Limitations of CA125 in the preoperative evaluation of a pelvic mass: struma ovarii and ascites

[Thyroid carcinoma on struma ovarii: Diagnosis and treatment]

Thyroid carcinoma on struma ovarii (TCSO) is a rare ovarian tumour, derivate from monodermic teratomas. It represents about 0.01% of overall ovarian tumours and 5 to 10% of struma ovarii. The diagnosis is histologic and retrospective after pelvic surgery; radiographic imaging being unspecific. Because of its rarity, the treatment of TCSO is not consensual and should be validated in multidisciplinary team involved in rare ovarian carcinoma. The first treatment is a surgical removal, with a laparoscopic approach. A fertility-conservative surgery is recommended for young women. If the tumour is unresectable and/or with metastatic spread, an adjuvant iodine 131 treatment might be proposed after thyroidectomy. Recurrence of TCSO should be taken care of as a thyroid carcinoma with tyrosine kinase inhibitor in case of progressive distant relapse, refractory to iodine 131 treatment. If the recurrence is localised, a complete surgery is the preferred option. There is no gold standard for the follow up.

Precise preoperative diagnosis of struma ovarii with pseudo-Meigs' syndrome mimicking ovarian cancer with the combination of 131I scintigraphy and 18F-FDG PET: case report and review of the literature

Background

Struma ovarii is a rare ovarian neoplasm that often appears malignant on conventional imaging. Pseudo-Meigs’ syndrome with ascites, pleural effusion, and elevated serum CA 125 levels is much rarer and leads to misdiagnosis of ovarian cancer and unnecessary extended surgery.

Case presentation

A 50-year-old woman with abdominal distention and dyspnoea was referred to our hospital. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) showed a polycystic ovarian tumor with a solid component, pleural effusion, and massive ascites with negative cytology. Her serum CA 125 level was 1237 U/ml, indicating the presence of ovarian cancer. Based on increased uptake of ¹³¹I but no uptake of ¹⁸F–FDG in the tumor, the preoperative diagnosis was struma ovarii with pseudo-Meigs’ syndrome, which was confirmed histologically. She had no evidence of ascites and pleural effusion six months after surgery.

Conclusions

To date, there have been no systematic reviews focused on preoperative diagnosis with imaging modalities. The combination of ¹³¹I scintigraphy and ¹⁸F–FDG PET/CT in addition to conventional imaging modalities can provide the precise preoperative diagnosis of struma ovarii with pseudo-Meigs’ syndrome mimicking ovarian cancer, leading to the appropriate treatment strategy.

Struma Ovarii with Pseudo-Meigs' Syndrome and Raised Cancer Antigen-125 Levels Masquerading as an Ovarian Carcinoma Case report and literature review

The monodermal teratoma struma ovarii is a rare ovarian tumour; however, struma ovarii presenting with pseudo-Meigs' syndrome and raised cancer antigen (CA)-125 levels is even rarer. In elderly patients, this presentation can potentially lead to a misdiagnosis of a malignant ovarian carcinoma, resulting in unnecessary extensive surgery. We report a 55-year-old female who presented to the Lok Nayak Jai Prakash Narayan Hospital, New Delhi, India, in 2016 with progressive abdominal discomfort, fatigue and abdominal distention. Clinical and radiological features were indicative of a malignant ovarian tumour and ascites. Serum CA-125 levels were elevated at 258 U/mL. A left-sided salpingo-oophorectomy was performed, after which the serum CA-125 levels normalised. There was no evidence of recurrence at a six-month follow-up. A frozen section procedure confirmed the diagnosis of a struma ovarii. This rare condition should be considered as a differential diagnosis in patients presenting with ovarian masses, ascites and raised CA-125 levels.

Treatment and follow-up of malignant struma ovarii: Regarding two cases

Malignant struma ovarii (SO) is a rare tumor, and as a consequence, treatments and follow-up procedures are not clearly established. Presented in this study are two cases of suspicious ovarian masses, resected and corresponding to malignant SO on histopathology. Similar to thyroid cancer, we proposed complementary radioiodine therapy (¹³¹I) after total thyroidectomy (no malignancy was observed at this level in our two patients). Patients underwent treatment with 3.7 GBq ¹³¹I followed by post-therapy whole-body scintigraphy, which can detect residual disease or occult metastases. Thyroid remnant ablation increases the sensitivity and specificity of follow-up testing using serum thyroglobulin levels as a tumor marker. Our two patients remained disease-free for 3 and 5 years, respectively, after treatment.

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Malignant struma ovarii is a rare ovarian tumor, corresponding to thyroid carcinoma.

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It is generally diagnosed after surgical resection of an ovarian mass.

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Iodine 131 therapy can be proposed for adjuvant therapy, after total thyroidectomy.

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Follow-up must be extended for 20 years, using thyroglobulin level as a tumor marker.

Struma ovarii: role of imaging?

As clinical features in struma ovarii patients in the absence of thyrotoxicosis are generally non-specific and resemble ovarian malignancy, preoperative radiological diagnosis becomes all the more relevant in order to avoid ovarian cancer type surgery (including bilateral salpingo-oophorectomy, hysterectomy, omentectomy and occasionally appendectomy) for this usually benign and rare ovarian mass. As struma ovarii is an uncommon entity, it is all the more important to perform state-of-the-art magnetic resonance (MR) imaging, including high-resolution imaging and diffusion-weighted imaging. The goal of this review paper is to give an update of the key findings of both benign and malignant struma ovarii and to present an unusual case of a purely cystic ovarian struma. Key Points • Clinical features in struma ovarii are generally non-specific and resemble ovarian malignancy.• Pre-operative radiological diagnosis is important to avoid ovarian cancer type surgery (bilateral salpingo-oophorectomy, hysterectomy, omentectomy and occasionally appendectomy).• State-of-the-art MR imaging might help to characterise this unusual ovarian mass.• Struma ovarii can occasionally present as a purely cystic lesion.• However, the role of imaging to identify struma ovarii preoperatively remains limited.

Struma ovarii associated with pseudo-Meigs' syndrome and elevated serum CA 125: a case report and review of the literature

The association of pseudo-Meigs' syndrome, elevation of CA 125 to the struma ovarii is a rare condition. So far only nine cases have been reported in English literature through MEDLINE search. Here we report a 46-year-old case of the struma ovarii, presented with ascites, hydrothorax, right ovarian mass and elevated serum CA 125 level. These findings were misdiagnosed for an ovarian malignancy at the first impression. Immediate resolution of the ascites, hydrothorax and normalization of the serum CA 125 level were followed by ovarian mass removal. Struma ovarii could be a rare cause of ascites, hydrothorax, ovarian mass and elevated CA 125. This rare condition should be considered in the differential diagnosis in patents with ascites and pleural effusions but with negative cytology.

Struma ovarii and peritoneal strumosis with thyrotoxicosis

BACKGROUND

Struma ovarii is a highly specialized form of mature ovarian teratoma consisting of thyroid tissue and exhibiting all the histological features of the thyroid gland. Malignant transformation of thyroid tissue in struma ovarii and metastasis are extremely uncommon. In rare cases, benign thyroid tissue may spread to the peritoneal cavity, and pathologic examination of the peritoneal implants shows multiple nodules of varying sizes of mature thyroid tissue similar to struma ovarii. This condition is termed "peritoneal strumosis."

SUMMARY

We report a 49-year-old woman with struma ovarii complicated by peritoneal strumosis with thyrotoxicosis. After surgical resection of the struma ovarii and peritoneal strumosis the patient became euthyroid.

CONCLUSION

To the best of our knowledge this is the first report of a patient with peritoneal strumosis complicated by thyrotoxicosis. The relative contribution to circulating thyroid hormones by the patient's struma ovarii as compared to the peritoneal strumosis is not known.

Clinical characteristics of struma ovarii

OBJECTIVE

To evaluate the clinical characteristics of struma ovarii.

METHODS

Twenty-five cases of struma ovarii were reviewed retrospectively from June 1994 to April 2007. The presenting clinical, radiologic, and pathologic features of the patients were reviewed.

RESULTS

The mean age of the patients in this study was 45.3 years. The majority was of premenopausal status. Sixteen patients had clinical symptoms such as low abdominal pain, palpable abdominal mass and vaginal bleeding. Although one patient had an abnormal thyroid function test, the laboratory findings normalized after operative treatment. CA-125 levels were elevated in 6 cases. Diagnosis by preoperative imaging studies were 8 dermoid cysts, while only 3 cases were diagnosed as struma ovarii. There were 4 cases of malignant struma ovarii, and no patients with recurrent disease.

CONCLUSION

Struma ovarii is a rare tumor. The presented clinical, laboratory and radiological findings of patients are very diverse. The diagnosis was confirmed by pathologic findings. The treatment of benign struma ovarii is surgical resection only. The cases of malignant struma ovarii may need adjuvant treatment, but recurrence is uncommon.

Struma ovarii showing clinical characteristics of ovarian malignancy

Struma ovarii is a rare form of ovarian neoplasm, composed entirely or predominantly of thyroid tissue and generally a benign germ cell tumor of the ovary. Ascites have been reported in approximately 15-20% of all cases. However, the combination of struma ovarii and elevated CA125 has rarely been reported. We experienced a rare case of a postmenopausal woman with benign struma ovarii associated with massive ascites, a complex pelvic mass. There was marked elevation of her CA125 level. The clinical impression was ovarian malignancy. Surgical excision of the ovarian mass induced immediate resolution of the ascites and a normalization of the serum CA125 level. No recurrence of the ascites or of the tumor has been observed during the 10-month follow-up. Struma ovarii can mimic ovarian malignancy clinically, particularly if complex and associated with ascites and an elevated CA125 level.

Pseudo-Meigs syndrome and elevated CA125 associated with struma ovarii

BACKGROUND

Struma ovarii is a rare form of ovarian neoplasm composed entirely and predominantly of thyroid tissue. The association of pseudo-Meigs syndrome, elevation of CA125 and hyperthyroidism to struma ovarii is a rare condition.

CASE

We report an unusual presentation of a postmenopausal woman with benign struma ovarii associated with pseudo-Meigs syndrome, hypertiroidism, and elevated CA125 serum level, and a large complex right pelvic mass thereby mimicking an ovarian cancer.

CONCLUSIONS

Struma ovarii is a rare cause of ascites, hydrothorax, elevated CA125, and hyperthyroidism. This rare condition should be considered in the differential diagnosis in patients with ascites and pleural effusions but with negative cytology.

Struma ovarii associated with pseudo-Meigs' syndrome and elevated serum CA 125

BACKGROUND

Struma ovarii, presenting as pseudo-Meigs' syndrome with an elevated CA 125 level, is a rare condition.

CASE

A 65-year-old patient presented with ascites, hydrothorax, right ovarian mass, and elevated CA 125 level. These findings were suspicious for an ovarian malignancy. The mass was removed and revealed struma ovarii, a specialized ovarian teratoma composed predominantly of mature thyroid tissue. In the setting of ascites and hydrothorax, the condition is known as pseudo-Meigs' syndrome. This is the second reported case in the English language literature of pseudo-Meigs' syndrome with an elevated CA 125 level resulting from struma ovarii.

CONCLUSION

Struma ovarii is a rare cause of ascites, hydrothorax, and an elevated CA 125 level.

Struma ovarii presenting as acute pseudo-Meigs syndrome with an elevated CA 125 level

A 62-year-old woman presented with acute hydrothoraces and ascites. The CA 125 level was greatly elevated and pelvic ultrasound revealed an adnexal mass with solid and cystic components. At surgery a benign pure struma ovarii was diagnosed and following removal of the tumour the patient had immediate and complete resolution of her symptoms. This is the first report of struma ovarii causing both pseudo-Meigs syndrome and a marked elevation of CA 125.