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. 2026 Feb 7;63:102041. doi: 10.1016/j.gore.2026.102041

Metastatic high-grade undifferentiated ovarian carcinoma: A case report from Sub-Saharan Africa

John Lugata a,b,⁎, Caleigh Smith c, Fortunata Nzota a, Abitalis Mayengela d, Tecla Lyamuya a,b, Albert Masenga a,b, Eusebious Maro a,b, Bariki Mchome a,b, Alex Mremi b,d,e
PMCID: PMC12908006  PMID: 41704940

Highlights

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    Undifferentiated ovarian carcinoma (UDOC) is a rare, aggressive epithelial ovarian malignancy with limited clinical characterization.

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    We report a case of metastatic undifferentiated ovarian carcinoma from Sub-Saharan Africa, an underrepresented setting in the literature.

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    Histopathologic and immunohistochemical findings excluded serous differentiation and supported a diagnosis of UDOC.

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    Advanced disease and limited surgical capacity precluded optimal cytoreductive surgery.

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    This case highlights diagnostic and treatment challenges for gynecologic malignancies in low-resource settings.

Keywords: Undifferentiated ovarian carcinoma, Ovarian neoplasms, Liver metastases, Immunohistochemistry, Resource-limited settings, Sub-Saharan Africa

Abstract

Background

Undifferentiated ovarian carcinoma (UDOC) is an exceptionally rare and highly aggressive subtype of epithelial ovarian cancer, accounting for less than 1% of cases and infrequently reported in the literature, particularly in resource-limited settings. To our knowledge, this represents the first reported case of metastatic UDOC from Sub-Saharan Africa.

Case presentation

We report a case of high-grade UDOC in a 63-year-old postmenopausal woman presenting to a tertiary referral center in Northern Tanzania with a one-year history of progressive abdominal pain, distension, early satiety, and weight loss. Imaging demonstrated a large heterogeneous pelvic mass with extensive exophytic hepatic metastases and omental involvement, consistent with advanced-stage disease. Exploratory laparotomy revealed a frozen pelvis with extensive adhesions and intraabdominal metastases, precluding optimal cytoreductive surgery. Histopathologic evaluation demonstrated sheets of poorly differentiated tumor cells with marked cytologic atypia and high mitotic activity, a high proliferative index, and negative staining for Wilms tumor 1 (WT1), estrogen receptor (ER), and epithelial membrane antigen (EMA), supporting the diagnosis of FIGO stage IVB UDOC. Multidisciplinary tumor board review recommended platinum-based chemotherapy; however, treatment was not initiated due to financial barriers, and the patient was subsequently lost to follow-up.

Conclusion

UDOC is a rare and aggressive malignancy that often presents at an advanced stage with nonspecific gastrointestinal symptoms and widespread metastases. This case highlights the intersection of aggressive tumor biology and structural healthcare barriers that continue to limit access to timely cancer diagnosis and treatment in resource-constrained settings, underscoring persistent disparities in global cancer care delivery.

1. Introduction

Ovarian cancer remains a leading cause of mortality among gynecological malignancies worldwide and is the eighth most commonly diagnosed cancer in women, with over 300,000 new cases and 200,000 deaths annually (Bray et al., 2024). Because early symptoms are often nonspecific, most cases are diagnosed at an advanced stage, contributing to poor outcomes. Epithelial ovarian cancers account for approximately 90% of cases, with high-grade serous carcinoma being the predominant histologic subtype (Lheureux et al., 2019).

Undifferentiated ovarian carcinoma (UDOC) is an exceptionally rare, high-grade subtype of epithelial ovarian cancer, representing less than 1% of cases (Silva et al., 2006, Nasioudis, 2017). Histologically, UDOC is characterized by sheets of highly atypical tumor cells with marked nuclear pleomorphism and high mitotic activity, lacking distinguishing features of differentiated epithelial subtypes (Cree et al., 2020). Accurate diagnosis is challenging due to morphological overlap with other poorly differentiated malignancies and often requires ancillary testing, which may be unavailable in resource-limited settings (Gilks and Prat, 2009).

Clinically, UDOC often presents with metastatic disease and is associated with poor prognosis (Silva et al., 2006, Nasioudis, 2017). Management is extrapolated from treatment paradigms for high-grade epithelial ovarian cancer, including cytoreductive surgery and platinum-based chemotherapy, but evidence specific to UDOC remains limited (Colombo et al., 2020). Given the scarcity of reported cases from Sub-Saharan Africa and persistent disparities in access to oncologic care, we describe metastatic UDOC in a postmenopausal woman from Tanzania, highlighting diagnostic challenges and systemic barriers to oncologic care in a low-resource setting.

2. Case description

A 63-year-old postmenopausal woman presented to Kilimanjaro Christian Medical Centre (KCMC), a tertiary referral hospital in Moshi, Tanzania, with a one-year history of progressive abdominal pain and distension. Symptoms included bloating, early satiety, dyspepsia, nausea, and emesis, along with unintentional weight loss, generalized weakness, dizziness, and palpitations. She denied fever, chest pain, dyspnea, vaginal bleeding, dysuria, or changes in bowel habits.

Her medical history was notable only for hypertension, and she reported no known family history of malignancy. Gynecological history included menarche at age 18, menopause at age 51, and prior total abdominal hysterectomy in 2014 for symptomatic uterine fibroids, with ovaries left in-situ.

On examination, she appeared markedly pale and jaundiced but was afebrile and hemodynamically stable. Abdominal examination revealed marked distension with right lower quadrant tenderness, a palpable mass extending from the right hypochondrium to the iliac fossa, and reduced bowel sounds. Pelvic exam demonstrated a well-healed vaginal cuff without bleeding, discharge or palpable masses. Examination of other systems was unremarkable. CA-125 was elevated at 364 U/mL and CEA at 5.8 ng/mL. Laboratory evaluation was otherwise notable for hemoglobin of 5.5 g/dL with normal renal and liver function tests. Baseline electrocardiogram and chest radiograph were normal. Pap smear was negative.

Ultrasound demonstrated a heterogeneous upper abdominal mass abutting the liver, with irregular borders and no appreciable Doppler vascularity, as well as a separate mixed cystic-solid pelvic mass suspected to arise from the right ovary. The liver had a heterogeneous echotexture with parenchymal irregularities suspicious for metastatic disease. Contrast-enhanced CT confirmed multiple exophytic masses in the right hepatic lobe, the largest measuring 21 × 18 × 17 cm, with significant mass effect on adjacent vascular and visceral structures (Fig. 1). A necrotic pelvic mass measuring approximately 12 × 12 × 12 cm was also identified, along with small, enhancing omental nodules. Overall findings were consistent with advanced ovarian malignancy with hepatic metastases and omental seeding.

Fig. 1.

Fig. 1

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Contrast-enhanced CT scan demonstrating a large heterogeneous pelvic mass (green arrows) with extensive exophytic hepatic metastases (blue arrows), consistent with advanced ovarian malignancy. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Given the high clinical suspicion for ovarian malignancy and the need for definitive tissue diagnosis, exploratory laparotomy was pursued. Although image-guided biopsy or diagnostic laparoscopy would typically be preferred, access to these modalities is limited in our setting due to availability and financial constraints. Following shared decision-making with the patient, we therefore proceeded with exploratory laparotomy via a vertical midline incision under general anesthesia. Intraoperatively, extensive adhesions and peritoneal deposits involving the ovaries, small bowel, and transverse colon were identified. Two large cystic masses were noted, one arising from the ovary and the other suspected to be retroperitoneal in origin. Pelvic washings were obtained for cytology, and biopsies were taken from multiple involved sites. Given the extent of carcinomatosis, with involvement of the bowel and liver as well, optimal cytoreduction was not feasible, and the procedure was aborted.

Histopathological examination demonstrated sheets of poorly differentiated tumor cells with marked nuclear atypia, variable cytoplasmic volume, and tumor giant cells, without glandular or papillary differentiation seen in other epithelial ovarian subtypes (Fig. 2). Immunohistochemical analysis revealed a high proliferative index (Ki67) with negative tumor cell expression for Wilms tumor 1 (WT1), estrogen receptor (ER), and epithelial membrane antigen (EMA), arguing against serous differentiation (Fig. 3). Comprehensive molecular testing was not available in this setting. Based on clinicopathological correlation, including clinical presentation, morphologic features, and immunohistochemical findings, the diagnosis of FIGO stage IVB high-grade UDOC (T3cN1bM1b) was made.

Fig. 2.

Fig. 2

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Histopathologic features of undifferentiated ovarian carcinoma demonstrating sheets of poorly differentiated tumor cells with marked cytologic atypia and numerous mitotic figures on hematoxylin and eosin staining (original magnification × 20).

Fig. 3.

Fig. 3

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Immunohistochemical (IHC) findings in undifferentiated ovarian carcinoma. IHC staining demonstrates a high proliferative (mitotic) index via Ki67 staining (A). Negative tumor cell expression for epithelial membrane antigen (EMA) (B), estrogen receptor (ER) (C), and Wilms tumor 1 (WT1) (D).

The postoperative course was uneventful, and the patient was discharged on postoperative day six. The case was reviewed by a multidisciplinary tumor board comprised of gynecologists, oncologists, and pathologists, which recommended systemic chemotherapy with carboplatin and paclitaxel in accordance with guideline-based management for advanced epithelial ovarian cancer. Bevacizumab and other targeted therapies were not pursued due to financial constraints and lack of availability. At follow-up two weeks later, the patient was counseled regarding treatment options, including systemic chemotherapy versus supportive care, and initially elected to receive chemotherapy. However, she was subsequently lost to follow-up despite repeated attempts to make contact, so treatment was not initiated. The patient’s current outcome remains unknown.

3. Discussion

Undifferentiated ovarian carcinoma (UDOC) is a rare and highly aggressive malignancy that remains poorly characterized, particularly in Sub-Saharan Africa (SSA). Diagnostic delay is common due to nonspecific symptoms and limited access to advanced imaging, specialized pathology, and molecular testing in low-resource settings. This case from a tertiary referral center in Northern Tanzania underscores the importance of maintaining clinical suspicion for ovarian malignancies in postmenopausal women with abdominal symptoms, as well as the need for early multidisciplinary involvement to guide diagnostic evaluation and management.

Epithelial ovarian cancers are heterogeneous, with high-grade serous carcinoma predominating, while rarer histologic entities like UDOC remain poorly described and account for only a small fraction of cases. Patients with UDOC typically present with nonspecific abdominal or gastrointestinal symptoms related to tumor bulk, ascites, or peritoneal dissemination (Silva et al., 2006, Nasioudis, 2017). In our patient, progressive abdominal distension, early satiety, dyspepsia, and unintentional weight loss over 12 months culminated in identification of a large pelvic mass with extensive hepatic involvement. Consistent with population-level data, over 70% of ovarian cancer patients present with advanced-stage disease due to the nonspecific nature of early symptoms (Bray et al., 2024). Severe anemia in this case further reflected chronic disease burden and nutritional compromise, factors that complicate perioperative management and systemic therapy in low-resource settings.

Imaging findings in ovarian cancer are generally nonspecific and cannot reliably distinguish UDOC from other high-grade epithelial subtypes. Cross-sectional imaging typically demonstrates large heterogeneous masses with solid and cystic components, areas of necrosis, and evidence of peritoneal or distant metastatic disease in advanced cases (Shan et al., 2022). In this case, imaging and surgical findings revealed significant hepatic, bowel, and omental involvement, consistent with both transcoelomic and hematogenous spread, corresponding to FIGO stage IVB disease. Hepatic involvement has been reported in approximately 20–40% of patients with stage IV ovarian cancer and is associated with poor prognosis (Shan et al., 2022).

Definitive diagnosis of UDOC relies on histopathologic evaluation, which remains limited in many low- and middle-income countries (LMICs). Histologically, UDOC is defined by sheets or nests of pleomorphic tumor cells with marked nuclear atypia and high mitotic activity, lacking the architectural features that allow classification into more differentiated epithelial subtypes (Silva et al., 2006, Köbel, 2017). When available, immunohistochemistry is essential to exclude other poorly differentiated malignancies and support epithelial lineage, via advanced staining for cytokeratins, Wilms tumor 1 (WT1), p53, PAX8, and markers of lineage like ER, PR, and Napsin A (Cree et al., 2020, Gilks and Prat, 2009, Köbel, 2017). In this case, the absence of WT1, ER, and EMA expression, together with a high Ki67 index, supported the diagnosis of UDOC, with histopathologic findings consistent with contemporary series despite molecular profiling not being available locally. Recent molecular studies further demonstrate that many undifferentiated and dedifferentiated ovarian carcinomas harbor TP53 alterations and frequent inactivation of the SWI/SNF chromatin-remodeling complex, supporting classification of these tumors as aggressive and genomically unstable malignancies (Zhang et al., 2016, Tessier-Cloutier et al., 2024). Limited availability of ancillary testing remains a common constraint in many LMICs and underscores reliance on careful morphologic assessment by experienced pathologists.

Obtaining tissue samples can also be challenging, although initiation of chemotherapy typically requires histopathological confirmation of malignancy. Minimally invasive diagnostic approaches such as image-guided biopsy or diagnostic laparoscopy are not routinely available in our setting due to limitations in specialized equipment, shortages of trained personnel, and financial constraints affecting both institutions and patients. Consequently, exploratory laparotomy often remains the most feasible approach for obtaining tissue diagnosis when ovarian malignancy is suspected, even when disease appears advanced on imaging, and therefore frequently precedes systemic therapy planning in our setting.

Due to its rarity, there are no treatment protocols specific to UDOC, and management is extrapolated from guidelines for high-grade epithelial ovarian cancer. International recommendations support maximal cytoreductive surgery followed by platinum-based chemotherapy, most commonly carboplatin and paclitaxel, for advanced-stage disease (Lheureux et al., 2019, Colombo et al., 2020, du Bois et al., 2009). While optimal cytoreduction remains the strongest prognostic factor, the feasibility of such extensive surgery is limited in many LMICs due to restricted surgical expertise, minimal perioperative resources, and challenges with postoperative care, particularly when multivisceral resections are required (Sankaranarayanan et al., 2010). In this case, extensive bowel and hepatic involvement precluded safe cytoreductive surgery, as bowel resections with or without ostomy creation are rarely performed in our low-resource setting due to substantial perioperative risk. Additionally, postoperative care requirements, including nutritional support, ostomy management, and close follow-up, are inaccessible to most patients, further increasing the risk of morbidity. Addressing these barriers will require targeted investment in gynecologic oncology surgical training, multidisciplinary team development, and healthcare infrastructure to safely expand access to cytoreductive surgery for women with advanced ovarian cancer in resource-limited settings.

Systemic therapy options are similarly constrained by access and cost. Despite tumor board recommendation for carboplatin and paclitaxel, treatment was not initiated in this case due to financial barriers and the patient was subsequently lost to follow-up, a challenge frequently reported in Sub-Saharan Africa and associated with increased cancer-related mortality (Sankaranarayanan et al., 2010, Lombe et al., 2023). Although platinum-based chemotherapy remains the backbone of treatment, targeted therapies such as bevacizumab have demonstrated benefit in select populations (Perren et al., 2011), but their role in UDOC remains poorly defined. Use of such therapies in low-resource settings is typically constrained by cost, limited molecular testing, and restricted availability.

Financial toxicity remains one of the most significant determinants of cancer outcomes in many LMICs. In our setting, the approximate cost per cycle of chemotherapy is USD 46 for carboplatin and USD 50 for paclitaxel, and expenses are typically paid out-of-pocket because insurance coverage for cancer treatment remains limited. For context, average monthly income in Tanzania is low relative to chemotherapy costs; World Bank data indicate a Gross National Income per capita around USD 1,100–1,200 annually (approximately USD 90–100 per month), with substantial variation by region and means of employment (World Bank). In Northern Tanzania, many households rely on subsistence farming or informal employment, resulting in irregular and difficult-to-quantify income. Consequently, even standard first-line chemotherapy often represents a prohibitive financial burden, contributing to delayed treatment initiation and limiting treatment completion.

Beyond medication costs, patients frequently face additional logistical challenges, including transportation expenses, long travel distances to referral centers, and the need for temporary accommodation during treatment (Lombe et al., 2023). These barriers disproportionately affect patients from rural communities and often contribute to delayed treatment initiation, non-adherence to recommended therapy, and loss to follow-up, further worsening outcomes for patients with advanced malignancies.

Access to formal palliative care services also remains limited in our setting, as in many regions of SSA. While available at some tertiary and referral centers, palliative care services are often initiated late and remain difficult to access due to workforce shortages, limited integration into oncology care, inconsistent availability of essential medications, and scarcity of community-based support programs. In the present case, earlier integration of palliative care may have helped address symptom burden, support treatment decision-making, and improve quality of life following the determination that optimal cytoreduction was not feasible and systemic therapy would likely represent a major financial burden. Notably, formal hospice services are not available in this setting despite being appropriate for many patients with advanced malignancies, underscoring a critical gap in end-of-life care infrastructure. Expansion of palliative care and hospice capacity represents an important opportunity to improve patient-centered outcomes when curative therapy is unattainable.

Although published data describing ovarian cancer outcomes in comparable low-resource settings remain limited, efforts across SSA are underway to improve access to oncology services through expansion of multidisciplinary care, strengthening referral pathways, and gradual development of specialized cancer treatment centers. Published literature from the region has largely focused on access challenges, registry-based incidence and survival estimates, and broader health-system constraints (Sankaranarayanan et al., 2010, Lombe et al., 2023), with comparatively fewer reports detailing treatment outcomes in low-resource tertiary settings. Consequently, much available data remains fragmented, underscoring the importance of continued reporting of institutional experiences from resource-limited regions to guide future investment and policy efforts aimed at improving gynecologic cancer outcomes. Continued investment in diagnostic and treatment infrastructure will be critical to improving outcomes for future patients with advanced gynecologic malignancies.

This case illustrates the compounded impact of aggressive tumor biology, financial toxicity, and limited palliative and oncology infrastructure on outcomes for women with rare gynecologic malignancies. Improving access to timely diagnosis, pathology services, surgical oncology expertise, systemic therapy, and supportive care will be essential to narrowing outcome disparities in resource-limited settings. Strengthening diagnostic infrastructure, expanding access to systemic therapy, investing in surgical oncology training, and reducing financial toxicity are critical steps toward improving survival for women with ovarian cancer globally. Greater international collaboration and health-system investment will be essential to ensuring that advances in gynecologic oncology translate into meaningful benefit for patients regardless of geographic location.

Ethics Statement: The patient provided written informed consent to allow for her de-identified medical information to be used in this publication. A waiver for ethical approval was obtained from the authors' institution review board committee.

Consent: Written informed consent for the publication of clinical details and images was obtained from the patient. A copy of the consent is available for review by the chief editor of this journal.

Data availability statement

No data generated from this study.

CRediT authorship contribution statement

John Lugata: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Caleigh Smith: Writing – review & editing, Writing – original draft, Visualization, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Fortunata Nzota: Writing – review & editing, Writing – original draft, Validation, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Abitalis Mayengela: Writing – review & editing, Writing – original draft, Validation, Methodology, Investigation, Formal analysis, Data curation. Tecla Lyamuya: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Albert Masenga: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Methodology, Funding acquisition, Data curation, Conceptualization. Eusebious Maro: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Bariki Mchome: Writing – review & editing, Writing – original draft, Visualization, Validation, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Alex Mremi: Writing – review & editing, Writing – original draft, Visualization, Validation, Resources, Methodology, Investigation, Formal analysis, Data curation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

The authors would like to thank the patient for her permission to use the medical information in this publication for shared learning purposes. We also appreciate the contributions and support from Julius Kaleshu and Agatha Kimboka in this work.

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