Mitotically active cellular ovarian fibroma with Meigs' syndrome and elevated CA-125: towards fertility preservation

Meigs Syndrome and Elevated CA-125: Case Report and Literature Review of an Unusual Presentation Mimicking Ovarian Cancer

Background and Objectives: Meigs syndrome is represented by a benign adnexal tumor, ascites, and hydrothorax. Even though the ovarian mass is often characterized by a fibroma-like origin, cancer antigen-125 (CA-125) serum levels could be elevated as in the development of ovarian cancer. Here, we present the case of a patient with Meigs syndrome and increased CA-125. Materials and Methods: We performed systematic research for articles including similar cases in PubMed, EMBASE, and Scopus in February 2023, adopting the string of idioms: "Meigs syndrome AND Cancer antigen 125", and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: Eligible records were 25. Hydrothorax was right-sided in 10 cases over 25; left-sided in two patients over 25. Concerning ascites, two patients showed more than 6 L of ascitic fluid, whereas three patients had 6 L or less. CA-125 elevation ranged from 149 IU/mL to 3803 IU/mL. Adnexal mass histotypes were: struma ovarii (12 cases), thecomas (two cases), fibrothecomas (five cases), fibromas (five cases), and one sclerosing stromal tumor (SST). Conclusions: In postmenopausal women with elevated CA-125 serum levels and an adnexal mass suspicious for malignancy at ultrasound (US), ascites and pleural effusion, surgery, and histopathological examination are necessary. MS is a diagnostic option, with an excellent prognosis after exeresis of the mass.

Rapid growth of mitotically active cellular fibroma of the ovary: a case report and review of the literature

BACKGROUND

Mitotically active cellular fibroma (MACF) of the ovary, characterized by relatively high mitotic activity without severe atypia, represents a relatively new disease entity. MACF is categorized as a benign ovarian tumor. However, due to a limited number of case reports, its clinical and pathological features and optimum management remains largely undetermined. Herein, we report on a rare case of MACF that grew rapidly in size and was diagnosed on detailed pathological examination.

CASE PRESENTATION

A 44-year-old Japanese woman, who detected a myoma-like lesion 1-year earlier, was referred to our hospital when the follow-up examination demonstrated that the mass had increased in size. Magnetic resonance imaging revealed a T1 isointense and T2 hyperintense tumor (11 cm in diameter) in the right pelvic cavity. Laparoscopy confirmed the presence of a right ovarian tumor and laparoscopic right adnexectomy was performed. The tumor cells consisted of dense cellular proliferations of spindle fibroblast-like cells without significant cytological atypia. The mitotic activity index was estimated at >15 mitotic figures per 10 high-power fields. Reticulin staining and FOXL2 mutation analysis excluded the possibility of an adult granulosa cell tumor, and the patient was diagnosed with a MACF of the ovary.

CONCLUSIONS

To the best of our knowledge, we are the first to report on a case of rapid growth of a MACF of the ovary during follow-up. When an increase in the size of a solid ovarian mass is detected, a MACF should be considered as a differential diagnosis.

Ovary preservation in the treatment of childhood Meigs syndrome

Meigs syndrome, the combination of benign ovarian tumor, ascites, and pleural effusion, is present in a small percentage of ovarian fibromas and is infrequently reported in children. When associated with elevated CA-125 suspicion is raised for malignancy, often prompting aggressive surgical intervention. We present a case of childhood Meigs syndrome and review the relevant literature with emphasis on ovary preservation. Out of nine identified pediatric cases, one involved ovary sparing treatment and none recurred or progressed to malignancy. Our report highlights the importance of presurgical identification of Meigs syndrome in order to curtail salpingo-oophorectomy when feasible.

Mitotically active cellular fibroma of the ovary: a case report and literature review

Background

The ovarian cellular fibrous tumor with mitotic figure >4 per 10 high power field without moderate to severe atypia is defined as mitotically active cellular fibroma according to the 2014 World Health Organization classification. As this category is new and rare now, we described here a case of MACF and reviewed the literature.

Case

We present a case of mitotically active cellular fibroma of the ovary with 10-year history that was treated with laparoscopic surgery.

Methods

We reviewed the relevant literature using PubMed search system and analyzed the previous cases.

Results

To date, only 5 cases of mitotically active cellular fibroma have been reported. Our patient is the first case of mitotically active cellular fibroma of the ovary treated with laparoscopic surgery.

Conclusion

MACF of the ovary is a newly defined category and few cases have been reported, while prognostic factors have also not yet been fully characterized. Long-term clinical follow-up is necessary.

Meigs syndrome presenting with axillary vein thrombosis and lymphadenopathy: a case report

Introduction

Meigs syndrome is a rare condition, occurring in less than 1% of ovarian tumors and has the characteristic features of a benign ovarian tumor, ascites and a pleural effusion. We present a case of Meigs syndrome in a young patient presenting initially with an axillary vein thrombosis and local lymphadenopathy.

Case presentation

A 28-year-old Caucasian woman presented with a short history of right arm swelling and shortness of breath as a result of an axillary vein thrombosis and pulmonary embolus.

The initial assessment also demonstrated right axillary and subclavian lymphadenopathy, a pleural effusion, ascites and a large ovarian mass. Serum levels of the tumor markers human chorionic gonadotropin and alpha-fetoprotein were normal and the CA-125 level was only moderately elevated.

The combination of thrombosis, lymphadenopathy and an ovarian mass raised the possibility of a disseminated malignancy potentially an epithelial ovarian cancer, a germ cell tumor or an ovarian sex cord-stromal tumor.

Surgery, performed after a short period of anticoagulation, demonstrated a 13.5cm ovarian cellular fibroma of low malignant potential. Postoperatively the patient made an excellent recovery and the ascites, pleural effusion and lymphadenopathy all resolved promptly.

Conclusions

In Meigs syndrome the classical findings of ascites, pleural effusion in combination with an ovarian mass can mimic disseminated malignancy but resolve spontaneously after surgery. In this current case, the patient also had lymphadenopathy and venous thrombosis, two other findings that are frequently associated with malignancy and was acutely unwell at presentation.

It is unclear if the thrombosis and lymphadenopathy were simply coincidental or shared the same etiology as the ascites and pleural effusion. This case indicates that Meigs syndrome may on occasion present with additional findings that can further mimic disseminated malignancy and may lead to diagnostic uncertainty.