{"paper_id":"39d90c91-962c-4ec8-adee-ef2d6b9fdcca","body_text":"Monteith et al. Obstet Gynecol Cases Rev 2020, 7:187\nVolume 7 | Issue 6\nDOI: 10.23937/2377-9004/1410187\nCitation: Monteith C, Kalisse T, Farrell RA, Shahabuddin Y, D’Arcy T (2020) A Pelvic Mass Masquer-\nading as High Stage Malignancy - An Interesting Presentation of Psuedo-Meigs Syndrome. Obstet \nGynecol Cases Rev 7:187. doi.org/10.23937/2377-9004/1410187\nAccepted: December 19, 2020: Published: December 21, 2020\nCopyright: © 2020 Monteith C, et al. This is an open-access article distributed under the terms \nof the Creative Commons Attribution License, which permits unrestricted use, distribution, and \nreproduction in any medium, provided the original author and source are credited.\n• Page 1 of 5 •\nMonteith et al. Obstet Gynecol Cases Rev 2020, 7:187\nOpen Access\nISSN: 2377-9004\nObstetrics and\nGynaecology Cases - Reviews\nA Pelvic Mass Masquerading as High Stage Malignancy - An \nInteresting Presentation of Psuedo-Meigs Syndrome\nCathy Monteith, PhD1* \n , Tamara Kalisse1 \n , Robert A Farrell1 \n , Yulia Shahabuddin1 and Thomas \nJohn D’Arcy, MD1,2,3\n1Department of Gynaecology, St. James Hospital, Dublin, Ireland\n2Coombe Women’s and Infant’s University Hospital, Dublin, Ireland\n3Trinity College Dublin, Dublin, Ireland\nCASe RePoRT\nAbstract\nThe lifetime risk of developing an ovarian malignancy is \nreported to be 1.4% [1,2]. Invasive epithelial ovarian can-\ncers have the highest prevalence in women between 60-64 \nyears while germ cell or borderline tumours pre-dominate in \nwomen under 40 years [2]. We report the case of a 33-year-\nold nulliparous woman with a 7 kg leiomyoma, extensive \nendometriosis and several radiological features suggestive \nof a high stage ovarian malignancy. Meigs syndrome typi-\ncally presents as a triad of ascites, pleural effusion and a \nbenign ovarian fibroma [3]. Psuedo-meigs syndrome differs \nby presentation with ascites, pleural effusion and alterna -\ntive benign tumours of the ovary such as mucinous cystad-\nenomas, teratomas, struma ovarii and uterine leiomyomas \n[4]. However, in this reported case we demonstrate normal \novarian appearance and histology.\nKeywords\nEndometriosis, Ovarian cancer, Neoplasms, Leiomyoma, \nFibroid, Meigs syndrome\n*Corresponding author: Dr. Cathy Monteith, PhD, Department of Gynaecology, St. James Hospital, Dublin, Ireland, Tel: \n+353-14103000\nCheck for\nupdates\nMeigs syndrome which differs in presentation with asci-\ntes, pleural effusion and alternative benign tumours of \nthe ovary such as mucinous cystadenomas, teratomas, \nstruma ovarii or uterine leiomyomas [4]. Uterine leio -\nmyomas are the most common benign gynaecological \nneoplasm with a reported lifetime risk of 30% [5].\nCase Description\nWe present a 33-year-old nulliparous woman with a \nprevious history of midline laparotomy and right oopho-\nrectomy in another institution for a ruptured Dermoid \ncyst. She presented to our unit with a two year history \nof progressive painless abdominal distension, weight \nloss, bilateral pitting oedema and cyclical bleeding from \nthe umbilicus. She delayed seeking medical attention \nas she was trying to conceive. On clinical examination \nshe was cachectic, had palpable cervical lymph nodes \nand auscultation of the lungs demonstrated reduced air \nentry. Palpation of abdomen revealed an irregular mass \narising from the right iliac fossa, non-mobile, extending \nto the right upper quadrant and a second additional \nseparate cystic mass palpable in left abdominal wall. \nLaboratory data were normal with the exception of ele-\nvated Ca125 of 233.\nA computed tomography (CT) revealed a large left  \npleural effusion, a 26 × 16 × 31 cm solid heterogenous \nmass with low attenuation areas suggestive of necrosis \nand overall appearance suggestive of ovarian malignan-\nIntroduction\nThe lifetime risk of developing an ovarian malignancy \nis reported to be 1.4% [1, 2]. Invasive epithelial ovarian \ncancers have the highest prevalence in women between \n60-64 years while germ cell or borderline tumours \npre-dominate in women under 40 years [2]. Meigs syn-\ndrome, first described by Meigs typically presents as a \ntriad of ascites, pleural effusion and a benign ovarian fi-\nbroma [3]. A similar presentation is described in pseudo \n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410187\nMonteith et al. Obstet Gynecol Cases Rev 2020, 7:187\n• Page 2 of 5 •\nstage (Stage III or IV) of disease in two thirds of cases \nwith associated ascites or pleural effusions [2].\nThe aetiology of the observed ascites and pleural ef-\nfusion in Meigs or Psuedo Meigs syndrome is unclear. \nThe suggested mechanisms have included hypo albu -\nminemia, peritoneal irritation, lymphatic obstruction, \nrelease of toxins or inflammatory mediators [6]. There \nis limited literature surrounding fertility conservation in \nthe setting of Meigs syndrome including those occurring \nin paediatric cases [7]. The attainment of a presurgical \ndiagnosis of Meigs or Psuedo Meigs syndrome remains \nchallenging especially in the setting of an elevated Ca \n125.\nCa 125 is a glycoprotein which was first associated \nand measured as a marker for established ovarian can-\ncer in the early 1980s [8]. While it does not offer a role \nin screening for ovarian cancer, a serum Ca 125 level is \na vital component of the risk of malignancy index (RMI) \nwhich is used to triage cases of suspected malignancy. \nAn increased serum Ca 125 has shown ethic variation \nwith higher levels in Caucasian women when compared \nto Black or Asian women. The following conditions have \nalso demonstrated increased serum Ca 125 levels: Pel-\nvic inflammatory disease, fibroids, cyst accident, en-\ndometriosis, tuberculosis, cirrhosis, ascites, hepatitis, \npancreatitis and pleuritis. Elevated levels have also \nbeen demonstrated in primary breast, pancreas, lung \ncy. In addition, there were multiple calcified lesions es-\npecially in the right upper quadrant abutting the liver \nrepresenting possible metastatic deposits. There was \nlarge volume ascites and a 19 × 4 cm fluid collection in \nthe left anterior abdominal wall.\nA pleuritic drain was inserted and yielded serous \nfluid with cytology negative for malignancy and pelvic \nbiopsy showed no evidence of necrosis, atypia or in -\ncreased mitoses and was in keeping with a smooth mus-\ncle lesion likely representing a benign leiomyoma. With \nthe clinical and radiological suspicions, the gynaecology \nmultidisciplinary meeting recommended progressing \nsurgery with pre-operative insertion of right ureteric \nstent, interval reduction in pleural effusion, coagulation \nspecialist opinion regarding insertion of a prophylactic \nIVC filter (advised prophylactic heparin only) and pro-\nphylactic uterine artery embolization which was per-\nformed six days pre-operatively.\nThe team proceeded to a total abdominal hysterec -\ntomy due to grossly distorted uterus inseparable from 7 \nkg mass, left salpingectomy, biopsy and conservation of \nleft ovary due to normal gross appearance, appendec -\ntomy, excision of presumed abdominal wall seroma, in-\nfra-colic omentectomy, refashioning of abdominal wall, \ndrainage of 2.6 L ascites, estimated blood loss 1000 ml.\nIntra-operative ascitic fluid was negative on cytology \nfor malignancy. Histopathology reported a 28 cm leio -\nmyoma with hyalinization, ischaemic necrosis second -\nary to embolization and extensive adenomyosis. There \nwas extensive endometriosis of the anterior abdominal \nwall, umbilicus, omentum and seroma with endometri-\notic cyst formation. The perihepatic calcifications were \nblood clot associated with aggregated macrophages, \nacute inflammatory cells and fragments of mesotheli -\num. Left ovarian biopsy demonstrated normal ovarian \nstroma with no evidence of endometriosis and similarly \nnormal assessment of the appendix and left fallopian \ntube.\nThe early post-operative course was complicated \nwith a third order pulmonary embolism and transfusion \nof four units red cells to correct anaemia. The ureteric \nstent was removed at three months post-operatively. At \nthe six month post-operative review the patient report-\ned an uncomplicated physical recovery with appropriate \nweight gain, healthy appearance, laboratory confirma-\ntion of preserved ovarian function with anti-mullerian \nhormone of 24 and satisfactory cosmetic result of ab-\ndomen. She was discharged at that visit to her general \npractitioner and a reproductive counsellor.\nConclusion\nOvarian cancer remains one of the most frequent \ncauses of death at 47% of all deaths from cancers of the \nfemale genital tract [2]. Women with ovarian cancer of-\nten report only vague symptoms of bloating, abdominal \ndistension and as a result frequently present at a late \n         \nFigure 1: Pre-operative CT imaging of a patient with \nPsuedo-Meigs Syndrome.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410187\nMonteith et al. Obstet Gynecol Cases Rev 2020, 7:187\n• Page 3 of 5 •\nThere have been previous reported cases of Pseudo \nMeigs syndrome secondary to uterine leiomyomas with \nreported elevated Ca 125 ranging between 83-1854 \n[6,9]. There have been previous case reports of ascites \n+/- pleural effusion in the setting of endometriosis. In \nthose cases the ascitic or pleuritic fluid was frequently \nreported as blood stained with the haemosiderin con -\ntent making interpretation of fluid cytology challenging \n[10]. Our reported case is unique and is in contrast to \nthe prior reports of pseudo Meigs syndrome describing \nmultiple pathologies of leiomyoma, adenomyosis and \nextensive endometriosis. In addition, our presented \ncase highlights that in the setting of benign fluid cytol-\nogy and benign pelvic biopsy that fertility conserving \nsurgery is a reasonable alternative (Figure 1, Figure 2, \nFigure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, or colon cancers where there is presence of peritoneal \nmetastasis.\n         \nFigure 2: Pre-operative fluoroscopy at time of fibroid \nembolisation in a patient with Psuedo-Meigs Syndrome.\n         \nFigure 3: Pre-operative examination of a patient with \nPsuedo-Meigs Syndrome.\n         \nFigure 4: Pre-operative clinical examination (lateral \nview) of a patient with Psuedo-Meigs Syndrome.\n         \nFigure 5: Intra-operative Pelvic mass.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410187\nMonteith et al. Obstet Gynecol Cases Rev 2020, 7:187\n• Page 4 of 5 •\nAuthors Declaration\nAll authors have had equal contribution to this sub -\nmission and all authors report no conflicts of interest.\nFigure 9 and Figure 10).\nFunding\nNo funding sources for this submission.\n         \nFigure 6: Intra-operative peri-hepatic calcified lesions.\n         \nFigure 7: Left abdominal wall subcuticular seroma/\nEndometriotic cyst capsule.\n         \nFigure 8: Excised pelvic mass Anterior view.\n         \nFigure 9: Excised pelvic mass Posterior view.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410187\nMonteith et al. Obstet Gynecol Cases Rev 2020, 7:187\n• Page 5 of 5 •\nReferences\n1. Gaughan EMG, Walsh TA (2014) Risk-reducing surgery for \nwomen at high risk of epithelial ovarian cancer. The Obste-\ntrician & Gynaecologist 16: 185-191.\n2. Berek JS, Kehoe ST, Kumar L, Friedlander M (2018) Can-\ncer of the ovary, fallopian tube, and peritoneum. Int J Gy-\nnaecol Obstet 143: 59-78.\n3. Meigs JV (1954) Fibroma of the ovary with ascites and \nhydrothorax; Meigs’ syndrome. Am J Obstet Gynecol 67: \n962-985.\n4. Peparini N, Chirletti P (2009) Ovarian malignancies with \ncytologically negative pleural and peritoneal effusions: De-\nmons’ or meigs’ pseudo-syndromes? Int J Surg Pathol 17: \n396-397.\n5. Younas K, Hadoura E, Majoko F, Bunkheila A (2016) A \nreview of evidence-based management of uterine fibroids. \nThe Obstetrician & Gynaecologist 18: 33-42.\n6. Dong RY, Jin CJ, Zhang Q, Yang XS, Kong BH (2015) \nCellular leiomyoma with necrosis and mucinous degener -\nation presenting as pseudo-Meigs’ syndrome with elevated \nCA125. Oncol Rep 33: 3033-3037.\n7. Fremed MA, Levin TL, Sun KY, Weiser DA (2015) Ovary \npreservation in the treatment of childhood Meigs syndrome. \nPediatr Blood Cancer 62: 2011-2014.\n8. Bast RC, Klug TL, St John E, Jenison E, Niloff JM, et al. \n(1983) A radioimmunoassay using a monoclonal antibody \nto monitor the course of epithelial ovarian cancer. N Engl J \nMed 309: 883-887.\n9. Adlan A-S, Chua PT, Huang K-G (2010) Laparoscopic \nresection of a subserosal leiomyoma presenting as pseu-\ndo-meigs’ syndrome. Journal of Gynecologic Surgery 36: \n222-225.\n10. Gungor T, Kanat-Pektas M, Ozat M, Zayifoglu Karaca M \n(2011) A systematic review: Endometriosis presenting with \nascites. Arch Gynecol Obstet 283: 513-518.\n         \nFigure 10: Three month post-operative abdominal \nexamination of a patient with Psuedo-Meigs Syndrome.","source_license":"CC0","license_restricted":false}