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Resection of recurrent bulky gynaecological side wall malignancy with iliac vessel reconstruction

Case report 1 A 46 year old woman presented with a right iliac fossa mass. Twenty-five years previously she had undergone a left oophorectomy for a borderline papillary serous tumour of the ovary. The tumour ruptured during surgery and she received thiotepa chemotherapy post-operatively. Two years later, she had developed a right adnexal mass and underwent total abdominal hysterectomy, right salpingooophorectomy, omentectomy, and peritoneal biopsies. Histological examination showed a similar borderline papillary serous tumour confined to the ovary with intact capsule. She had remained well following this and had been discharged from review. At presentation a mass fixed to the pelvic side wall was palpable in the right iliac fossa from the inguinal ligament to the level of the anterior superior iliac spine. Serum CA125 was 206U/mL. Magnetic resonance imaging scan showed a 7 x 7cm partly cystic mass arising from the right pelvic side wall anterior to ilio-psoas. This encased the right common and internal iliac vessels and extended distally along the external iliac artery to invade the inguinal ligament and the muscles of the lateral abdominal wall (Fig. 1). No ureteric obstruction was seen. Computed tomography of the chest, abdomen and pelvis was otherwise negative. Trucut biopsy showed a borderline papillary serous tumour similar histologically to the previous ovarian primary. Laparotomy was performed through an extended midline incision in the abdomen and a vertical incision in the right groin. The mass was mobilised from the anterior pubic ramus. The inguinal ligament, the lower external oblique, internal oblique and transversalis muscles were excised. The ureter was mobilised medially. The common iliac artery was divided and the common iliac vein excised obliquely, flush with the vena cava. The femoral artery and vein were divided and the mass mobilised dividing the internal iliac artery and vein. Frozen sections were performed to ensure negative resection margins. The arterial supply to the right leg was reconstructed using a 6mm vascular graft from the right common iliac to the right common femoral artery. The venous supply was not reconstructed. The right inguinal ligament was replaced with a Marlex graft sutured from the pubic tubercle to the anterior-superior iliac spine. This was sutured to the fascia of the leg and the oblique abdominal muscles giving a satisfactory closure. The right leg was double bandaged over a TED stocking to minimise swelling. Histology of the resected specimen showed extensive papillary serous tumour with a spectrum of features, ranging from borderline papillary serous areas with foci of micropapillary pattern to moderately differentiated frankly invasive papillary serous adenocarcinoma. Complete excision was achieved but metastatic adenocarcinoma was identified in a right inguinal lymph node. Post-operative recovery was satisfactory and much improvement in leg ooedema achieved on resumption of full mobility. Carboplatin/paclitaxel adjuvant chemotherapy was started four weeks following surgery. She is currently well with no signs of recurrent disease and with good function 11 months following surgery