{"paper_id":"fcf51c2d-8198-44a9-a254-fda56fe863e5","body_text":"International Journal of Gynaecology Research \n \n1 \nInternational Journal of Gynaecology Research \nwww.gynecologyjournal.net \nOnline ISSN: 2664-8938, Print ISSN: 2664-892X \nReceived Date: 01-01-2019 Accepted Date: 02-02-2019; Published: 09-02-2019 \nVolume 1; Issue 1; 2019; Page No. 01-04 \n \n \nDecasualization of a haemorrhagic ovarian cyst during pregnancy mimicking malignancy \n  \nTomoko Matsuzono1*, Li Wai Hon2 \n1-2 Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong \n \nAbstract \nThe incidence of ovarian tumour in pregnancy varies widely from 1 in 81 (1) to 1 in 8000 (2) live births in the earlier literature. On a \nmore recent literature, an incidence of 1 in 505 (3) has been reported. Majority of the ovarian tumours found during pregnancy were \nbenign but between 2.4 to 5.3% (4, 3) of those were found to be malignant. In recent times, detection of ovarian tumours during \npregnancy was increased due to routine prenatal ultrasound checkups. As a result, there is an increased need to distinguish between a \nbenign versus malignant ovarian tumour. This is often challenging as decidualised benign ovarian cyst may mimic featur es of \nmalignancy. Other challenges lie in the decisions regarding the need to operation and when to operate on such ovarian tumours. Most  \nsymptomatic tumours or those showed borderline or malignancy features on ultrasound are ones likely to require surgery. Historically, \npregnant women with symptomatic or suspicious masses underwent elective removal in the second trimester (12) and this is relatively \nsafe. Any surgical Intervention beyond the 24 weeks’s gestation is associated with poorer obstetric outcome such as spontaneous \nmiscarriage, preterm labour or preterm premature rupture of membranes (13). The decision to operate hence is a challeng ing one \nespecially when one needs to balance between the upstaging of the suspicious malignant ovarian mass and the wellbeing of the fetus. \nHere we report a case where decidualised haemorrhagic ovarian cyst without evidence of endometriosis showed excresence whi ch \nobliged us to perform surgery during pregnancy. As the findings were found in the 3 rd trimester, the operation along with a caesarean \nsection was carried out prematurely at 35 weeks of gestation to achieve fetal maturity, fetal wellbeing as well as the possibility of staging \noperation in the form of total abdominal hysterectomy oophorectomy if tumour was deemed malignant. \n \nKeywords: ovarian tumour, pregnancy, Decidualization, malignancy \n \n1. Introduction \nThe incidence of ovarian tumour in pregnancy varies widely from \n1 in 81 [1] to 1 in 8000 [2] live births in the earlier literature. On a \nmore recent literature, an incidence of 1 in 505 [3] has been \nreported. Majority of the ovarian tumours found during \npregnancy were benign but between 2.4 to 5.3% [4, 3] of those \nwere found to be malignant. In recent times, detection of ovarian \ntumours during pregnancy was increased due to routine prenatal \nultrasound checkups. As a result, there is an increased need to \ndistinguish between a benign versus malignant ovarian tumour. \nThis is often challenging as decidualised benign ovarian cyst may \nmimic features of malignancy. Other challenges lie in the \ndecisions regarding the need to operation and when to operate on \nsuch ovarian tumours. Most symptomatic tumours or those \nshowed borderline or malignancy features on ultrasound are ones \nlikely to require surgery. Historically, pregnant women with \nsymptomatic or suspicious masses underwent elective removal in \nthe second trimester [12] and this is relatively safe. Any surgical \nintervention beyond the 24 weeks’s gestation is associated with \npoorer obstetric outcome such as spontaneous miscarriage, \npreterm labour or preterm premature rupture of membranes [13]. \nThe decision to operate hence is a challenging one especially \nwhen one needs to balance between the upstaging of the \nsuspicious malignant ovarian mass and the wellbeing of the fetus. \nHere we report a case where decidualised haemorrhagic ovarian \ncyst without evidence of endometriosis showed excresence which \nobliged us to perform surgery during pregnancy. As the findings \nwere found in the 3 rd trimester, the operation along with a \ncaesarean section was carried out prematurely at 35 weeks of \ngestation to achieve fetal maturity, fetal wellbeing as well as the \npossibility of staging operation in the form of total abdominal \nhysterectomy oophorectomy if tumour was deemed malignant. \n \n2. Case report \nMs WLS is a 36 years old lady in her first pregnancy with a \nfamily history of diabetes mellitus and no known history of \nendometriosis of her own. Antenatal booking bloods, 14 th week \nDown’s screening, fetal DNA test in the form of Safety 21 were \nentirely normal. As a result of her family history and age, oral \nglucose tolerance test performed at 28 weeks suggested the \ndiagnosis of gestational diabetes. She remained a diet control \ngestational diabetic throughout her pregnancy with satisfactory \ncontrol of her glucose and HbA1c throughout her pregnancy. \nDuring her first scan at 14 weeks, she was found to have a right \nadnexal elongated cystic mass 3.5x7.6cm with hypoechoic \ncontent and irregular thickening of the inner wall which measured \n1.4x2.3cm, likely of right ovarian or tubal origin with no obvious \nsuspicion of malignancy. A routine morphology scan by a private \ndoctor showed the baby to be a female fetus with no gross \nabnormality but did not comment on the existing right adnexal \nmass. At 26 weeks, patient had a repeat scan in the hospital. A \ncombination of transabdominal and transvaginal ultrasound scan \nshowed the right adnexal cystic mass’s size has increased to \n\nInternational Journal of Gynaecology Research \n \n2 \n6.8x5.2x5.9cm. The complex cystic mass was mainly of \nhypoechoic in nature with specs of solid / hyperechoic shadow \nwithin the cyst and a papillary growth projection of 3.6x1.9cm \nwas seen within.  \n(Figure 1 and 2) \n \n \n \nFig 1 \n \n \n \nFig 2 \n \nGiven the growth and nature of the cyst, suspicion of a borderline \nor malignant tumour explained to the patient. Ca125 was not \nperformed explaining the non-specific nature of Ca125 during \npregnancy. For further investigation for the suspicious ovarian \ncyst, a plain MRI abdomen was done at 28 weeks. Other than a \nsingleton intrauterine pregnancy, it showed a 3.1x5.2x5.9cm \n(TSxAPxLS) predominant cystic mass (hypotense on T1 and \nhyperintense on T2-weighted sequence) at the right adnexa. The \nwall is slightly irregular with some nodularities. Image suggested \na complex cystic lesion at the right adnexa with irregular thick \nwall with nodularity and suspicious eccentric signal change that \nmay represent presence of haemorrhage or high proteinaceous \ncontent. Left ovary, spleen, adrenal, small and large bowel, \nbilateral kidney, liver and pancreas were all normal. There was \nno frank evidence of liver or peritoneal metastesis. \n \n \nFig 3: Axial T1 weighted image \n \n \n \nFig 4: Axial T2 weighted image \n \n \n \nFig 5: Sagittal T2 weighted image \n \n\n\nInternational Journal of Gynaecology Research \n \n3 \nA repeat USG scan at 31, 32 and 34+6 weeks showed the \ncomplex lesion to be 5.2x7.5x4.5 cm (31 weeks), 6.26x5.93cm \n(32 weeks) and 5x6cm (34+6 weeks) respectively. Growth of the \nbaby remains at 25 percentile throughout. \nAfter a joint meeting involving obstetricians, gynaecological \noncologists, patient and her relatives, decision was made to \ndeliver the baby by laparotomy and Caesarean section with \nantenatal corticosteroid injection at 35 weeks on the balance of \npossible disease progression and fetal maturity. A unilateral \novarian cystectomy or salpingo-oopherectomy and subsequent \nfrozen pathological section was also planned in view of further \ntotal abdominal hysterectomy, remaining salpingo-\noopherectomy and staging to be carried out if the frozen section \ndeemed borderline or malignant in nature. At 35 weeks, patient \nunderwent a sub umbilical midline laparotomy. Lower segment \ncaesarean section performed giving birth to a female baby who \nweighed 2.17kg and Apgar score of 4 and 7 at 1 and 5 minutes \nrespectively. Subsequently right ovarian cystectomy was perform \nwith cyst remain intact as the appearance of cyst suggested an \nendometriotic cyst. Further dissection of the cyst after its removal \nappeared to consist of a 6.5 unilocular cyst containing chocolate \nmaterial with soft edematous nodules ranging from 2mm to 8mm \nlining in the inner surface of cyst wall. Immediate frozen section \nof the cyst to pathology confirmed the cyst to be of haemorrhagic \ncyst of the ovary which was surrounded by denuded stromal \ntissue with prominent decidual changes. As a result of this \nfinding, no further surgical intervention was carried out and \nabdomen was closed in the usual fashion. Final pathology of the \nright ovarian cyst again confirmed the cyst was haemorrhagic \novarian tissue in nature with decidualisation with no evidence of \nendometriosis. There was no evidence of malignancy while there \nwere also no signs of malignancy in the histopathology of the \nplacenta. Patient and baby recovered well post operatively and \ndischarged together on day 4 post procedure.  \n \n3. Discussion \nTo our knowledge, this is one of the few cases of decidualized \nbenign ovarian haemorrhagic cyst mimicked malignancy to be \nreported in the literature. Decidualization is the conversion of the \nnormal endometrium into a specialized uterine lining adequate \nfor optimal accommodation of the gestation during pregnancy. \nThis change is caused mainly by progesterone and involves \nhypertrophy of the endometrial stromal cells leading to \nthickening of the normal endometrium and giving rise to the \ndecidua. Decidualized tissue can grow during pregnancy to \nacquire a gross appearance that macroscopically mimics a \nmalignant tumor [8]. Several reports have described decidualized \novarian endometriosis [5, 11 . During pregnancy, decidualisation \nnot only occurs within the uterine endometrium but also to \nextrauterine endometrium in particularly in areas of \nendometriosis. How decidualization occurs within a \nhaemorrhagic cyst without the presence of endometriosis in our \ncase remains uncertain, it is likely to be due to the decidualsation \nof ectopic sites, namely stromal ovary in this case which \nmimicked features of malignancy [15]. Intracystic papillary \nexcrescences which are vascularized on colour Doppler \nexamination are a sonographic association with malignancy [14] \nhowever they are also mimicked by decidualised cysts. These  \nfindings during ultrasound examination creates a dilemma \nbetween further investigating a potentially benign mass, \nsometimes through invasive procedures that may complicate \npregnancy, versus conservative observation of a potential \nmalignant state. MRI has been suggested in providing more \ninformation and possibility to differentiate between a \ndecidualised ovarian cyst from malignancy. However results \nfrom other studies found no characteristic pattern. In general, \nexcrescense showed low intensity in T1 in general but may show \nintermediate or high intensity on T2 which is similar to our \npresented case. However, ovarian malignancies exhibit a variety \nof MRI findings regardless whether they are of the same \nhistological type or of different histological type [10] thus MRI \nmaybe unable to definitely distinguish decidualization from \nmalignacy. Other investigation such as Ca125 cancer antigen \nlevel is often used during investigation for ovarian tumour. It may \nbe particularly high in malignant tumours, however during \npregnancy, they are found to be normally elevated in most \npatients particularly in the third trimester hence they are not \nparticularly useful in the diagnosis of ovarian malignancy [17]. As \ndistinguish between decidualization and malignancy remains \ndifficult, the need for surgery often based on the size of the \ntumour, the symptoms that the patient may suffer, the level of \nsuspicions the practitioner may have as well as the patient’s \ngeneral anxiety. Majority of the cysts including neoplasms are \nfound in the early parts of the pregnancy and operations are \nusually performed in the second trimester, in particular 16-18 \nweeks. At this gestation, uterus is not as large to obscure view or \nincrease operative difficulties hence laparoscopic approach is a \npossibility. It is also associated with less adverse events compare \nto those done above 23 weeks gestation which includes \nspontaneous miscarriage, preterm labour or preterm premature \nrupture of membranes [13]. However decidualization of ovarian \ntissues only occurs during pregnancy. There is this possibility \nwhere vascularization in the papillary excrescences was not \ndetectable in the first examination but present later in the \npregnancy, while with malignancy, one would expect \nvascularization to be present from the first examination [7]. \nSimilar to our case, the ultrasonic presentation of papillary \nexcrescences in ovarian cyst which mimic malignancy may \nappear beyond the ideal operative window. Once the diagnosis or \nstrong suspicion of neoplastic tumour is made, its removal is \nimperative to prevent acute complications and to resolve the \npossibility of malignancy. However, surgical removal of ovarian \ntumours in the third trimester remains controversial. \nManipulation of the uterus at this stage of pregnancy may lead to \npremature labour [7]. Aspiration of cyst under ultrasound \nguidance for diagnosis and symptom relief while minimize risk \nof preterm labour have also been reported [16], however there is a \nrisk of fluid re-accumulation and the possibility of upstaging its \nmalignancy staging if the tumour was malignant. In our case, the \ndecision was made to deliver the baby via caesarean section at 35 \nweeks while remove parts of the cyst for frozen section and \nsubsequent total abdominal hysterectomy and staging if frozen \nsection was deemed malignant. At 35 weeks, it is globally \naccepted to have a good fetal outcome and prevented the chance \nof extreme prematurity while keeping the fetal wellbeing in mind, \nsuch decision limited the delay of diagnosis and management of \nsuspected malignancy to the minimum.  \n\nInternational Journal of Gynaecology Research \n \n4 \n4. Conclusion \nDecidualisation of ovarian cysts during pregnancy is rare in \npregnancy. It occurs to endometriotic cysts but even less common \nto ovarian cyst with no evidence of endometriosis. Its ultrasounic \nappearance often mimic those of malignancy but none of the \ninvestigations clearly diffrenciates one from another. Surgical \nintervention remains the key to diagnosis and in preventing cyst \ncomplication or resolve possible malignancy but timing of the \noperation remains crucial when they are found late in particular \nduring the third trimester. Decidualized ovarian cysts should be \nadded to the differential diagnosis when there is a suspicion of \novarian malignancy during pregnancy to reduce risk of early \nsurgical intervention and subsequent risks of preterm labour and \nfetal extreme prematurity.  \n \nReference \n1. Grimes WH, Bartholomew RA, Colvin ED, Fish JJ, Lester \nWM. Ovarian cysts omplicating pregnancy. Am J Obstet \nGynecol. 1954; 68:549-605. \n2. Creasman WT, Rutledge F, Smith JP. Carcinoma of the \novary associated with pregnancy. Obstet Gynecol. 1971; \n38:111-116. \n3. Gasim T, Al Dakhiel SA, Al Ghamdi AA, Al Ali M, Al \nJama F, Rahman J, et al. Ovarian tumours associated with \npregnancy: a 20-year experience in a teaching hospital. \nArch Gynecol Obstet. 2010; 282:529-533. \n4. Beischer NA, Buttery BW, Fortune DW, Macafee CAJ. \nGrowth and malignancy of ovarian tumours in pregnancy. \nAust NZ J Obstet Gynecol. 1971; 11:208-211. \n5. Miyakoshi K, Tanaka M, Gabionza D, Takamatsu K, \nMiyazaki T, Yuasa Y, et al . Decidualized ovarian \nendometriosis mimicking malignancy. AJR Am J \nRoentgenol. 1998; 171:1625-1626. \n6. Tanaka YO, Shigemitsu S, Nagata M, Shindo M, Okamoto \nY, Yoshikawa H, et al. A decidualized endometrial cyst in \na pregnant women: a case observed with steady-state free \nprecession imaging sequence. Magn Reson Imaging. 2002; \n20:301-304. \n7. Fruscella E, Testa AC, Ferrandina G, Manfredi R, Zannoni \nGF, Ludovisi M, et al . Sonographic features of \ndecidualized ovarian endometriosis suspicious for \nmalignancy. Ultrasound Obstet Gynecol. 2004; 24:578-\n580. \n8. Sammour RN, Leibovitz Z, Shapiro I, Degani S, Levitan Z, \nAharoni A, et al. Decidualization of ovarian endometriosis \nduring pregnancy mimicking malignancy. J Ultrasound \nMedicine. 2005; 24:1289-1294. \n9. Iwamoto H, Suzuki M, Watanabe N, Minai M, Hirata S, \nHoshi K, et al . Case study of a pregnant women with \ndecidualized ovarian endometriosis whose preoperative \nfindings suggested malignant transformation. Eur J \nGynaecol Oncol. 2006; 27:301-303. \n10. Barbieri M, Somigliana E, Oneda S, Ossola MW, Acaia B, \nFedele L, et al . Decidualized ovarian endometriosis in \npregnancy: a challenging diagnostic entity. Human \nreproduction. 2009; 24(8):1818-1824. \n11. Machida S, Matsubara S, Ohwada M, Ogoyama M, Kuwata \nT, Watanabe T, et al . Decidualization of ovarian \nendometriosis during pregnancy mimicking malignancy: \nreport of three cases with a literature review. Gynecol \nObstet Invest. 2008; 66:241-247. \n12. Hess LW, Peaceman A, O’Brien WF, Winkel  CA, \nCruikshank DP, Morrison JC, et al . Adnexal mass \noccurrine with intrauterine pregnancy: report of fifty-four \npatients requiring laparotomy for definitive management. \nAm J Obstet Gynecol. 1988; 158:1029-1034. \n13. Agarwal N, Parul, Kriplani A, hatla N, Gupta A. \nManagement and outcome of pregnancies complicated \nwith adnexal masses. Arch Gynecol Obstet. 2003; 267:18-\n152. \n14. Guerriero S, Alcazar JL, Coccia ME, Ajossa S, Scarselli G, \nBoi M, et al. Complex pelvi mass as a target of evaluation \nof vessel distribution by color Doppler sonography for the \ndiagnosis of adnexal malignancies. J Ultrasound Med. \n2002; 21:1105-1111. \n15. Zaytsev P, Taxy JB. Prenancy-associated ectopic decidua. \nAm J Surg Pathl. 1987; 11(7):526-530. \n16. Hutt R, Long M, Sturdy J. Conservative management of \novarian cysts in pregnancy during third trimester and \nintrapartum. J Obstet Gynecol. 2000; 5:495-498. \n17. Han SN, Lotgerink A, Gziri MM, Van Calsteren K, \nHanssens M, Amant F, et al. Physiological variations of \nserum tumor markers in gynecological malignancies during \npregnancy: a systemic review. BMC Medicine. 2012; \n10:86-96.","source_license":"CC0","license_restricted":false}