{"paper_id":"77abb82a-4523-4daa-b89a-65f94f1fc5e7","body_text":"Submit Manuscript | http://medcraveonline.com\nAbbreviations: CEA, carcinoembryonic antigen; MRI, \nmagnetic resonance imaging; MOO, massive ovarian oedema; SST, \nsclerosing stromal tumour\nIntroduction\nAn 18-year-old unmarried girl was referred to our clinic with self-\nlimited and vague abdominal pain for 3 months with no relieving \nor aggravating factors. Her menstrual cycles were regular and had \nrheumatoid arthritis controlled by immunosuppressive disease-\nmodifying antirheumatic drug.\nOn physical examination, she had a non-tender mobile adnexal \nmass measuring 14cm, extending from the pelvis to the liver. \nUltrasound examination revealed an adnexal mass measuring \n150x101mm with thick septations but no papillary projections. Color \nDoppler was negative. There was no ascetic fluid seen. The serum \nlevels of Cancer Antigen 153 (CA – 15.3), Carcinoembryonic Antigen \n(CEA) and Cancer Antigen 19.9 (CA 19.9) were within normal limits. \nCancer Antigen 125 (CA – 125) serum levels were at 71.80. Magnetic \nresonance imaging (MRI) of the pelvis showed a mass lesion in the \nleft pelvic region, measuring 142x93x125mm with multiple thick \nseptations (Figure 1).\nFigure 1 MRI image of an enlarged left ovary. There are peripheral enlarged \nfollicles.\nBased on the above described findings, the lack of guidelines and \nmisleading clinical symptoms, our tumor board decided to offer the \npatient a laparotomy with left salpingo-oophorectomy. We performed \nan infraumbilical incision of the abdomen. The right ovary and uterus \nwere macroscopically normal. Gross examination showed a marked \nleft ovarian enlargement with smooth white external surface. The \nuncertainty of malignant potential due to the size of the lesion was \nthe reason to perform a salpingo–oophorectomy. En bloc resection \nof the tumor was performed. One litre of clear fluid emerged after \nthe incision of the surface. Microscopic examination revealed marked \noedema of ovarian stroma with its architecture preserved. Normal \ngerminal follicles were present without signs of necrosis but abundant \ncystic lesions were seen on the upper surface of the ovary (Figure 2) \n(Figure 3).\nFigure 2 Fibroblastic stroma with lymphatic channels. Stromal oedema on \nthe left.\nFigure 3 Central region of fibrosis with vascular and lymphatic channels. \nCortex with oedematous infiltration on the left.\nFollowing surgery, the patient showed marked symptomatic \nimprovement and was discharged three days later on oral contraceptive \npills.\nDiscussion\nMassive ovarian oedema (MOO) is a tumour-like enlargement \nObstet Gynecol Int J . 2018;9(5):344‒345. 344\n© 2018 Escayola et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nMassive ovarian oedema: a case report\nVolume 9 Issue 5 - 2018\nCecilia Escayola,1 Guillermo Ripoll,1 Antonio \nCardesa,2 Juan Jose T orrent3 \n1Gynecological Surgeon, Hospital el Pilar, Spain\n2Department of Pathology, Hospital el Pilar, Spain\n3Gynecological Oncological Surgeon, Hospital el Pilar, Spain\nCorrespondence: Cecilia Escayola MD, Gynecological Surgeon, \nHospital el Pilar, Barcelona, Balmes 271, Spain, T el 34687439884, \nEmail ceciliaescayola@gmail.com\nReceived: August 13, 2018 | Published: October 03, 2018 \nAbstract\nMassive ovarian oedema is a rare entity, non-neoplastic tumor of the ovary. We report \na case of massive ovarian oedema (MOO) in a 18-year-old female who presented \nwith abdominal pain along with large solid pelvis mass. It is widely accepted that \nMOO results from the incomplete torsion of the ovary causing accumulation of fluid \nwithin the stroma and enlargement of the ovary. Awareness of this rare lesion due to \nits lack of pathognomonic features may allow surgeons to a conservative management \npreventing unnecessary ooohorectomy in young patients.\nObstetrics & Gynecology International Journal \nCase Report\n Open Access\n\n\nMassive ovarian oedema: a case report\n345\nCopyright:\n©2018 Escayola et al.\nCitation: Escayola C, Ripoll G, Cardesa A, et al. Massive ovarian oedema: a case report. Obstet Gynecol Int J . 2018;9(5):344‒345. \nDOI: 10.15406/ogij.2018.09.00361\nof the ovary due to oedema fluid. It was first described in 1969 by \nKalstone as a “massive, solid enlargement of the ovary associated with \ninterstitial oedema without neoplastic changes”1 and it is thought to be \nthe result of incomplete torsion of the ovary interfering venous and \nlymphatic drainage but without causing necrosis.2 The great majority \nof cases are unilateral, affecting young women in the child-bearing \nperiod and can be easily mistaken for neoplasm. It has also been \ndescribed during pregnancy and in postmenopausal women. MOO \ncan occur as primary or secondary process. Primary MOO is seen in \nmore than 85% of the reported cases and occurs when the ovary is \nnot diseased and the torsion or twisting of the ovarian pedicle does \nnot affect the arterial blood flow. Secondary massive ovarian oedema \ntakes place in the setting of a diseased ovary such as an ovarian mass, \nmalignancy, fibromatosis, polycystic ovary or secondary to the drugs \nused for ovulation induction. 3 Common symptoms include pain, \nabdominal mass, menstrual irregularities, virilisation, precocious \npuberty and infertility.\nOvarian lymphatic vasculature is thought to play a vital role in \nfluid homeostasis and hormone trafficking, and alongside blood \nvasculature has been linked to several ovarian disorders such as \npolycystic ovary syndrome, ovarian hyperstimulation syndrome and \nmassive ovarian oedema. The lymphatic dysfunction alters the normal \nluteinisation of the ovary which may lead to changes in normal \novarian steroidogenesis responsible for the clinical symptomatology \nof the MOO. Thus, masculinisation and precocious puberty could be \ncommon symptoms among women affected by this entity.\nMOO is considered a rare disorder and unknown for most \nclinicians. A review of the literature proves that most patients are \nover treated with salpingo-oophorectomy on the basis that a primary \novarian neoplasm is suspected. In the review conducted by Praveen \net al. 151 cases out of 177 were primary massive ovarian oedema \nand 88.7% of them did not have fertility-sparing surgery. 4 Despite \nadvanced radiological imaging MOO can easily over-diagnosed as \novarian neoplasm. However, the presence of peripherally embedded \nfollicles may enable to differentiate between oedema and a neoplastic \nlesion.5 A twisted vascular pedicle between the enlarged ovary and the \nuterus may help to differentiate an adnexal torsion from MOO.\nThe differential diagnosis of MOO includes ovarian myxoma, \nfibromatosis and sclerosing stromal tumour (SST). Pure ovarian \nmyxoma is sharply circumscribed, and normal ovarian tissue can \nbe seen at its periphery, whereas massive ovarian edema often \nincorporates follicular structures at its periphery and spares the \nperipheral cortex. The SST has often a pseudolobular appearance \nwith cellular areas separated by hyalinised connective tissue. Ovarian \nfibromatosis is a rare entity. Microscopy typically shows proliferation \nof spindle-shaped cells surrounding the normal follicular structure \nof the ovary. The superficial cortex is thickened and shows acellular \nbands of dense collagen.6 MOO is a non-neoplastic disorder; therefore \nclinicians should consider this condition and take under consideration \nthe age of patients presenting with this entity in order to preserve \nhormonal functions and their fertility.\nConclusion\nDue to absence of pathognomonic clinical or radiological signs, \nwhen young women in the reproductive age group present with acute \nor chronic abdominal pain and a solid ovarian tumour-like mass, \nMOO should be suspected and conservative treatment proposed. \nConsidering that medical management is not an option for this \ncondition, wedge resection at the time of surgery and frozen section \nmust be taken into consideration in order to preserve the fertility of \nthese young patients.\nAcknowledgments\nNone. \nConflicts of interest\nThe authors declare that they have no conflict of interest.\nReferences\n1. Kalstone CE, Jaffe RB, Abell MR. Massive edema of the ovary \nsimulating fibroma. Obstet Gynecol. 1969;34(4):564−571.\n2. Daboubi MK, Khreisat B. Massive ovarian oedema: literature review \nand case presentation. East Mediterr Health J. 2008;14(4):972−977.\n3. Callen AL, Illangasekare T, Poder L. Massive ovarian edema, due to \nadjacent appendicitis. Emerg Radiol. 2017;24(2):215−218.\n4. Praveen R, Pallavi V , Rajashekar K, et al. A clinical update on \nmassive ovarian oedema - a pseudotumour? Ecancermedicalscience. \n2013;7:318.\n5. Tamai K, Koyama T, Saga T, et al. MR features of physiologic and \nbenign conditions of the ovary. Eur Radiol. 2006;16(12):2700−2711.\n6. Roth LM, Gaba AR, Cheng L. The pathogenesis of ovarian myxoma: \na neoplasm sometimes arising from other ovarian stromal tumors. Int J \nGynecol Pathol. 2013;32(4):368−378.","source_license":"CC0","license_restricted":false}