Perioperative management of a patient with unexpectedly detected early-stage ovarian mucinous carcinoma combined with progressive bulbar paralysis: a case report and literature review

BACKGROUND

Giant ovarian cysts (GOCs)complicated with progressive bulbar paralysis (PBP) are very rare, and no such literature about these cases have been reported. Through the diagnosis and treatment of this case, the perioperative related treatment of such patients was analyzed in detail, and early-stage ovarian mucinous carcinoma was unexpectedly found during the treatment, which provided reference for clinical diagnosis and treatment of this kind of diseases.

CASE PRESENTATION

In this article, we reported a 38-year-old female patient. The patient was diagnosed with PBP 2 years ago. Examination revealed a large fluid-dominated cystic solid mass in the pelvis measuring approximately 28.6×14.2×8.0 cm. Carbohydrate antigen19-9(CA19-9) 29.20 IU/mL and no other significant abnormalities were observed. The patient eventually underwent transabdominal right adnexal resection under regional anesthesia, epidural block. Postoperative pathology showed mucinous carcinoma in some areas of the right ovary. The patient was staged as stage IA, and surveillance was chosen. With postoperative follow-up 1 month later, her CA19-9 decreased to 14.50 IU/ml.

CONCLUSIONS

GOCs combined with PBP patients require a multi-disciplinary treatment. Preoperative evaluation of the patient's PBP progression, selection of the surgical approach in relation to the patient's fertility requirements, the nature of the ovarian cyst and systemic condition are required. Early mucinous ovarian cancer accidentally discovered after operation and needs individualized treatment according to the guidelines and the patient's situation. The patient's dysphagia and respiratory function should be closely monitored during the perioperative period. In addition, moral support from the family is also very important.

Aversion of surgical exploration in patients with complex ovarian cysts secondary to overt hypothyroidism: A series of three cases

Long-standing, overt hypothyroidism-induced bilateral multiloculated ovarian cysts represent an infrequent occurrence. Our first case, presented with bilateral complex ovarian masses, exhibited overt hypothyroidism symptoms, including lethargy, weight gain and subfertility, prompting consideration for surgical intervention. Similarly, in the second case, a girl aged 11 years with stunting, delayed bone age and academic challenges was referred for surgical exploration due to bilateral complex ovarian masses. Both cases revealed elevated thyroid-stimulating hormone levels during preoperative workup. Commencing levothyroxine replacement therapy resulted in complete regression of ovarian cysts and substantial symptom improvement within an 8-week timeframe. The third case, a previously diagnosed patient with Hashimoto's thyroiditis, benefited from the lessons gleaned in managing the initial cases, responding well to levothyroxine therapy, thereby averting the necessity for surgery in all three instances. These cases underscore the significance of considering thyroid function in the evaluation of ovarian masses and highlight the efficacy of levothyroxine replacement therapy in resolving both hypothyroidism and associated ovarian cysts, thereby obviating the need for surgical intervention.

Rare case of haemoperitoneum secondary to a ruptured ovarian ectopic pregnancy superimposed by a bleeding corpus luteum cyst

An adolescent female presented with an acute abdomen and elevated beta-human chorionic gonadotropin levels and underwent a laparoscopy for a suspected ruptured ectopic pregnancy. Intraoperatively, a ruptured haemorrhagic corpus luteal cyst and tissues suggestive of products of conception were noted in the same ovary. Histology confirmed an ovarian ectopic pregnancy. Haemorrhagic ovarian cysts, and ectopic pregnancies, can cause acute pelvic pain in women of childbearing age. Their similar clinical signs and symptoms pose a diagnostic dilemma for any gynaecologist. Ruptured corpus luteal cysts, as well as ruptured ovarian ectopic pregnancies, should be considered rare but differential diagnoses in women presenting with acute abdominal pain, an adnexal mass and ultrasound features of haemoperitoneum. The mainstay of treatment is a diagnostic laparoscopy, which is a safe and feasible management strategy without compromising patient safety or ovarian function in the long run.

Clinical course of peripheral precocious puberty in girls due to autonomous ovarian cysts

OBJECTIVE

Peripheral precocious puberty (PPP) is the precocious development of secondary sexual characteristics without pulsatile gonadotropin-releasing hormone (GnRH) secretion. In girls, PPP suggests a hyper-oestrogenic state, such as autonomous ovarian cysts and McCune-Albright syndrome (MAS). We aimed to investigate PPP in girls with ovarian cysts, with or without MAS.

DESIGN

A retrospective study design was used.

PATIENTS AND MEASUREMENTS

The study included 12 girls diagnosed with ovarian cysts with PPP between January 2003 and May 2022. Pelvic sonography was performed in cases of vaginal bleeding or areolar pigmentation in PPP. The clinical characteristics, clinical course and pelvic sonographic findings of girls with ovarian cysts were investigated.

RESULTS

We found 18 episodes of ovarian cysts in the 12 girls. The median size of the ovarian cysts was 27.5 mm. Five of the girls were diagnosed with MAS. The median time to spontaneous regression was 6 months. Later, 4 out of 12 girls progressed to central precocious puberty (CPP), and three of them had a recurrence of ovarian cysts. Compared to the non-recurrent and recurrent groups, there was a difference in peak luteinizing hormone (LH) in the GnRH stimulation test and period to cyst regression.

CONCLUSIONS

Most ovarian cysts in PPP spontaneously disappear. However, this could be one of the findings of MAS. Some girls progress from PPP to CPP. Therefore, follow-up is necessary for ovarian cysts in patients with PPP. The recurrence of ovarian cysts may occur when spontaneous regression is prolonged.

Pediatric Psoriasis Associated with Van Wyk Grumbach Syndrome: A case report

INTRODUCTION

Psoriasis is a common chronic inflammatory condition, often beginning in childhood in approximately one-third of cases. It can be associated with various other autoimmune diseases such as rheumatoid arthritis, celiac disease, and thyroid disorders. However, its co-occurrence with Van Wyk Grumbach syndrome has not been described in the pediatric population. This syndrome, resulting from untreated hypothyroidism, is characterized by early puberty and ovarian cysts.

OBSERVATION

A 15-year-old adolescent with a diagnosis of psoriasis since the age of 9 presented with chronic constipation and headaches. She exhibited early puberty (menarche at 9 years) and academic regression. Clinical examination revealed growth retardation and arterial hypertension. Hormonal analyses revealed primary hypothyroidism : Free Thyroxine (FT4)=7pmol/mL(9- 20 pmol/l), Thyroid Stimulating Hormone (TSH)=200 mIU/mL( 0,4 - 5 mUI/ml.). The ultrasound and scintigraphic appearance were suggestive of thyroiditis. Additionally, she experienced menstrual irregularities and pelvic pain. Radiological exploration revealed a left ovarian cyst. The diagnosis of Van Wyk Grumbach syndrome was established due to early puberty, hypothyroidism, and polycystic ovary. Treatment with l-thyroxine led to stabilization of blood pressure and hormonal levels. Her height remained below the target adult height.

CONCLUSION

Assessment of thyroid function appears necessary in pediatric patients with psoriasis. Early hormonal replacement therapy for hypothyroidism may alleviate the symptoms of Van Wyk Grumbach syndrome and mitigate its impact on stature.

Voluminous bilateral adnexal cysts in a young female: the challenge of fertility preservation

An ovarian benign cyst is a common finding in women of reproductive age. However both the disease and its treatment may have an impact on ovarian reserve, resulting in a significant risk of premature ovarian insufficiency. The counselling on fertility preservation is of paramount importance in such cases. We report the management of a young woman with giant bilateral benign adnexal cysts, highlighting the complexity of fertility preservation in such scenario.

[Pseudoascitis by giant ovaric cyst]

The term pseudoascitis is used in patients who give the false impression of ascites, with abdominal distension but without peritoneal free fluid. The case of a 66-year-old woman, hypertensive and hypothyroid with occasional alcohol consumption, who consults due to progressive abdominal distension of 6 months of evolution and diffuse percussion dullness is presented, in whom a paracentesis is performed with the wrong endorsement of examination ultrasound that reports abundant intrabdominal free fluid (Fig. 1), later finding in the CT scan of the abdomen and pelvis an expansive process of cystic appearance of 295mm x 208mm x 250mm. Left anexectomy is programmed (Fig. 2) with pathological report of mucinous ovarian cystadenoma. The case report refers to the availability of the giant ovarian cyst within the differential diagnosis of ascites. If no symptoms or obvious signs of liver, kidney, heart or malignant disease are found and / or ultrasound does not reveal typical signs of intra-abdominal free fluid (fluid in the bottom of the Morrison or Douglas sac, presence of floating free intestinal handles), a CT scan and / or an RMI should be requested before performing paracentesis, which could have potentially serious consequences.

Ovarian cyst torsion in a pre-menopausal woman causing intestinal obstruction: a case report

Intestinal obstruction due to adnexal torsion is a rare complication that can be occurred during torsion of an ovarian cyst. A premenopausal woman presented to the emergency department with complaints of abdominal distension, abdominal pain, and obstipation for 2 days. An abdominal radiograph showed signs of large bowel partial obstruction. Hence admission to the surgical department was ordered. Due to deterioration of the patient, a gynaecological evaluation took place. Ultrasonography demonstrated a large ovarian cyst, which was also confirmed by an abdominal computed tomography scan and thus immediate laparotomy was decided. Abdominal hysterectomy with bilateral salpingo-oophorectomy was performed due to torsion of a giant ovarian cyst, which caused intestinal obstruction by compression. The post-operative course of the patient was uneventful. Ovarian torsion should not be eliminated from differential diagnosis when it comes to female patients with clinical presentation relevant to small and/or large bowel obstruction.

Obstructed inguinal hernia containing ovary with an ovarian cyst: a case report

A 27-year-old married woman came to the emergency room (ER) with the chief complaint of severe pain in the abdomen for 3 days, which was more pronounced in the right iliac fossa, along with the complaint of multiple episodes of vomiting for the last 6 hours. She also gave a history of swelling in the right inguinal region for last 9 months with the complaint of mild on and off pain in the swelling. On physical examination, diagnosis of obstructed inguinal hernia was made. Ultrasonography (USG) of abdomen was of no use, as it only commented on hernial defect and not on the contents of the hernial sac. An emergency surgery was planned; marsupialisation of ovarian cyst, repositioning of fallopian tube along with ovary and herniorrhaphy was performed without any difficulty.

Postmenopausal woman with 24 kgs ovarian mucinous cystadenoma: a rare case report

A case of a 53-year-old postmenopausal woman presenting a giant ovarian cystic mucinous tumor weighing 24 kg is reported here. When she was seen first at our outpatient clinic, she had gross abdominal distension since 2 years, and she complained of unbearable aggressive pain. Her computed tomography (CT) scan was done which came suggestive of ovarian serous cystadenoma of large massive size 35 x 40 x 32 cm with moderate ascites. On exploratory laparotomy, a giant, totally cystic, vascularized and smooth mass attached to the right ovary was encountered. On the postoperative tenth day, she was discharged without any problem. Histopathology report of the right ovarian cystic mass came suggestive of multiloculated cyst with capsule intact with Borderline Mucinous tumor of right ovary weighing 24 kg. This is both one of the largest known examples in the literature and the largest ovarian cyst ever seen at our institution.

Post-appendectomy abdominal pain attributed to incidental ovarian cyst: a case report

Acute abdominal pain in adolescents has a multitude of diagnoses to consider ranging from life-threating ones to other less obvious. In this case report, a 15-year-old girl presented with right lower quadrant abdominal pain and tenderness one month after successful surgical management of acute appendicitis. Post-appendectomy abdominal pain could easily be attributed to post-operative complications, while, in reality, a different disease state may be the cause of the pain. Physicians should have a high index of clinical suspicion, even though the temporal association of events may suggest otherwise. Hemorrhagic ovarian cyst (HOC) should be included in the differential, as it was confirmed with imaging in our case. A conservative treatment approach with progesterone was chosen, with menses resuming 2 days later, leading to regression of the cyst. The clinical significance of this case relies on the timely recognition of a disease entity, in order to distinguish it from complications arising postoperatively.

A curious case of ovarian cysts

ABSTRACT

Benign mature cystic teratomas are a form of ovarian germ cell tumor that originates from primordial germ cells in the ovaries. Of the three types of teratoma neoplasms, benign mature cystic teratomas (also called dermoid cysts) are the most common. Patients may present with intermittent abdominal or pelvic pain, abdominal enlargement, dysmenorrhea, dyspareunia, or may be asymptomatic. Clinicians should have a high suspicion for benign mature cystic teratomas, which account for more than 20% of all ovarian neoplasms. This article focuses on the clinical symptoms, ovarian growth characteristics, pathophysiology, potential complications, management options, and recurrence of benign mature cystic teratomas.

Anti-glomerular basement membrane disease with rupture of the newly formed bilateral corpus luteum cysts: A case report

RATIONALE

Anti-glomerular basement membrane (anti-GBM) disease during gestation is sparse and even rarer when combined with bilateral large corpus luteum cysts. In this case, we report a case of anti-GBM disease in the early stage of pregnancy with ruptured newly formed bilateral large corpus luteum cysts.

PATIENT CONCERNS

A 24-year-old female was initially diagnosed with anti-GBM disease. During treatment, abdominal distention and vaginal bleeding successively staged. The results of the first gynecological ultrasound and abdominal CT were negative.

DIAGNOSIS

Based on the dynamic imaging change of the ovaries, the elevated human chorionic gonadotropin (hCG) and sex hormones, and the pathological findings, a diagnosis of anti-GBM disease with rupture of the newly formed bilateral corpus luteum cysts during early pregnancy was considered.

INTERVENTIONS

The patient was treated with corticosteroids, plasma-exchange along with intensive hemodialysis. Then, to confirm the diagnosis, laparoscopic debulking of bilateral ovarian cysts and curettage were performed.

OUTCOMES

After treatment, the anti-GBM antibody titer declined and the condition of the patient was still stable 2 months following discharge.

LESSONS

As clinicians, we should be aware that even if the first imaging tests are negative, the relevant indicators should be reviewed dynamically based on the condition of the patients. Additionally, this case raised the question of whether anti-GBM disease was associated with pregnancy and giant corpus luteum cysts, which needs further investigations.

[Neonatal bilateral ovarian cystadenoma: Conservative or surgical treatment?]

INTRODUCTION

Bilateral complex ovarian cysts in newborns are rare and their reporting becomes imperative to in crease knowledge about the best therapeutic management.

OBJECTIVE

To describe the clinical case of a newborn with a diagnosis of bilateral complex ovarian cysts and to discuss the conditions for conservative or surgical management according to the ultrasound characteristics of the cyst.

CLINICAL CASE

At 35 weeks of gestational age, prenatal ultrasound identified the presence of cystic masses in both adnexa, so it was decided to interrupt the pregnancy by cesarean section at 37 weeks. After birth, bilateral ovarian cysts of 3.5 x 4.4 x 2.7 and 3.4 x 2.4 x 3.3 cm, right and left, respectively, were corro borated. The right cyst had a septum of 1.4 mm thick and thickened wall of 3 mm which was com patible with complex cysts. On the 4th day of extrauterine life, laparoscopic vacuum aspiration and deroofing with electrocautery of the upper wall of both cysts was performed, without complications. The diagnosis of ovarian serous cystadenoma was made by pathological anatomy.

CONCLUSIONS

We describe a case with adequate prenatal diagnosis and laparoscopic surgical intervention of a bilateral ovarian cyst > 4 cm. Prenatal diagnosis is essential for choosing the best therapy management (con servative or surgical) depending on the echography characteristics of the cyst. Neonatal surgery is recommended for simple ovarian cysts >4 cm, complex cysts regardless of their size, and those that become complex cysts during conservative management.

Clinical Presentation of Paraovarian Cysts

BACKGROUND

A paraovarian cyst (POC) is located between the ovary and the fallopian tube. In many cases POCs are diagnosed and managed as ovarian cysts. But since POC are a distinct entity in their clinical presentation and surgical intervention, they should be better defined.

OBJECTIVES

To describe the clinical perioperative and operative characteristics of patients with POCs in order to improve pre-operative diagnosis and management.

METHODS

A retrospective cohort study of patients with an operative diagnosis of POC between 2007 and 2019 in a single university-affiliated tertiary care medical center was included. Demographic characteristics as well as symptoms, sonographic appearance, surgery findings, and histology results were retrieved from electronic medical records.

RESULTS

During the study period 114 patients were surgically diagnosed with POC, 57.9% were in their reproductive years and 24.6% were adolescents. Most presented with abdominal pain (77.2%). Preoperative sonographic exams accurately diagnosed POC in only 44.7% of cases, and 50.9% underwent surgery due to suspected torsion, which was surgically confirmed in 70.7% of cases. Among women with confirmed torsion, 28.9% involved the fallopian tube without involvement of the ipsilateral ovary. Histology results showed benign cysts in all cases, except two, with a pathological diagnosis of serous borderline tumor.

CONCLUSIONS

POC should always be part of the differential diagnosis of women presenting with lower abdominal pain and sonographic evidence of adnexal cysts. If POC is suspected there should be a high level of suspicion for adnexal torsion and low threshold for surgical intervention, especially in adolescent, population who are prone to torsion.

Littoral cell angioma disguised as huge ovarian cyst: A thought to ponder

Littoral cell angioma (LCA) of the spleen is a rare vascular tumour. It was thought to be a benign and incidental lesion. Given the relative lack of specific symptom in many cases, these tumours are found incidentally during abdominal surgery during a non-related procedure. Clinical manifestation of a huge adnexal mass and the atypical appearance of splenomegaly, explains the often misguided diagnosis. To the best of our knowledge, there has been no case of incidental finding of LCA disguised as a huge ovarian cyst in Malaysia. We present a case report of a focal solitary LCA incidental finding after splenectomy.

"Follow the Fallopian tube": A technique to improve sonographic identification of ovaries in children

Ovary detection is the first step in confirming ovarian lesions. The daughter cyst sign is widely used for this purpose; however, it is not always applicable. Recent improvements in image resolution allow Fallopian tube delineation, which can serve as a guide to identify the ovary. This anatomical approach ("follow the Fallopian tube" technique) comprises three steps: (1) confirm the uterus; (2) follow the Fallopian tube; and (3) find the ovary. Other applications of this approach include the differentiation between nonovarian and ovarian masses and ruling out ovarian torsion and an auto-amputated ovary.

The Significance of Planned Fertility Preservation for Women With Endometrioma Before an Expected Ovarian Cystectomy

Endometrioma is known to reduce the ovarian reserve and the extent of the decrease is more severe when ovarian surgery is performed. Therefore, to prevent this decline in fertility, patients with endometrioma are considered candidates for preoperative fertility preservation (FP). In this study, we evaluate the efficacy of FP in women with endometrioma before planned ovarian surgery. A total of 95 cycles in 62 patients with endometrioma, undergoing controlled ovarian stimulation (COS) for FP using a gonadotropin-releasing hormone (GnRH) antagonist protocol before an expected ovarian surgery, were enrolled retrospectively. COS outcomes were compared according to endometrioma laterality. Additionally, first COS cycle outcomes in patients with endometrioma were compared with those in infertile patients, or in patients with a benign ovarian cyst using propensity score matching. When multiple COS cycles were performed, the results of cumulative cycles were analyzed. Embryo quality was worse in the bilateral endometrioma group. Compared with the infertile patient group, the patients with endometrioma had significantly lower Anti-Müllerian Hormone (AMH) and fewer numbers of oocytes retrieved (median, 3.3 vs. 1.2, p<0.001; 7.0 vs. 4.0, p=0.009, respectively). Compared with mature oocytes in infertile patients or patients with a benign cyst, mature oocytes were fewer in patients with endometrioma, but this was not statistically significant (median, 4.0 vs. 3.0, p=0.085; 5.5 vs. 3.0, p=0.052, respectively). The median value of the cumulative number of cryopreserved oocytes or embryos was 14.5 up to the fourth cycle compared to 3 up to the first cycle, with cumulative effect. Women with endometrioma should be counseled for FP before planned ovarian cystectomy. The number of cryopreserved oocytes or embryos can be increased by repeated cycles.

Torsion of Functional Adnexal Cysts in Pregnancy: Aspiration and Drainage are Important in Preventing Recurrence

BACKGROUND

Adnexal torsion in pregnancy is often associated with functional adnexal cysts, especially in pregnancies conceived by ovulation induction (OI) or in-vitro fertilization (IVF). During laparoscopy for adnexal de-torsion, drainage of the functional cysts can be attempted, although this procedure may cause bleeding.

OBJECTIVES

To investigate the characteristics of ovarian torsion in pregnancy associated with functional cysts and to compare the rate of torsion recurrence following de-torsion alone versus cyst drainage.

METHODS

All cases of surgically diagnosed adnexal torsion occurring during pregnancy between January 2007 and April 2019 in our department were retrospectively analyzed. The cases of torsion associated with presumed functional ovarian cysts were selected. The rate of recurrent torsion during the same pregnancy was compared for de-torsion alone versus de-torsion and cyst aspiration.

RESULTS

Of the 113 women who experienced adnexal torsion during pregnancy, 71 (67.0%) of torsion cases were caused by presumed functional ovarian cysts. Among women with torsion of functional ovarian cysts, the rate of torsion recurrence was significantly higher in patients who underwent de-torsion alone (n=28) compared to women who underwent aspiration and drainage of the ovarian cysts (n=43) (14.3% vs. 0, P = 0.021). There were no cases of intra- or post-operative bleeding in the study cohort.

CONCLUSIONS

Functional ovarian cysts are the most common adnexal pathology encountered in pregnant women with torsion. Intra-operative cyst aspiration and drainage may reduce the risk of recurrent torsion. Further multi-center studies are required to validate our data prospectively.

Exacerbated mini-puberty of infancy in an ex-extreme preterm girl

Vaginal bleeding can occur shortly after delivery in 3%-5% of newborns as a consequence of placental hormone withdrawal . Although usually benign, its differential diagnosis includes central precocious puberty, tumours and other pathological conditions. A girl born at 26 weeks of gestation presented with five episodes of vaginal bleeding, each lasting less than a week, initiated at 4 months of age. Luteinising hormone and oestradiol levels were in the pubertal range. Later, she exhibited breast development, with no other pubertal signs. An ultrasonography test revealed an impregnated endometrium and a right ovarian cyst with 43 mm of diameter. A cranioencephalic MRI was unremarkable. Clinicians adopted expectant management and there was clinical, hormonal and radiological resolution in 3 months. The spontaneous resolution suggested mini-puberty of infancy. This is usually an asymptomatic condition, but to date, four cases of an exacerbated form in extremepremature infants have been reported. Long-term follow-up data are missing.A girl born at 26 weeks of gestation presented with five episodes of vaginal bleeding, each lasting less than a week, initiated at 4 months of age. Luteinising hormone and oestradiol levels were in the pubertal range. Later, she exhibited breast development, with no other pubertal signs. An ultrasonography test revealed an impregnated endometrium and a right ovarian cyst with 43 mm of diameter. A cranioencephalic MRI was unremarkable. Clinicians adopted expectant management and there was clinical, hormonal and radiological resolution in 3 months. The spontaneous resolution suggested mini-puberty of infancy. This is usually an asymptomatic condition, but to date, four cases of an exacerbated form in extremepremature infants have been reported. Long-term follow-up data are missing.

Is serum anti-Müllerian hormone (AMH) assay a satisfactory measure for ovarian reserve estimation? A comparison of serum and peritoneal fluid AMH levels

BACKGROUND

Clinical cases have been reported with women who got pregnant with confirmed low serum anti-Müllerian hormone (AMH) concentrations, thus demonstrating that low serum AMH concentration cut-points could be fairly specific for poor ovarian response (POR) to gonadotrophin stimulation, but not for pregnancy. That observation prompted the question whether serum AMH concentration accurately corresponded to the whole amount of AMH secreted by granulosa cells.

OBJECTIVES

To measure AMH levels in peritoneal fluid and their correlations with serum AMH concentrations.

MATERIAL AND METHODS

The reported study involved 48 female patients, aged 18-40 years, diagnosed with benign ovarian cysts and qualified for a laparoscopic cystectomy. Prior to surgery, the ovarian reserve was assessed using serum AMH concentration assay. The peritoneal fluid was also collected during the laparoscopy and AMH concentrations in peritoneal fluid were measured.

RESULTS

The AMH present in the peritoneal fluid strongly correlated with AMH levels in blood serum (r = 0.54; p < 0.001) and higher serum AMH concentrations corresponded to higher AMH concentrations in the peritoneal fluid. There was also a significant correlation between AMH levels in serum and in peritoneal fluid, collected from patients with endometrioma and other benign cysts (r = 0.61; p = 0.001 vs r = 0.43; p = 0.03).

CONCLUSIONS

The AMH is present in the peritoneal fluid and its concentrations significantly correlate with AMH levels in serum. The assessment of AMH concentration in the peritoneal fluid may be a valuable complement to the evaluation of ovarian reserve and the diagnosis of infertility after adnexal surgery.

Dermoid cyst with secretion of CA 19-9 detected by 18F-FDG PET/CT: A case report

INTRODUCTION

Carbohydrate antigen 19-9 (CA 19-9) is a tumor glycolipid, frequently elevated in the serum of patients due to malignancies from gastrointestinal organs; in particular, the pancreas. This carbohydrate antigen is also expressed in benign diseases.

PATIENT CONCERNS

A case of a 27-year-old female who has an unknown origin CA 19-9 elevation for 2 years.

DIAGNOSIS

After the left ovarian cystectomy and microscopic examination, the final diagnosis is a dermoid cyst. The dermoid cyst shows increased F-fluorodeoxyglucose (F-FDG) uptake in the F-FDG positron emission tomography (PET)/computed tomography (CT) study.

INTERVENTION AND OUTCOMES

The laparoscopic oophorocystectomy was performed. It was observed that the patient's CA 19-9 level returned to normal after the surgery 6 months later. This showed that the dermoid cyst was responsible for the abnormal CA 19-9 level.

CONCLUSION

In this case, we can learn that the F-FDG PET/CT scan has potential use in patients with unknown origin of elevation CA 19-9.

Hemodynamic changes detected by Doppler ultrasonography in the ovaries of cattle during early development of cystic ovarian disease

A common reproductive disease in dairy cattle is Cystic Ovarian Disease. To study its development, there was use of an experimental model of follicular persistence to detect hemodynamic changes occurring in ovaries by using Doppler ultrasonography. After estrous synchronization, control cows received no additional treatment and were evaluated at proestrus (CG), whereas treated cows (PG) received sub-luteal doses of progesterone for 15 days and were evaluated at proestrus, and after 0, 5, 10 and 15 days of follicular persistence. Spectral Doppler was used to evaluate blood flow in the ovarian artery, and power Doppler for evaluation of blood flow in the ovarian parenchyma and follicular wall of persistent and dominant preovulatory follicles. Findings using power Doppler signals indicated there were no differences between groups in the parenchyma of both right (P =  0.455) and left (P =  0.762) ovaries. In contrast, power Doppler signals of blood flow were less in walls of persistent follicles from day 0 to 15 when there was follicular persistence than in dominant follicles of the CG (P <  0.001). Blood flow in ovarian arteries was less (P <  0.05) in diastolic velocity and time averaged maximum velocity in all PG groups than in the CG. Peak systolic velocity was less (P <  0.05) in all PG than in the CG, with the exception of P15 (P >  0.05). These findings indicate there are marked changes in blood irrigation area of walls of persistent follicles during the 15 days of follicular persistence.

Oligosypthomatic ovarian hyperstimulation syndrome in a spontaneous uneventful pregnancy. A case report

Spontaneous hyperstimulation syndrome (spOHSS) is a rare event in pregnancies following natural conception. Only a few cases are reported in the scientific literature and result associated with massive ovarian enlargement with multiple cysts, dehydration, and fluid accumulation in the "third space". We report a novel case of spOHSS in a naturally conceived singleton pregnancy. The spOHSS was characterized by massive ovarian enlargement with multiple cysts. No dehydration and no signs of ascites were observed. The pregnancy uneventful evolved up to term.

A case of functioning gonadotroph adenoma in a reproductive aged woman

A 34-year-old woman presented our hospital with complaint of irregular menstruation and abnormal uterine bleeding lasting for a month. After her second parturition at the age of 27, her menstrual cycle had been regular, but it suddenly became irregular at the age of 30. Transvaginal ultrasound revealed the presence of ovarian mass, and the patient underwent diagnostic laparoscopic surgery. Bilateral ovaries temporally shrink after puncture but the size soon resumed. Gonadotropins were almost normal, but estradiol and PRL levels turned out to be elevated, and cabergoline treatment was initiated. After referral to our hospital, we found that the ovaries showed multifollicular appearance. Brain magnetic resonance imaging showed an 18-mm macroadenoma in the suprasellar area. To suppress the secretion of endogenous gonadotropins and estrogen, low-dose estrogen-progestin was prescribed. Surprisingly, the treatment temporarily reduced the size of the ovaries. The patient was referred to a neurosurgeon, and a functioning gonadotroph adenoma was suspected. After the resection of the pituitary tumor, her menstrual cycle became regular, and the size of bilateral ovaries became normal. We also noticed that her ovarian reserve judged by anti-Müllerian hormone had been almost diminished after the surgical treatment, probably reflecting the exhaustion of follicular pool. Women with multifollicular ovaries and elevated estradiol levels may have functioning gonadotroph adenomas, although the level of FSH is relatively normal, and ovarian reserve can be followed by measuring anti-Müllerian hormone.

Hyperreactio luteinalis - two accidental findings during cesarean section

OBJECTIVE

To present two cases of patients with hyper-reactio luteinalis at the cesarean section.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, Hospital Tren&#269;ín; Medirex Group Academy n.o., Bratislava.

CASE REPORT

We report two cases of women with preeclampsia who we diagnosed with bilateral multi-cystic ovarian enlargement by chance during cesarean section. At both of them the level of human chorionic gonadotropin was above normal, one of the patients had medical history of ovarian serous borderline tumor and this pregnancy was multiple after in vitro fertilization and embryo transfer. Adnexectomy, resection of ovaries and biopsy were carried out. Histologically hyperreactio luteinalis was confirmed in both patients.

CONCLUSION

We discuss the necessity of surgical treat-ment, the authors want to emphasize the need for proper preoperative diagnosis and indication of conservative management of patients with hyperreactio luteinalis.

Ovarian hydatid cyst - systematic review of clinicopathological and immunohistochemical characteristics of an unusual entity

Primary ovarian hydatid disease (HD) is a rare entity, produced by the larval stage of Echinococcus granulosus. HD commonly involves liver, lung, abdomen cavity, spleen and is unusually identified in pelvic organs. Based on our knowledge, the paper reviews 27 literature reports of ovarian HD, diagnosed during the last 20 years, providing a valuable database. Patients' ages ranged between 12-76 years, the gross appearance was that of 40-330 mm diameter hydatid cysts (HCs), 66.66% of them being primary. According to these reports, ovarian HD has non-specific clinical manifestations, such as abdominal or pelvic pain, nausea, dysmenorrhea or amenorrhea. The diagnosis may be achieved by abdominal ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI), serological exams, such as eosinophilia (in 10-30% of patients) or indirect hemagglutination and immunoglobulin (IgG) antibodies detection. Ovarian HC microscopic pattern is characterized by three layers: pericyst or adventitia (host origin), germinal layer (endocyst), and laminated membrane (ectocyst). The immunoreaction triggered by parasites is initially rich in macrophages and neutrophils, followed by eosinophils and lymphocytes, with numerous cluster of differentiation 8 (CD8)-positive T-cells in active lesions and progressive forms. Concomitant ovarian diseases are relatively rare, being represented by borderline tumors (n=2 cases), mucinous cystadenoma (n=1 case), hemorrhagic cyst (n=1 case), and serous adenocarcinoma (n=1 case). In conclusion, the ovarian location of HD should be considered in any differential diagnosis of a cystic lesion, while it does not exclude synchronous ovarian tumors. These cases reinforce the necessity of better measures of prophylaxis and screening of HD in endemic areas.

Squamous cell carcinoma arising from mature cystic teratoma of the ovary: A challenging question for gynecologic oncologists

Mature cystic teratomas of the ovary have an incidence of 1.2-14.2 cases per 100.000 people per year. Malignant transformation occurs in approximately 2% of the cases, and usually consists of squamous cell carcinoma. The preoperative detection is difficult and the diagnostic accuracy of ultrasound, magnetic resonance imaging, and computed tomography is debated. The diagnosis is frequently made in the operating room or on final histological examination. Standard treatment consists of bilateral salpingo-oophorectomy, total hysterectomy and comprehensive surgical staging in early disease and optimal cytoreductive surgery in advanced disease. Paclitaxel/carboplatin- based chemotherapy is the most used adjuvant treatment, whereas more aggressive regimens can be adopted in patients with high tumor burden or recurrent disease. The efficacy of radiotherapy is still unproven. The prognosis is poor when the tumor has spread beyond the ovary. There are few information to provide commonly accepted guidelines for this malignancy.

Differential Tumor Microenvironment in Human Ovarian Cystic Tumors

Aims and Background

Cells and soluble mediators obtained from tumor effusions are useful in evaluating the tumor microenvironment. Our aim was to examine cytologically and to quantify the leukocyte infiltrate, nitric oxide, cytokines and tumor markers in the intracystic fluid from patients with a cystic adnexal mass, for a possible differentiation between benign and malignant findings.

Methods and Study Design

Sixty-six women who had their cystic fluids collected were prospectively divided into benign tumor (22, 33.3%), malignant tumor (10, 15.2%) or other gynecological alterations (34, 51.5%). Cytology, total and differential leukocyte counts were determined by light microscopy. Tumor markers, cytokines and nitric oxide were assayed in the supernatants using the Immutile system, ELISA and Griess reaction, respectively.

Results

The sensitivity and specificity of the cytological analysis was 66.7% and 97.7%, respectively. The levels of CA 19.9, CA 15.3, α-fetoprotein, carcinoembryonic antigen, progesterone and β-HCG were significantly higher in the benign and/or malignant group than in the other gynecological alterations. Also, the local concentrations of CA 15.3 and β-HCG were significantly higher in malignant than in benign tumors. In malignant tumors, increased leukocyte counts and higher concentrations of IL-6, IL-10 and nitric oxide were detected than in benign tumors or other gynecological alterations.

Conclusions

In malignant tumors, the microenvironment could be differentiated from benign tumors or other gynecological alterations by cystic fluid analysis.

Adnexal masses in pregnancy: perinatal impact

The incidence of adnexal masses in pregnancy has increased significantly over the last decades and this is mostly because of the widespread use of ultrasound for pregnancy surveillance. Although a clear majority of adnexal masses found in the first trimester are functional cysts, which have a small diameter and disappear spontaneously, those that do persist into the second and third trimester require ultrasound surveillance for proper management. The presence of a large adnexal mass in the third trimester of pregnancy represents solid grounds for delivery via Caesarean section (C-section) both because of the risk of dystocia and the advantage of one-step approach of cystectomy/oophorectomy at the time of C-section. This is a retrospective study of all the third trimester pregnancy related adnexal masses that delivered in our Hospital in the last 10 years via C-section where cystectomy was also performed. Our aim was to look at the histological type of ovarian mass and to compare our results to those previously published by other authors. We also wanted to see whether the clinical suspicion based on prenatal ultrasound aspect, where this was available, was similar to the postnatal histology report. Secondary outcomes were gestational age at delivery, fetal weight and Apgar score. We found that dermoid cysts are the most common type of adnexal mass with an incidence of 46%, followed by mucous cysts 27%, serous cysts 18% and endometrioses 9%, which is consistent with the data published by other authors in larger series. In terms of prenatal clinical diagnosis, detailed ultrasound assessment of the ovarian mass was available only in less than half of these cases, but in these, the clinical suspicion was confirmed by histology report. In our series, we had no case that required premature delivery because of adnexal mass-related complications and fetal outcome was very good with normal birth weight and high Apgar score. Although this is a small series of cases, it confirms the incidence previously published of the different histological types of ovarian tumors. It also shows that fetal outcomes are very rarely affected by the presence of ovarian masses and premature iatrogenic delivery for maternal well-being is the only note wordy one of them.

Diagnosis and Management of Adnexal Masses

Adnexal masses can have gynecologic or nongynecologic etiologies, ranging from normal luteal cysts to ovarian cancer to bowel abscesses. Women who report abdominal or pelvic pain, increased abdominal size or bloating, difficulty eating, or rapid satiety that occurs more than 12 times per month in less than a year should be evaluated for ovarian cancer. Pelvic examination has low sensitivity for detecting an adnexal mass; negative pelvic examination findings in a symptomatic woman should not deter further workup. Ectopic pregnancy must be ruled out in women of reproductive age. A cancer antigen 125 (CA 125) test may assist in the evaluation of an adnexal mass in appropriate patients. CA 125 levels are elevated in conditions other than ovarian cancer. Because substantial overlap in CA 125 levels between pre- and postmenopausal women may occur, this level alone is not recommended for differentiating between a benign and a malignant adnexal mass. Transvaginal ultrasonography is the first choice for imaging of an adnexal mass. Large mass size, complexity, projections, septation, irregularity, or bilaterality may indicate cancer. If disease is suspected outside of the ovary, computed tomography may be indicated; magnetic resonance imaging may better show malignant characteristics in the ovary. Serial ultrasonography and periodic measurement of CA 125 levels may help in differentiating between benign or potentially malignant adnexal masses. If an adnexal mass larger than 6 cm is found on ultrasonography, or if findings persist longer than 12 weeks, referral to a gynecologist or gynecologic oncologist is indicated.

Lymphangioma Arising From the Ovary

Primary lymphangioma arising from the ovary is a rare tumor, with only 24 cases reported to date. As it is often accompanied by ascites or recurrence, similar to a malignant tumor, an aggressive treatment approach is used for disease control. In this report, we describe a 75-year-old woman with a left ovarian lymphangioma that increased in size during the menopause period. Microscopic examination of the tumor showed thin-walled multilocular cystic spaces and immunoreactivity for D2-40, a specific marker for lymphatic endothelium, lining the cystic spaces. The patient has been doing well for 5 years postoperatively. Ovarian cystic lymphangioma should be included in the differential diagnosis of an ovarian cyst and long-term follow-up is recommended to exclude malignant behavior. We also summarize a total of 25 cases, including the case presented here.

Occasional finding of giant bladder diverticulum that simulated an ovarian cyst: A case report and literature review

We present a case of a preoperatively unrecognized giant bladder diverticulum in a 63-year-old postmenopausal woman. We carried out preoperative ultrasonographic evaluation and suspected an ovarian cyst. We performed two transvaginal ultrasonography scans before surgery, asking the patient to totally empty her bladder. Consequently, we decided to subject the patient to laparoscopic cyst removal. However, during surgery, the presumed ovarian cyst was not found and a bladder diverticulum was suspected. To confirm our hypothesis, we filled the bladder with saline until the reappearance of giant swelling and we recognized a bladder diverticulum. This case shows that diagnosis based on imaging alone can reveal unpleasant pitfalls. It is important to integrate clinical information, and to consider other possible investigations in order to reduce the chances of a misdiagnosis.

Large abdominal cystic masses: Report of seven cases

Cystic abdominal tumours are encountered quite often and are diagnosed more frequently due to the availability of better imaging possibilities. Presentation of huge cysts has become rare as most of them are diagnosed and treated early. But we still have patients with enlarged abdominal cysts; majority with cases of serous cystadenomas of the ovary. Absolute diagnosis is only possible with laparotomy and histopathological findings. In this report, seven patients with enlarged gynaecological or mesenteric cystic masses and gastroenterological symptoms are reported. Four of these cases were serous cystadenoma, two were mucinous cystadenoma and one was a paratubal cyst. Gynaecological tumours and mesenteric cysts should not be missed in female patients showing gastrointestinal symptoms.

MMP3 in Comparison to CA 125, HE4 and the ROMA Algorithm in Differentiation of Ovarian Tumors

Ovarian cancer is a highly malignant neoplasm with high mortality rates. Research to identify markers facilitating early detection has been pursued for many years. Currently, diagnosis is based on the CA 125 and HE4 markers, as well as the ROMA algorithm. The search continues for new proteins that meet the criteria of good markers A total of 90 patients were included in the present study, allocated into: group 1, ovarian cancer, with 29 patients; group 2, endometrial cysts, with 30s; and group 3, simple ovarian cysts, with 31. Following histopathological verification, the CA 125, HE4, and metalloproteinase 3 (MMP3) levels were determined and the ROMA algorithm was calculated for all patients. The mean concentrations of all determined proteins, CA 125, HE4, and MMP3, as well as the ROMA values, were significantly higher in group 1 (ovarian cancer) compared to group 3 (simple ovarian cysts). The highest significant differences for the CA 125 levels (<0.000001) and ROMA (<0.000001) values were observed in postmenopausal women. For HE4, statistical significance was at the level of p=0.00001 compared to p=0.002 for MMP3. For the differentiation between ovarian cancer and endometrial cysts, the respective AUC ratios were obtained for CA 125, HE4, and MMP3 levels, as well as the ROMA values ( 0,93 / 0,96 / 0,75 / 0,98). After removing the post-menopausal patients, the MMP3 AUC value for ovarian cancer vs. benign ovarian cysts increased to 0.814. For post-menopausal women, the MMP3 AUC value for ovarian cancer vs. endometrial cysts was 0.843. As suggested by the results above, both the CA 125 and HE4 markers, as well as the ROMA algorithm, meet the criteria of a good diagnostic test for ovarian cancer. MMP3 seems to meet the criteria of a good diagnostic test, particularly in postmenopausal women; however, it is not superior to the tests used to date.

Ovarian Damage after Laparoscopic Cystectomy for Endometrioma

INTRODUCTION

Despite extensive research endometriosis is an area with important controversies. The European Society of Human Reproduction and Embriology issued in 2014 the last Guideline for endometriosis management including the statement that among 83 recommendations in 32 cases the best available evidence was only based on good clinical practice, further research being necessary to solve the lack of evidence in this pathology. The prevalence of endometriosis is unknown in Romania but in the medical literature estimates range from 2 to 10% of women of reproductive age, to 50% of infertile women, worldwide. Ovarian endometrioma prevalence goes up to 44%. A Cochrane review published in 2008 by Hart et al. concluded that excisional surgery of ovarian endometriosis results in a more favorable outcome compared to drainage and ablation with regard to recurrence, pain symptoms and subsequent spontaneous pregnancy in subfertilewomen- so the gold standard was set. But several authors revealed that ovarian tissue was inadvertently excised together with the cyst wall and endometrioma cystectomy is associated with a significant decrease in residual ovarian volume that may result in diminished ovarian reserve and function. The aim of our retrospective study was to evaluate whether or not ovarian parenchyma is inadvertently removed during laparoscopic surgery for endometrioma in a Romanian academic center.

MATERIAL AND METHOD

We performed a retrospective study including women having undergone endometrioma excision, between January 2009 to June 2014 in the Department of Gynecology and Obstetrics of Targu-Mures University Hospital. Histological specimens of excised endometriomas were reviewed by different pathologists, who carried out serial microscopic sections according to pathology protocol for diagnosis of ovarian mass but not specific for the ovarian parenchyma removed with the cyst.

RESULTS

Among 202 endometriomas, drainage and ablation was done in 60 cases and excisional surgery in the remaining 152 cases. Ovarian parenchyma was found in 40% of cases of endometrioma cystectomy.

DISCUSSION

We observed that endometrioma cystectomy leads to ovarian tissue removal in an important number of cases. Furthermore, at the time of surgery the amount of ovarian parenchyma loss may increases proportionally with increases in cyst diameter and patient age. Considering that most of the woman in our series were infertile and because of data from series using plasma energy, a shift in the endometrioma treatment paradigm is likely to occur.

Peculiarities of data interpretation upon direct tissue analysis by Fourier transform ion cyclotron resonance mass spectrometry

The importance of high-resolution mass spectrometry for the correct data interpretation of a direct tissue analysis is demonstrated with an example of its clinical application for an endometriosis study. Multivariate analysis of the data discovers lipid species differentially expressed in different tissues under investigation. High-resolution mass spectrometry allows unambiguous separation of peaks with close masses that correspond to proton and sodium adducts of phosphatidylcholines and to phosphatidylcholines differing in double bond number.

Accuracy of intra-operative frozen section and its role in the diagnostic evaluation of ovarian tumors

Summary

OBJECTIVE

This retrospective study was undertaken to evaluate the accuracy and role of intra-operative frozen section in the diagnosis of ovarian tumors.

MATERIALS AND METHODS

Retrospective study of 804 ovarian frozen section results between June 2010 and June 2014 was examined to determine the accuracy of frozen section diagnosis. The intra-operative frozen section diagnosis was compared with the permanent (paraffin) section and the overall accuracy, sensitivity, specificity, and positive and negative predictive values of the frozen section were studied.

RESULTS

The overall accuracy to determine the status of malignancy was 92.6%. There were 38 (7.4%) false negative and no false positive frozen section diagnoses.The sensitivity, specificity, and positive predictive and negative predictive values for benign ovarian tumors were 100.0%, 97.0%, 91.3%, and 100.0%, respectively; for borderline tumors they were 64.3%, 97.0%, 91.5%, and 94.0%, respectively, and for malignant tumors they were 90.0%, 100.0%, 100.0%, and 85.5%, respectively.

CONCLUSION

This study concluded that frozen section appears to be an adequate technique for the histopathological diagnosis of ovarian tumors, with some limitations observed among borderline and mucinous tumors.

[Urinary retention secoundary to cervical myoma large items]

OBJECTIVES

To describe the clinical-diagnostic importance of cystic appearance of a cervical myoma large elements result produced secondary

METHOD

We described a case of a 40-year-old with abdominal discomfort producing difficulty walking, dyspareunia, urinary retention seven months of evolution. The USG diagnosis was a cystic mass consistent with a right ovarian cyst. The surgical abdominal total hysterectomy is performed.

RESULTS

Histopathological study of approximately 1 3x6 cm uterus with myoma fund of approximately 4 cm and myoma level cervical posterior surface of 15x12 cm.

Advancing Urinary Protein Biomarker Discovery by Data-Independent Acquisition on a Quadrupole-Orbitrap Mass Spectrometer

The promises of data-independent acquisition (DIA) strategies are a comprehensive and reproducible digital qualitative and quantitative record of the proteins present in a sample. We developed a fast and robust DIA method for comprehensive mapping of the urinary proteome that enables large scale urine proteomics studies. Compared to a data-dependent acquisition (DDA) experiments, our DIA assay doubled the number of identified peptides and proteins per sample at half the coefficients of variation observed for DDA data (DIA = ∼8%; DDA = ∼16%). We also tested different spectral libraries and their effects on overall protein and peptide identifications and their reproducibilities, which provided clear evidence that sample type-specific spectral libraries are preferred for reliable data analysis. To show applicability for biomarker discovery experiments, we analyzed a sample set of 87 urine samples from children seen in the emergency department with abdominal pain. The whole set was analyzed with high proteome coverage (∼1300 proteins/sample) in less than 4 days. The data set revealed excellent biomarker candidates for ovarian cyst and urinary tract infection. The improved throughput and quantitative performance of our optimized DIA workflow allow for the efficient simultaneous discovery and verification of biomarker candidates without the requirement for an early bias toward selected proteins.

Review of 244 cases of ovarian cysts

OBJECTIVES

To review cases of ovarian cysts managed at a University Hospital, and to identify the factors necessitating the use of laparotomy over laparoscopy.

METHODS

We carried out a retrospective chart review of all cases of ovarian cysts diagnosed and managed at the Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 2010 and August 2014. All data collected from medical record charts, patents details, clinical presentations, ovarian cysts description, and pathology type were recorded, and management by laparoscopy or laparotomy was identified. Ethical approval was obtained from ethical hospital committee.

RESULTS

There were 244 cases of ovarian cysts during the study period. The age ranged from 3 months to 77 years of age. The parity from 0-6. The height range from 37-180 cm. The weight range from 3-161 kg, and calculated body mass index ranged from 12-47. Out of 244 patients diagnosed, 165 were married (67.4%). Of those, only 16 patients were pregnant (6.6%). The most common presentation was abdominal pain in 142 patients (58.2%). Only 79.9% were ovarian cysts, and 17.5% were either para-ovarian or retroperitoneal. The right ovaries were affected in 63.1%, and only 18.9% were bilateral. The types of ovarian cysts included functional cysts 33.2%, benign cyst-adenoma 19.3%, and dermoid cysts 12.3%.

CONCLUSION

Factors associated with laparotomy management rather than laparoscopy included older age more than 35, single, pregnant, or patients presenting with abdominal pain, and more than one cyst.

The approach to chronic pelvic pain in the adolescent

Adolescents present to outpatient and acute care settings commonly for evaluation and treatment of chronic pelvic pain (CPP). Primary care providers, gynecologists, pediatric and general surgeons, emergency department providers, and other specialists should be familiar with both gynecologic and nongynecologic causes of CPP so as to avoid delayed diagnoses and potential adverse sequelae. Treatment may include medications, surgery, physical therapy, trigger-point injections, psychological counseling, and complementary/alternative medicine. Additional challenges arise in caring for this patient population because of issues of confidentiality, embarrassment surrounding the history or examination, and combined parent-child decision making.

Relationships among ketosis, serum metabolites, body condition, and reproductive outcomes in dairy cows

We determined the relationships among ketosis, serum metabolites, body condition, and reproductive disorders and performance in dairy cows. Blood samples from 213 dairy cows were collected at 4 and 2 weeks prepartum, just after calving, and at 1, 2, 4, 6, and 8 weeks postpartum to measure serum β-hydroxybutyrate, nonesterified fatty acids (NEFAs), glucose, total cholesterol, urea nitrogen, aspartate aminotransferase, γ-glutamyltransferase, and progesterone concentrations. Cows were grouped on the basis of the β-hydroxybutyrate concentration at 1 and/or 2 weeks postpartum into two groups: the ketotic group (≥1200 μmol/L, n = 59) and the nonketotic group (<1200 μmol/L, n = 154). The body condition score (BCS) was assessed simultaneously with blood collection. Clinical endometritis was diagnosed by observation of vaginal discharges (>50% pus), and subclinical endometritis was diagnosed by evaluation of uterine cytology (>18% neutrophils) at 4 weeks postpartum. Ovarian cysts were diagnosed by ultrasonography, and resumption of postpartum cyclicity was evaluated by progesterone concentrations (≥1 ng/mL) at 4, 6, and 8 weeks postpartum. In the ketotic group, NEFA levels were higher (P ≤ 0.0005), whereas glucose (P < 0.05-0.0005) and urea nitrogen levels (P < 0.05-0.01) were lower than those in the nonketotic group during the postpartum period. Aspartate aminotransferase levels were higher (P < 0.01) in the ketotic group than those in the nonketotic group at 2 weeks postpartum. The BCS of the ketotic group was higher than the nonketotic group during the prepartum (P < 0.001) and postpartum (P < 0.05-0.001) periods. The probabilities of clinical endometritis (odds ratio = 2.55) and ovarian cysts (odds ratio = 2.80) were higher (P < 0.05) in the ketotic group than those in the nonketotic group. The hazards of resumption of postpartum cyclicity by 8 weeks postpartum (hazard ratio = 0.67) and pregnancy by 360 days postpartum (hazard ratio = 0.68) were lower (P < 0.05) in the ketotic group. In conclusion, a higher BCS during prepartum and postpartum period and increased NEFA and aspartate aminotransferase levels, along with decreased glucose and urea nitrogen levels during postpartum, were associated with ketosis, increased reproductive disorders, and decreased reproductive performance in dairy cows.

Ovarian macrocysts and gonadotrope-ovarian axis disruption in premenopausal women receiving mitotane for adrenocortical carcinoma or Cushing's disease

CONTEXT

Mitotane is an adrenolytic and anticortisolic drug used in adrenocortical carcinoma (ACC), Cushing's disease (CD), and ectopic ACTH syndrome. Its effects on the ovaries are unknown.

OBJECTIVE

To evaluate the ovarian and gonadotrope effects of mitotane therapy in premenopausal women.

PATIENTS

We studied 21 premenopausal women (ACC: n=13; CD: n=8; median age 33 years, range 18-45 years) receiving mitotane at a median initial dose of 3 g/day (range 1.5-6 g/day).

METHODS

Gynecological history was collected and ovarian ultrasound was performed. Four women also underwent ovarian CT or magnetic resonance imaging. Serum gonadotropin, estradiol (E2), androgens, sex hormone-binding globulin (SHBG), and circulating mitotane levels were determined at diagnosis and during mitotane therapy.

RESULTS

In the women included, ovarian macrocysts (bilateral in 51%) were detected after a median 11 months (range: 3-36) of mitotane exposure. The median number of macrocysts per woman was two (range: 1-4) and the median diameter of the largest cysts was 50 mm (range: 26-90). Menstrual irregularities and/or pelvic pain were present in 15 out of 21 women at macrocyst diagnosis. In two women, the macrocysts were revealed by complications (ovarian torsion and hemorrhagic macrocyst rupture) that required surgery. Mitotane therapy was associated with a significant decrease in androstenedione and testosterone levels and a significant increase in LH levels. Serum FSH and E2 levels were also increased, and SHBG levels rose markedly.

CONCLUSIONS

Mitotane therapy causes significant morphological and ovarian/gonadotrope hormonal abnormalities in premenopausal women. Follicular thecal steroid synthesis appears to be specifically altered and the subsequent increase in gonadotropins might explain the development of macrocysts. The mechanisms underlying these adverse effects, whose exact prevalence in this population still needs to be determined, are discussed.

Investigation and management of an ovarian mass

BACKGROUND

Ovarian masses are very common in pre- and postmenopausal women and are typically an incidental finding.

OBJECTIVE

This article aims to provide a systematic approach to an ovarian mass for general practitioners including investigations, risk of ovarian cancer and referral considerations.

DISCUSSION

Investigation for an ovarian mass includes both transvaginal and transabdominal ultrasound. Simple, anechoic cysts 200. Complications of ovarian cysts include cyst rupture and torsion. Torsion is a gynaecological emergency and requires urgent review.

Precocious pseudopuberty due to ovarian causes

BACKGROUND

It is important to differentiate central from peripheral causes of precocious puberty because of distinct management options.

CASE CHARACTERISTICS

4 girls with discordant pubertal development.

OBSERVATIONS

All had low basal and GnRHa stimulated FSH and LH level with high estradiol level. Abdominal ultrasonogram helped in diagnosing precocious pseudopuberty- ovarian cyst in 3 children and juvenile granulosa cell tumour in one.

OUTCOME

Case 1 and 4 underwent surgery in view of persistent cyst and tumor, respectively. Rest were managed conservatively. Regression of pubertal signs observed in all children during follow-up.

CONCLUSION

Precocious pseudopuberty can be differentiated from central precocious puberty by GnRHa Stimulation test, bone age and abdominal ultrasound.

Recurrence factors in women underwent laparoscopic surgery for endometrioma

AIM

The aim of this paper was to assess the risk factors for endometrioma recurrence in women underwent laparoscopic surgery for endometrioma.

METHODS

This retrospective designed study included 113 cases that underwent laparoscopic surgery for endometrioma; of these women, recurrent endometrioma was detected in 33 (29.20%) subjects and other showed no recurrence (70.80%). Age, gravidity, parity, diameter of the mass, bilaterality, previous pelvic surgery, operation type, presence of adhesions, Ca 125 levels and recurrence time was obtained from hospital records and special gynecology forms.

RESULTS

Demographic and obstetric past history of the cases showed no statistically significant difference between the groups (P>0.05). Higher diameter of the mass, previous pelvic surgery, operation type, presence of adhesion and higher Ca 125 levels were risk factors for endometrioma recurrence (P<0.05). Receiver operator curve (ROC) analysis demonstrated that diameter of the mass, previous pelvic surgery and Ca 125 levels may be discriminative risk factors for endometrioma recurrence.

CONCLUSION

Endometriomas ≥ 4.5 cm, especially in cases with pelvic adhesions, previous pelvic surgery and higher Ca 125 levels should be excised totally.