International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 164-168

Case Report: Ovarian feigning carcinoma in a young female: a rare case presentation Dr. Kandukuri Mahesh Kumar , Dr. Swarupa Ravuri, Dr. Sudhir Kumar Vujhini, Dr. V. Indira Name of the Institute/college: Department of Pathology , Malla Reddy Institute of Medical Sciences, Suraram , Hyderabad ,Andhra Pradesh , India Corresponding author : Dr. Kandukuri Mahesh Kumar

ABSTRACT Ovarian fibroma is a stromal (mesenchymal) tumor, which accounts for 4%- 5% all ovarian tumors. It usually occurs in patients beyond 40 years of age. Ovarian tumors in childhood and adolescence are rare, accounting for approximately less than 1% of all malignant in the age range of 0-18 years. Ovarian are rare in women below 20 years of age, constituting about 4% of all ovarian neoplasms . Ovarian fibromas usually present as unilateral, solid, hard masses with a smooth to bosselated external surface. Most of the ovarian fibromas are benign in nature. Meig’s Syndrome constitute ovarian fibromas in association with ascites and hydrothorax. Hysterectomy with bilateral Salpingo-oophorectomy can be considered in perimenopausal or postmenopausal women, and ovariectomy or unilateral salphingo-oopherectomy only can be performed in young women. Surgical removal of these solid ovarian tumors is recommended to prevent occurrence of malignancy . We report a rare case of ovarian fibroma occurring in a 20 year old young female with elevated CA 125 levels. KEY WORDS: Ovarian fibroma, CA-125, Mesenchymal tumor.

INTRODUCTION CASE REPORT Ovarian fibroma is a stromal (mesenchymal) tumor, A 20-year-old female presented to the out-patient which accounts for 4% of all ovarian tumors. It department with complaints of pain and heaviness in usually occurs in patients beyond 40 years of age. the left lower abdomen for the past one and half year Ovarian fibromas usually present as unilateral, solid, that had suddenly increased during the 5 days prior to hard masses with a smooth to bosselated external reporting to the hospital. She gave a history of surface. Edematous ovarian fibromas are soft in increased menstrual flow with passage of clots in the consistency and cyst formation is common in such last few months. She also complained of fever, tumors. The cut surface shows homogenous grey vomiting, constipation, increased frequency of white whorled appearance and may show occasional micturition, decreased appetite , weight loss , areas of calcification and long standing cases may lethargy and fatigability since last 20 days. Patient also show cystic change. Majority of the ovarian attained menarche at the age of 14 years, regular fibromas are benign in nature, until and unless periods 3-5/28 days, scanty flow. Her general proved. Large fibromas are associated with ascites physical examination was normal . An abdominal and hydrothorax known as Meig’s Syndrome. We examination showed a 12-13 weeks size, tender report a rare case of ovarian fibroma occurring in a supra-pubic mass arising from the pelvis localized to young female with elevated CA 125 levels. the left iliac region. Per vaginal examination revealed

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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 164-168 an irregular, firm mass. Haematomogy and 2 x 0.5 cm. Fallopian tube measuring 1.5 cm length. biochemical parameters were within normal limits The ovarian mass was well circumscribed, well except CA 125 levels. The patient’s blood CA-125 encapsulated and external surface smooth. Cut- levels were raised to 135 U/ml (normal < 35 U/ml). section of the ovarian mass showed homogenous grey Clinical presentation and laboratory investigations white, whorly appearance. There were no areas of pointed towards provisional clinical diagnosis of papillary projections, necrosis or hemorrhage. On malignant and left salpingo-oophe- gross examination the provisional histopathology rectomy was planned. diagnosis was a benign ovarian tumor. (FIGURE 1) RADIOLOGICAL FINDINGS MICROSCOPIC FINDINGS An abdominal ultra-sonography revealed a left On microscopic examination, multiple sections taken ovarian mass measuring 7.2 x 5.8 x 4.2 cm – Features from the ovarian mass revealed tumor tissue are suggestive of benign ovarian tumor, possibility of composed of spindle shaped cells arranged in ovarian fibroma .The right and uterus were fascicles and bundles with uniform oval to elongated unremarkable. bland nuclei and scant cytoplasm. There are areas of Left salpingo-oophorectomy was done and specimen edema and hyalinization in between the tumor tissue. sent for histopathological examination. Multiple sections were evaluated to rule out any PATHOLOGICAL FINDINGS focus of epithelial differentiation. GROSS FINDINGS Impression : Histological features suggestive of Received left sided ovarian mass measuring 7.5 x 6 x Fibroma ovary. (FIGURE 2,3,4) 4 cm, ovary compressed to one side measuring 2.5 x

FIGURE 1 FIGURE 2

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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 164-168

FIGURE 3 FIGURE 4

Figure (1) showing the gross picture of ovarian fibroma with ovary compressed to one side. Figure (2 & 3) showing the low power view of the a benign diagnosis (3) . Spinelli, et al (4) also reported a tumor tissue arranged in bundles and fascicles with case of benign ovarian fibroma with elevated CA-125 few areas of hyalinization. Figure (4) showing the levels. In our case, there was a strong clinical, and high power view of the tumor tissue with spindle serological suspicion of malignancy, but left shaped cells, scant cytoplasm and oval to elongated salphingo-oopherectomy was planned keeping in bland nuclei. view the age of the patient. Intra-operatively the DISCUSSION swelling appeared to be of benign nature. Post- Ovarian fibromas are stromal/ mesenchymal tumors operatively patient’s CA-125 level fell to 18 U/ml composed of spindle, oval or round cells producing within 9 weeks of surgery. The present case report collagen (1) . Fibromas are usually solid , oval to emphasizes the rare presentation of ovarian fibroma spherical, slightly lobulated, well circumscribed, in a young female and also reinforces the non grey-white mass covered by a glistening, intact specificity of CA-125 as a marker of ovarian capsule . Fibromas most frequently occur during malignancy. It beckons us to re- evaluate the middle age, with an average age being 45 years . presumption that thorough clinical examinations Ovarian fibromas are benign tumors. Surgical supported by laboratory investigations and imaging removal of these solid ovarian tumors is modalities are fool proof in themselves. recommended because of the low probability of Histopathological diagnosis plays a major role in malignancy (2) . CA-125 as an ovarian carcinoma differentiating benign and malignant tumors based on tumor marker has been suggested as a valuable tool the cell morphology. to assist in distinguishing between benign and ASSOCIATED FEATURES RELATED TO malignant neoplasms. Unfortunately, it has not OVARIAN FIBROMAS proved to be a reliable predictor of as • Ascites and hydrothorax are seen in the normal values do not exclude the presence of cases where the size of fibroma exceeds 10 carcinoma and elevated levels can be associated with cm diameter.

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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 164-168

• Incidence of Meig’s syndrome is 1 % of all oophorectomy can be considered in perimenopausal ovarian fibromas. or postmenopausal women, and ovariectomy or • Meig’s syndrome is the triad of ovarian unilateral salphingo-oopherectomy only can be fibroma with ascites and pleural effusion. performed in young women. Surgical removal of Pleural effusion and ascites resolve with these solid ovarian tumors is recommended to (2) successful resection of the ovarian tumor. prevent occurrence of malignancy . • Ascites is sometimes present, and the serum CONCLUSION CA 125 level increase, which may lead to Ovarian fibromas are uncommon but are the most the mistaken diagnosis of a malignant tumor common benign solid tumors of the ovary. They of the ovary (5,6). constitute about 4% of all ovarian tumors. • Meig’s suggested that the production of Gynecologists should be aware of this type of tumor ascites is due to irritation of the peritoneal because of the difficulties in diagnosis. This tumor is surfaces by a hard, solid ovarian tumor (7,8). often misdiagnosed as a uterine myoma in • CA-125 as an ovarian carcinoma tumor ultrasonographic findings and is sometimes mistaken marker has been suggested as a valuable tool for a malignant tumor of the ovary, because of its to assist in distinguishing between benign solid nature, increased tumor marker levels, and and malignant neoplasms. Unfortunately, it accompanying ascites. However, ovarian fibromas has not proved to be a reliable predictor of are benign and can be treated completely by surgical ovarian cancer as normal values do not removal, and laparoscopic surgery can be an effective exclude the presence of carcinoma and and safe alternative approach. This case is presented elevated levels can be associated with a in a view of highlighting a rare case of ovarian benign diagnosis (3). fibroma in an unmarried 20 yr old female with Surgery is the recommended treatment for ovarian elevated CA-125 levels. fibroma. Hysterectomy with bilateral Salpingo-

REFERENCES 1. Tavassoli FA, Mooney E, Gersell DJ, et al. Sex-Cord Stromal Tumors In: World Health Organisation Classification of Tumors, Pathology and Genetics of Tumors of the Breast and Female Genital Organs. Lyon, France: IARC Press; 2003, 149-51. 2. Leung SW, Yuen PM. Ovarian fibroma: A review on the clinical characteristics, diagnostic difficulties and management option in 23 cases. Gynecol Obstet Invest 2006;62:1.6. 3. Walker JL, Manetta A, Mannel RS, Shu-Yuan L. Cellular fibroma masquerading as ovarian carcinoma. Obstet Gynecol 1990;76:530. 4 Spinelli C, Gadducci A, Bonadio AG, Berti P, Micolli P. Benign ovarian fibroma associated with free peritoneal fluid and elevated serum CA 125 levels. Minnerva Ginecol 1999;51:403.7. 5 Sivanesaratnam V, Dutta R, Jayalakshmi P, Ovarian fibroma–clinical and histopathological characteristics-Int J Gynecol Obstet. 1990;33:243–247.

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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 164-168

6 Patsner B. Meigs syndrome and “false positive” preoperative serum CA-125 levels: analysis of ten cases. Eur J Gynecol Oncol-2000; 21:362–363 7 Meigs JV. Fibroma of the ovary with ascites and hydrothorax; Meigs’ syndrome. Am J Obstet Gynecol-1954; 67:962–85. 8 Terada S, Suzuki N, Uchide K, Akasofu K. Uterine leiomyoma associated with ascites and hydrothorax, Gynecol Obstet Invest-1992;33:54–8.

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