Bilateral Adnexal Masses Research Articles

Diagnosis of pituitary gonadotroph adenomas in reproductive-aged women

To describe the clinical symptoms associated with the diagnosis of pituitary gonadotroph adenoma in premenopausal women. Report of three separate cases. University medical center. Three patients: a 31-year-old woman with primary infertility, recurrent adnexal masses, and highly elevated estradiol level; a 30-year-old woman with recurrent multicystic ovaries following multiple cystectomies and transvaginal cyst aspirations, and elevated estradiol level; a 43-year-old woman with bilateral complex cystic adnexal masses and an elevated estradiol level, who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a suspected granulosa cell tumor. Transsphenoidal resection of a pituitary mass. Serum estradiol, FSH, and LH levels; transvaginal ultrasonography of the ovaries; histologic examination of pituitary tumors. Transsphenoidal resection of pituitary adenomas resulted in normalization of serum estradiol and FSH levels and resolution of adnexal masses in two of the women. Pituitary gonadotroph adenoma must be considered in the differential diagnosis in reproductive-aged women presenting with the clinical symptom triad of new onset oligomenorrhea, bilateral cystic adnexal masses, and elevated estradiol and FSH levels with suppressed levels of LH; timely diagnosis may prevent unnecessary and potentially damaging surgical procedures.

Giant Cell Arteritis of the Female Genital Tract: Report of a Case and Review of the Literature

A 65-year-old female presented with constitutional symptoms of fever and weight loss with bilateral adnexal masses on physical examination. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed and subsequently revealed giant cell arteritis involving numerous small arteries in the ovaries, fallopian tubes, paraovarian and paratubal soft tissues, myometrium, and cervix. After surgery, the patient continued to have constitutional symptoms. Corticosteroid therapy led to a significant improvement and eventual resolution of symptoms. Several similar cases of giant cell arteritis of the female genital tract have been described, both with and without concomitant temporal arteritis. Implications for diagnosis and treatment are discussed.

Recurrent small cell lung cancer presenting as bilateral adnexal masses

Background Small cell lung cancer (SCLC) carries a very poor prognosis, although recent advances in chemotherapy have produced some long-term survivors. Despite this, recurrences are common, and these patients require a high level of surveillance. Given that the female gender is a favorable prognostic factor in patients with SCLC and that more women are becoming lung cancer survivors, it is important to consider sites of metastasis that are restricted to women. Case This is a presentation of a 42-year old previously diagnosed with SCLC who presented with an isolated recurrence of SCLC in the ovaries. This is a case report of an isolated recurrence of SCLC in the ovaries with a review of the literature. Conclusion Although systemic relapses and recurrences often occur in these patients, isolated metastasis such as this can occur and should be considered in female patients with a history of small cell lung cancer.

24-year-old female with amenorhea: bilateral primary ovarian Burkitt lymphoma

Background Burkitt's lymphoma (BL) occurs mostly in children. Isolated bilateral ovarian involvement presenting with amenorrhea is extremely rare in young adults. Case A 24-year-old female presented with secondary amenorrhea. Bilateral adnexal masses were identified on physical examination and abdominal computed tomography (CT). She underwent total abdominal histerectomy and bilateral salpingoophorectomy. Histopathologic evaluation yielded a diagnosis of BL of ovaries. Combined chemotherapy was administered. After complete remission an autologous bone marrow transplantation (ABMT) was performed. She died 35 days after ABMT. Conclusion Although rare, BL should be kept in mind when isolated ovarian tumors are detected in young patients.

Giant pelvic retroperitoneal leiomyoma arising from the rectal wall

Background Pelvic retroperitoneal leiomyomas arising from the rectal wall are rare. We present a case of a giant retroperitoneal leiomyoma mimicking bilateral solid adnexal masses in a postmenopausal woman. Case A 54-year-old postmenopausal woman presented with a large abdominopelvic mass. At surgery, the uterus was displaced anteriorly by a large retroperitoneal mass. The rectosigmoid colon was noted to course through the retroperitoneal mass. The patient underwent complete excision of the retroperitoneal mass along with a rectosigmoid resection of the involved colon with primary reanastomosis. Histopathology showed a leiomyoma arising from the muscularis propria of the rectum wall. Conclusion Retroperitoneal masses that extend into the pelvis may mimic adnexal masses and, therefore, represent a rare finding at gynecologic surgery.

Bilateral calcified ovarian fibromas in a patient with Sotos syndrome

Objective: To present a case of bilateral calcified ovarian fibromas in Sotos syndrome (cerebral gigantism). Design: Descriptive case study. Setting: Mackay Memorial Hospital. Patient(s): A 26-year-old woman with Sotos syndrome and bilateral solid adnexal masses on gynecologic ultrasound. Intervention(s): Surgical removal of an 8 × 6 × 6 cm left ovarian fibroma and a 3 × 2 × 2 cm right ovarian fibroma. Main Outcome Measure(s): Ultrasound. Result(s): Histopathologic examination revealed bilateral ovarian fibromas with extensive foci of calcification and occasional ossification. Conclusion(s): The presence of bilateral calcified ovarian fibromas in this patient with Sotos syndrome may reflect the effects of overgrowth in Sotos syndrome on ovarian tumorigenesis or may be a coincidence.

Markedly elevated β-hCG levels in a normal singleton gestation with hyperreactio luteinalis

BACKGROUND: Human chorionic gonadotropin (hCG) is produced by the trophoblast early in pregnancy and peaks at a level of approximately 100,000 IU/liter around the ninth week of gestation. Abnormally high levels are usually noted in association with multiple gestation, molar gestation, and specific ovarian or gestational malignancies. CASES: A multiparous patient in the second trimester was referred for evaluation after a maternal triple marker screen was incalculable due to a β-hCG level of 2.1 million IU/L. Targeted sonography revealed bilateral complex adnexal masses with a solid component of the left ovary, a normal fetus, and normal placenta. The patient underwent an exploratory laparotomy at 18 weeks’ gestational age. A left oophorectomy was performed. Pathology confirmed hyperreactio luteinalis. The remainder of the pregnancy was remarkable for preterm labor and delivery at 35 weeks’ gestational age. At delivery, the hCG level was noted to be 24,210 IU/L, and the fetus and placenta were normal. CONCLUSION: Markedly elevated hCG levels rarely occur in normal singleton pregnancy and can be associated with hyperreactio luteinalis. When noted, a work-up to evaluate possible malignancy, molar gestation, and multiple gestation should be pursued.

Markedly Elevated β-hCG Levels in a Normal Singleton Gestation With Hyperreactio Luteinalis

BACKGROUND Human chorionic gonadotropin (hCG) is produced by the trophoblast early in pregnancy and peaks at a level of approximately 100,000 IU/liter around the ninth week of gestation. Abnormally high levels are usually noted in association with multiple gestation, molar gestation, and specific ovarian or gestational malignancies. CASES A multiparous patient in the second trimester was referred for evaluation after a maternal triple marker screen was incalculable due to a β-hCG level of 2.1 million IU/L. Targeted sonography revealed bilateral complex adnexal masses with a solid component of the left ovary, a normal fetus, and normal placenta. The patient underwent an exploratory laparotomy at 18 weeks' gestational age. A left oophorectomy was performed. Pathology confirmed hyperreactio luteinalis. The remainder of the pregnancy was remarkable for preterm labor and delivery at 35 weeks' gestational age. At delivery, the hCG level was noted to be 24,210 IU/L, and the fetus and placenta were normal. CONCLUSION Markedly elevated hCG levels rarely occur in normal singleton pregnancy and can be associated with hyperreactio luteinalis. When noted, a work-up to evaluate possible malignancy, molar gestation, and multiple gestation should be pursued.

Primary Serous Papillary Carcinoma of the Peritoneum: CT Findings

AIM: To describe the computed tomography (CT) findings of primary serous papillary carcinoma of the peritoneum. MATERIAL AND METHODS: The clinical data and imaging studies of 36 women aged 37–85 years with primary papillary serous carcinoma of the peritoneum were retrospectively evaluated. Twenty-seven patients presented with general abdominal complaints; all had elevated levels of CA-125. Thirty-two women were post-menopausal, four had had bilateral salpingo-oophorectomy. RESULTS: The most common findings on pre-operative abdominal CT, performed in 30 patients, were a variable amount of ascites (n=29), omental involvement (n=28), irregular parietal peritoneum thickening (n=22) and mural thickening of the sigmoid colon (n=10). Thoracic findings included enlarged cardiophrenic nodes (n=15) and pleural effusion (n=11). Six patients had unilateral or bilateral adnexal masses of soft tissue density, which proved to be surface serous papillary carcinoma. CONCLUSION: Diffuse peritoneal disease on CT in patients with normal-sized ovaries or following bilateral salpingo-oophorectomy, with elevated level of serum CA-125, but without an identifiable primary tumour, should suggest the diagnosis of primary serous papillary carcinoma of the peritoneum. Associated adnexal masses or focal bowel wall thickening may be seen, representing surface involvement by this tumour. Zissin, R. et al(2001). Clinical Radiology56, 740–745.

Spontaneous conception in the presence of stage IIIC endometrioid ovarian cancer

Objective: To describe a rare case of spontaneous conception in a patient with a preexisting metastatic ovarian cancer. Design: Case report. Setting: University hospital. Patient(s): A 39-year-old Asian woman who conceived while undergoing an evaluation for primary infertility and newly detected bilateral adnexal masses. Intervention(s): Staging laparotomy and total abdominal hysterectomy and bilateral salpingooophorectomy. Main Outcome Measure(s): Anatomic pathology diagnosis. Result(s): Blighted ovum and stage IIIC endometrioid adenocarcinoma of ovary. Conclusion(s): Metastatic ovarian cancer does not prevent either spontaneous ovulation or spontaneous conception.

Intra-mammary lymph node metastases in an early stage ovarian cancer of low malignant potential

Ž . Low malignant potential LMP tumors of the ovary are usually associated with an excellent prognosis, due, in part, to their early stage at diagnosis. Approximately 50% of LMP tumors are stage I at presentation compared to only 10% of frankly malignant ovarian epithelial cancers. Both LMP and frankly malignant ovarian cancer rarely present with disease outside of the abdominal cavity. We have reported a case of an apparent stage I ovarian LMP tumor with early intramammary lymph node metastases. A 30-year-old female was found to have bilateral adnexal masses upon physical examination during the work-up of her primary infertility. There was no significant family history, but her CA 125 was elevated at 200 IUrml. She underwent an exploratory laparotomy in December 1998, which disclosed bilateral ovarian masses. A frozen-section diagnosis was consistent with a mucinous tumor of low malignant poten-

P138A case of bilateral mature cystic teratoma with calcified elements in an old age postmenopausal woman

BackgroundDermoid cysts are interesting tumours in which all body tissues may be represented. Neither presence of calcified elements, nor postmenopausal age, nor bilaterality are usual for them. We present here, a case of postmenopausal woman in whom bilateral dermoid cysts were found with calcified elements. Ultrasonographic features, clinical presentation, differential diagnosis and treatment modalities of this rare case are presented and discussed.Case70‐year‐old woman gravida 0 para 0 was referred to our Department complaining of postmenopausal bleeding for the last two months. She was postmenopausal for the last 27 years during which she had never been treated with estrogen replacement therapy. On a gynaecologic examination, bilateral adnexal mass found. Ultrasonographic scanning demonstrated a normal sized anteverted uterus with an endometrial thickness of 4 mm with an hypoechoic ring around it. Transverse ultrasonogram showed bilateral adnexal highly reflective echogenic well circumscribed mass with solid and cystic components. Endometrial biopsy showed granulomatous endometritis. At surgery, a bilateral ovarian tumour measuring 4 × 5 cm in diameter was seen. A pathologic examination confirmed bilateral dermoid cysts with no malignant component. Peritoneal washing was also negative. Total abdominal histerectomy with bilateral salphingooopherectomy was performed. On discharging from Hospital, estrogen replacement therapy was given.

Leuprolide acetate and intravascular leiomyomatosis

Intravascular leiomyomatosis is an uncommon uterine tumor characterized by grossly visible intravascular proliferation of benign smooth muscle. Based on its role in reducing the size of leiomyomas, leuprolide acetate was given as induction therapy for extensive inoperable intravascular leiomyomatosis. A 44-year-old woman, gravida 1, para 1-0-0-1, presented in July 1992 with abnormal uterine bleeding. Pelvic examination and ultrasonography revealed the presence of a large irregular pelvic mass. At laparotomy, uterine and bilateral adnexal masses were noted extending up to the pelvic inlet and into the broad and infundibulopelvic ligaments. This tumor was not resectable. Based on histologic and immunoperoxidase studies, the lesion was interpreted as a plexiform epithelioid smooth-muscle tumor of uncertain malignant potential. Leuprolide acetate depot therapy (7.5 mg every 4 weeks) was begun in September 1992 and continued for a total of 20 months. Maximal tumor regression was achieved after 9 months. Subsequent reexploration at 20 months revealed a resectable tumor. Resection was accomplished successfully, leaving no apparent residual disease. Leuprolide acetate induced tumor regression and rendered debulking surgery feasible in a patient with previously unresectable, widespread, retroperitoneal intravascular leiomyomatosis. Primary hormone therapy may provide alternative therapeutic options for certain cases of intravascular leiomyomatosis.

Transitional Cell Carcinoma of the Renal Pelvis With Symptomatic Ovarian Metastases

A 39-year-old woman underwent nephrectomy and ureterectomy for a transitional cell carcinoma involving the right renal pelvis and upper ureter. Four years later, the patient complained of vaginal spotting and abdominal pain. Bilateral adnexal masses were palpable on pelvic examination and a hysterectomy with bilateral salpingo oophorectomy was performed. The ovaries were both replaced by multicystic neo plasms measuring 10 and 12 cm in maximum dimension. Microscopic examination showed cysts lined by transitional cells, and nests of transitional cells permeated the intervening stroma. Prominent lymphatic and vascular invasion was also present. Tumor also filled the lumens of both fallopian tubes. Although only limited superficial invasion was demonstrated in the nephrectomy specimen, the features of the case strongly suggest that the ovarian tumors represent metastases from the transitional cell carcinoma of the renal pelvis. This represents only the third well documented case of clinically significant ovarian spread of this tumor. Problems that may be encountered in distinguishing between metastasis and an independent primary transitional cell ovarian tumor, (proliferative or malignant Brenner tumor, transitional cell carcinoma) are discussed. Int J Surg Pathol 2(3):231-236, 1995

Partial Hydatidiform Molar Pregnancy Presenting with Severe Preeclampsia Prior to Twenty Weeks Gestation: A Case Report and Review of the Literature

A previously healthy 37-year-old Latin American female presented at 17 6/7 weeks gestation with clinical manifestations of preeclampsia. Ultrasound revealed a growth-retarded fetus with hypoechoic bowel, a thickened cystic placenta, bilateral multicystic adnexal masses, and oligohydramnios. The patient had laboratory evidence of hyperthyroidism and the maternal serum alpha-fetoprotein was 12.3 multiples of the mean. Subclinical disseminated intravascular coagulation rapidly ensued and an induction of labor was performed. This was productive of a 110-g female fetus with a markedly distended abdomen and syndactyly. The placenta weighted 650 g with gross hydropic changes throughout. The clinical aspects of this case and review of the literature on partial molar pregnancies will be discussed.

Bilateral extrinsic endometriosis of the ureters with renal failure: A case report

Ureteral involvement in endometriosis is usually overlooked because it complicates less than 0.5% of cases and remains asymptomatic in the majority. Despite its rarity, ureteral endometriosis is important because the consequent irreversible renal damage may cause considerable morbidity. A case of chronic renal failure caused by bilateral extrinsic endometriosis is described. The patient presented with acute abdominal pain prior to the planned radical surgical procedure. She did not complain of menstrual dysfunction or urinary symptoms. Bilateral adnexal masses and the sensory loss of pelvic nerve compression were found on physical examination. Incidental routine investigations showed deranged renal function and obstructive uropathy. Ureterolysis, bilateral salpingooophorectomy and subtotal hysterectomy successfully relieved the obstruction. The potential existence of ureteral endometriosis should be realized. Vigilance in performing surgery offers the best chance of cure.

Pelvic Venous Dilatation Mimicking an Adnexal Mass in a Postmenopausal Woman

With the increasing use of expectant or laparoscopic management of cystic adnexal masses in postmenopausal women, adequate preoperative evaluation and assessment of malignant potential assume a critical role. Ultrasonography has become a cornerstone in this evaluation process. We describe a case of ultrasonographically identified bilateral cystic adnexal masses that at laparoscopy appeared to be massively dilated pelvic varicosities. In a postmenopausal patient, especially if a prior history of venous stasis is elicited, pelvic varicosities should be considered in the differential diagnosis of ultrasonographically diagnosed cystic adnexal masses. (J GYNECOL SURG 9:49, 1993)

Laparoscopic Ovarian Cystectomy During Pregnancy

A pregnant woman with a history of endometriosis and persistent bilateral adnexal masses underwent laparoscopic ovarian cystectomies at 16 weeks of gestation. There were no adverse sequelae, and the patient had an otherwise uneventful pregnancy and delivery. Operative laparoscopy should be considered to replace laparotomy in appropriate cases during pregnancy.