTs). The laboratory studies showed a normal white count (8.9), hemoglobin (13), normal BMP, and LFTs within normal limits. Urine was negative.
A computed tomography (CT) scan of the abdomen and pelvis without contrast showed a postoperative ureteral diversion, a 4-mm caliceal stone in the lower pole of the right kidney, severe hepatic steatosis, and a 3-cm right ovarian cyst.
3. EVALUATION
Based on the information obtained to this point, differential diagnoses could include, but are not limited to, neoplasia, pelvic inflammatory disease, pelvic adhesions, ovarian remnant syndrome, and endometriosis.
A gynecologic consultation was ordered for further evaluation of the patient’s pain and the nonspecific right adnexal tissue. Previous pathology showed no evidence of endometriosis. It was suspected that the right-lower-quadrant pain and the cyst seen on imaging were likely due to a right ovarian remnant.
To further help identify this right-lower-quadrant lesion as being hormone-related, a three-month trial of a luteinizing hormone-releasing hormone (LHRH) agonist, leuprolide (Eligard, Lupron), was initiated to suppress ovarian function. If the pain were to dissipate during the course of therapy, it would be reasonable to attribute the pain to an ovarian remnant.
Leuprolide was to be administered in three 30-mg doses, with each dose delivered four weeks apart. After the first eight weeks of leuprolide therapy, the patient reported that she was no longer experiencing any right-sided abdominal pain. However, she did experience significant side effects from the leuprolide including hot flashes, nausea, and anxiety. Therefore, the third injection of leuprolide was not given.
The absence of pain with leuprolide therapy further confirmed the suspicion that the right-lower-quadrant lesion was a functional ovarian remnant (Figure 1).
Figure 1. A lesion in the right lower quadrant was causing the patient cyclic pain.
4. TREATMENT
Due to the small but nonetheless valid risk of ovarian remnants containing malignant cells, the surgical approach by laparotomy or laparoscopy is the primary treatment option.1However, this patient was deemed to be a high-risk surgical candidate as a result of her previous multiple and difficult surgeries. Therefore, a noninvasive approach to treatment was recommended.
Ms. L was referred for a meeting with a radiation oncologist to discuss radiation therapy in this setting. The radiation oncologist recommended that Ms. L receive a course of external beam radiation therapy to the right ovarian remnant, with the goal of therapy being to stop ovarian function.
Ms. L received external beam radiation of 200 centigray (cGy) units in 10 fractions over 10 treatment days, for a total of 2,000 cGy. The radiation was delivered using a three-dimensional (3D) conformal technique and was completed in May 2012. The patient experienced no adverse effects from radiation and completed all planned treatments with resolution of her right-lower-abdominal pain.
5. FURTHER SYMPTOMS, TREATMENT
Ms. L did well until six months later, when she developed pain in the left lower quadrant similar to the previous right-sided pain. She returned for further evaluation, bringing with her copies of a CT scan of the abdomen and pelvis performed with contrast in November 2012.
The imaging revealed a diffuse fatty infiltration of the liver, cholecystectomy clips, a small calculus within the lower pole of the right kidney, postoperative changes within the pelvis, and a left ovarian cyst of 2.3 cm. The right ovary was not identified. The patient’s previous hysterectomy was identified, as were changes to the anterior abdominal wall. The right ureter appeared to cross the midline. The distal ureters were not well seen.
A transvaginal and pelvic ultrasound was performed to help identify the ovarian cyst seen on the CT scan. The ultrasound revealed a hypoechoic solid structure in the left adnexa measuring 4.0 × 1.5 × 2.7 cm. On previous scans, the structure had measured 3.0 × 1.5 × 2.3 cm.
There was minimal vascular flow in this lesion, with no clear cystic structures present within it. Because of the radiographic similarities between this lesion (Figure 2) and the previous lesion identified as being an ovarian remnant, radiation therapy was again initiated.
The same treatment regimen was used for this left-sided lesion as had been used for the right-sided lesion (Figure 3). The treatment was completed in April 2013. The patient tolerated the treatment well, experiencing no acute side effects.
6. OUTCOME
Since completing radiation treatment for bilateral ovarian remnants, Ms. L has been followed by a urologist for ongoing issues related to chronic urinary tract infections that predated her radiation treatments. She occasionally takes a short-acting opioid, oxycodone (Roxicodone) for pain associated with those infections.
However, she has not experienced any further symptoms related to the ovarian remnants and remains pain-free from that standpoint. She experienced no acute side effects during radiation treatment for the ovarian remnants, and has had no ongoing issues related to that treatment.
Figure 3. The same radiation treatment regimen was used for the left-sided lesion as had been used for the right-sided lesion
7. DISCUSSION
Incomplete removal of ovarian tissue can cause symptoms of pelvic pain, which is often cyclic in nature.
Other symptoms of ovarian remnant syndrome include dyspareunia, dysuria, and/or pain with urination or defecation. Ovarian remnant syndrome can also present as a pelvic mass, with or without pain.3Symptoms usually begin within the first five years after oophorectomy.1
Evaluation of ovarian remnant syndrome should begin with a detailed medical history, including gynecologic history, previous surgeries, and description of symptoms. Tests can include lab work to measure levels of follicle-stimulating hormone (FSH), which should be very high after bilateral oophorectomy, and estradiol, which should be very low. If these are not the results, functioning ovarian tissue may be present.
CT scans, ultrasounds, and magnetic resonance imaging (MRI) can identify abnormal tissue to help determine the diagnosis.
Surgical excision, radiation therapy, and/or medication are all therapeutic options for ovarian remnants, with surgery being the first-line treatment.4Radiation therapy for this condition can be delivered in a short amount of time with minimal to no side effects, making it a viable treatment option for women with ovarian remnants who are not good surgical candidates.
Pam Zimmerman, MSN, FNP-C, OCN, is a family nurse practitioner as well as an assistant professor of radiation oncology at Mayo Clinic Arizona in Phoenix.
References
- Kho RM, Abrao MS. Ovarian remnant syndrome: etiology, diagnosis, treatment and impact of endometriosis. Curr Opin Obstet Gynecol. 2012;24(4):210-214.
- Magtibay PM, Nyholm JL, Hernandez JL, Podratz KC. Ovarian remnant syndrome. Am J Obstet Gynecol. 2005;193(6): 2062-2066.
- Dereska NH, Cornella J, Hibner M, Magrina JF: Mucinous adenocarcinoma in an ovarian remnant. Int J Gynecol Cancer. 2004;4(4): 683-686.
- Kho RM, Magrina JF, Magtibay PM. Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome. Fertil Steril. 2007;87(5):1005-1009
