Bilateral Adnexal Masses Research Articles

Nongestational ovarian choriocarcinoma with bilateral teratoma: A rare case report and literature review.

Trophoblastic neoplasms are often associated with pregnancy, and nongestational trophoblastic neoplasms are extremely rare. Nongestational ovarian choriocarcinoma (NGCO) is a highly aggressive germ cell-derived tumor frequently presenting with early hematogenous metastasis. Herein, we report a case of a 28-year-old unmarried woman with regular menstruation who experienced vaginal bleeding 1 week after her last menstrual cycle. Doppler ultrasound revealed bilateral adnexal masses and elevated serum human chorionic gonadotropin (hCG) levels. The patient was initially misdiagnosed as presenting an ectopic pregnancy. The final pathology confirmed an International Federation of Gynecology and Obstetrics stage IA NGCO with bilateral mature teratoma of the ovary. This is an extraordinary instance of ovarian choriocarcinoma which emerged without any prior gestation, and the patient's lack of a history of pregnancy made the diagnosis ignored. After initial surgery and 1 cycle of bleomycin, etoposide, and cisplatin (BEP) chemotherapy, a laparoscopic fertility-preserving comprehensive staging surgery was performed. Two cycles of chemotherapy with BEP were administered as supplemental therapy postsurgery, and leuprorelin was administered to protect ovarian function. Menstruation resumed 4 months after chemotherapy completion, and tumor indicators were within the normal range. No signs of recurrence were observed at the 36-month follow-up. NGCO should be considered if a female patient exhibits irregular vaginal bleeding and masses in the adnexal area. The present case and our literature review also highlighted that fertility-sparing surgery and multidrug chemotherapy are effective methods for treating NGCO.

Clinical analysis of 12 cases of ovarian yolk sac tumor

Objective: To investigate the diagnosis, treatment and prognosis of ovarian yolk sac tumor (OYST). Methods: The clinicopathological data and follow-up data of 12 patients with OYST admitted to the Affiliated Hospital of Qingdao University from January 2013 to December 2020 were retrospectively analyzed, and the diagnosis, treatment and prognosis of OYST patients were summarized. Results: (1) The age of 12 patients with OYST ranged from 11 to 37 years, with a median age of 20 years. At the first visit, all 12 patients had pelvic masses. Reasons for seeing a doctor: 6 cases of abdominal distension and abdominal pain, 4 cases of mass in the lower abdomen, 1 case of vaginal bleeding, and 1 case of appendicitis. International Federation of Obstetrics and Gynecology (FIGO) 2014 staging: 4 cases in stage Ⅰa, 2 cases in stage Ⅰc, 1 case in stage Ⅱc, 4 cases in stage Ⅲc, and 1 case in stage Ⅳb. (2) All 12 patients were examined by color Doppler ultrasound before operation, among which 10 cases showed unilateral adnexal masses and 2 cases bilateral adnexal masses. The median maximum diameter of tumor was 16.5 cm (range: 6.0-28.0 cm). The preoperative levels of alpha fetoprotein (AFP) in 12 patients (all >1 210 μg/L) were significantly higher than normal (<25 μg/L). Among the 11 patients with cancer antigen 125 (CA125) detection results, 9 patients showed elevated serum CA125 levels. (3) Among the 12 patients, 8 young infertile patients who needed to preserve their reproductive function underwent appendectomy, 3 infertile patients underwent staged surgery for ovarian malignant germ cell tumor, and only one bilateral lesion and infertile patient underwent unsatisfactory staged surgery for ovarian malignant germ cell tumor. Of the 12 patients, 11 patients were given combined chemotherapy regimen of bleomycin, cisplatin, and etoposide (BEP) after operation. One patient without chemotherapy developed metastasis 3 months after operation, and was given BEP chemotherapy, and her condition was controlled. (4) The deadline for follow-up was December 31st, 2022, and the median follow-up time was 60 months (range: 25-115 months). All the 12 patients survived without tumor during the follow-up period, and the median disease-free survival time was 84.5 months (range: 25-115 months). Conclusions: OYST mostly occurs in children and young women. Color Doppler ultrasound examination and serum AFP and CA125 detection have diagnostic value for OYST. Surgical treatment after diagnosis of OYST includes surgery to preserve reproductive function and timely and standardized chemotherapy after operation. The prognosis of patients is good regardless of stage.

Pelvic Inflammatory Disease Mimicking Ovarian Cancer: A Case Series from A Tertiary Cancer Center

The female pelvis has a complex anatomy, and benign adnexal diseases can present as malignant ovarian masses clinically and radiologically. Between 1 June 2011 and 28 September 2022, we included in this study all the patients who were diagnosed initially with suspicious ovarian masses in the Department of Surgical Oncology, Oncology Center, Mansoura University, Egypt, and after surgical exploration revealed pelvic inflammatory disease and we assessed their diagnostic, operative, and postoperative outcomes. In this case series we had 41 patients of a total of 803 cases with suspicious adnexal mass that revealed pelvic inflammatory disease after surgical exploration, abdominal pain was the common presentation in 53.7% of the cases, and low-grade fever was reported in seven cases. The serum cancer antigen 125 was elevated in 70.7% of the cases. Unilateral adnexal mass was found in 30 cases and 11 cases had bilateral adnexal masses. We followed up on the patients within 47 months (range 12–88 months); recurrent pelvic inflammatory disease has developed in one case after 62 months and ovarian cancer has developed in another case after 80 months. We concluded that benign adnexal masses such as tubo-ovarian abscess secondary to pelvic inflammatory disease should be considered a differential diagnosis in patients with radiological suspicious adnexal masses when the tumor markers such as cancer antigen 125 are normal or mildly elevated, especially in premenopausal women, and the clinical presentations are not specific to either benign or malignant adnexal diseases.

Primary Monophasic Omental Synovial Sarcoma in Nulliparous Female: A Case Report

Synovial Sarcoma (SS) is an uncommon soft-tissue malignancy that primarily occurs near tendon sheaths and bone joints. Its primary intra-abdominal location is infrequent and characterised by non specific clinical signs. The mainstay of treatment remains wide local excision with negative margins. Hereby the authors report a rare case of monophasic omental SS in a 30-year-old nulliparous female who presented with chief complaints of an enlarging lump in the right abdominopelvic region over the past year and constipation for three months. The mass was non mobile and non tender. The rest of the physical and laboratory examinations were normal. She has a history of diagnostic laparoscopic excision (for the same complaint) of bilateral adnexal masses with right salpingectomy done three months ago in an outside set-up where histopathology diagnosed the mass as a low-grade fibromyxoid tumour. Presently, Contrast- enhanced Magnetic Resonance Imaging (CEMRI) revealed a large lobulated heterogeneous mass of 19.5×15.4×20 cm extending into mesorectal fat and encasing the sigmoid colon, rectosigmoid junction, uterus, and bilateral ovaries. The patient was taken for emergency surgery as she started displaying symptoms of acute obstruction. Debulking surgery (R2 resection) with ileostomy was performed. Histopathology and immunohistochemistry confirmed the diagnosis of monophasic SS. The patient was started on doxorubicin and has completed three cycles of chemotherapy. SS is an infrequent entity with high mortality rates. The main course of treatment is surgery with healthy resection margins. Long-term follow-up is required due to the high recurrence rate.

A rare case of cervical gastric-type adenocarcinoma mimicking bilateral ovarian malignancy in a genetically confirmed Peutz-Jeghers syndrome without known polyposis

Abstract Introduction/Objective Cervical gastric-type adenocarcinoma (GAS) is rare and accounts for 2-4% of cervical cancer. GAS is usually sporadic but can be associated with Peutz-Jeghers syndrome (PJS), a rare autosomal dominant disorder caused by germline STK11 mutations and characterized by hamartomatous polyposis in the gastrointestinal (GI) tract, mucocutaneous pigmentation, and cancer predisposition. Although cases of GAS may occur in patients with PJS associated with polyposis, our patient with GAS has an unusual and perhaps unique association with the PJS mutation that is unassociated with polyposis. Methods/Case Report A 33-year-old female presented with abdominal pain, abnormal uterine bleeding, vaginal discharge, weight loss, and fatigue for one year. Pigmentations were noted on lips, gum, tongue, and hands. She had a family history of maternal ovarian and pancreatic cancers. Computerized tomography revealed large bilateral multiloculated complex cystic adnexal masses, thickened endometrium extending into the endocervix, and ascites. Tumor markers showed increased CA19-9 and CA125, suggesting either a primary ovarian malignancy or possible metastatic GI tract cancer to both ovaries. Her PAP smear demonstrated atypical glandular cells that favored endocervical origin. HPV was not detected. A cervical biopsy showed bland gastric-type glands without obvious stromal invasion. Given the clinical concern for malignancy, a cervical cone biopsy was performed, demonstrating unequivocal invasion by gastric-appearing glands. The tumor cells were positive for CK7, CEA, and PAX8, and were negative for CK20, CDX2, and p16. The pathologic diagnosis confirmed a primary GAS with a spread to bilateral ovaries. Although the upper GI tract and left colon were free of polyps or masses by endoscopic exam, the genetic evaluation revealed a germline heterozygous STK11 mutation consistent with PJS. Results (if a Case Study enter NA) NA Conclusion To our knowledge, this is the first case of occult PJS (confirmed by genetic analysis) presenting with widely advanced metastatic GAS without known polyposis.

Bilateral ovarian fibromas as the sole manifestation of Gorlin syndrome in a 22-year-old woman: a case report and literature review

BackgroundNevoid basal cell carcinoma syndrome (NBCCS, Gorlin syndrome) is a rare autosomal dominantly inherited disorder that is characterized by multisystem disorder such as basal cell carcinomas, keratocystic odontogenic tumors and skeletal abnormalities. Bilateral and/or unilateral ovarian fibromas have been reported in individuals diagnosed with NBCCS.Case presentationA 22-year-old female, presented with low back pain, and was found to have bilateral giant adnexal masses on pelvic ultrasonography, which had been suspected to be malignant ovarian tumors. Positron emission tomography/computed tomography showed multiple intracranial calcification and skeletal abnormalities. The left adnexa and right ovarian tumor were resected with laparotomy, and pathology revealed bilateral ovarian fibromas with marked calcification. We recommended the patient to receive genetic testing and dermatological examination. No skin lesion was detected. Germline testing identified pathogenic heterozygous mutation in PTCH1 (Patched1).ConclusionsThe possibility of NBCCS needs to be considered in patients with ovarian fibromas diagnosed in an early age. Skin lesions are not necessary for the diagnosis of NBCCS. Ovarian fibromas are managed with surgical excision with an attempt at preserving ovarian function. Follow-up regime and counseling on options for future fertility should be offered to patients.

9525 Pelvic Rhabdomyosarcoma in an Adolescent Presenting with Bilateral Adnexal Masses Treated with Minimally Invasive Surgical Resection

9525 Pelvic Rhabdomyosarcoma in an Adolescent Presenting with Bilateral Adnexal Masses Treated with Minimally Invasive Surgical Resection

SAT588 Cushing’s Syndrome Due To Ectopic ACTH Secretion From Ovarian Teratomas

Abstract Disclosure: Y. Kang: None. M.S. Gildenberg: None. B.J. Quade: None. R.A. Blair: None. Background: Approximately 9-18% of Cushing’s syndrome (CS) cases are secondary to ectopic ACTH secretion, most commonly from sources in the lung or mediastinum. However, ACTH-producing tumors are rarely found in distant organs, occasionally making the localization and management challenging. Clinical Case: A 32-year-old woman with class 3 obesity, hidradenitis suppurativa, anxiety, and depression experienced atraumatic pelvic and sacral fractures. DXA scan result showed Z-scores of -3.1 in the lumbar spine, -2.6 in the femur neck, and -0.5 in the total hip. She reported a steady weight-gain of 250 lbs over 7 years despite lifestyle modifications and liraglutide. On examination, she had a round face with plethora, acne, violaceous abdominal striae, and dorsocervical fat pad. Laboratory findings revealed elevated midnight salivary cortisol levels of 453 and 424 ng/dL (n: &amp;lt;100 ng/dL), elevated 24-hour urine cortisol levels of 254 and 741 (n: 3.5-45 mcg), and an abnormal 1 mg dexamethasone suppression test (DST) result at 15.1 ug/dL. AM plasma ACTH and cortisol levels were 190 pg/mL and 18.5 ug/dL, suggesting ACTH-dependent hypercortisolism. The plasma cortisol level after an 8 mg DST was unsuppressed at 13.1 ug/dL with a dexamethasone level of 3,380 ng/dL (n: &amp;gt;800 ng/dL). Abdominal CT and MRI scans showed large bilateral adnexal masses measuring up to 13.7 cm on the left and 9.3 cm on the right, with heterogeneous solid and cystic components, consistent with mature cystic ovarian teratomas. DOTATE-PET scan did not show any areas of increased uptake. The patient underwent a laparoscopic right cystectomy and left oophorectomy, with immediate drop in cortisol (1.6 ug/dL) and signs of adrenal insufficiency post-operatively, requiring hydrocortisone replacement. After holding hydrocortisone for 24 hours prior to laboratory assessment one week post-operatively, her ACTH and cortisol were undetectable, reflecting successful source removal. Pathology report showed neuroendocrine tumor with pituitary differentiation with positive ACTH immunohistochemical staining and Ki-67 proliferative index of 22.6% on the left adnexal mass, and a mature cystic teratoma on the right. Conclusion: Although rare, pituitary differentiation of ovarian teratomas should be considered as a possible source of ectopic ACTH secretion in CS patients without obvious sources identified in commonly involved organs. Presentation: Saturday, June 17, 2023

RET/PTC rearrangement in papillary thyroid carcinoma arising in malignant struma ovarii with abdominal wall metastasis and cervical thyroid gland: a case report and review of the literature

BackgroundStruma ovarii refers to rare mature cystic teratomas containing at least 50% of thyroid tissue, and malignant transformation is known to be even rarer. The synchronous development of malignant struma ovarii and cervical thyroid carcinoma are also scarce and poorly understood due to limited data about molecular features. Here, we present the first report of RET/PTC 1 rearrangement in synchronous metastatic malignant struma ovarii to the abdominal wall and cervical thyroid cancer.Case presentationWe described a 47-year-old multigravida woman with bilateral adnexal and lower abdominal wall masses detected during the evaluation of abnormal uterine bleeding. The patient underwent a hysterectomy, bilateral salpingo-oophorectomy, and surgical removal of abdominal wall mass. Then, the pathological evaluation revealed papillary thyroid carcinoma (PTC) within struma ovarii and metastatic PTC in the abdominal wall fibro adipose tissue. Further, cervical thyroid gland physical examination and ultrasound illustrated a nodule within the left lobe. Subsequently, a total thyroidectomy was performed, and a histological examination revealed PTC. Furthermore, all affected tissue, i.e., struma ovarii, abdominal wall metastasis, and cervical thyroid gland tested for BRAF and RAS mutations and RET/PTC 1 rearrangement. RET/PTC 1 rearrangement was identified among all three different sites. Finally, after six years of follow-up, the patient had no evidence of recurrence or distant metastasis.ConclusionsIn light of these findings, malignant struma ovarii might yield a clue to cervical thyroid carcinoma, and the molecular analysis could provide valuable information for understanding the underlying mechanism, tumor clinicopathological behaviors, and prognosis.

Two Cases of Burkitt Lymphoma Presenting as Solid Ovarian Masses

Background: Endemic Burkitt lymphoma has been associated with the Epstein Barr Virus (EBV), particularly in malaria-endemic regions. Primary ovarian Burkitt is an infrequent entity of this disease, and its diagnosis still poses a challenge. Summary: We present two cases. The first case is that of a 23-year-old female G1P1 who presented with a two-week history of abdominal pain and progressive distension. Her examination was remarkable for two pelvic masses and signs of ascites. An ultrasound scan showed bilateral solid adnexal masses, ascites, and mild splenomegaly. Tumor markers for ovarian and germ cell tumors were within the normal ranges. Cytology on ascitic fluid was negative for malignancy. Lactate dehydrogenase (LDH) level and further imaging were not done due to financial constraints. With the working diagnosis of an ovarian epithelial malignancy versus drop metastases, she underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, and debulking of peritoneal implants. Histopathology two weeks after surgery showed Burkitt lymphoma. The second case is that of a 12-year old female whose management averted surgery, following the recommendations made from our first case. Conclusion: Lymphomas are amongst the most common tumors in the pediatric age group. Clinicians should maintain a high index of suspicion in the face of fast-growing tumors. Burkitt lymphomas respond well to chemotherapy, and surgery is seldom necessary except for life-threatening presentations. Management of oncologic cases that are not straightforward should follow a multidisciplinary approach.

Isolated Axillary Lymph Node Recurrence from Serous Ovarian Carcinoma: A Case Report

Ovarian cancer is the most mortal gynecological malignancy among women worldwide. The appropriate treatment protocol is cytoreductive surgery and the main aim is to remove all primary carcinoma focus and all metastatic lesions. A 37 years old woman (gravida 5, para 3) presented with complaints of abdominal distension. During the gynecological examination, bilateral adnexal masses in the solid structure were observed. Staging surgery was performed and 8 cycles of adjuvant chemotherapy regimen were given. A pathological axillary lymph node was detected in the positron emission tomography-computed tomography (PET/CT) imaging at the follow-up 6 months after the end of the chemotherapy regimen. The biopsy result from the axillary lymph node was reported as serous carcinoma metastasis. Metastasis of ovarian carcinoma to the axillary lymph node is uncommon and has a poor prognosis. High-grade ovarian serous carcinoma with axillary lymph node metastasis was presented in this case report.

LBODP097 Malignant Struma Ovarii: Long Term Successful Treatment. Outcome

Abstract 18 year old African American female saw her GYN in 9/2008 for abdominal pain. CT: bilateral adnexal masses (10×8 cm left; 6.3×3.1 cm right). Surgical pathology reported a left benign cystic teratoma and right corpus luteum cyst. Pain recurred in 2010. MRI showed: 9×7.5×4 cm right adnexal mass. Repeat surgery was done. Pathology: benign cystic teratoma with focal thyroid tissue - "Struma Ovarii". Abdominal pain recurred yet again in 2012. Sonography revealed a mixed solid/cystic pelvic mass measuring 10.6×7.9×7.6 cm. Exploratory laparotomy 9/2012 revealed a right adnexal mass and widespread peritoneal nodules. Pathology reported follicular tissue with colloid in the nodules - "Peritoneal Strumatosis" suggesting benignity. Upon further review was reclassified as metastatic well differentiated follicular thyroid cancer of ovarian origin with follicular thyroid tissue identified in peritoneal lymph nodes, spleen, bladder and rectal wall. The patient was then referred to endocrinology at our facility. On exam she was clinically euthyroid without thyromegaly or nodularity. Thyroid hormone levels were normal. Antithyroid antibodies were absent. Serum Thyroglobulin (Tg): elevated (229; normal 2-35 ng/ml) as was CA125 (64; normal &amp;lt;21 U/ml). Immunohistochemistry: positive for Tg and Thyroid transcription factor-1. Molecular markers: no mutations in BRAF, RAS, or TP53. In preparation for radioactive iodine (RAI) therapy, total thyroidectomy was performed 4/13/2013 and reported as normal thyroid tissue. Dosimetry findings: very iodine avid tissue with prolonged retention (33% at 6 days). Maximum tolerated dose: 200 mCi. A 62.8 mCi RAI was administered 7/13/2013. Post RAI whole body scan (WBS): numerous focal areas of increased uptake in abdomen and pelvis consistent with metastatic disease. Treatment with L-thyroxine was given to suppress TSH. Follow up WBS 12/26/2013 showed persistent increased uptake in abdomen and pelvis. Serum Tg was high (198. 0). A second RAI dose of 104.8 mCi was given. Post RAI WBS confirmed multiple areas of metastatic disease in abdomen and pelvis. Subsequent serum Tg levels down trended. WBS 11/12/2014: only two residual abnormal foci in the lower neck and one inferior to the liver without abdominal or pelvic foci. Given the dosimetry issue and the reassuring serum Tg levels, surveillance was continued. WBS 9/25/2015: unchanged. Now age 27, WBS 1/26/2022: only residual faint lower neck uptake, resolution of the focus inferior to the liver and no distant foci. Stimulated Tg was normal at 2.2 ng/ml with stimulated TSH &amp;gt;110. 0 uIU/ml. Presentation: No date and time listed

8346 Polypoid Endometriosis: A Distinct Variant

<h3>Study Objective</h3> To examine a case study of polypoid endometriosis and perform a literature review. <h3>Design</h3> Case Report. <h3>Setting</h3> Academic institution <h3>Patients or Participants</h3> 1 Patient. <h3>Interventions</h3> Surgical resection. <h3>Measurements and Main Results</h3> A 34-year-old nulliparous woman with complex adnexal masses and severe left hydronephrosis presented for consultation. Menarche occurred at 12 years-old, followed by regular monthly menses lasting 5 days. The patient reported multiple emergency room visits for severe dysmenorrhea and was taking combined hormonal contraceptives with good effect since adolescence. Of note, she had discontinued her contraceptives as she was trying to conceive. Examination revealed a non-obese female with bilateral lower abdominal tenderness to palpation. Initial labs showed elevations in CA125, HE4, and CA19-9. Imaging demonstrated a complex 7cm right adnexal mass with severe left hydronephrosis secondary to enhancing fibrosis in the left hemipelvis. This was suspicious for deep infiltrating endometriosis. The patient underwent robotic bilateral ovarian cystectomy, excision of endometriosis, right salpingectomy, left ureteral reimplantation with psoas hitch, appendectomy, and cystoscopy. Stage IV endometriosis was noted intraoperatively. Intraoperative frozen pathology was benign. Her recovery was overall uncomplicated. Final pathology was consistent with polypoid endometriosis. Follow up imaging revealed recurrence of bilateral complex adnexal masses. <h3>Conclusion</h3> Polypoid endometriosis is an uncommon, distinct variant of endometriosis with histological features suggestive of an endometrial polyp. Unlike usual-type endometriosis, which commonly affects reproductive-aged women, polypoid endometriosis primarily affects older patients with a mean age of 52.5-years-old. Patients with polypoid endometriosis often present with mass effect or vaginal bleeding. It is characterized by a tendency to mimic neoplastic processes clinically, intra-operatively, and on gross examination. Polypoid endometriosis also demonstrates a high rate of recurrence after surgical excision, as seen in our case study. Given the ability of polypoid endometriosis to mimic malignancy, intraoperative frozen pathology may prevent a more extensive surgery and excessive resection in patients of childbearing age.

Management of a rare ovarian carcinosarcoma: A case report and literature review.

Ovarian carcinosarcoma (OCS) is a rare and lethal gynecological cancer. The present study reports on the case of a 61-year-old post-menopausal female with abdominal distension who was detected to have a large OCS. The patient underwent cytoreductive surgery, including sub-extensive hysterectomy, bilateral adnexectomy, sigmoid colon and partial rectal resection, and lymph node dissection. Postoperative pathology of the bilateral adnexal masses revealed carcinosarcoma. The main components of the carcinoma included serous carcinoma and a small amount of squamous cell carcinoma. The sarcoma components mainly contained fibrosarcoma, as well as a small amount of chondrosarcoma and rhabdomyosarcoma. Infiltrating cells in cancer tissues or metastasis were observed in the serosal surface, muscular and subserosal layers of the uterus, as well as the sigmoid colon and part of the rectum. The patient was diagnosed postoperatively with International Federation of Gynecology and Obstetrics stage IIIC ovarian carcinosarcoma and T3cN1M0 based on the TNM system. The patient then received six cycles of combination chemotherapy using carboplatin, paclitaxel plus bevacizumab. As severe myelosuppression occurred during and after chemotherapy, and bevacizumab was expensive, bevacizumab therapy was not maintained after chemotherapy. However, following chemotherapy, the patient received niraparib oral maintenance therapy. At 6 months after the sixth chemotherapy, cancer antigen 125 levels dropped to 4.55 U/ml (within normal range). Short-term follow-up of 6 months after the end of chemotherapy indicated that the patient had a remission prognosis based on the ultrasonography, computed tomography, magnetic resonance imaging examinations and serum tumor marker levels. The present study indicated that combined chemotherapy and targeted therapy after cytoreductive surgery may be a promising way for the treatment of OCS.

TO ANALYSE THE EFFICACY OF TRANSVAGINAL ULTRASONOGRAPHY AND COLOUR DOPPLER IN EVALUATION OF ADNEXAL MASSES

Objective- The objective of this study is to evaluate the transvaginal ultrasound and colour doppler sonography for differentiation between benign and malignant adnexal masses. Methods-In this study total 100 patients were selected from gynaecology OPD. At the end of this study there were 84 patients left and with some having bilateral adnexal masses, so total of 112 adnexal masses were evaluated. The transvaginal ultrasound (TVS) was used to study morphology of the adnexal masses and scoring was assigned using De Priest scoring system. The colour doppler study (CD-study) evaluates the presence or absence of blood ow within the adnexal mass, whether the ow is central or peripheral and the resistance index of the ow. The combined TVS morphological scoring and colour doppler study (TVS+CD) were used for evaluating the adnexal masses. The conrmatory diagnosis was made either by histopathological examination or ne needle cytological examination. The accuracy of TVS-morphological study and colour doppler sonography for differentiation of adnexal masses were assessed by calculating sensitivity, specicity, positive predictive value and negative predictive value. Conclusion-TVS-morphological scoring is one of the best tools for adnexal mass evaluation but when it is combined with colour doppler sonography its diagnostic accuracy increases.

"Duplex Ureter": ¿Are we Aware of this Uncommon Finding?

A 27-year-old, gravida 0 para 0, female presented herself for an evaluation of recurrent urinary tract infections and severe dysmenorrhea. The ultrasound revealed a bilateral small but complex adnexal mass, suggesting endometriosis (Figure 1). Ca 125 was 88 U. Laparoscopic surgery was performed, showing evidence of infiltrative endometriosis and entrapment of the right ureter on the right pelvic sidewall (Figure 2); During the initial anatomical inspection a duplicated ureter was diagnosed (Figure 3).

Bilateral Xanthogranulomatous Oophoritis Mimicking Malignancy- A Rare Case Report

Xanthogranulomatous Oophoritis is an uncommon form of chronic inflammation of genitourinary system. The exact aetiology of this entity is unknown, but it shares similar histopathological findings to those occurring in various other organs, including the gallbladder and kidney. It is often mistaken for ovarian malignancy clinically and radiologically. A vigilant histopathological evaluation is important to diagnose the disease. The current case is of 38-year-old, premenopausal female presented with fever and lower abdominal pain. The case was suspected as bilateral malignant adnexal mass by imaging and tumor marker studies. Final diagnosis of bilateral xanthogranulomatous oophoritis was established after histopathological examination.

A case of primary adenocarcinoma of Meckel’s diverticulum presenting as ovarian mass and literature review

Meckel’s diverticulum (MD) is the most common congenital anomaly affecting the gastrointestinal tract. It is located on the anti-mesenteric border of the small intestine and occurs due to incomplete obliteration of the omphalomesenteric duct during embryogenesis. Tumors, particularly cancers, are rare complications of MD. Carcinoids are the most common malignancies in this site. Adenocarcinomas are extremely rare and carry a poor prognosis. Here, we present the case of adenocarcinoma of MD presenting as Krukenberg tumor in a 42-year-old lady and causing a diagnostic dilemma. Pelviabdominal examination revealed large bilateral adnexal masses along with ascites and computed tomography-guided fine-needle aspiration cytology from the right adnexal mass was suggestive of adenocarcinoma. At exploratory laparotomy, a MD was found with hard intramural growth palpable at the tip of MD adnexal deposits and omental caking. Immunohistochemistry revealed CK 7- and CK 20+ve and also CDX2 positive. The rarity of presentation of bilateral adnexal mass due to primary adenocarcinoma of MD urges us to report this case.

PULMONARY ROCKS! A CASE OF PULMONARY ALVEOLAR MICROLITHIASIS

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Pulmonary alveolar microlithiasis (PAM) is an extremely rare lung disease characterized by the development of calcium phosphate deposits (microliths) within the alveolar spaces. Genetic mutations in the SLC34A2 gene (solute carrier family 34 member 2 gene), which encodes for a sodium-phosphate co-transporter, have been described as the cause of the disease. This co-transporter is located on type II alveolar pneumocytes and is responsible for removing phosphate ions from the alveolar space. Without effective transport, phosphate ions bind to calcium ions leading to calcium phosphate deposits within the alveoli. Over time this often leads to pulmonary fibrosis and progressive respiratory failure. Here, we present a case of pulmonary alveolar microlithiasis that was initially suspected to be metastatic endometrial carcinoma. CASE PRESENTATION: A 37-year-old female presented to gynecology clinic for evaluation of abnormal uterine bleeding. Endometrial biopsy showed endometrioid adenocarcinoma of the uterus. Staging CT scans revealed bilateral adnexal masses, metastatic disease in the liver, peritoneal carcinomatosis, and concern for lymphangitic carcinomatosis in the lungs due to calcification of the pleura and diaphragm. Liver biopsy confirmed metastatic disease of ovarian primary consistent with synchronous stage IV ovarian cancer. She underwent chemotherapy with carboplatin and paclitaxel as well as abdominal hysterectomy and debulking surgery with good response; however, repeat CT chest showed persistent pulmonary disease with innumerable calcified micronodules and extensive pleural, fissural, and interlobular calcifications. Transbronchial biopsies were obtained and revealed diffuse intra-alveolar laminated concentric deposits consistent with microliths and diagnostic of pulmonary alveolar microlithiasis. At the time of diagnosis her pulmonary function testing showed mild restriction. She has no family history of pulmonary disease and had no pulmonary symptoms. Calcium supplements were discontinued, and she was treated with a low phosphorus diet. She continues to undergo monitoring for the development of symptoms as well as monitoring of her pulmonary function. DISCUSSION: PAM is an extremely rare genetic disease caused by a defective sodium-phosphate co-transporter that leads to the accumulation of microliths within the alveolar spaces. Pulmonary fibrosis and progressive respiratory failure is the typical cause of death, although the rate of progression is variable. There is no known effective treatment except for lung transplant. A low phosphorus diet, bisphosphonates, and repeated bronchoalveolar lavage have been studied without clear clinical benefit. CONCLUSIONS: (See Discussion) REFERENCE #1: Castellana G, Castellana G, Gentile M, Castellana R, Resta O. Pulmonary alveolar microlithiasis: review of the 1022 cases reported worldwide. Eur Respir Rev. 2015 Dec;24(138):607-20. REFERENCE #2: Saito A, McCormack FX. Pulmonary Alveolar Microlithiasis. Clin Chest Med. 2016;37(3):441-448. doi:10.1016/j.ccm.2016.04.007. DISCLOSURES: No relevant relationships by Carlos Cardenas, source=Web Response No relevant relationships by Sakda Sathirareuangchai, source=Web Response No relevant relationships by Andrew Tomlinson, source=Web Response

Bilateral ovarian carcinoma with colorectal metastases - An unusual presentation

Primary ovarian carcinoma may metastasize to the peritoneum leading to malignant ascites. Four percent cases of primary ovarian carcinoma can involve the colorectum. We present a case report of a 50-year-old women who had complaints of bilateral adnexal mass and disturbed menstruation with altered bowel habits. Computed tomography scan of the abdomen and pelvis showed a bilaterally enlarged ovaries and a lobular rectal mass. Proctoscopy substantiated the rectal mass as an ulcerated lesion. Histopathology confirmed the diagnosis as bilateral serous papillary cystadenocarcinoma. Left hemicolectomy specimen illustrated foci of atypical glands. Immunohistochemical staining of both the tumor masses showed strong cytokeratin 7 positivity with negative cytokeratin 20 expression. Bilateral involvement of the ovaries with colorectal metastasis is very uncommon, which is highlighted in this paper. Keywords: Bilateral, Cancer, Colorectum, Immunohistochemistry, Ovary, Metastasis.