Bilateral Adnexal Masses Research Articles

OP19.05: Ultrasound for discrimination between acute salpingitis and other conditions in patients with clinical signs and symptoms suggesting acute salpingits: a prospective observational cross sectional study

Objectives: To describe ultrasound findings in patients with acute salpingitis and to determine if it is possible using ultrasound to discriminate between acute salpingitis and other painful conditions mimicking clinical symptoms/ findings of acute salpingitis. Methods: 52 patients underwent a standardized transvaginal ultrasound scan before diagnostic laparoscopy because of clinical suspicion of acute salpingitis. The laparoscopist was blinded to scan results. Final diagnosis was based on laparoscopy, histology of the endometrium or other histology where relevant. Results: 29 patients had a final diagnosis of cervicitis (n = 3), endometritis (n = 9), or salpingitis (n = 17), 23 (44%) had a diagnosis unrelated to genital infection. In 4 cases the salpingitis was mild, in 8 moderate, in 5 severe (pyosalpinx). Bilateral adnexal masses and bilateral masses lying adjacent to the ovary were seen more often at scan in patients with salpingitis than with other diagnoses (14/17 vs. 6/35, P = 0.000; 11/17 vs. 6/35, P = 0.001). In salpingitis, the masses lying adjacent to the ovaries were on average 2–3 cm in diameter, solid (n = 14), unilocular (n = 4) or multilocular (n = 3) cystic, or multilocular solid (n = 1), and well vascularized at color Doppler. Spectral Doppler results overlapped between patients with different diagnoses. The sensitivity with regard to acute salpingitis of subjective assessment of scan findings by the sonologist was 82%, specificity 77%, positive and negative likelihood ratio (LR+) 3.6 and 0.23. Those of scan findings of bilateral masses lying adjacent to the ovary were 65%, 83%, LR+ 3.8 and LR− 0.42. The corresponding figures for bilateral adnexal masses were 82%, 83%, 4.8 and 0.22. Conclusions: In patients with clinical suspicion of acute salpingitis, absence of bilateral adnexal masses at scan decreases the odds of acute salpingitis 5-fold.

Torsion Hematosalpinx and Paraovarian Cyst Mimicking Bilateral Ovarian Neoplasm in an Adolescent Girl

Background: The occurrence of fallopian-tube torsion as well as bilateral adnexal masses are rare in adolescents. Case: A 13-year-old girl who had attained menarche 6 months previously, complained of back pain of 7 months' duration and lower abdominal pain of 1 month's duration. Findings from her general and other systemic examinations were normal. Her hymen was intact, and rectal examination revealed a tender mass of 5×6 cm, which was felt anterior to the rectum. Transabdominal sonography showed bilateral adnexal masses, of which the left one was a complex echogenic mass of 7.43×5.41 cm, and the right one was an anechoeic mass of 7.3×6 cm. Tumor markers, Mantoux test, chest radiograph, and hydatid serology were normal. Because of the bilaterality, malignancy was suspected, and hence laparotomy was performed, which revealed a left-sided twisted hematosalpinx and a right-sided paraovarian cyst. Both ovaries were normal. Excision of the hematosalpinx and paraovarian cystectomy were performed. Histopathologic examination was consistent with left hematosalpinx, and the right paraovarian cyst was reported as serous cystadenoma. Results: The patient came for follow-up after 6 weeks and was happy to confirm the benign nature of her condition as was noted on the histologic report. Conclusions: The case illustrates bilateral adnexal masses of different etiologies that mimicked malignant ovarian tumors. Diagnostic laparoscopy may be performed to determine the correct origin of an adnexal mass, even if it is bilateral, in order to avoid laparotomy. (J GYNECOL SURG 27:285)

Bilateral adnexal torsion due to postmenopausal hydatidiform mole

Occurrence of gestational trophoblastic neoplasia (GTN) and adnexal torsion is rare in postmenopause. We report a 58-year-old postmenopausal woman with adnexal torsion caused by hydatidiform mole. The patient was admitted to our clinic complaining of acute abdominal pain, nausea and vomiting lasting one day. Ultrasonography showed an enlarged uterus including hypo/hyperechogenous cystic areas in the endometrial cavity and bilateral adnexal masses. β-HCG level was investigated and determined as 157.000 IU/l, because of the suspicion of GTN in ultrasonography. Doppler sonography revealed enlarged left adnexa with absence of vascular flow. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. β-HCG decreased to normal ranges in the fourth postoperative week. The resected uterus contained an endometrial, cystic, grapelike tumor. The ovaries were enlarged bilaterally with necrotic appearance. Histopathology revealed complete hydatidiform mole and theca lutein cysts. To our knowledge, the present case is the first hydatidiform mole associated with bilateral adnexal torsion caused by theca lutein cysts in postmenopausal period.

Unilateral malignant struma ovarii in a case of bilateral ovarian teratoma with raised CA-125 level: A rare case with treatment dilemmas

Struma ovarii are specialized form of mature ovarian teratoma comprised predominantly of thyroid tissue (>50%). Most of the struma ovarii are benign; rarely can they undergo malignant transformation. Elevated CA-125 levels with benign struma ovarii have been seen in only 5 cases in literature. The association of malignant struma ovarii and high CA-125 levels with pseudo-Meig syndrome has been reported in only 2 cases in English literature. We describe a case of a 46-year-old multigravida who presented with an abdominal mass and raised CA-125 levels. Radiological investigations revealed bilateral cystic adnexal masses with ossified elements on left side suggesting a teratoma. Intraoperative frozen section and final pathology revealed bilateral teratoma with follicular variant of papillary thyroid carcinoma arising in the left ovary. To the best of our knowledge, this is the first case of malignant struma ovarii in combination with bilateral teratoma. The dilemmas related to preoperative diagnoses with elevated CA-125 levels, mimicking an epithelial ovarian neoplasm; intraoperative frozen section consultation; management and follow-up issues in this rare malignancy are discussed.

Ovarian Fibromas in Pediatric Patients With Basal Cell Nevus (Gorlin) Syndrome

Background Gorlin syndrome is a rare genetic condition consisting of multiple basal cell nevi associated with other entities such as medulloblastoma, skeletal abnormalities, and ovarian fibromas. Case A 15-year-old girl presented with abdominal discomfort. Magnetic resonance imaging showed multiple bilateral solid adnexal masses, the largest measuring 5.5 cm × 6.1 cm × 5.6 cm. At laparoscopy, 10 ovarian fibromas, ranging from 3 mm to 7 cm in size, were removed from each ovary. Concurrent with her gynecologic course, she was found to have maxillary sinus cysts and multiple basal cell nevi. The patient’s history was also significant for a medulloblastoma as an infant. Given this constellation of findings, a diagnosis of Gorlin syndrome was made. Conclusion The development of ovarian fibromas in the pediatric population is rare. When diagnosed, the possibility of Gorlin syndrome must be considered. Furthermore, females with Gorlin syndrome would benefit from regular gynecologic surveillance.

Lipid Cell Tumors in Two Women With von Hippel-Lindau Syndrome

Lipid-cell tumors are rare, functioning ovarian neoplasms. They have not been reported in women with von Hippel-Lindau syndrome, an autosomal-dominant tumor-suppressor gene mutation that is associated with renal cell carcinoma, and other vascular tumors. Two women with von Hippel-Lindau syndrome and kidney tumors were evaluated for secondary amenorrhea, hirsutism, and complex adnexal masses seen on computed tomography. The first patient had known renal cancer and bilateral adnexal masses, one with central necrosis. Because metastatic renal cell cancer could not be excluded on frozen section, bilateral salpingo-oophorectomy was performed. The second patient underwent right salpingo-oophorectomy after human chorionic gonadotropin testing confirmed that the ovarian tumor produced testosterone. Final pathology in both cases revealed testosterone-secreting lipid cell tumors. Lipid cell ovarian tumors should be considered in women with von Hippel-Lindau presenting with adnexal mass, amenorrhea, and hirsuitism.

Primary and bilateral tubal carcinoma is associated with long‐standing granulomatous inflammation and primary infertility: A case report

We report a case of bilateral and primary tubal carcinoma associated with granulomatous inflammation and long-standing primary infertility. A 38-year-old woman with a 17-year history of primary infertility presented with lower abdominal pain and granulomatous inflammation in the endometrial biopsy. Bilateral adnexal masses measuring 4 and 6 cm in size were detected and the serum cancer antigen 125 level was 141 IU/ml. Laparoscopic surgical exploration and frozen section on the resected tubes revealed bilateral fallopian tube adenocarcinoma and then a staging laparotomy was performed. Histopathological examination showed a primary bilateral Grade 2 tubal serous adenocarcinoma of Stage 1b associated with granulomatous salpingitis. Primary fallopian tube carcinomas in young women are extremely rare gynecological tumors that are infrequently diagnosed prior to surgical exploration and their cause is unknown. A definitive diagnosis could be made on the histopathological examination in our case with the evidence of chronic pelvic inflammation. Our findings suggest that chronic pelvic inflammation may play a role in carcinogenesis in the tubes of infertile women.

Krukenberg's tumour

Krukenburg's tumour, a metastatic cancer to the ovary can pose difficulties in early diagnosis. The paucity of reports from our environment coupled with the difficulties we encountered makes it imperative that we report this case. We present a 32-year-old lady who presented with mucoid and bloody diarrhoea associated with menstrual irregularity, weight loss and lower abdominal pains 2 years after surgical treatment for gastric cancer. Literature on Krukenburg's tumour was also reviewed. While serum level of CEA was found to be elevated and colonoscopy showed an ulcerated mass obliterating the lumen of the sigmoid colon, abdominal CT scan revealed bilateral adnexal masses. The histology of the colonic lesion showed signet ring carcinoma while the enlarged ovaries turned out to have evidence of metastatic adenocarcinoma. Early diagnosis of KT can be difficult. Periodic surveillance is, therefore, essential especially in those who have had a gastrointestinal malignancy.

Bilateral ovarian laparoscopic cystectomy of dermoid cysts and pregnancy

Significant ovarian masses complicate 0.2% to 2% of pregnancies. Although the risk of malignancy is low, complications resulting from distention, rupture and/or torsion of the adnexa can be a significant concern. As laparoscopic procedures improve and our experience with laparoscopy in pregnant women increases, more and more patients with these complications find that they can forego laparotomy and manage their condition safely through laparoscopic removal of the mass. The subject of the case study presented here was a 39-year-old woman diagnosed with bilateral adnexal masses during the first trimester of pregnancy. A bilateral ovarian laparoscopic cystectomy was performed at 16 weeks with a favourable outcome. The pathological diagnosis was “mature cystic teratoma” on both sides. This case demonstrates that laparoscopic surgery can be performed safely and effectively in pregnant women with an adnexal mass.

Bilateral lipid cell tumors in a woman with von hippel-lindau syndrome

OBJECTIVE: Present the first case of bilateral lipid cell ovarian tumors in Von Hippel-Lindau (VHL) syndrome.DESIGN: Case report.MATERIALS AND METHODS: 28-year old obese African-American woman, with VHL syndrome and a 2 cm renal cell carcinoma was referred for evaluation of secondary amenorrhea, hirsutism, and bilateral complex adnexal masses seen on computed tomography scan. From age 18, she had hirsuitism and began shaving. Others diagnosed congenital adrenal hyperplasia (CAH) and gave her oral contraceptives which failed to treat her hirsutism. After stopping them, her menstrual cycles were first regular but then stopped a year ago. Pelvic examination revealed clitoromegaly and mobile, bilateral adnexal masses. On transvaginal ultrasound, a multilobed right adnexal mass with areas of necrosis measured 5.6x4.5 cm; a solid left ovarian mass measured 3x2.6 cm. She had elevated levels of serum total testosterone (189 ng/dl range: 20-76), free testosterone (52pg/ml range: 1-21), and 17-OH progesterone (382 ng/dl range: 30-290). Tumor markers were negative. ACTH stimulation test excluded CAH. Other than ovarian masses, metastatic work-up of renal cancer was negative.RESULTS: At exploratory laparotomy, frozen section could not exclude possible metastatic renal cell cancer. Bilateral salpingo-oophorectomy was performed to remove all potential metastatic renal cancer. Final pathology revealed bilateral lipid cell tumors that stained positive for inhibin and calretinin. Post-operatively, testosterone levels dropped, hirsuitism lessened and she lost 10 pounds.CONCLUSIONS: VHL is characterized by benign and malignant vascular tumors in multiple organs. While broad ligament and adnexal papillary cystadenomas have been reported in VHL women, lipid cell tumors have not. Lipid cell tumors are rare, usually unilateral, functioning ovarian neoplasms. On histologic examination, Leydig cells, luteinized ovarian stromal cells, or adrenal cortical cells result in steroid-production and are associated with a variety of clinical manifestations. In this case, considering metastatic renal disease in these ovarian masses was warranted because of bilaterality. Lipid cell tumors containing mainly adrenal cortical cells may be mistakenly diagnosed as adrenal or renal metastases. Because lipid cell tumors appear to be “great impersonators”, definitive diagnosis can only be made with the aid of special stains. OBJECTIVE: Present the first case of bilateral lipid cell ovarian tumors in Von Hippel-Lindau (VHL) syndrome. DESIGN: Case report. MATERIALS AND METHODS: 28-year old obese African-American woman, with VHL syndrome and a 2 cm renal cell carcinoma was referred for evaluation of secondary amenorrhea, hirsutism, and bilateral complex adnexal masses seen on computed tomography scan. From age 18, she had hirsuitism and began shaving. Others diagnosed congenital adrenal hyperplasia (CAH) and gave her oral contraceptives which failed to treat her hirsutism. After stopping them, her menstrual cycles were first regular but then stopped a year ago. Pelvic examination revealed clitoromegaly and mobile, bilateral adnexal masses. On transvaginal ultrasound, a multilobed right adnexal mass with areas of necrosis measured 5.6x4.5 cm; a solid left ovarian mass measured 3x2.6 cm. She had elevated levels of serum total testosterone (189 ng/dl range: 20-76), free testosterone (52pg/ml range: 1-21), and 17-OH progesterone (382 ng/dl range: 30-290). Tumor markers were negative. ACTH stimulation test excluded CAH. Other than ovarian masses, metastatic work-up of renal cancer was negative. RESULTS: At exploratory laparotomy, frozen section could not exclude possible metastatic renal cell cancer. Bilateral salpingo-oophorectomy was performed to remove all potential metastatic renal cancer. Final pathology revealed bilateral lipid cell tumors that stained positive for inhibin and calretinin. Post-operatively, testosterone levels dropped, hirsuitism lessened and she lost 10 pounds. CONCLUSIONS: VHL is characterized by benign and malignant vascular tumors in multiple organs. While broad ligament and adnexal papillary cystadenomas have been reported in VHL women, lipid cell tumors have not. Lipid cell tumors are rare, usually unilateral, functioning ovarian neoplasms. On histologic examination, Leydig cells, luteinized ovarian stromal cells, or adrenal cortical cells result in steroid-production and are associated with a variety of clinical manifestations. In this case, considering metastatic renal disease in these ovarian masses was warranted because of bilaterality. Lipid cell tumors containing mainly adrenal cortical cells may be mistakenly diagnosed as adrenal or renal metastases. Because lipid cell tumors appear to be “great impersonators”, definitive diagnosis can only be made with the aid of special stains.

Ocular Adnexal Lymphoma Associated With IgG4+ Chronic Sclerosing Dacryoadenitis: A Previously Undescribed Complication of IgG4-related Sclerosing Disease

IgG4-related sclerosing disease is a recently recognized inflammatory lesion frequently involving pancreas, submandibular gland, lacrimal gland, and lymph node. We report 3 cases of ocular adnexal lymphoma arising in IgG4-related chronic sclerosing dacryoadenitis, a phenomenon that has not been previously reported. The patients presented with bilateral or unilateral ocular adnexal mass usually present for many years. One patient also had asymptomatic diffuse lymphadenopathy. Two patients had biopsy-proven IgG4-related chronic sclerosing dacryoadenitis before the current presentation, and 1 had systemic involvement by IgG4-related sclerosing disease as evidenced by increased IgG4+ cells in a prior nasopharyngeal biopsy. Two cases showed features of extranodal marginal zone lymphoma of mucosa-associated lymphoid-tissue type (1 with large cell transformation) and 1 follicular lymphoma. Thus, the lymphoid hyperplasia of IgG4-related sclerosing disease can provide a substrate for the emergence of lymphoma. In addition, we report 3 cases of ocular adnexal extranodal marginal zone B-cell lymphoma that show sclerosing inflammation in the background and numerous IgG4+ monotypic plasma cells. In the absence of prior biopsies or information on serum IgG4 titer, it is unclear whether these cases represent lymphoma complicating IgG4-related sclerosing disease or de novo lymphoma. Nonetheless, these cases are distinctive in that the neoplastic cells express IgG4 (light chain restricted), whereas unselected cases of ocular adnexal lymphomas do not show IgG4 expression.

Primary fallopian tube carcinoma associated with ovulation induction; a case report

The potential relationship between ovulation induction and gynecological cancer has been raised recently. Primary fallopian tube carcinoma (PFTC) is an uncommon malignancy, not previously associated with fertility drugs use. We describe a case of a 38-year-old woman with primary infertility and a history of three ovulation inductions with gonadotropin-releasing hormone agonist and gonadotrophins, referred for treatment of bilateral ovarian cysts, which were discovered in the beginning of the last cycle. During laparotomy, bilateral adnexal masses were identified, presumed to be of ovarian origin, and total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, and retroperitoneal lymph nodes sampling were performed. Histologic examination showed a primary right fallopian tube endometrioid adenocarcinoma and bilateral adnexal endometriosis. Surgery was followed by six cycles of combination chemotherapy using paclitaxel and carboplatin without significant complications. Although evidence of a direct causal link between ovarian stimulation and PFTC does not yet exist, this case highlights the importance for careful evaluation of all discovered adnexal masses in women undergoing ovulation induction treatment.

Sonographic Features of Female Pelvic Tuberculous Peritonitis

The purpose of this study was to evaluate the sonographic features of tuberculous peritonitis in an attempt to facilitate the recognition of this disorder preoperatively. The sonographic findings of 16 patients who had tuberculous peritonitis were reviewed. The sonographic findings showed that 14 of the 16 patients had ascites; 10 of these had fine, complete and incomplete mobile septations. Of these 10 patients, 4 had ascites with a latticelike appearance, and 2 had ascites with a parallel violin string appearance, which to our knowledge has not been described previously; 3 had particulate ascites. Peritoneal and omental thickening or nodules were identified in 9 patients. Two patients showed bilateral complex adnexal masses with multiloculated fluid with a thick wall-like tubo-ovarian abscess. Tuberculous peritonitis seems to have characteristic sonographic features, especially the findings of peritoneal and omental thickening and ascites with fine, mobile septations. These sonographic findings may provide valuable information to help with further investigations and may prevent unnecessary laparotomies.

Radiological Reasoning: Imaging Characterization of Bilateral Adnexal Masses

A 46-year-old woman presented with bilateral adnexal masses on pelvic sonography, a complex cystic mass on the right, and a homogeneously hypoechoic, solid-appearing mass on the left. Pelvic MRI showed a T1 hypointense, T2 hyperintense, nonenhancing mass in the right ovary and a homogeneously T1 hyperintense lesion with mixed T2 signal in the left ovary. Fat-saturated T1-weighted sequences showed the left ovarian lesion to be an endometrioma containing a high concentration of hemoglobin breakdown products and revealed other endometriotic implants in the right ovary, broad ligament, and cul-de-sac. Follow-up pelvic sonography 9 weeks later showed resolution of the right complex cystic ovarian mass, indicating that it was a physiologic hemorrhagic cyst. Imaging features of benign and malignant ovarian masses overlap. If imaging is inconclusive in characterizing an adnexal mass as benign, the mass will be resected rather than followed up because of the concern for a rapidly growing ovarian cancer. Thus, the goal of imaging is to identify unequivocally the benign lesions that can be left untreated. Pelvic MRI provides a powerful adjunct to pelvic sonography in characterizing adnexal masses as benign.

Endometriosis mimicking advanced ovarian cancer

To report a case of endometriosis associated with massive ascites, pleural effusion, and extremely elevated Ca-125. Case report. University hospital. A 46-year-old, white nulligravida with bilateral adnexal masses, Ca-125 of 3,504 U/mL, abdominal pain, ascites, and a pleural effusion. Chemotherapy followed by exploratory laparotomy for suspected ovarian cancer. Surgical findings and histopathology. Intraoperative examination and histology ruled out malignancy but found stage IV endometriosis. In rare instances advanced endometriosis may be associated with ascites, pleural effusions, and large pelvic masses. For this reason endometriosis should be included in the differential diagnosis of reproductive-age women presenting with apparent ovarian malignancy.

Bilateral actinomyces abscesses mimicking pelvic malignancy

Pelvic actinomycosis is a rare disease caused by Actinomyces israelii [1]. Patients typically present with weakness, weight loss, and pain associated with a unilateral mass [2]. Diagnosis is difficult without surgery and histopathologic examination [2,3]. A 44-year-old woman presented with a 3-month history of lower abdominal pain, nausea, vomiting, weakness, and a 16-kg weight loss. An intrauterine device (IUD) that she had kept for 8 years had been removed 3 months previously. An abdominopelvic examination revealed bilateral adnexal masses. Her hemoglobin level was 10.7 g/dL and white blood cell count 17,200/mm. Her body temperature, blood biochemistry, tumor markers,

Bilateral tubal tuberculosis as a cause of chronic pelvic pain and sterility

A 29-year-old woman presented with a 12-month history of subfebrile chronic pelvic pain. Prior to this she had no previous medical history of pelvic inflammatory disease. On gynecological examination, bilateral adnexal masses were palpable. Ultrasonographically, bilateral adnexal masses 8×6 cm were visible with different echogenicity, and the Douglas space was totally filled with masses. On power Doppler examination, blood flow was detected bilaterally through the masses with a resistive index of 0.42. Neither ovary was visible. Laparoscopically we found bilateral tubal tuberculosis with no other pathology. Bilateral salpingectomy was undertaken. After surgery the patient received tuberculostatic therapy for 6 months.

Case 6-2006

A 71-year-old woman with the recent onset of urinary incontinence was found to have bilateral adnexal masses in the pelvis and a mass in the bladder. A diagnosis of transitional-cell carcinoma was ...

Hyperreactio Luteinalis Presenting with Marked Hyperglycemia and Bilateral Multicystic Adnexal Masses at 21 Weeks Gestation

We present an unusual case in which a 23-year-old nulliparous patient was noted to have bilateral multicystic adnexal masses at 21 weeks gestation. Subsequent severe nausea, vomiting, and hyperglycemia with a serum glucose level of 450 mg/dL led to the diagnosis of gestational diabetes. Gradual development of marked maternal virilization ensued and was associated with a serum testosterone level of 4030 ng/mL (free testosterone level of 224 pg/mL), with normal serum dehydroepiandrostendione, estriol, and cortisol levels, leading to the diagnosis of hyperreactio luteinalis. Following vaginal delivery at 38 weeks gestation, gradual and complete spontaneous resolution of signs, symptoms, adnexal masses, diabetes, and testosterone levels were documented.

Complications after fertility-preserving radical trachelectomy

We report a case of cervical cancer treated by radical trachelectomy complicated by pelvic inflammatory disease, tubo-ovarian complex, and infertility. Case report. Tertiary referral university hospital. A 35-year-old with stage IB1 cervical cancer underwent an uneventful radical vaginal trachelectomy. Three years later she presented with pelvic pain and fever after a new partner. Cervical chlamydia was positive, and sonography showed bilateral complex adnexal masses. Her symptoms resolved with prolonged IV, followed by oral, antibiotics. Temperature, cultures, and blood tests have all normalized but her sonogram demonstrates persistent bilateral hydrosalpinx. She has not conceived and underwent laparoscopic salpingectomy prior to IVF. She remains cancer free. Radical vaginal trachelectomy, salpingectomy and assisted reproductive techniques. Cancer disease status and fertility preservation. Three years later, the patient remains cancer free but has been unable to conceive or carry a pregnancy. Fertility-preserving cancer treatments are relatively new. Complications may be encountered that must be reported, collected, and analyzed to maximize cancer cure and fertility preservation.