Multidisciplinary management of adult-type ovarian granulosa cell tumor in a patient with severe peripheral arterial disease and chronic limb-threatening ischemia: a case report

Abstract

Reports describing the concurrent management of adult-type granulosa cell tumor (AGCT) and chronic limb-threatening ischemia (CLTI) are exceedingly rare, highlighting the challenges of treating a rare gynecologic malignancy in a medically fragile patient with severe peripheral arterial disease (PAD). Although AGCTs generally follow an indolent clinical course, management becomes considerably more complex in patients with advanced disease and significant vascular comorbidity. This case illustrates the importance of multidisciplinary collaboration and individualized treatment planning in patients with overlapping oncologic and vascular disease. A 59-year-old Hispanic woman with severe peripheral arterial disease presented with a large pelvic mass and advanced chronic limb-threatening ischemia. Computed tomography angiography demonstrated a large pelvic tumor causing compression of the distal abdominal aorta in the setting of severe multilevel aortoiliac and femoropopliteal occlusive disease. Biopsy and subsequent surgical pathology confirmed an adult-type granulosa cell tumor of the ovary with pelvic extension (FIGO stage IIB). The patient underwent cytoreductive surgery followed immediately by complex vascular reconstruction. Her postoperative course was complicated by progressive ischemia requiring bilateral below-knee amputations, recurrent infections, impaired wound healing, osteomyelitis, and delays in systemic chemotherapy. Endocrine therapy with letrozole was initially selected because of severe medical comorbidity and ongoing vascular complications. The patient subsequently developed an isolated recurrent perihepatic (hepatic capsular) peritoneal recurrence and was treated with sequential systemic chemotherapy, endocrine therapy, and percutaneous cryoablation during a prolonged multidisciplinary treatment course. This case highlights the complexity of managing advanced AGCT in the setting of severe PAD and CLTI, where vascular disease, impaired wound healing, and infectious complications substantially influenced oncologic treatment planning and tolerance of systemic therapy. Successful management required close multidisciplinary collaboration among gynecologic oncology, vascular surgery, infectious disease, wound care, rehabilitation medicine, and pathology teams. In medically fragile patients with advanced AGCT, treatment decisions regarding surgery, systemic therapy, endocrine therapy, local ablative therapy, and surveillance should be individualized according to disease status, comorbidity burden, functional status, and overall treatment goals.