Large twisted ovarian fibroma associated with Meigs' syndrome, abdominal pain and severe anemia treated by laparoscopic surgery

The first report of ovarian torsion causing intracoelomic hemorrhage and subsequent hemorrhagic shock in a captive Humboldt penguin (Spheniscus humboldti)

A 21-year-old captive female Humboldt penguin (Spheniscus humboldti) was in good health until the day before the animal died. However, the animal suddenly exhibited symptoms of vomiting and anorexia, and died in shortly thereafter. The autopsy revealed a blood clot in the abdominal air sac and 280 mL of dark red fluid in the body cavity. The ovary was twisted around a blood vessel. Based on the findings described, it was considered that the cause of death was hypovolemic shock due to massive intracoelomic hemorrhage by vascular collapse resulting from ovarian torsion. This is the first report of ovarian torsion in penguins.

Relevance of Molecular Pathology for the Diagnosis of Sex Cord-Stromal Tumors of the Ovary: A Narrative Review

Ovarian sex cord-stromal tumors (SCSTs) account for 8% of all primary ovarian neo-plasms. Accurate diagnosis is crucial since each subtype has a specific prognostic and treatment. Apart from fibrosarcomas, stromal tumors are benign while sex cord tumors may recur, sometimes with a significant time to relapse. Although the diagnosis based on morphology is straightforward, in some cases the distinction between stromal tumors and sex cord tumors may be tricky. Indeed, the immunophenotype is usually nonspecific between stromal tumors and sex cord tumors. Therefore, molecular pathology plays an important role in the diagnosis of such entities, with pathognomonic or recurrent alterations, such as FOXL2 variants in adult granulosa cell tumors. In addition, these neoplasms may be associated with genetic syndromes, such as Peutz-Jeghers syndrome for sex cord tumors with annular tubules, and DICER1 syndrome for Sertoli-Leydig cell tumors (SLCTs), for which the pathologist may be in the front line of syndromic suspicion. Molecular pathology of SCST is also relevant for patient prognosis and management. For instance, the DICER1 variant is associated with moderately to poorly differentiated SLCTS and a poorer prognosis. The present review summarizes the histomolecular criteria useful for the diagnosis of SCST, using recent molecular data from the literature.

Anesthesia management of a patient with Meigs' syndrome: A case report and literature review

INTRODUCTION

Herein, we describe a case of Meigs' syndrome, a complex condition that poses a challenge for anesthesiologists to manage. Good anesthetic management of this syndrome is necessary to preserve the prognosis.

PRESENTATION OF CASE

An 80-year-old woman was admitted to the emergency department with complaints of abdominal pain, particularly in the left lower abdomen, with aggravation after activity. The patient was unable to sleep in a supine position. Her serum carbohydrate antigen 125 level was 253.15 U/mL-1, and laboratory examinations were nonspecific. On auscultation, breath sounds were absent from the base of the right lung. Abdominal computed tomography (CT) was performed to screen for a possible tumor consisting of both solid and cystic components, but the findings were inconclusive. Chest CT showed large right pleural effusions and hiatal hernia.

DISCUSSION

A multidisciplinary team conducted careful preoperative preparation, while the anesthesiology team prepared detailed peri-anesthesia management strategies to regulate acid-base and electrolyte balance and maintain respiratory and hemodynamic stability. The surgeon resected the tumor successfully. The patient was discharged after 1 week. A postoperative pathology test confirmed fibrothecomas.

CONCLUSION

We provided an effective strategy for the anesthetic management of Meigs' syndrome, which remains a complex challenge for anesthesiologists. It is important that anesthesiologists perform adequate preoperative evaluation and prudent peri-anesthesia management to ensure that patients have a good prognosis and discharge healthily. A multidisciplinary team is essential when caring for patients with Meigs' syndrome.

Ovarian Fibroma Presents As Uterine Leiomyoma in a 61-Year-Old Female: A Case Study

Uterine leiomyoma should be considered when a female patient reports symptoms of abdominal pressure and abnormal vaginal bleeding. However, the symptoms of a uterine leiomyoma are vast and overlap with other possible diseases that are difficult to distinguish even with imaging studies. This is why it is important for physicians and healthcare providers to keep an open mind and have a broad differential diagnosis.  In this case study, we present a 61-year-old postmenopausal female patient who presented to the emergency department with complaints of pelvic and abdominal pain, as well as vomiting and diarrhea. She was admitted for observation. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis revealed no abnormalities; a pelvic ultrasound and CT scan reported possible adnexal torsion. The patient remained stable and the pain had subsided when she was seen the next morning by her gynecologist (GYN) who discharged her to follow-up in the office. Subsequent examinations that aided in the diagnosis included, but were not limited to pelvic and transvaginal ultrasounds, an abdominal and pelvic CT, and a pelvic MRI. In this case, the MRI revealed an 11-cm mass that could represent a torsioned pedunculated necrotic fibroid originating from the uterus. Radiology recommended surgical removal. Upon removal and review of the pathology of the mass, it was revealed to be a torsioned, partially necrotic fibroma that had originated from the ovary and not from the uterus, as imaging had originally suggested.

Meigs’ syndrome caused by granulosa cell tumor accompanied with intrathoracic lesions: A case report

BACKGROUND

Meigs’ syndrome is regarded as a benign ovarian tumor accompanied by pleural effusion and ascites, both of which resolve after removal of the tumor. Patients often seek treatment in the Department of Respiratory and Critical Care Medicine or other internal medicine departments due to symptoms caused by ascites or hydrothorax. Here, we report a rare case of Meigs' syndrome caused by granulosa cell tumor accompanied with intrathoracic lesions.

CASE SUMMARY

A 52-year-old women was admitted to the Department of Respiratory and Critical Care Medicine due to coughing and expectoration accompanied with shortness of breath. Chest X-ray and chest computed tomography showed a modest volume of pleural fluid with pleural thickening in the right lung. The carbohydrate antigen 125 (CA125) concentration was 150.8 U/mL (normal, 0-35 U/mL) and no tumor cells were observed in pleural fluid. Nodules and a neoplasm with a fish meat-like appearance in the parietal pleura and nodules with a ‘string of beads’-like appearance in the diaphragm were found by thoracoscopic examination. Furthermore, pelvic magnetic resonance revealed a pelvic mass measuring about 11.6 cm × 10.0 cm × 12.4 cm with heterogeneous signal intensity and multiple hypointense separations. Total abdominal hysterectomy, bilateral adnexectomy, and separation of pelvic adhesion were performed under general anesthesia. The pathology results showed granulosa cell tumor. At the 2-mo follow-up after the surgery, the hydrothorax subsided, and the CA125 level returned to normal.

CONCLUSION

For postmenopausal women with unexplained hydrothorax and elevated CA125, in addition to being suspected of having gynecological malignancy, Meigs’ syndrome should be considered.

Pelvic mass, ascites, hydrothorax: a malignant or benign condition? Meigs syndrome with high levels of CA 125

Introduction

Abdominal-pelvic mass, ascites and pleural effusion are suggestive of malignant metastatic ovarian cancer. This triad is also present in a rare benign condition called Meigs syndrome. Rarely this condition is associated with an increased CA 125 level.

Case report

A 62-year-old woman with a history of abdominal pain underwent an ultrasound (US) examination and a chest X-ray. The imaging revealed the presence of a large pelvic mass and ascites with a monolateral pleural effusion and a high level of the tumor marker CA 125. The patient underwent a total abdominal hysterectomy, salpingoophorectomy, removal of the pelvic mass, pelvic lymphadenectomy and peritoneal biopsies. The histology showed an ovarian fibrothecoma.

Discussion

The US analysis according to international ovarian tumor analysis simple rules revealed “inconclusive results”; the logistic regression model LR2 and Adnex suggested a high risk of malignancy. The presence of ascites and the size of the lesion associated with a high level of CA 125 affected the correct assessment of the risk of malignancy, exposing the patient to overtreatment

Conclusions

Meigs syndrome is characterized by the resolution of symptoms after surgical removal of the pelvic mass. However, it mimics the clinical picture of a malignant metastatic ovarian cancer. Clinicians have to exclude ovarian cancer and recognize the syndrome to reduce inappropriate procedures.

A Case of Synchronous Primary Corpus and Ovarian Cancer with Pseudo-Meigs Syndrome: Utilization of a Diagnostic Laparoscopy for the Accurate Diagnosis

We report a case of synchronous primary corpus and ovarian cancer (SPC) with massive ascites due to Pseudo-Meigs syndrome (PMS). A 48-year-old woman presented with complaints of abnormal genital bleeding and abdominal discomfort. Massive ascites and tumors in the endometrium and right ovary were detected. Although imaging tests showed no evidence of dissemination, and ascites cytology was negative, we performed a diagnostic laparoscopy to exclude the possibility of microdissemination because pathological findings of the corpus tumor were suggested to be so-called Type-2 endometrial cancer. Laparoscopy clearly confirmed no dissemination in the peritoneum. We ultimately diagnosed this patient with SPC with massive nonmalignant ascites due to PMS and performed an appropriate treatment. This report is the first case of SPC that developed PMS.

Spontaneous Abdominal Bleeding from an Infundibulopelvic Ligament Tear in a Patient with Large Ovarian Fibroma

Ovarian fibromas are rare benign solid tumors of the ovary which are often difficult to differentiate from uterine leiomyomas preoperatively. The symptoms usually include abdominal discomfort and may have ascites and/or an elevation in CA-125 levels. There have been no publications of associated abdominal bleeding to date. The treatment is surgical removal via a laparoscopic or laparotomic approach. We present a case of a 19 cm unilateral ovarian fibroma with abdominal bleeding from a spontaneous right infundibulopelvic ligament (IPL) tear who underwent a laparoscopic and mini-laparotomic right salpingo-oophorectomy. Patients with large ovarian fibromas should be cautioned that abdominal bleeding and/or acute abdominal pain can occur and that a minimally invasive surgical approach is feasible.

The Effect of Age and Body Mass Index on the Surgical Anatomy of Supraumbilical Port Insertion: Implications for Laparoscopic and Robotic Surgery

BACKGROUND

Minimally invasive surgery is the preferred approach for performing many gynecologic procedures. Occasionally, supraumbilical port placement may be preferable to optimize visibility and maneuverability although the risks of complications are less well characterized compared to umbilical entry.

METHODS

We conducted a retrospective review of computed tomograms from 92 patients to evaluate the anatomic considerations for umbilical and supraumbilical port entry based on patient age, body mass index (BMI), parity, abdominal wall thickness, and distance to the great vessels.

RESULTS

Supraumbilical entry was not associated with differences in distance to the great vessels compared to the umbilicus. However, supraumbilical location and BMI were associated with greater abdominal wall thickness. Age and BMI were associated with greater distance to the great vessels, while age was associated with thinner abdominal wall. Multiple linear regression confirmed independent effects of age and BMI. No association between parity and distance to retroperitoneal vessels was observed.

CONCLUSION

Younger patients may be at increased risk for great vessel injury and pre-peritoneal insufflation. Obese patients may be at risk for pre-peritoneal insufflation, while patients with BMI < 30, particularly with a skin-to-aorta distance < 7 cm, may be at an increased risk for great vessel injury. Surgeons should consider these factors when considering supraumbilical port entry.

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.

Value of diffusion-weighted imaging combined with conventional magnetic resonance imaging in the diagnosis of thecomas/fibrothecomas and their differential diagnosis with malignant pelvic solid tumors

Background

Our study aims to determine the value of diffusion-weighted imaging (DWI) combined with conventional magnetic resonance imaging (MRI) in the diagnosis of thecomas/fibrothecomas and their differential diagnosis with malignant pelvic solid tumors.

Methods

In total, 36 thecomas/fibrothecomas and 40 malignant pelvic solid tumors were included in our study. All patients underwent 1.5 T conventional MRI and DWI examinations except one patient with a fibrothecoma in whom DWI examination was not performed. The clinical features and characteristics of conventional MRI and DWI of these two groups were analyzed. Apparent diffusion coefficient (ADC) values were measured and compared between groups. Univariate analysis, multivariate logistic regression analysis, and the receiver operating characteristic curve were used for statistical analysis.

Results

All the thecomas/fibrothecomas showed isointensity on T1 weighted imaging (T1WI) and 77.8 % (28/36) lesions showed hypo- to isointensity on T2 weighted imaging (T2WI). After administration of contrast medium, 94.4 % (34/36) tumors appeared as minor to mild enhancement. On DWI, they showed a diversity of low to very high signal intensity. All malignant pelvic masses manifested as hyperintensity on T2WI and 87.5 % (35/40) tumors showed very high signal (grade 3) on DWI. Higher area under the curve (AUC) and specificity could be achieved by using the lowest ADC value than the mean ADC value. Multivariate logistic regression analysis showed that shape, signal intensity on T2WI, capsule, and the lowest ADC value were the important indicators in discriminating thecomas/fibrothecomas from malignant pelvic solid tumors.

Conclusions

The combination of DWI and conventional MRI is of great value in the diagnosis of thecomas/fibrothecomas and their differential diagnosis with malignant pelvic solid tumors.

CT diagnosis in the thecoma-fibroma group of the ovarian stromal tumors

The aim of this study was to investigate characteristic CT manifestations of the group of ovarian thecoma-fibroma. 24 patients (26 lesions) presenting with the ovarian thecoma-fibroma were analyzed retrospectively, and the diagnosis were confirmed by pathology after surgery. Our findings included: 22 patients were unilateral, while 2 were bilateral; 12 lesions were located in the right side of ovary, while 14 lesions were in the left side. Of the 26 lesions, there were ovarian thecoma (16 lesions), fibrothecoma (6 lesions), and fibroma (4 lesions). The largest diameters of tumor ranged from 37 to 231 mm with the mean value of 100 ± 44.29 mm. 14 patients were accompanied by ascites. All the tumors had well-defined borders. The shape of  22 lesions appeared round or oval, and 4 lesions were irregular. The tumors were solid in 19 lesions, cystic in 2 lesions, and mixed in 5 lesions. Most of the tumors were of heterogeneous density. There were no (20 lesions) or slight enhancement (6 lesions) after injection of the contrast medium. CT values of plain scan, arterial phase and venous among three groups had no significant difference. The enhancement were in the range of 0-5 HU in 10 lesions, and 6-17 HU in 16 lesions. In conclusion, the characteristic CT manifestations of the group of ovarian thecoma-fibroma were: often unilateral solid mass with the shape of oval and well defined border; no enhancement or slight enhancement; accompanied by small amount of ascites.

Supraumbilical primary trocar insertion for laparoscopic access: the relationship between points of entry and retroperitoneal vital vasculature by imaging

OBJECTIVES

Advances in laparoscopy have demonstrated that supraumbilical primary ports can be desirable in complex cases with large masses. This study evaluated distances to vital retroperitoneal vasculature that were encountered with 45- and 90-degree angle entry from the umbilicus and 2 commonly described supraumbilical entry points at 3 and 5 cm cephalad from the umbilicus.

STUDY DESIGN

Retrospective analysis of computed tomography scans of the abdomen and pelvis from 100 randomly selected women who were 18-50 years old with normal anatomy was performed. Three-dimensional models of sagittal sections were generated using IMPAX software. Measurements from the abdominal wall at the umbilicus and 3 and 5 cm cephalad with 45- and 90-degree angles to retroperitoneal structures were performed.

RESULTS

With 90-degree angle entry, the abdominal wall thickness (AWT) was thinnest at the umbilicus; however, the thickness at 3 and 5 cm was similar. AWT increased at all sites with 45-degree angle entry, and the same pattern was observed. AWT and intraperitoneal distance positively correlated with body mass index and supraumbilical entry points. With 90-degree angle entry, the aorta was 1.9 cm (95% confidence interval [CI], 1.4-2.4) and 2.5 cm (95% CI, 2.0-2.9) farther away at 3 and 5 cm cephalad compared with umbilical entry. In one-third of the cases, regardless of port placement, a vascular structure other than the aorta was the most anterior vessel. With 45-degree angle entry at the umbilicus, no vessels were encountered. With 45-degree angle entry at 3 and 5 cm cephalad, the aorta was the most anterior vessel in 1% and 2% of cases, respectively, and was noted to be 1.0 cm (95% CI, 1.0-1.0) and 2.3 cm (95% CI, 1.2-3.3) farther away than with 90-degree angle entry. A vessel other than the aorta was encountered in 4% and 7% of cases at 3 and 5 cm, respectively.

CONCLUSION

According to theoretic modeling, supraumbilical primary port placement can be implemented safely in laparoscopy. With supraumbilical entry, the distance to retroperitoneal vessels was greater than at the umbilicus. Compared with a 90-degree angle, with a 45-degree angle entry, it was uncommon to encounter vasculature, and all measured distances were greater.

Large twisted ovarian fibroma in menopausal women: a case report

Ovarian fibroma is the most common benign solid tumors of the ovary, commonly misdiagnosed as uterine fibromaor as malignant ovarian tumors. It occurs generally in older perimenopausal and postmenopausal women. Occasionally large fibromas may undergo torsion causing acute abdominal pain. Doppler Ultrasonographyimaging is the choice study. CT and MRI are often needed for further characterization and differentiation from other solid ovarian masses. The choice treatment is surgical removal with intraoperative frozensection. Immunohistochemicalanalysis is recommended to rule out the differential diagnosis. Here we present a case of a postmenopausal woman with a large twisted ovarian fibroma reflecting diagnostic and management difficulties including potential misdiagnosis of the tumor as a malignant ovarian neoplasm that may influence the surgical approach.