Struma ovarii showing clinical characteristics of ovarian malignancy

Precise preoperative diagnosis of struma ovarii with pseudo-Meigs' syndrome mimicking ovarian cancer with the combination of 131I scintigraphy and 18F-FDG PET: case report and review of the literature

Background

Struma ovarii is a rare ovarian neoplasm that often appears malignant on conventional imaging. Pseudo-Meigs’ syndrome with ascites, pleural effusion, and elevated serum CA 125 levels is much rarer and leads to misdiagnosis of ovarian cancer and unnecessary extended surgery.

Case presentation

A 50-year-old woman with abdominal distention and dyspnoea was referred to our hospital. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) showed a polycystic ovarian tumor with a solid component, pleural effusion, and massive ascites with negative cytology. Her serum CA 125 level was 1237 U/ml, indicating the presence of ovarian cancer. Based on increased uptake of ¹³¹I but no uptake of ¹⁸F–FDG in the tumor, the preoperative diagnosis was struma ovarii with pseudo-Meigs’ syndrome, which was confirmed histologically. She had no evidence of ascites and pleural effusion six months after surgery.

Conclusions

To date, there have been no systematic reviews focused on preoperative diagnosis with imaging modalities. The combination of ¹³¹I scintigraphy and ¹⁸F–FDG PET/CT in addition to conventional imaging modalities can provide the precise preoperative diagnosis of struma ovarii with pseudo-Meigs’ syndrome mimicking ovarian cancer, leading to the appropriate treatment strategy.

Struma Ovarii with Pseudo-Meigs' Syndrome and Raised Cancer Antigen-125 Levels Masquerading as an Ovarian Carcinoma Case report and literature review

The monodermal teratoma struma ovarii is a rare ovarian tumour; however, struma ovarii presenting with pseudo-Meigs' syndrome and raised cancer antigen (CA)-125 levels is even rarer. In elderly patients, this presentation can potentially lead to a misdiagnosis of a malignant ovarian carcinoma, resulting in unnecessary extensive surgery. We report a 55-year-old female who presented to the Lok Nayak Jai Prakash Narayan Hospital, New Delhi, India, in 2016 with progressive abdominal discomfort, fatigue and abdominal distention. Clinical and radiological features were indicative of a malignant ovarian tumour and ascites. Serum CA-125 levels were elevated at 258 U/mL. A left-sided salpingo-oophorectomy was performed, after which the serum CA-125 levels normalised. There was no evidence of recurrence at a six-month follow-up. A frozen section procedure confirmed the diagnosis of a struma ovarii. This rare condition should be considered as a differential diagnosis in patients presenting with ovarian masses, ascites and raised CA-125 levels.

Struma ovarii: management and follow-up of a rare ovarian tumour

INTRODUCTION

Struma ovarii represents about 1.0% of all ovarian tumours. While management involves surgery, there is a paucity of data regarding the extent and approach of surgery, and postoperative management. This study aimed to delineate the management of struma ovarii, its associated complications, and postoperative follow-up and investigations.

METHODS

We retrospectively reviewed cases of benign struma ovarii treated at KK Women's and Children's Hospital, Singapore, between January 2000 and May 2011.

RESULTS

A total of 68 patients underwent surgical removal of ovarian cyst or mass (24 cystectomy, 20 salpingo-oopherectomy and 24 total hysterectomy and bilateral salpingo-oopherectomy). Of the 68 surgeries, 39 (57.4%) included intraoperative frozen section sampling or procedures for staging of ovarian malignancy. The majority (73.5%) of surgeries were laparotomies. Histology revealed benign struma ovarii in all (98.5%) but one patient. Only 7 (10.3%) patients had postoperative complications - 3 wound-related, 2 thyroid-related, 1 incisional hernia and 1 nonspecific. The mean length of hospital stay was 4.2 days. During follow-up, 45 (66.2%) patients required no additional investigations. The most common investigation done was ultrasonography (n = 18, 26.5%). While no recurrences were diagnosed histologically, two patients were subsequently found to have complex/dermoid ovarian cysts on the ipsilateral side of the previous struma ovarii on ultrasonography.

CONCLUSION

Simple surgery is recommended for patients with struma ovarii, especially if they have fertility potential. Laparoscopic surgery is the recommended approach due to its shorter recovery time and lower morbidity. Most patients do not require extended periods of follow-up or postoperative investigations.

From struma ovarii to Hashimoto disease--an unusual diagnosis of primary hypothyroidism: case report

CAPSULE

Authors report a case of a 52-year-old woman after struma ovarii with chronic lymphocytic inflammation excision. Finally thyroxin treatment was started and patient's hypothyroidism symptoms diminished.

CASE SUMMARY

Struma ovarii is a type of mature teratoma in which thyroid tissue forms the main component. In most cases struma ovarii is composed of normal thyroid tissue while lymphocytic thyroiditis in struma ovarii occurs very rarely. The authors report a case of a 52-year-old woman after ovarian tumor excision. In histopatholgical examination struma ovarii with chronic lymphocytic inflammation was diagnosed. Additional studies revealed a typical ultrasonographic picture of Hashimoto disease in the thyroid gland and an increased concentration of thyroglobulin antibodies. A final diagnosis of Hashimoto disease was confirmed. Initially, thyroid gland function was normal but 11 months after surgery, supplementation therapy with thyroxin was administered. In this case, an early diagnosis of Hashimoto disease resulted from excision of struma ovarii with chronic lymphocytic inflammation. It induced early thyroxin treatment and allowed to reduce hypothyroidism symptoms.

[Rational application of tumor marker CA 125 in gynecological oncology]

INTRODUCTION

CA 125 determination started in 1981, when Bast et al. discovered monoclonal antibody OC-125 belonging to immunoglobulin G class (IgG1) using Köhler and Milstein's technique of hybridization. CA 125 antigen is produced in amniotic cells of the 7 week-old embryo, while in adults it can be detected in epithelium of most organs which originate from Müller ducts. The upper level of referent values for CA 125 in serum is 35 U/mL and can be seen in about 99% of healthy people. APPLICATION OF TUMOR MARKER CA 125 IN GYNECOLOGICAL ONCOLOGY: More than 83% of patients with epithelial ovarian carcinoma have elevated values of CA 125 higher than 35 U/mL at the moment of diagnosing the disease. In cases of ovarian carcinoma, preoperatively determined values of CA 125 in serum are correlated with the extent of the expansion of the disease, histological type of tumor and degree of differentiation of malignant cells. Elevated values up to 65 U/mL in sernum can also be found in other malignant minors (pancreas, breast, colon, bladder, lungs, liver) and in different benign diseases. The level of serum CA 125 after the surgery can indicate regression or progression of ovarian carcinoma in more than 90% of the patients who had had elevated values of CA125 prior to the surgery. Postoperative levels of CA 125 >35 U/ mL in patients with no residual tumor and values >65 U/mL in those with residual tumor implants represent a separate prognostic factor in further course of the disease.

CONCLUSION

The importance of continuous determination of CA 125 tumor marker has to be adjusted to each single case.

Expression of benign and malignant thyroid tissue in ovarian teratomas and the importance of multimodal management as illustrated by a BRAF-positive follicular variant of papillary thyroid cancer

BACKGROUND

The most common type of ovarian germ cell tumor is the teratoma. Thyroid tissue, both benign and malignant, may be a component of an ovarian teratoma. Here we review this topic and illustrate major features by presenting multimodal management of a patient with BRAF-positive disseminated follicular thyroid cancer arising in an ovarian teratoma.

SUMMARY

Malignant thyroid tissue is often difficult to distinguish from benign thyroid tissue arising in ovarian teratomas. Preoperatively, an elevated thyroglobulin (Tg) level, laboratory or clinical evidence of hyperthyroidism, or ultrasonography appearance of "struma pearl" should prompt referral to oncologist for surgical management of a possibly malignant ovarian teratoma. Postoperatively, tumor tissue should be referred to pathologists experienced with differentiating benign from malignant struma ovarii. Once diagnosed, treatment of this rare condition should be handled by a team of specialists with combined treatment modalities. We cared for woman with disseminated thyroid cancer arising in an ovarian teratoma whose history illustrates the complexity of managing ovarian teratomas with malignant thyroid tissue. At age 33 she had an intraoperative rupture of an ovarian cyst, thought to be struma ovarii. During her next pregnancy, pelvic masses were noted; biopsies revealed well-differentiated papillary thyroid carcinoma, follicular variant. She was euthyroid, but had elevated serum Tg levels. Surgical staging demonstrated widely metastatic intraabdominal dissemination. A thyroidectomy revealed no malignancy. A post-(131)I treatment scan revealed diffuse uptake throughout the abdomen. She then developed abdominal pain and, on computed tomography, was found to have multiple intraabdominal foci of disease. Serum Tg was 264 ng/mL while on L-thyroxine for hypothyroidism and to obtain thyrotropin suppression. A 18 fluorodeoxyglucose positron emission tomography scan showed no pathological uptake. The tumor was found to be BRAF mutation positive (K601E). She underwent extensive secondary debulking and a second course of (131)I with lithium pretreatment. Posttreatment scan revealed diffuse abdominal uptake. Six months posttherapy, the patient is asymptomatic with a serum Tg of 18.1 ng/mL.

CONCLUSIONS

Aggressive multimodal management appears to be the most promising approach for malignant thyroid tissue arising in ovarian teratomas.

Struma ovarii associated with pseudo-Meigs' syndrome and elevated serum CA 125: a case report and review of the literature

The association of pseudo-Meigs' syndrome, elevation of CA 125 to the struma ovarii is a rare condition. So far only nine cases have been reported in English literature through MEDLINE search. Here we report a 46-year-old case of the struma ovarii, presented with ascites, hydrothorax, right ovarian mass and elevated serum CA 125 level. These findings were misdiagnosed for an ovarian malignancy at the first impression. Immediate resolution of the ascites, hydrothorax and normalization of the serum CA 125 level were followed by ovarian mass removal. Struma ovarii could be a rare cause of ascites, hydrothorax, ovarian mass and elevated CA 125. This rare condition should be considered in the differential diagnosis in patents with ascites and pleural effusions but with negative cytology.

Struma ovarii and peritoneal strumosis with thyrotoxicosis

BACKGROUND

Struma ovarii is a highly specialized form of mature ovarian teratoma consisting of thyroid tissue and exhibiting all the histological features of the thyroid gland. Malignant transformation of thyroid tissue in struma ovarii and metastasis are extremely uncommon. In rare cases, benign thyroid tissue may spread to the peritoneal cavity, and pathologic examination of the peritoneal implants shows multiple nodules of varying sizes of mature thyroid tissue similar to struma ovarii. This condition is termed "peritoneal strumosis."

SUMMARY

We report a 49-year-old woman with struma ovarii complicated by peritoneal strumosis with thyrotoxicosis. After surgical resection of the struma ovarii and peritoneal strumosis the patient became euthyroid.

CONCLUSION

To the best of our knowledge this is the first report of a patient with peritoneal strumosis complicated by thyrotoxicosis. The relative contribution to circulating thyroid hormones by the patient's struma ovarii as compared to the peritoneal strumosis is not known.

[Cystic struma ovarii, a rare form of ovarian tumor--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.

A large struma ovarii tumor removed via laparoscopy in a 16-year-old adolescent

Struma ovarii is rare ovarian tumor that is characterized by the presence of at least 50% thyroid tissue on histologic examination. This usually benign neoplasm is predominantly found in women between the ages of 40 and 60 years and infrequently in the pediatric age group. In the foregoing report, we present an unusual case of a large struma ovarii in a 16-year-old adolescent girl with abdominal pain and increasing abdominal girth. Removal of the mass was achieved via a laparoscopic approach. We conclude that the diagnosis of struma ovarii should be considered in adolescent girls presenting with large cystic ovarian masses and that a laparoscopic approach to management is the treatment of choice.