Objective: To report the management of patient with unexpected ovarian malignancy in histology after reproductive laparoscopic surgery in University Malaya Medical Centre.

Case Report: Madam ASL, 39 year old lady, Para 2, referred for chronic pelvic pain with left ovary cyst. No mass was palpable per abdomen. Ultrasound scan showed bilateral ovarian cysts measuring 4×4 cm each. Tumour markers including CA 125 were normal. In view of chronic pelvic pain with bilateral ovarian cysts, the diagnosis of possible endometriosis was made. During laparoscopy on 16th December 2016, both fallopian tubes were normal. Bilateral endometriotic cysts about 4×4 cm each were found. Laparoscopic bilateral Ovarian cystectomy was done. Both cyst walls were removed laparoscopically. Histological examination revealed that outer surface of both cyst walls were smooth. Inner surface of right cyst was haemorrhagic and that of left cyst wall was smooth macroscopically. However, the presence of a poorly differentiated adenocarcinoma of left ovarian cyst in two fragments were detected microscopically in addition to bilateral endometriotic cysts. The immunohistochemical and morphological features of the tumour are in keeping with a high grade endometroid adenocarcinoma with possibilty arising from endometrium or malignant transformation of endometriosis. However, endometrial sampling showed only secretory endometrium. After lengthy counselling to both patient and her husband, she underwent staging laparotomy on 13th February 2017. Intraoperatively, a tumour measuring 3×3 cm was protruding from the surface of left ovary. TAHBSO, omentectomyand bilateral pelvic lymphnode dissection were performed. Histology confirmed a Stage 1C poorly differentiated adenocarcinoma of the left ovary with positive peritoneal cytology. She is currently undergoing on adjuvant chemotherapy (Carboplatin and Paclitaxel).

Madam ASL is in her late thirties and keen to have one more child. Preoperatively and intraoperatively, there were no suspicion of ovarian malignancy. A poorly differentiated ovarian endometroid adenocarcinoma was discovered on microscopic examination after initial fertility sparing laparoscopic surgery. Definitive staging laparotomy was performed within 28 days following initial laparoscopic surgery.

Conclusion: Nowadays, unexpected ovarian malignancy may be detected after reproductive laparoscopic fertility sparing surgery in either elective or emergency setting for women in reproductive age group. Management will be challenging in these cases. Every effort should be made for definitive surgery as soon as possible to reduce the risk of cancer spread and recurrence. With multidisciplinary team approach and shared decision making by the couple, optimal outcome can be achieved in patients with unexpected ovarian malignancy following reproductive laparoscopic surgery.