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Gynecologic Oncology 91 (2003) 648 – 650
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Case Report
Massive ovarian edema revealing gastric carcinoma: a case report Marc Bazot, M.D.,a,* Romain Detchev, M.D.,b Annie Cortez, M.D.,c Serge Uzan, M.D.,b and Emile Darai, M.D., Ph.D.b a
b
Department of Radiology, Hoˆpital Tenon, 4 rue de la Chine, 75020 Paris, France Department of Obstetrics and Gynecology, Hoˆpital Tenon, 4 rue de la Chine, 75020 Paris, France c Department of Pathology, Hoˆpital Tenon, 4 rue de la Chine, 75020 Paris, France Received 26 May 2003
Abstract Tumor-like enlargement of the ovaries due to accumulation of edema fluid within the ovarian stroma is referred to as massive ovarian edema (MOE). The pathogenesis of MOE is thought to be intermittent torsion of the ovary on its pedicle, causing partial obstruction of venous and lymphatic drainage. The diagnosis of MOE is based on imaging techniques. The case described here due to ovarian lymphatic vessel obstruction by carcinoma cells shows that metastatic disease may be a cause of MOE. © 2003 Elsevier Inc. All rights reserved.
Introduction Tumor-like enlargement of the ovaries due to accumulation of edema fluid within the ovarian stroma is referred to as massive ovarian edema (MOE) [1]. MOE is thought to result from intermittent torsion of the ovarian pedicle, hindering venous and lymphatic drainage [1]. Preoperative diagnosis of MOE by sonography and/or magnetic resonance imaging has been reported [2–5], together with its conservative management [6]. We report the first case of massive ovarian edema following obstruction of ovarian vessels by carcinoma cells from gastric carcinoma.
Case report A 35-year-old woman (gravida 2, para 1) was referred with a 3-month history of nausea and vomiting and an episode of acute right pelvic pain. She had been amenorrheic for 2 months and was on medication for 8 weeks for a gastroduodenal ulcer diagnosed by gastroscopy. A systematic gastric biopsy was performed but remained noncon* Corresponding author. Service de Radiologie, Hoˆpital Tenon, 4 rue de la Chine, 75020 Paris, France. Fax: ⫹33-1-56-01-64-02. E-mail address:
[email protected] (M. Bazot). 0090-8258/$ – see front matter © 2003 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2003.08.016
tributive. Physical examination revealed large palpable masses in the lower abdomen, together with uterine bleeding and androgenic manifestations (hirsutism). Laboratory findings were normal, including  HCG ⬍3, carcinoembryonic antigen 0.7 ng/ml (normal 0 –3 ng/ml). The LH, FSH, E2, prolactin, progesterone, and testosterone levels were also normal. CA 125 was moderately increased to 145 U/ml (normal 0 –35 U/ml). Transabdominal and transvaginal Doppler sonography showed a right adnexal mass of 18 cm; the echotexture was homogeneous, except for a small cyst. A left posterior echogenic mass of 10 cm was also found and contained an echogenic structure resembling a luteal cyst (Fig. 1). Sonography also revealed an echogenic vesselcontaining tubular structure measuring 29 mm, between the right mass and the uterine cornua. The presence of peritoneal fluid in the pouch of Douglas was noted. Doppler examination revealed the presence of flow in the left mass and decreased flow in the right mass. Computed tomography showed no arterial vessels during the arterial dynamic phase (20 s after the start of the bolus injection) but late accumulation of contrast medium within the two masses and thickening of the right fallopian tube (4 min after the start of the bolus injection). No abnormalities were detected in the upper abdomen. Together, the sonographic and CT findings suggested massive ovarian edema. We then obtained transaxial and sagittal MR images with a 1.5-T superconducting
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Fig. 1. Transvaginal sonography shows a left posterior ovarian echogenic mass of 10 cm containing an echogenic structure resembling a luteal cyst.
system equipped with a four-element torso phased-array multicoil. Breath-hold flash 2D images with and without fat saturation and breath-hold fast T2-weighted images (true FISP) were performed. MR showed two massively enlarged ovaries (right, 160 ⫻ 140 ⫻ 115 mm; left, 100 ⫻ 100 ⫻ 80 mm). The ovaries were slightly hypointense relative to muscle on T1-weighted sequences and isointense to urine on fast T2-weighted sequences (Fig. 2). The presence of a peripheral circumscribed hyperintense area on fat-sat suppression T1-weighted sequences of both ovaries was suggestive of luteal cysts. A corkscrew-like structure with an isointense signal on T1- and T2-weighted images was seen on the lower lateral part of the right ovary, in keeping with the edematous right fallopian tube. Laparoscopy performed 4 h after diagnosis revealed bilateral ovarian enlargement due to massive edema. The right ovary was huge, soft, and fluctuate, twisted on its pedicle, and exuded a watery fluid (Fig. 3). The right ovary shrank immediately on detorsion. No torsion of the left edematous ovary was seen. Fluid was found in the abdominal–pelvic cavity. Surgical findings were in keeping with the preoperative diagnosis of MOE, and conservative management, without wedge biopsy of the ovaries, was chosen, as the woman wished to conserve her childbearing potential. Fifteen days after surgery, sonography and MR imaging showed that the right and left ovaries measured 10 and 5 cm, respectively. Pain resolved within 1 month, and the patient’s general status improved. Management consisted of clinical and sonographic follow-up only. Anechoic cysts were subsequently detected on both ovaries. Doppler sonography showed flow within both ovarian masses. Three months later, the patient was readmitted for acute pelvic pain. Sonographic and MR imaging showed that the left ovary had again increased in size to 16 cm, while the size of the right ovary remained stable. Laparotomy was performed because of persistent pain and asthenia and showed huge bilateral
Fig. 2. Sagittal fast T2-weighted MR (true FISP sequence) showing two massively enlarged ovarian masses which has a signal similar to that of urine.
ovarian tumors (Fig. 4). Bilateral adnexectomy was performed, and a right edematous ovarian fibroma was diagnosed on multiple frozen sections. The final histologic diagnosis was ovarian edema secondary to venous and
Fig. 3. Laparoscopy shows a huge right ovary, twisted on its pedicle.
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Fig. 4. Pathological specimen showing an enlarged white ovary.
lymphatic involvement by carcinoma cell clusters. A new gastroscopy with multiple biopsies yielded a diagnosis of gastric linitis. A chemotherapy regime was performed. The patient died 6 months later of sepsis subsequent to pancytopenia.
Discussion The diagnosis of MOE is mainly based on imaging techniques. Although most of the reported patients with MOE have been treated by oophorectomy, the condition should be managed conservatively [1]. In the present case, as in previous reports, sonography showed large bilateral solid ovaries containing cystic structures that mimicked follicular cysts and varied in number and size during followup. The utility of Doppler sonography for diagnosing adnexal torsion has been reported [7], but, as previously underlined by Pena et al. and confirmed here, Doppler flow can be normal [7]. In contrast, the presence of an echogenic tubular structure between the uterine borders and an adnexal mass is suggestive of adnexal torsion [8]. MR in patients with ovarian torsion shows deviation of the uterus, ascites, and protrusion of the lesion on the
twisted side [9]. All these features were observed in the present case. As adnexal torsion is a surgical emergency with nonspecific clinical findings, MR or CT may be useful when ultrasound is inconclusive. The MR aspect of MOE has been reported in only three cases, based on standard T1and T2- or TSE T2-weighted images [2–5]. In the current case, like the TSE T2-weighted sequences, flash 2D and true FISP sequences showed the two pelvic masses containing hemorrhagic cysts, thickening of the right tube related to torsion, and pelvic ascites. These rapid sequences are thus useful in pelvic emergencies. Many authors have reported that MOE can be diagnosed by MR, offering the option of conservative management with a detorsion and ovarian suspension procedure [4,5]. However, the case described here, together with the few previous reports of MOE due to ovarian lymphatic vessel obstruction by carcinoma cells, shows that metastatic disease may be a cause of MOE [6]. A systematic ovarian biopsy should be performed to rule out differential diagnosis and to avoid potential medicolegal issues. The persistence or early recurrence of adnexal masses with imaging features of MOE may point to a malignant process. References [1] Clement PB. Book. In: Kurman RJ, editor. Nonneoplastic lesions of the ovary. 4th ed. New York: Springer-Verlag; 1995, p. 597– 645. [2] Lee AR, Kim KH, Lee BH, Chin SY. Massive edema of the ovary: imaging findings. Am J Roentgenol 1993;161:343– 4. [3] Hall BP, Printz DA, Roth J. Massive ovarian edema: ultrasound and MR characteristics. J Comput Assist Tomogr 1993;17:477–9. [4] Kramer LA, Lalani T, Kawashima A. Massive edema of the ovary: high resolution MR findings using a phased-array pelvic coil. J Magn Reson Imaging 1997;7:758 – 60. [5] Umesaki N, Tanaka T, Miyama M, Nishimura S, Kawamura N, Ogita S. Successful preoperative diagnosis of massive ovarian edema aided by comparative imaging study using magnetic resonance and ultrasound. Eur J Obstet Gynecol Reprod Biol 2000;89:97–99. [6] Young RH, Scully RE. Fibromatosis and massive edema of the ovary, possibly related entities: a report of 14 cases of fibromatosis and 11 cases of massive edema. Int J Gynecol Pathol 1984;3:153–178. [7] Pena JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril 2000;73: 1047–1050. [8] Ghossain MA, Buy JN, Bazot M, Haddad S, Guinet C, Malbec L, Hugol D, Truc JB, Poitout P, Vadrot D. CT in adnexal torsion with emphasis on tubal findings: correlation with US. J Comput Assist Tomogr 1994;18:619 – 625. [9] Kimura I, Togashi K, Kawakami S, Takakura K, Mori T, Konishi J. Ovarian torsion: CT and MR imaging appearances. Radiology 1994; 190:337–341.
