Pelvic Ascites Research Articles

An Abnormal Presentation of Ascites

Purpose: A 73-year-old female patient with a history of hypertension, gastro-esophageal reflux disease, and hemorrhoids presented with abdominal distention, pain, and alternating constipation and diarrhea. On exam, she was hypotensive, and her abdomen was distended with a positive fluid wave. Computer tomography (CT) imaging of the abdomen showed minimal to moderate bilateral pleural effusions, and moderate abdominal pelvic ascites. Diagnostic paracentesis demonstrated a serum ascites-albumin gradient (SAAG) of greater than 1.1, with cytology revealing cells of malignant adenocarinoma, mullerian in origin. While the majority of patients who present with ascites have underlying liver disease, 20% demonstrate an extrahepatic etiology, half of which are malignancy-related ascites.1 Malignant ascites is a sign of peritoneal carcinomatosis,2 diagnosed when paracentesis demonstrates positive cytology, elevated protein concentrations, and a low SAAG.3 Accurate characterization of the malignancy is vital, as proper treatment can result in positive responses in a majority of patients, with a minority making complete recovery.4 Though surgical debulking with adjuvant chemotherapy is the preferred treatment,5 chemotherapy alone was initiated, as our patient was a poor surgical candidate. She responded to carboplatin and paclitaxel, with CA-125 decreasing from 15,000 to 600 over 5 months, but chemotherapy was stopped due to an illness, and her CA-125 increased to 7,000 over two months. A follow-up CT showed an increase in peritoneal carcinomatosis with upper abdominal lymphadenopathy and omental disease. She has since restarted chemotherapy. Common presentations of rare diseases are difficult to diagnose. This patient's rare cause of ascites, mullerian adenocarcinoma, is a prime example of this scenario. As ascites can signify a multitude of different diseases and pathologies, maintaining a broad differential when faced with ascites is important to decrease unnecessary treatment, reduce hospitalizations, and improve patient care.

Editorial

A 64-year-old woman referred to Gynaecological Oncology secondary to the finding of pelvic mass and ascites. Imaging showed multiple pelvic masses, with the largest mass measuring 20 cm in diameter, as well as bilateral pleural effusions and abdominal ascites, suspicious for ovarian carcinoma. Laboratory findings included elevated cancer antigen 125 (CA-125) of 2124 units/mL. The patient underwent an exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy for pathological evaluation. Postoperatively, the patient had resolution of ascites and pleural effusion. Surgical pathology revealed a 26 cm right ovarian fibroma, confirming the diagnosis of Meigs syndrome. Despite the high suspicion for ovarian carcinoma in patients presenting with elevated CA-125 level, pelvic mass, ascites and pleural effusion, the diagnosis of Meigs syndrome cannot be excluded without pathological evaluation of mass.

Tense Ascites in a Postpartum Woman

Question: A 36-year-old woman originally from Haiti presented to the emergency department with 2 weeks of abdominal distention, diarrhea, and blood-tinged emesis. She had given birth to her first child by uncomplicated caesarean section 9.5 weeks earlier. There was no history of recent travel, diet change, or sick contacts. She denied alcohol, tobacco, or illicit drug use and was not taking any medications or supplements. She was allergic to chloroquine (itchiness) and had no history of atopy. She was not aware of any family history of liver disease or allergy, although her paternal history was unknown. Upon being admitted to the general medicine service, the patient was afebrile and hemodynamically stable. She did not have any stigmata of chronic liver disease. Her abdomen was distended and diffusely tender with rebound tenderness and guarding (Figure A). Serum studies were notable for white blood cell count of 14.5 k/μL with 46% eosinophils (absolute count 6660/mm3). Other values, including serum human chorionic gonadotropin, were normal. Computed tomography of the abdomen and pelvis (Figure B) showed a large amount of abdominal and pelvic ascites (arrow) with mild small bowel wall thickening. There was no evidence of organomegaly or vessel thrombosis. Subsequent diagnostic paracentesis demonstrated an exudative effusion with total nucleated cells 4545/mL, with 82% eosinophils. Large-volume paracentesis of 4000 mL of straw-colored fluid relieved the patient's abdominal pain. Fluid bacterial and tuberculosis cultures were negative, and cytology showed no evidence of malignancy. Peripheral blood smear was unremarkable. Stool culture, stool ova and parasites, urine culture, and blood culture were all negative. Because of these findings, the gastroenterology service was consulted. Esophagoduodenoscopy and colonoscopy showed mild rectal mucosal erythema (arrow) without masses, bleeding, ulcers, or polyps (Figure C). What is the diagnosis? What is the appropriate management? Look on page 467 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Colonic (Figure D) and esophageal (Figures E and F) mucosal biopsies were obtained, which showed dense eosinophilic infiltrate of the esophageal and rectal submucosa and the rectal deep mucosa. These findings were consistent with eosinophilic gastroenteritis (EGE), mural type. She was empirically treated with 2 doses of ivermectin given the concern for possible underlying parasitic infection given her country of origin, and she was started on oral prednisone 40 mg/d. Eosinophilia and symptoms improved rapidly with this regimen. One month after discharge, her parasitic serology was notable for antifilarial immunoglobulin (Ig)G and IgG4 being positive. At 2-month follow-up, she felt well and denied any abdominal pain or distention with resolution of her peripheral eosinophilia. The diagnosis of EGE is usually made by endoscopic biopsy showing proliferation of eosinophils in areas of the gastrointestinal tract where eosinophils are uncommon (eg, esophagus, small bowel).1Chen M.J. Chu C.H. Lin S.C. et al.Eosinophilic gastroenteritis: clinical experience with 15 patients.World J Gastroenterol. 2003; 9: 2813-2816Crossref PubMed Scopus (161) Google Scholar It is associated with allergy or atopy, and eosinophil-predominant ascites is a rare presentation of EGE.2Hepburn I.S. Sridhar S. Schade R.R. Eosinophilic ascites, an unusual presentation of eosinophilic gastroenteritis: a case report and review.World J Gastrointest Pathophysiol. 2010; 1: 166-170Crossref PubMed Google Scholar Eosinophilic ascites in the context of postpartum EGE has been described at least twice in case reports.3Ogasa M. Nakamura Y. Sanai H. et al.A case of pregnancy associated hypereosinophilia with hyperpermeability symptoms.Gynecol Obstet Invest. 2006; 62: 14-16Crossref PubMed Scopus (6) Google Scholar It should be noted that eosinophilic infiltration of the gastrointestinal tract may be present in certain conditions including IgE-mediated food allergies and inflammatory bowel disease. Although certain dietary restrictions can rarely lead to resolution of EGE, systemic steroids are most often used and lead to improved symptomatic response. Our patient's positive filarial serology, although not associated with EGE in the literature, is the first known documented association between likely filariasis and EGE. She is presently being further evaluated for active filarial parasitemia and consideration of diethylcarbamazine therapy. The authors thank Dr Jay Luther for his guidance and manuscript review and Dr Daniel Pratt for obtaining images.

Is MRI a useful tool to distinguish between serous and mucinous borderline ovarian tumours?

To analyse the morphological magnetic resonance imaging (MRI) features of borderline ovarian tumours (BOT) and to evaluate whether MRI can be used to distinguish serous from mucinous subtypes. A retrospective study of 72 patients who underwent BOT resection was undertaken. MRI images were reviewed blindly by two radiologists to assess MRI features: size, tumour type, grouped and irregular thickened septa, number of septa, loculi of different signal intensity, vegetations, solid portion, signal intensity of vegetations, normal ovarian parenchyma, and pelvic ascites. Statistical analysis was performed using Mann-Whitney and Fisher's exact tests. Logistic regression analysis was used to assess the predictive value of the MRI findings for histological subtypes. At histology, there were 33 serous BOT (SBOT) and 39 mucinous BOT (MBOT). Predictive MRI criteria for SBOT were bilaterality, predominantly solid tumour, and the presence of vegetations, especially exophytic or with a high T2 signal (p<0.01), whereas predictive MRI criteria for MBOT were multilocularity, number of septa, loculi of different signal intensity, and grouped and irregular thickened septa (p<0.01). Using multivariate analysis, vegetations were independently associated with SBOT [odds ratio (OR)=29.5] and multilocularity with MBOT (OR=3.9). Vegetations and multilocularity are two independent MRI features that can help to distinguish between SBOT and MBOT.

Ultrasound evaluation of intra‐abdominal sites of disease to predict likelihood of suboptimal cytoreduction in advanced ovarian cancer: a prospective study

To analyze in advanced ovarian cancer patients the ability of ultrasound to evaluate the extent of intra-abdominal disease and to predict the likelihood of suboptimal cytoreduction. Into this prospective study, 147 patients with advanced ovarian cancer were enrolled consecutively between January 2005 and October 2008. All patients underwent standard laparotomy and maximal surgical effort was attempted. To create a new scoring system to predict suboptimal cytoreduction we considered the following sonographic parameters: peritoneal carcinomatosis, bowel mesentery involvement, omental involvement, massive pelvic involvement, ascites and liver and/or spleen metastases. Those parameters achieving a negative predictive value ≥ 50% and a positive predictive value ≥ 50% in predicting suboptimal cytoreduction were included in the ultrasound scoring system, which was then calculated for each patient. Ultrasound allowed a virtually conclusive diagnosis of massive pelvic involvement (sensitivity, 94%; specificity, 97%), parenchymal liver metastases of any size (sensitivity, 93%; specificity, 98%) and ascites (sensitivity, 98%; specificity, 97%) and a very reliable diagnosis of peritoneal carcinomatosis (sensitivity, 91%; specificity, 88%) and omental involvement (sensitivity, 94%; specificity, 90%), whereas it was not very good at excluding parenchymal spleen metastases or splenic hilum involvement (sensitivity, 75%; specificity, 98%) and bowel mesentery involvement (sensitivity, 67%; specificity, 88%). Ultrasound-assessed peritoneal carcinomatosis, bowel mesentery involvement, omental involvement, massive pelvic involvement and ascites were included in our ultrasound score (which had a range of 0-6 points). With a cut-off value of > 5, the sensitivity and specificity of the ultrasound score with regard to prediction of suboptimal cytoreduction were 31% (20/64) and 92% (46/50), respectively. Ultrasound examination is able to assess intra-abdominal disease in advanced ovarian cancer patients, with satisfactory concordance with laparotomic findings. Our ultrasound score can predict suboptimal cytoreduction and might be clinically useful.

Current Concepts in the Management of Tuberculosis

Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden.

Small Bowel Obstruction Secondary to Strangulation Through a Defect in the Falciform Ligament After Blunt Abdominal Trauma in a Pediatric Patient

Obstruction caused by strangulation internal hernia secondary to incarceration within the falciform ligament, although rare, has been previously reported in the literature. These cases, however, were unrelated to trauma. We report on the first case in the pediatric literature of a strangulated internal hernia secondary to incarceration in the falciform ligament precipitated by blunt abdominal trauma. A 12-year-old girl presented to the emergency room less than 24 hours after sustaining a kick to the right upper quadrant. She described sharp, nonradiating, right-upper-quadrant abdominal pain, which was associated with nausea and vomiting. A KUB (kidney, ureter, bladder) view showed a paucity of bowel in the right upper quadrant with distended adjacent bowel. An ultrasound showed a small amount of abdominal ascites and a prominent liver. Computed tomography scan revealed a linear hypodensity at the tip of the right lobe of the liver, suggestive of a laceration. Moderate abdominal and pelvic ascites and multiple collapsed small-bowel loops with diffuse wall thickening and poor enhancement were seen in the right upper quadrant. Significantly, pneumatosis was noted, raising the question of obstruction/volvulus and/or bowel ischemia. An exploratory laparotomy revealed incarcerated small bowel herniated into a defect in the falciform ligament, which was resected. The defect was repaired. Seemingly trivial trauma may play a precipitating role in strangulation in a patient who already has a defect in the falciform ligament.

Desmoplastic Small Round-Cell Tumor: An Adult with Previous Exposure to Agent Orange

Desmoplastic small round-cell tumor is an uncommon, highly aggressive tumor with a predilection for pediatric age groups and young adults. It is very unusual in the elderly population. Although Agent Orange has been associated with soft-tissue sarcoma, an association with desmoplastic small round-cell tumor has not been reported. A 52-year-old male presented with abdominal distention, dyspnea, and a 9 kg weight loss. Prior history was significant for hepatitis C and diabetes. He was a Vietnam veteran and he admitted being exposed to Agent Orange. On physical examination, the abdomen was distended and tense. Computed tomography scan of the chest, abdomen and pelvis demonstrated extensive mediastinal and retroperitoneal adenopathy, diffuse omental masses and extensive pleural, intra-abdominal and pelvic ascites. Omental core needle biopsy was consistent with desmoplastic small round-cell tumor based on morphology and immunohistochemistry. He responded poorly to chemotherapy with high-dose cyclophosphamide, doxorubicin and vincristine and died 5 months after presentation secondary to neutropenic sepsis despite G-CSF support and antibiotics.

Diagnostic dilemma of abdominopelvic tuberculosis:a series of 20 cases

To establish more effective diagnostic procedures to identify the characteristic features of abdominopelvic tuberculosis (APTB) mimicking advanced ovarian cancer. A retrospective review of 20 cases of APTB mimicking advanced ovarian cancer was undertaken. The mean age of the patients was 28.9 ± 10.8 years. The main clinical manifestations were abdominal pain (45%) and distention (45%). CA125 level was elevated in 18 cases (90.0%). Pelvic mass in 18 patients (90.0%) and ascites in 12 patients (60.0%) were detected by using abdominal US. The bacteriologic cultures and cytological studies were all negative (10 cases, 100%). Laparotomy (17 cases) and laparoscopic evaluation (1 case) was performed with the presumptive diagnosis of advanced ovarian cancer except for 2 patients treated with diagnostic anti-TB chemotherapy. The common intra-operative findings were miliary nodules (14 cases, 77.8%) and widespread adhesion (10 cases, 55.6%). Intra-operative frozen section was obtained in 10 cases, and the typical tuberculosis tubercles were detected in all cases. APTB should be considered in all cases with pelvic mass, ascites and high levels of CA125, although clinical features and laboratory results specifically indicate neither ovarian malignancy nor APTB. Diagnostic laparotomy is a direct and safe method. To avoid extended surgery, the cases with APTB can be diagnosed through intra-operative frozen section in conjunction with clinical features.

Group G Streptococcus - A Rare Cause of Peritonitis: A Case Report

Purpose: A 54-year-old female on continuous ambulatory peritoneal dialysis for 19 years presented with generalized, dull abdominal discomfort associated with non-bilious vomiting for four days. She denied sick contacts and pets at home. Physical examination was remarkable for normal bowel sounds, soft, distended abdomen with generalized tenderness. There was no erythema or increased warmth around dialysis catheter site. Initial laboratory tests were unremarkable including white blood cell count. Cultures from the peritoneal fluid grew Streptococcus G. Patient was started on antibiotics with peritoneal dialysis. Repeat peritoneal fluid and blood cultures were negative. Computed tomography (CT) of the abdomen and pelvis revealed large abdominal and pelvic ascites with no abscess or fluid collection. Due to patient's persistent abdominal tenderness and distension, peritoneal catheters were removed and patient was started on hemodialysis. Discussion: Beta-hemolytic Streptococci group G comprises of 2 species: a small colony forming Streptococcus milleri group and a large colony Streptococcus canis group, the majority of S. canis are isolated from the skin, pharynx, vagina and gastrointestinal tract.(1,2) Pharyngitis, septic arthritis, endocarditis, cholangitis, cholecystitis, liver infections, pneumonia and skin and soft tissue infections are associated with large colony Streptococcus G.(3)Small colony Streptococcus G can cause peritonitis as a complication of hematogenous spread or through bowel perforation. (3) We believe that our patient had infection from the skin via peritoneal catheters. A pharyngeal swab was negative for Streptococcus G. Infection with Streptococcus G is associated with underlying malignancy and chronic debilitating illnesses such as chronic alcoholism and uncontrolled diabetes mellitus. (4) Patients without any history of malignancy respond better to antibiotics especially with skin and soft tissue infections (4) Although, group G Streptococci are sensitive to penicillins, aminoglycosides are added for synergy.(5)

Primary Peritoneal Serous Carcinoma Presenting as Inflammatory Breast Cancer

Metastasis to the breast from extramammary malignancies is rare. Nevertheless, its recognition is important because the prognosis and treatment differ from that of primary breast cancer. We report a unique case of primary peritoneal serous carcinoma that initially presented as inflammatory breast cancer. The patient received neoadjuvant chemotherapy for breast cancer and subsequently underwent bilateral total mastectomy and bilateral sentinel lymph node biopsy. She was found to have extensive intralymphatic carcinoma in both breasts, with only focal minimal breast parenchymal involvement, and residual metastatic carcinoma in bilateral sentinel lymph nodes. Further work-up revealed pelvic ascites and omental nodularities. The patient underwent laparoscopic bilateral salpingo-oophorectomy, which revealed high-grade serous carcinoma involving both ovaries and fallopian tubes. Molecular testing of tumor from the ovary and axillary lymph node showed an identical pattern of allelic loss, confirming a common origin for both tumors. To our knowledge, this is the first reported case of an extramammary primary malignancy that not only presented as inflammatory breast cancer but also was diagnosed and initially treated as such.

Torsion of the fallopian tube and acute pelvic pain: an unusual presentation of genital tuberculosis

A case of a genital tuberculosis found during laparoscopic evaluation for recurrent acute pelvic pain is presented. The symptoms of genital tuberculosis can vary greatly, and a laparoscopic approach is effective for making the diagnosis. Clinicians should consider tuberculosis as a differential diagnosis when encountering clinical presentations of pelvic pain and ascites.

Cystic struma ovarii presenting as pseudo-Meigs' syndrome with elevated CA125 levels. A case report and review of the literature

Struma ovarii is a rare ovarian teratoma consisted predominantly of mature thyroid tissue. Although the vast majority of strumas are benign, they can present mimicking malignancy. We report a case of a postmenopausal woman who presented with a large pelvic mass, ascites, and high CA125 levels. Further investigation confirmed the existence of bilateral pleural effusions. The patient underwent laparotomy, and histology revealed a benign struma ovarii. Twelve months after the removal of the tumor, the patient remained disease free, with no clinical or radiologic evidence of effusion, and normal CA125 levels. This is only the fifth case in the English literature of a benign struma ovarii presenting as pseudo-Meigs' syndrome with elevated CA125. Struma ovarii should be included in the differential diagnosis of a pelvic mass that presents with ascites, hydrothorax, and elevated tumor markers.

Cystic struma ovarii, a rare form of ovarian tumor – a case report, and review of the literature

Struma ovarii represents less than 3% of ovarian teratomas. It can be associated with thyroid biology abnormalities, and in exceptionally rare cases it can be malignant. The authors report a case of a 31-year-old woman who underwent resection of a left ovarian cyst, presenting with the clinical features of an ovarian cancer (large pelvic mass, ascites and elevated CA-125 serum levels). The pathologic diagnosis was benign struma ovarii. The postoperative thyroid function remained normal.

Phase I study of SS1P, a recombinant anti-mesothelin immunotoxin for targeted therapy of mesothelin expressing mesotheliomas, ovarian and pancreatic cancer

3553 Background: Mesothelin, a cell surface glycoprotein, is an attractive candidate for targeted cancer therapy given its limited expression on normal mesothelial cells and high expression in several human cancers including mesothelioma, ovarian and pancreatic cancer. We conducted a phase I study to determine the maximum tolerated dose (MTD), toxicity and pharmacokinetics of SS1P, a recombinant anti-mesothelin immunotoxin. Methods: SS1P given as a 30 minute intravenous infusion was administered to 34 patients (pts) with advanced mesothelioma (n = 19), ovarian (n = 13) and pancreatic (n = 2) cancer. SS1P was administered every other day (QOD) for 6 doses to 17 pts and then QOD for 3 doses to 17 other pts. Results: The initial cohort of 17 pts received SS1P QOD x 6 doses and the MTD was 18 μg/kg/dose. Dose-limiting toxicity (DLT) included grade 3 urticaria (1 pt) and grade 3 vascular leak syndrome (2 pts). To allow further SS1P dose escalation 17 pts were treated on the QOD x 3 schedule and the MTD was 45 μg/kg/dose. The DLT was grade 3 pleuritis and was seen in 2/2 pts treated at a dose of 60 μg/kg and in 1/9 pts treated at a dose of 45 μg/kg. In all cases the pleuritis resolved completely. No grade 4 toxicity was observed. The most common grade 1/2 toxicities included hypoalbuminemia (21 pts), fatigue (17 pts), fever (9 pts) and edema (9 pts). At the MTD of 45 μg/kg the mean Cmax of SS1P was 483 ng/ml and half-life was 466 minutes. Of the 33 evaluable pts treated, 4 had minor response, 18 had stable disease and 11 had progressive disease. Two pts with stable disease had complete resolution of their ascites. A pt with peritoneal mesothelioma had complete resolution of her abdominal ascites, required no further therapy and died of unrelated causes 5 years after SS1P treatment. In the other pt with ovarian cancer there was resolution of abdominal and pelvic ascites that lasted 6 months. Conclusion: SS1P is well tolerated with pleuritis as the DLT at the highest dose level. Anti-tumor activity was noted in a group of heavily pretreated patients. Based on pre-clinical studies that show marked synergy between SS1P and chemotherapy, phase II clinical trials of SS1P in combination with chemotherapy for the treatment of mesothelin expressing cancers will open in 2007. No significant financial relationships to disclose.

Laparoscopic Prophylactic Oophorectomy Plus N3 Lymphadenectomy for Advanced Rectosigmoid Cancer

The primary aim of the present retrospective study was to evaluate the feasibility and efficacy of laparoscopic prophylactic oophorectomy plus N3 lymph node dissection for patients with rectosigmoid cancer. The secondary aim was to explore the clinicopathologic features of ovarian micrometastasis from rectosigmoid cancer. We performed 244 laparoscopic resections of rectosigmoid cancer in women during a 6-year period. In them, 34 patients (13.9%) were subjected to prophylactic oophorectomy plus N3 lymphadenectomy in addition to the standard anterior or low anterior resection of rectosigmoid cancer, because the patients presented with ovarian cystic lesions, tethering of the ovary to the primary rectosigmoid tumor, and/or pelvic ascites accumulation, which were postulated as the indicative findings for the synchronous ovarian micrometastasis. The surgical procedures are detailed in the attached video. The surgical outcomes were compared between patients with (n = 34) and without (n = 210) these two additional procedures. In analyzing the clinicopathologic features of ovarian micrometastasis, we included both cases of laparoscopic (n = 34) and traditional open surgery (n = 30), whose prophylactic oophorectomy was performed by the same surgical indications. Although the operation time was significantly longer (264.2 +/- 24.5 vs. 192.5 +/- 24.2 minutes, P < .0001) in patients with prophylactic oophorectomy and N3 lymphadenectomy, there was no significant difference between patients with and without the two additional procedures in blood loss, wound length, postoperative complications, diverting ileostomy, and mortality. Although flatus passage, hospitalization, postoperative pain, and return to partial activity were statistically different between the study groups, they were deemed clinically unimportant because the difference of mean was very small. Foley removal was delayed in patients with N3 lymphadenectomy by 2 days. With respect to surgical efficacy, we found that patients undergoing the two additional procedures could collect significantly more lymph nodes (22.0 +/- 4.0 vs. 14.4 +/- 2.4, P < .0001) for pathologic staging and facilitated upstaging of nodal status in three patients (8.8%). Patients undergoing prophylactic oophorectomy plus N3 lymphadenectomy could achieve good oncologic outcome, with the estimated 5-year survival rate of 62.5% and 69.2% in patients with and without ovarian micrometastasis, respectively. Clinicopathologically, patients with ovarian micrometastasis (n = 15) tended to have vascular invasion of tumor cells, as compared with those without (n = 49). However, ovarian micrometastasis was not related to menstrual status of patients, tumor location, tumor size, morphology, differentiation, mucin production, T stage, nodal invasion, and level of carcinoembryonic antigen. Laparoscopic surgical techniques could be safely applied to perform prophylactic oophorectomy plus N3 lymphadenectomy with acceptable efficacy in a highly selected subset of patients with rectosigmoid cancer.

Computed Tomographic Features of Appendiceal Serositis in Pelvic Inflammatory Disease

The purpose of this study was to describe the computed tomographic (CT) features of the appendiceal serositis in women with pelvic inflammatory disease and to compare these with the pathological findings. Appendiceal serositis was pathologically evaluated in patients with pelvic inflammatory disease who underwent surgery within 3 days of computed tomography. On retrospective review of CT findings, each appendix was evaluated for the following characteristics: location relative to the cecum, maximal diameter, morphology of wall thickening, contrast enhancement, and presence of appendicolith and cecal wall thickening. The presence of fatty infiltration of the periappendiceal fat, mesentery, and omentum was evaluated. The presence of pelvic abscess or ascites, lymph nodes, and paralytic ileus was noted. On pathological review, 10 patients were shown to have appendiceal serositis: mild serositis in 3 patients, moderate in 4, and severe in 3. The maximal appendiceal diameter ranged from 5.4 to 8.9 mm (mean diameter, 7.1 +/- 0.9 mm). Diffuse wall thickening with collapsed lumen was detected in 6 patients. Focal wall thickening with intraluminal gas bubbles or an air-fluid level was detected in 4 cases. Peripheral rim enhancement of the appendix was detected in 3 patients with focal wall-thickened appendix. There was no association between the feature of appendiceal wall thickening and the pathological severity of serositis. Mesenteric fatty infiltration was detected in 5 patients and omental fatty infiltration in 3 patients. Fatty infiltration of the mesentery and omentum was more commonly presented in patients with severe serositis. Pelvic abscesses, including pyosalpinx, were detected in 7 patients; a small amount of free fluid was seen in 8 patients. The CT findings of appendiceal serositis are diffuse or focal wall thickening without severe distension, common association with mesenteric fatty infiltration, and pelvic abscesses.

Ovarian sclerosing stromal tumor presenting as Meigs’ syndrome with elevated CA‐125

Meigs' syndrome caused by sclerosing stromal tumor is extremely rare and only two cases have been reported to date. An elevated serum level of CA-125 is also unusual and it has been thought that it is the consequence of physical irritation and inflammation. In this report, we present the case of a 50-year-old postmenopausal woman with a sclerosing stromal tumor presenting with Meigs' syndrome and an elevated CA-125 level (1476.8 IU/mL). This case highlights the difficulty in discerning the diagnosis of Meigs' syndrome from that of an ovarian malignancy and it should be considered in the differential diagnosis in postmenopausal patients with pelvic mass, ascites, pleural effusions and elevated serum CA-125.

Guidelines for Referral of the Patient With an Adnexal Mass

Gynecologists have to differentiate between benign and malignant adnexal masses. We review the evidence supporting to the specialty care of a gynecologic oncologist on the basis of the physical examination, imaging studies, family history, and CA 125 determination. We recommend adherence to the ACOG/SGO Joint Opinion guidelines. Specifically, referral to a gynecologic oncologist seems warranted for postmenopausal women with elevated CA 125, nodular or fixed pelvic mass, metastatic disease, ascites, or family history of breast or ovarian cancer. Premenopausal women should be referred if the CA 125 is elevated above 200 U/mL, there is an evidence of metastatic disease or ascites, or strong family history of breast or ovarian cancer.

An Unusual Case of Metastatic Gastric Adenocarcinoma in a 19-yr-Old with Gastric Outlet Obstruction Safely Managed by Tandem Enteral Wallstents with Excellent Outcome

A 19-year-old girl was referred by her pediatrician for post prandial vomiting and a weight loss of 11lbs over one month. On examination a 10 cm X 10 cm firm mass was felt in the epigastrium which was very tender. Laboratory data showed hematocrit of 29 and CA 125 of 65.4 (normal 35). CT abdomen had shown thickening of mid to distal stomach, with surrounding fat infiltration, peri-gastric lymph nodes, thickening of transverse colon and pelvic ascites. On EGD a thickened, nodular and infiltrated appearing stomach with narrowed antrum and near complete obstruction of the pylorus was seen. Endoscopic biopsies were inconclusive. An upper GI series revealed a 13 cm long stricture extending from the distal stomach to the duodenum. EUS showed thickening of stomach wall consistent with linnitis plastica, but FNA samples were inconclusive. On surgical exploration a large intramural mass in the distal stomach was noted along with omental lesions above the transverse colon, peritoneal implants on the fallopian tubes, and ascites. Pathology revealed a poorly differentiated gastric adenocarcinoma with abundant mucin or signet ring cell carcinoma. As the tumor was unresectable, a decision was made to bypass the gastric outlet obstruction with enteral stents. Two Wallstents (Microvasive) enteral endoprostheses measuring 90mm and 60mm in length were placed, in a tandem fashion with partial internal overlap to bypass the stricture. Patient was discharged home on a liquid and puree diet. Chemotherapy with 5-Flurouracil, Cisplatin and Tamoxifen was given as an outpatient. At a 20 week follow up, patient has good oral intake with weight gain. Outpatient follow up barium studies and CT scans have shown patent stents with good flow of dye. (figure 1)FigureGastric adenocarcinoma in young patients can present as advanced disease with metastasis and gastric outlet obstruction. Here we report one of the first cases of gastric outlet obstruction from metastatic gastric adenocarcinoma in a young patient managed with Wallstent showing feasibility, safety, and good long term patency.[figure 1]