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

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.

Struma ovarii with synchronous ascites and elevated CA125 level: a retrospective cohort study

BACKGROUND

Benign struma ovarii (SO) with synchronous ascites and elevated CA125 level is extremely rare that the incidence, clinical characteristics, and risk factors remain unclear.

METHODS

We conducted a retrospective study of patients with SO treated in our hospital between 1980 and 2022. Logistic regression was used to identify potential risk factors for SO patients presenting with ascites and elevated CA125 levels. The receiver operating characteristic (ROC) curve was used to evaluate the predictive performance of the identified risk factors.

RESULTS

A total of 21 patients with synchronous ascites and elevated CA125 levels were identified in 229 patients with SO, the crude incidence rate was 9.17%, and four patients (1.75%) had pseudo-Meigs' syndrome. Ascites were completely involuted within 1 month postoperatively and the serum CA125 level decreased to normal between 3 d and 6 weeks after surgery. Multivariate logistic regression showed that age ≥49 years (OR 3.71, 95% CI 1.29 - 10.64, p = 0.015), tumor size ≥10.0 cm (OR 8.79, 95% CI 3.05 - 25.35, p < 0.001), and proliferative SO (OR 11.16, 95% CI 3.01 - 41.47, p < 0.001) were the independent risk factors for patients presenting ascites and elevated CA 125 level. The ROC curve revealed that the predictive performance for age and tumor size was unsatisfactory with an area under the curve (AUC) was 0.646 and 0.682, respectively. Linear regression demonstrated that the serum CA125 level has a moderate positive correlation with the volume of ascites (log2CA125 = 0.6272*log2ascites + 2.099, p = 0.0001, R2 = 0.5576).

CONCLUSIONS

Less than one-tenth of patients with SO would present ascites and elevated CA125 levels, while age ≥49 years, tumor sizes ≥10 cm, and the presence of proliferative SO were the risk factors.

Giant struma ovarii with pseudo-Meigs’syndrome and raised cancer antigen-125 levels: A case report

BACKGROUND

Struma ovarii is a type of monodermal mature teratoma composed entirely or mainly of thyroid tissue, accounting for 1% to 3% of all ovarian teratomas and 0.3% to 1.0% of all ovarian tumors. Of which, struma ovarii with ascites and pleural effusion, called pseudo-Meigs’syndrome and raised cancer antigen-125 levels (CA 125) is even rarer.

CASE SUMMARY

This paper reports the diagnosis and treatment of a patient of struma ovarii with pseudo-Meigs’syndrome, presenting with the clinical features of ovarian carcinoma: Complex pelvic mass, gross ascites, right pleural effusion and markedly elevated serum CA 125 levels. During the operation, a cystic-solid mass about 20 cm × 10 cm × 5 cm in the right adnexa and a solid mass with the size of 3 cm × 2 cm × 0.1 cm in the left ovary were observed. She underwent right adnexectomy and resection of the left ovarian mass and histopathology revealed a mature left-sided ovarian teratoma and struma ovarii of right adnexal mass. During 1-year follow-up, the patient recovered well, tumor markers and other indicators returned to normal.

CONCLUSION

The diagnosis and treatment process of this case suggests that the clinical symptoms of struma ovarii with pseudo-Meigs’syndrome are lack specificity, which is easily misdiagnosed. Clinicians should improve the understanding of this disease, enhance the awareness of early screening, and improve the level of diagnosis and treatment.

Struma Ovarii Associated with Ascites and Elevated CA125: Two Case Reports and Review of the Literature

Struma ovarii is a rare variety of specialized monodermal mature ovarian teratoma, it is composed predominantly of thyroid tissue. Ascites is present in one third of patients. The combination of struma ovarii, marked ascites and elevated CA125 is a rare condition, which may mimic ovarian cancer. We described two cases presenting with pelvic mass, ascites and elevated serum CA125 levels, frozen section and final pathology turned out to be struma ovarii. Ascites disappeared and the level of CA125 returned to normal level after operation. One of the cases was associated with pleural effusion, leading to a condition called pseudo-Meigs' syndrome. Then we reviewed the related literatures to explore the possible mechanism of ascites and pleural effusion, the reason of CA125 elevation and imaging manifestations of struma ovarii. In conclusion, struma ovarii should be considered in the differential diagnosis preoperatively, when presented with pelvic mass, ascites and an elevated CA125 level.

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.

Coexistence of benign struma ovarii, pseudo-Meigs' syndrome and elevated serum CA 125: Case report and review of the literature

Struma ovarii is an uncommon ovarian teratoma comprised predominantly of mature thyroid tissue. The combination of pseudo-Meigs’ syndrome, and elevation of CA 125 to the struma ovarii is a rare condition that can mimic ovarian malignancy. We reported a case of benign struma ovarii, presenting with the clinical features of advanced ovarian carcinoma: complex pelvic mass, gross ascites, bilateral pleural effusion and markedly elevated serum CA 125 levels. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Ascites and pleural effusion were not evident and the CA 125 levels returned to normal following surgical excision. A systematic review of reported cases of coexistent benign struma ovarii, pseudo-Meigs’ syndrome and elevated serum CA 125 was performed. Struma ovarii accompanied by pseudo-Meigs’ syndrome and elevated serum CA 125 should be considered in the differential diagnosis of ovarian epithelial cancer.

Ovarian malignant germ cell tumors: cellular classification and clinical and imaging features

Ovarian malignant germ cell tumors (OMGCTs) are heterogeneous tumors that are derived from the primitive germ cells of the embryonic gonad. OMGCTs are rare, accounting for about 2.6% of all ovarian malignancies, and typically manifest in adolescence, usually with abdominal pain, a palpable mass, and elevated serum tumor marker levels, which may serve as an adjunct in the initial diagnosis, monitoring during therapy, and posttreatment surveillance. Dysgerminoma, the most common malignant germ cell tumor, usually manifests as a solid mass. Immature teratomas manifest as a solid mass with scattered foci of fat and calcifications. Yolk sac tumors usually manifest as a mixed solid and cystic mass. Capsular rupture or the bright dot sign, a result of increased vascularity and the formation of small vascular aneurysms, may be present. Embryonal carcinomas and polyembryomas rarely manifest in a pure form and are more commonly part of a mixed germ cell tumor. Some OMGCTs have characteristic features that allow a diagnosis to be confidently made, whereas others have nonspecific features, which make them difficult to diagnose. However, imaging features, the patient's age at presentation, and tumor markers may help establish a reasonable differential diagnosis. Malignant ovarian germ cell tumors spread in the same manner as epithelial ovarian neoplasms but are more likely to involve regional lymph nodes. Preoperative imaging may depict local extension, peritoneal disease, and distant metastases. Suspicious areas may be sampled during surgery. Because OMGCTs are almost always unilateral and are chemosensitive, fertility-sparing surgery is the standard of care.

Pseudo-Meigs' syndrome associated with hydropic degenerating uterine leiomyoma: a case report

Pseudo-Meigs' syndrome secondary to uterine leiomyoma is a rare entity. A 50-year-old Japanese woman presented with a 3-month history of shortness of breath. Chest X-ray and magnetic resonance imaging revealed massive right pleural effusion, ascites and a large subserosal uterine myoma. She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The pathology was consistent with a benign leiomyoma. The ascites and pleural effusion rapidly disappeared postoperatively. The serum interleukin-6 level was 3.9 pg/mL before surgery and declined to 1.6 pg/mL postoperatively. Previous published work has demonstrated that vascular endothelial growth factor and interleukin-6 may play a role in the pathogenesis of Meigs' syndrome and that vascular endothelial growth factor may contribute to the development of pseudo-Meigs' syndrome due to metastatic ovarian cancer. This is the first English-language study showing the possibility that interleukin-6 is relevant to the pathogenesis of pseudo-Meigs' syndrome caused by degenerating uterine leiomyoma.

Meigs' syndrome with elevated serum CA125 in a case of ovarian fibroma /thecoma

BACKGROUND

CA125 levels in Meig's syndrome can increase or be normal which an unusual laboratory condition is. In this paper, we present a case of Meigs' syndrome associated with increased CA125 level due to ovarian fibroma / thecoma.

CASE PRESENTATION

A 50-year old Iranian woman presented with fever, abdominal pain and distention and in imaging assessment, a 90×109 mm heterogeneous pelvic mass with free abdominopelvic fluid was reported. Pleural effusion was detected in CXR. Aspiration of ascetic fluid showed no evidence of malignancy. CA125 level was greater than 600 IU/mL. The patient went under laparotomy in which a 120×100 mm mass was detected in her left adnexa attached to colon, bowels and bottom of pelvis. Histology reported ovarian fibro/ thecoma. The mass was resected and after that, the symptoms disappeared and CA125 level reached to 15 IU/mL. The patient had no problem after 18 months of follow up.

CONCLUSION

Meigs' syndrome should be considered at the differential diagnosis for a patient with pelvic mass, pleural effusion and ascites with normal cytology, increased CA125 levels.

Bilateral Ovarian Fibrothecoma Associated with Ascites, Bilateral Pleural Effusion, and Marked Elevated Serum CA-125

Background. The risk of ovarian cancer is increased in the association of ovarian tumor, ascites, and hydrothorax with the significant elevated tumor marker CA-125. However, this association can be observed in a rare clinical and benign pathological entity, that is Demons-Meigs' syndrome. Objective. To describe a rare case of Demons-Meigs' syndrome observed in our department. Methods. A black African woman of 35 years old, seventh gravida and fourth parous, underwent a total abdominal hysterectomy with bilateral salpingoophorectomy for large bilateral ovarian masses associated with significant ascites, bilateral pleural effusion, and particular highly elevated tumor marker CA-125 (1835 UI/mL) in a pronounced general alteration condition. Results. The postoperative course was uneventful characterized by a complete remission of hydrothorax and ascites with normal level of CA-125 three months after tumor excision. Histology of both masses revealed a bilateral ovarian fibrothecoma, a benign tumor of the ovary, thus confirming the diagnosis of Demons-Meigs' syndrome. Conclusion. The Demons-Meigs syndrome, although it strongly mimics the clinical picture of malignant metastatic ovarian cancer, remains a disease with benign prognosis after surgical tumor resection. This is a rare condition that must be known and recognized by practitioners to avoid unnecessary practices.

Optimal surgical management of well-differentiated thyroid cancer arising in struma ovarii: a series of 4 patients and a review of 53 reported cases

BACKGROUND

Well-differentiated thyroid cancer arising in struma ovarii is rare. The optimal management of this entity remains undefined. Unilateral cystectomy, unilateral salpingo-oophorectomy (USO), or total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO), in addition to total thyroidectomy and radioactive iodine (RAI) ablation, have been employed by various groups. We hypothesized that in patients with thyroid cancer arising within struma ovarii, pelvic surgery alone would be sufficient, provided there is no evidence of gross extra-ovarian extension.

METHODS

We review a series of four patients from a single institution and 53 cases from the literature, comparing the extent of treatment and outcomes. Our literature review focused on low-risk patients with struma ovarii confined to the ovary, without evidence of gross extra-ovarian spread or distant metastases. Cumulative recurrence rate was determined by using the Kaplan-Meier method.

RESULTS

We report the treatment of four patients with well-differentiated thyroid cancer arising within struma ovarii. Patients underwent USO, BSO, or TAH/BSO. One patient underwent prophylactic total thyroidectomy in anticipation of RAI treatment, and was found to have a synchronous papillary thyroid carcinoma. All patients clinically remain without evidence of disease at a median follow-up of 9 (range 0.8-13) years. Treatment strategies in 53 cases from a review of the literature varied. The pooled cumulative recurrence rate of 57 cases with struma ovarii confined to the ovary was 7.5% at 25 years.

CONCLUSIONS

Thyroid cancer arising in struma ovarii is rare. Controversy exists regarding the extent of pelvic resection and management of the thyroid gland. In our series of four patients, all patients are alive without evidence of disease, and the 25-year recurrence rate of 57 cases was low (7.5%), despite a variety of approaches to surgical resection and adjuvant treatment. Extensive pelvic surgery and prophylactic total thyroidectomy to facilitate RAI therapy may be reserved for patients with gross extra-ovarian extension or distant metastases.

Struma ovarii associated with Pseudo-Meig's syndrome and high serum level of CA 125; a case report

Struma ovarii is a rare form of ovarian neoplasm in a form of mature teratoma and is composed predominantly of thyroid tissue. In the literature review, there has only been 10 cases of this tumor, associated with ascites and pleural effusion (Meig's Syndrome) and increased CA125 so far. In such cases, the tumor mimics malignant ovarian tumor. In this article, the case of a 72-year-old symptomatic woman with a pelvic mass, pleural and peritoneal effusion and high level of serum CA125 is presented. Cytological evaluation for the pleural fluid was performed. She underwent hysterectomy and bilateral salpingo-oophorectomy. The result of pathologic diagnosis is presented in this paper. The patient was well in postoperative period and paraclinical tests including CA 125 were normal as well.