Ovarian granulomas: a report of 32 cases

Granulomatous Salpingo-oophoritis Secondary to Crohn's Disease

Crohn's disease (CD) represents a subtype of inflammatory bowel disease and can affect any portion of the gastrointestinal tract, from the mouth to the anus, with the capacity to affect extraintestinal organs. Salpingo-oophoritis is an uncommon manifestation of CD. There is only a limited number of documented case reports. We present the case of a patient with ileocolonic CD and secondary granulomatous salpingo-oophoritis. We emphasize the significance of clinical suspicion and an interdisciplinary approach as crucial factors in ensuring the effective management of the case.

O-RADS Ultrasound Version 1: A Scenario-Based Review of Implementation Challenges

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk stratification and management system was first published by the American College of Radiology in 2020. It provides standardized terminology for evaluation of ovarian and adnexal masses, aids risk stratification, and provides management guidelines for different categories of lesions. This system has been validated by subsequent research and found to be a useful diagnostic and management tool. However, as noted in the system's governing concepts, in some clinical scenarios, such as patients with acute symptoms or with a history of ovarian malignancy, O-RADS US does not apply, or the system's standard management may be adjusted. Additional scenarios, such as an adnexal mass in pregnancy, present challenges in the application of O-RADS US to assist diagnosis and management. The purpose of this article is to highlight 10 clinical scenarios in which O-RADS US version 1 may not apply, may be difficult to apply, or may require modified management. Additional scenarios in which O-RADS US can be appropriately applied are also described.

Ovarian Crohn's Disease: A Case Report and Review of the Literature

We present to you a rare case of Crohn's disease involving the ovary in a 28-year-old nulligravida Eritrean patient. This is considered a rare manifestation of Crohn's disease that is believed to be due to fistulization between the ovary and intestines.

Pulse granuloma presenting as a complex pelvic cyst

Pulse granuloma, a benign granulomatous lesion, develops due to foreign body reactions to food particles. This rare entity occurs occasionally in the abdominal cavity. However, it has never been reported as a pelvic mass or a recurrent case. A 37-year-old woman with a medical history of pelvic granulomatous lesions treated in Thailand, was admitted for abdominal pain. Imaging study revealed a pelvic complex cyst and disseminated nodules. Ovarian cancer or tuberculous peritonitis was suspected. The appearance at laparotomy was an inflammatory mass encased in adhesions; therefore, only biopsy was performed. The pathology diagnosis was pulse granuloma. The pathology report from Thailand was obtained only after her discharge, suggesting that the previous granulomatous lesion contained vegetable matter. This report demonstrates that pulse granuloma can present as a pelvic mass and may relapse. For complex cystic lesions with solid components in the pelvis, pulse granuloma should be considered as a differential diagnosis.

Granuloma formation associated with patellar tendon necrosis in response to Ethibond confirmed by histopathological examination

The aim of this study is to describe a case of delayed granuloma formation associated with tendon necrosis in response to Ethibond confirmed by histopathological examination and to review and discuss the related literature. A 40-year-old woman underwent a patellar tendon repair with Krakow-like #5 Ethibond sutures. Four years after the repair, she noticed progressive soreness with knee extension and swelling. An ultrasound examination revealed a proximal partial patellar tendon rupture. Based on these findings, the patient was advised to undergo surgical intervention due to a diagnosis of re-rupture. Tendinosis, fibrosis and necrosis scar tissue surrounding the previous suture were observed and excised, and samples were sent for histopathological and microbiological examination. Stripping of the patellar paratenon was performed. Surprisingly, a giant cell foreign body reaction surrounding the synthetic refringent material, as well as polymorphonuclear cells surrounding the necrotic tendon, was reported.

Laparoscopic Intervention in Acute Crohn's Disease Involving an Ovary

Crohn's disease (CD) is a chronic inflammatory disorder that may involve any part of the gastrointestinal tract. Acute manifestations in female internal reproductive organs are rare and have been described in only a few cases. A 27-year-old nulligravida woman diagnosed with CD presented with pelvic pain, fever, and a palpable mass (confirmed by ultrasound) in the right lower quadrant of the abdomen. She underwent diagnostic laparoscopy because of worsening symptoms suggestive of a tubo-ovarian abscess. The right adnexa were excised after adhesiolysis. Pathologic examination revealed an ovarian granuloma consistent with CD. This case shows that a laparoscopic approach is possible for active CD, with all the benefits of a minimally invasive approach. Although the involved ovary was removed, similar to previous reports using laparotomy, conservative therapy should be considered if preoperative diagnosis can be made. Improvements in preoperative diagnosis and development of management guidelines is critical for ovarian preservation and conservative treatment options.

Sarcoidosis of female reproductive organs in a postmenopausal woman: a case report and review of the literature: is there a potential for hormone therapy?

OBJECTIVE

Sarcoidosis is a multisystem inflammatory disorder of unknown cause that affects multiple organs. To date, only isolated cases of extrapulmonary sarcoidosis of the female reproductive tract, which rarely affects postmenopausal women, have been reported.

METHODS

We describe the case of a postmenopausal woman with sarcoidosis of multiple structures of the genital tract accompanied by pulmonary involvement. A review of the literature was performed to examine the role of sex hormones in the pathogenesis of sarcoidosis.

RESULTS

We describe the case of a 60-year-old white, nulliparous, nulligravid postmenopausal woman with sarcoidosis of the cervix, uterus, mesosalpinx, and right ovary, accompanied by pulmonary involvement. The diagnosis was based on the identification of noncaseating granulomas in reproductive tract organs. Although imaging methods (high-resolution CT and chest x-ray) and pulmonary function tests did not reveal any abnormality, lung involvement was confirmed histologically by transbronchial biopsy. Treatment with steroids was successful and led to normalization of serum biomarker (serum angiotensin-converting enzyme, soluble interleukin-2 receptor, and neopterin) levels.

CONCLUSIONS

This particular case and a brief literature review of female genital tract sarcoidosis in postmenopausal women suggest the role of sex hormones in the pathogenesis of sarcoidosis. Hormone therapy may be a prospective therapeutic alternative to corticosteroids in postmenopausal women.

Digestive diseases mimicking primary gynecological diseases or with secondary gynecological manifestations

A wide range of gastrointestinal diseases may spread to and involve genital organs by different pathways. These pathways result in extension of the pathological process into the extraperitoneal spaces and between the extra- and intraperitoneal spaces. These communications occur either via mesenteries and ligaments or via the posterior parietal peritoneum. Thus, infectious, inflammatory or tumoral digestive diseases can extend into the pelvic organs and present with a misleading clinical picture and/or radiological features, showing the complexity of pelvic diseases in women. This article reviews, illustrates and discusses these different presentations and provides certain clues to help reach a definite diagnosis.

Crohn's Disease With Ovarian Granuloma: A Case Report and Review of the Literature

We present an interesting case of a 35-year-old nulligravida with Crohn's disease with ovarian involvement. This is a rare manifestation of Crohn's disease, felt to arise from fistulization between the ovary and the intestine, most commonly the ileum. Our review of the literature revealed 11 additional case reports published in English with a total of 15 cases. The mean age at time of presentation was 33.7 years, with a predominance of right-sided involvement. This series included 10 patients with affected right ovaries, 3 with affected left ovaries, and 2 with bilateral involvement. We conclude that ovarian involvement in Crohn's disease, although rare, can exist, and that the gynecologic surgeon should be aware of this relevant disease manifestation.

Uterine sarcoidosis: a rare extrapulmonary site of sarcoidosis

Sarcoidosis is a multisystem disease which is most commonly manifested in the pulmonary system. However, extrapulmonary manifestations have also been frequently reported. Isolated occurrence of sarcoidosis in the genital system is rare and poses a diagnostic and therapeutic dilemma. Uterine sarcoidosis can present with cervical erosions, endometrial polypoid lesions, and recurrent serometra. In majority of cases, it is diagnosed by endometrial curettage, but it has also been detected by examination of hysterectomy, polypectomy, and autopsy specimens. Nonnecrotizing granulomas are the characteristic pathologic finding of sarcoidosis. However, many infectious and noninfectious etiologies including certain neoplasms can produce similar granulomatous reactions in the female genital tract. These conditions affect the female genital tract more commonly than sarcoidosis, and therefore it is important to rule out these conditions first before making a diagnosis of sarcoidosis. Treatment of sarcoidosis is different from treating these other conditions and the most commonly used systemic or local corticosteroids can be hazardous if the underlying cause is infection. In this case report, the clinical presentation, histopathology, clinical course, and treatment of a patient with isolated uterine sarcoidosis are described, and a brief literature review of sarcoidosis of the female genital tract is provided.

Peritoneal bile granulomas identified at Cesarean section and mimicking disseminated malignancy

A 37-year-old woman was found to have multiple peritoneal nodules, including on the uterine serosa, at Cesarean section. Histology showed yellow crystalline material surrounded by histiocytes and occasional multinucleate giant cells. Further enquiry revealed that the patient underwent a cholecystectomy for a perforated gallbladder 3 years earlier. Pathologists should be aware of this uncommon complication of bile leakage, which has the potential to clinically mimic disseminated malignancy. This may become increasingly common in the future since bile leakage is more likely to occur with laparoscopic than open cholecystectomy.

Talcum powder, chronic pelvic inflammation and NSAIDs in relation to risk of epithelial ovarian cancer

Chronic inflammation has been proposed as the possible causal mechanism that explains the observed association between certain risk factors, such as the use of talcum powder (talc) in the pelvic region and epithelial ovarian cancer. To address this issue we evaluated the potential role of chronic local ovarian inflammation in the development of the major subtypes of epithelial ovarian cancer. Factors potentially linked to ovarian inflammation were examined in an Australia-wide case-control study comprising 1,576 women with invasive and low malignant potential (LMP) ovarian tumours and 1,509 population-based controls. We confirmed a statistically significant increase in ovarian cancer risk associated with use of talc in the pelvic region (adjusted odds ratio 1.17, 95% CI: 1.01-1.36) that was strongest for the serous and endometrioid subtypes although the latter was not statistically significant (adjusted odds ratios 1.21, 95% CI 1.03-1.44 and 1.18, 95% CI 0.81-1.70, respectively). Other factors potentially associated with ovarian inflammation (pelvic inflammatory disease, human papilloma virus infection and mumps) were not associated with risk but, like others, we found an increased risk of endometrioid and clear cell ovarian cancer only among women with a history of endometriosis. Regular use of aspirin and other nonsteroidal anti-inflammatory drugs was inversely associated with risk of LMP mucinous ovarian tumours only. We conclude that on balance chronic inflammation does not play a major role in the development of ovarian cancer.

Idiopathic Uterine Granulomas

Granulomas in the uterine corpus and cervix are rare, with most examples obviously a result of a previous operative or ablative procedure. In this report, we describe 8 cases where granulomas, not associated with a previous procedure, were identified as an incidental finding in the myometrium or cervical stroma. A review of the clinical records revealed no obvious cause for the granulomatous inflammation, and we propose the term "idiopathic uterine granulomas." In all cases, the granulomas, which in most cases were multiple, were well circumscribed and intimately related to thin-walled vascular channels that showed no evidence of vasculitis. This resulted in a characteristic histological appearance similar to that seen with so-called "idiopathic ovarian cortical granulomas." Although local and systemic causes of granulomatous inflammation should be excluded, granulomas in the myometrium and cervical stroma may occur without an obvious underlying cause.

The 3020insC Allele of NOD2 Predisposes to Cancers of Multiple Organs

The NOD2 gene has been associated with susceptibility to Crohn's disease and individuals with Crohn's disease are at increased risk for cancer at a number of organ sites. We studied the association between the 3020insC allele of the NOD2 gene and cancer among 2604 cancer patients and 1910 controls from Poland. Patients were diagnosed with one of twelve types of cancer in the Szczecin region between 1994 and 2004. Significant associations were found for colon cancer (OR = 1.8; 95% CI 1.2 to 2.6), for lung cancer (OR = 1.7; 95% CI = 1.1 to 2.5) and for ovarian cancer (OR = 1.6; 95% CI 1.1 to 2.3). In addition, a significant association was found for early-onset laryngeal cancer (OR = 2.9; 95% CI 1.4 to 6.2) and for breast cancer in the presence of DCIS (OR = 2.1 95% CI = 1.2 to 3.6). The NOD2 3020insC allele is relatively common (in Poland 7.3% of individuals) and may be responsible for an important fraction of cancer cases. We estimate that the lifetime cancer risk among carriers of this allele is 30% higher than that of individuals with two wild-type alleles.

Recent Advances in Endometriosis With Emphasis on Pathogenesis, Molecular Pathology, and Neoplastic Transformation

This article reviews recent advances in our understanding of endometriosis with special reference to its pathogenesis, recent molecular studies, and relationship to neoplasia. Pathogenetic factors include familial predisposition, immunological factors, cell adhesion factors, angiogenic factors, and hormonal factors. Recent molecular findings in endometriosis include the monoclonality of endometriotic cysts and loss of heterozygosity in the majority of cases associated with adenocarcinoma. Women with a long-standing history of endometriosis have an increased risk of ovarian cancer, most commonly endometrioid and clear cell adenocarcinomas. In these cases, there is a high frequency of atypia in the endometriosis, and the endometriosis and the associated ovarian carcinoma may show identical PTEN mutations.

Uterine granulomas: clinical and pathologic features

We retrospectively studied the clinical and pathologic features of uterine granulomas over a 10-year period. Granulomas were detected in 30 women, 22 to 81 years old, in the cervix (n = 12/1,090 cervical specimens; 1.1%) or uterine corpus (n = 18/12,000 uterine specimens; 0.15%). They were discovered during evaluation of abnormal bleeding, cytologic specimens, or other gynecologic conditions. None of the patients had constitutional symptoms. These granulomas were often focal (n = 25 [83%]), exhibiting features of foreign body-type (n = 17 [68%]); or they were diffuse (n = 5 [17%]), all with negative acid-fast bacilli or fungal stains and sometimes necrotizing (2 [40%]). Focal granulomas were highly associated with a preceding biopsy or surgery (22/25 vs 14/53 age-matched control subjects). Follow-up of 28 patients (median, 16 months) showed that 27 remained healthy; only 1 patient developed generalized lesions consistent with sarcoidosis 16 months later Uterine granulomas are rare. They are eitherfocal, related to previous biopsy or surgery, or diffuse, usually representing local reaction without an obvious cause. Association with infection or systemic granulomatous disorders is uncommon.

Postmenopausal tubo-ovarian abscess due to Pseudomonas aeruginosa in a renal transplant patient: a case report and review of the literature

BACKGROUND

Pseudomonas aeruginosa is an uncommon cause of infection in the female genital tract. We report a case of postmenopausal tubo-ovarian abscess (TOA) due to P. aeruginosa in a renal transplant recipient. The presentation included mild abdominal symptoms with rapid progression of peritonitis and surgical abscess drainage. This is the first such case in an organ transplant recipient described in the English literature.

METHODS AND RESULTS

Published reports of 1040 cases of TOA were reviewed. The most common features were a history of sexually transmitted disease or pelvic inflammatory disease, and symptoms including abdominal pain and fever. Escherichia coli, Bacteroides spp., and Klebsiella pneumoniae were the most frequently encountered pathogens. Neisseria gonorrhoeae and Chlamydia trachomatis, which are frequently isolated from cervical cultures, are uncommonly isolated from tubo-ovarian abscesses. Forty percent of patients were treated with antibiotics alone, 18.8% with abdominal surgery, and 32% with surgery and antimicrobial therapy.

CONCLUSION

This report illustrates the muted presentation and atypical microbiology of gynecologic infection in an organ transplant recipient.