Accepted: Received: yahoo.com Dr_aminimoghaddam@ E-mail: Iran Valiasr Square, Tehran, of MedicalSciences, Hospital, Iran University Department, Firoozgar Gynecology Soheila Aminimoghadam, * CorrespondingAuthor: cheal patients. Some patientsmisinterpret young and menstrual irregularitiesmay occur inmenar- duce pressuresymptomsrectum, onthebladderor - GynecologyOncologyDepartment,Iran Un Soheila Aminimoghaddam Ovarian Malignant Mixed Ge lated and subacute pelvicpainre- are characterizedby an tumors, germ cellmalignanciesrapidly grow nant (1). germmalig- cellorigin,andone-thirdoftheseare ades of life,almost 70% of ovarian tumors areof these tumors aremalignant.dec- Inthe firsttwo plasms areofgerm about3% of cellorigin,only crosis. as MolarPregnancy In contrasttotheslow-growingepithelialovari-

25% to Although20 dial germthe ovary. cellsof ermfromprimor- celltumorsare derived the to

The

capsular May. May. 5, 2015 Aug. 4, 2015 Aug. 4,

of

rapidly

all

benign

distention Introduction

enlarging

and Reprod Infertil. 2016;17(2):133-136. 2016;17(2):133-136. Infertil. Reprod Malignant Mixed : ACase of Unusual Presentation as . J cite thisarticle:To VAC, Yolksactumor Keywords: inthediagnosis. which canleadtoadelay oplasmthose ofpregnancy as Conclusion: ovary. phosphamide (VAC)regimentwo cour in imen in fourcourses and ,Actinomycin D () andCyclo- reg- (BEP) and received , tumoral she mass.Finally, tumor histologicalexam wasconfirmedby af MRI done mass CTand wasconfirmedby ultrasound exam,massExtra-uterine anextra-uterineheterogeneous wasfound. normal and no molar tissue was found in pathologic examination. Atintraoperative tive. Assuctioncurettagewasperformed for previous ultrasonic reportsandpositive pelvic mass examination. inphysical The fi Abdominalmolar pregnancy. enlargement Case Presentation: pregnancy. mixedcell tumor,presented asmolar germ Background: Abstract * , Iman Mohseni, Azadeh Afzalzadeh, Shooka Esmaeeli

malignant (2),

pelvic

hemorrhage

BEP, , Germ cell tumor, Molar pregnancy, Tumor marker,

mass J Reprod Infertil. 2016;17(2):133-136 Infertil. 2016;17(2):133-136 Reprod J Some patientsmisinterpret symptoms young theearly ofanovarianne- iversity of Medical

ovarian neo- This researchwasconductedtointr rm CellTumor: ACaseof

may AminimoghaddamS, Mohseni I,Afzalzadeh A,Esmaeeli OvarianSh.

. The patient was a 16 year old woman old admitteda 16year of Thepatientwas withdiagnosis or ne-

pro- Sciences, Tehran,Iran immature (80%), EST (Endodermal SinusTumor) (70%), components of suchtumors asdysgerminoma cell tumors. Literaturereports the most common contain ovarian malignancies. Mixedgerm celltumors of These ovariantumorsfor about1% account indiagnosis. whichcanleadtoadelay pregnancy symptomsa neoplasmof of the early asthose of cases(3). %75 could beseenin or withoutpelvicpainthat ovarian germ celltumors isabdominal painwith mostalso the commonpresenting symptomin mon combination isdysgerminomaand andEST carcinomaThe mostcom-and embryonal (16%). Endodermal Sinus Tumors occurinpatientswith β

at eta HCG. Urine pregnancy testwasposi- eta HCG. Urinepregnancy ses and Diphereline for saving the other for savingthe ses andDiphereline rst diagnosiswas dueto molar pregnancy was the only complaint. Shehadalarge was theonly

least ination after laparatomy and removingafter laparatomy and ination her, surprisingly, the size of uterus was thesizeofuterus her, surprisingly, ter suction curettage. Mixed germcell ter suctioncurettage.

two UnusualPresentation oduce apatientwithrareovarian

(%53) components ,

of

malignant germ Case Report

(20%)

,

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134 of molar pregnancy was seen by hysteroscopy. of hysteroscopy. was molarseen by pregnancy evidence and innormalsize. No uterus wasempty with the diagnosis of butthe molar pregnancy ogist’s firstdiagnosiswasmolar pregnancy. HCG thegynecol- and diagnosisof sonography, wasnormal.right ovary mass wasnotseenbut in uterusandleft ovary 9.4 was test wasnormalbut Hb function and kidney omy, it rised to 918.Serum biochemistry forliver adnexal mass(ovarian). or abnormaldue tonormal (mole) pregnancy and uterus oradnexalwasnotpossible. pelvis but thedifferentiationbetweenenlarged and in bimanual exam, amass was palpablein and inspeculum examination, cervixwasnormal pelvic examination, externalgenitaliawasnormal pated withoutguardingorreboundtenderness.In huge mass from pubistoumbilicus couldbepal- lor inconjunctiva.Onabdominal examination, a pal- stable butwith vital signwas tion wasgood, size. dominal circumference ab- menstrualsudden increasein retardationand 3 months.Her complaintwas dation forabout agoandcameabout 1 year withmenstrual retar- sonic reportsandpositive agnosis ofmolar pregnanc to FiroozgarhospitalinSeptemberdi- 2013with (Bleomycin, EtoposideandCisplatin). with combinationBEP , preferably of the tumor. Theselesionsshouldbemanaged HCG, both orneitherdependingoncomponents germ cell tumors may secreteeither Mixed IV (5%)(3). occur atstage fewcases only and stage;stageI(75%) early cur atarelatively germsion and/orrupture.Ovarian celltumorsoc- domen ab- mately, 10%ofpatientspresentwithanacute mass isdocumentedApproxi- in10%ofpatients. 75% of patients,whereasanasymptomatic pelvic most frequent initialsymptom, occurringinabout time of diagnosis. Abdominal orpelvic pain isthe third ofthepatientsareinpre-menarche ageatthe a median ageof (4).Aboutone- 16 to18 years

JRI Suction curettage and hysteroscopy weredone Suction curettage and hysteroscopy Due to retardedmenstruation andpositive revealed(4)asolidcystic Ultra sonography β Differential diagnosis was the enlargeduterus examination,In her physical heroverallcondi- nulliparous womanreferred old, was The 16year eta HCG was622

mg/dl

A Case of Unusual Presentation as Molar Pregnancy Molar as Presentation Unusual A Case of secondary . Case Presentation

to

intracapsular J Reprod Infertil, Vol 17, No 2, Apr-Jun 17, No 2016 2, Infertil, Vol Reprod J mIU/ml β duetopreviousultra- y eta HCG. She marriedeta HCG.She andpriortolaparot-

hemorrhage, tor-

α FP, β β eta eta

of theovariangermcelltumor 1. Figure ovarian germcelltumor 2. Figure ures 1and2).Omentumfree oftumor.was histological examination(Fig- were reportedby dodermal Sinus Tumor andembryonal carcinoma tumresected. were done. Some lymph nodeslessthan2 toneal exploringandinfracolicomentectomywere ture. Unilateralsalpingooophorectomy, retroperi Tumoral massremovedrup- was intact without and 300 left ovary tumors,performed. was fetoprotein: more than1000 137/1 to37), CA125: HCG=622 distinct leftovary. anterior wallofuterusbutitwasnotpossibleto massto adjacent ters) abdominaland cystic solid pelvic MRI showedalarge(17*16*10centime- and extra-uterine. Abdominalpelvic CT-scan and seemedbe huge masswas revealed, to nation, a and proliferativeendometrium. report was notneoplastictissue,molar tissue Endometrial andthe tissue wassent for pathology BEP regimenpa- is suggestedin chemotherapy Mixed germ celltumor withcomponents ofEn- A large necroticmass 20*12*6 Therefore, withthediagnosisofmixed germ cell Serum tumor markerswere measured as abdominalexami-In intra-operative ultrasound Pathology report, embryonal carcinomacomponent report,embryonal Pathology Pathology report, yolk sac tumorcomponentofthe report,yolk Pathology mIU/ml , CA19-9:131/4 ml mIU/ml bloody ascites were found. ascites were bloody mIU/ml (up to 35),andalpha cm (upto5/5). arisingfrom cm mIU/ml inomen- (up β eta

Downloaded from http://www.jri.ir mg/m 20 given tothepatientasfollows:Bleomycin BEPregimenwas ovary, preservation ofright tine 1 β the were received therapy patient afternegative by of VACregimenchemo-HCG <5).Twocourses were bothdecreasedtonormal measurement ( chemotherapy, courses of ter 4 Af- ) wasgiven. mycin Dand with VAC therapy regimen (Vincristine,Actino- morechemo- two coursesof Bleomycin toxicity, regimen,chemotherapypreventing withBEP for of four courses 3 weeks×4.After 1-5q daily just inafewcasereports(6). reported dermalrare and SinusTumor(EST) are HCG. reports and positive duetoultrasonic nancy mors (5). Second,itwas presenting asmolar preg- least common (16%)component of germ celltu- Tumorcarcinomathe andembryonal whichis tumors withcomponents ofEndodermalSinus causes. First, itwas a rarecase of mixed germ cell months foratleast2years. tumor markers monthly and CT scanning each3 under observation andfollow up withchecking daily×5. of one dose of Diphereline 3/75 dose of of one tients withgerm celltumor.administration After origin. Mildascitesisalsoseen is ovary but left is evident, ovary lesion. Right favoring nonuterine sagittal MRimages, necrotic zone.Uterusis obvi centrally and at periphery, solid andenhancing The massis uterus, with anterior tothe Figure 3.

daily×5, andCyclophosphamide 500 daily×5, IV daily 1-5q3 weeks×4, Cisplatin20 IV daily eta HCG due to BEP regimen Vincris- toxicity, Cases of mixed embryonal carcinoma andEndo- different importantreported for This caseis tobe About 6 months after surgery, thepatientwas About 6months aftersurgery, 2 mg/m IV day 1q 3 weeks×4,Etoposide100 IV day CTandMRimages show ahugepelvicmass,just 2 IV day 1,Actinomycin 0.5 IVday Discussion upward extension to the abdomen. to the upward extension obscured, suggesting leftovarian ously separatedfromthemasson ously

α FP and mg for fertility fertility for mg/m β mg/m mg/m eta HCG mg/m J Reprod Infertil, Vol 17, No 2, Apr-Jun 17, No 2016 2, Infertil, Vol Reprod J 2 2 β β 2 IV IV IV eta eta 2

Aminimoghaddam S,et al. ng/ml levels, rangingfrom1000 >100tofarhigherthan Sinus Tumorelementselevated serum have el andimportant. nov- which makethis case inliterature pregnancy reports of germ cell tumors presentingasmolar (7). which make thediagnosisacomplicated process symptoms canhavedifferent but molar pregnancy isabnormalpregnancy va within theendometrium(8). echoes solid collectionof of aheterogeneous is described assnowstorm appearance,consisting moleultrasonographic appearanceofacomplete classic diagnosis. The top of at the was pregnancy the positive with cavity uterine massreported in heteroechoic was a cystic liparous patients(7). about 29% of molar pregnancies are among nul- first, thepatientwasnulliparousand pregnancy; CHT several methods preservationbefore offertility used chemotherapeutics (12).Inwomen, thereare of somecommonlythe action by tion, particularly is the ovary result of primordial folliclesdestruc- damagethe Functional to ovary. with justone (POF) which become more important inthiscase ovarian damage andpremature ovarianfailure negative consequence of chemotherapy (CHT)is patient management, itis known thatthefrequent Although chemotherapy isthe principal stepof sults of tumor markers, should be considered(11). re- mors,courses, afternegative otheradditional should beperformed.apy In mixed germ celltu- chemother- 3to4coursesof cell tumors. Usually as BEPchemotherapy arerecommended ingerm latin containingcombinationsuch chemotherapy Cisp- response (10).But GTN hasshowedgood managementline chemotherapy in risk ofhigh tinomycin, VincristinandCisplatinum)first asthe analogues (GrRH-a) during CHT. It is assumedanalogues (GrRH-a)during CHT.Itis ing ovarian damage isth prevent- ing femalefunction andfor reproductive methodsprotect- of the for One cryopreservation. and freezingandovariantissueharvesting embryo or ovarian stimulationand oocyte cessful onesare higher thancommon range(9). Mixed germ celltumorsEndodermal containing many To theauthor’sknowledge,therearenot The most common presentingsymptom inmolar in previous Secondly, patient’s ultrasonicreport, points aremimickingMany this case asamolar EMA-CO

with . Thetiterofserum

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regimen

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outcomes. ginal bleeding(93.5%) β α eta HCG andmolar FP in this case was FP inthiscase

Methotrexate,

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136 agement. ovarian damage CHTintumor man- causedby usage of GnRH-awhichhas a protectiveeffectfor the is tumors. Anotherconclusionofthisstudy mixedchemotherapy regimenfor these germcell good BEP regimenconsidered asa shouldbe whenthereisapelvicmass. sidered especially report, mixed germ celltumor alsoshouldbecon- age whohavepositive should beconsideredinwomen ofreproductive 4. 3. 2. 1. ies (12). in animal models andalso in severalhuman stud- demonstratedfect of GnRH-ahasbeenrepeatedly ef- The protective the CHT. effectsof cytotoxic the less sensitiveto is quiescent (inactive)ovary that, due to the administration of GnRH-a,the

JRI Although thediagnosis The authors have no any conflictofinterest. The authorshavenoany

Sh. CR,PatilT,Chandanwale PM,Gore Pagaro 342 p. oncology. 8th ed.Elsevier Health Sciences; 2012. gynecologic DiSaia PhJ,Creasman Clinical WT. and reviewofliterature. germ cell tumour ofovary--an unusual combination Goyal LD,KaurS,Kawatra K.Malignant mixed Berek JS,HackerNF.& liams& Wilkins; 2009.912p. ic Oncology. 5th ed.NewYork: Lippincott Wil-

A Case of Unusual Presentation as Molar Pregnancy Molar as Presentation Unusual A Case of Conflict ofInterest Conclusion References J Reprod Infertil, Vol 17, No 2, Apr-Jun 17, No 2016 2, Infertil, Vol Reprod J β eta HCG and sonographic eta HCGand J OvarianRes.2014;7:91.

of molar pregnancy of molarpregnancy

’ s Gynecolog-

10. 9. 8. 7. 6. 5. 12. 11.

rence. Gynecol Obstet Invest. 2003;55(1):58-60. el diagnosed asamixed germ cell tumor after recur- inomaslightly with a elevated alpha-fetoproteinlev- Dysgerm-Aoki Y,KaseH,FujitaK,TanakaK. nancies. JUltrasound Med. 1999;18(9):589-94. graphic appearance ofearly complete molar preg- Sono- Lazarus E,HulkaC,SiewertB,LevineD. 3(2):210-4. South-East Nigeria. AnnMed Health Sci Res.2013; in Management Outcomesof in a TertiaryHospital Igwegbe A,ElejeG.Hydatidiform mole: AReview oncology. 6th ed.US: Mosby; 2002.675p. gynecologic Creasman Clinical DiSaia PhJ, WT. 89. ysiscases. Obstet of30 Gynecol.1976;48(5):579- tumorstheA clinical ovary. of and pathologicanal- Kurman RJ,Malignant Norris HJ. mixed germcell of Dr.DYPatilUniv.2013;6(3):298-301. Mixed germ celltumors: two report cases.MedJ of

Gynecol Cancer. 2004;14(2):360-5. in high-riskGTTpatients(stageII-IV).IntJ chemotherapy multipleregimen, agent asfirstline EMA-EP N, etal. N, MoosaviAZ,Khanafshar Ghaemmaghami F, Modares M, Arab M, Behtash Reprod. 2008;23(4):863-8. therapy in Hodgkin lymphoma patients. Hum tion damageanaloguechemo-a GnRH by during J, Smardova L,et al. Prevention ofovarian func- Huser M, Crha I, VentrubaP, Hudecek R,Zakova fallopian tube cancers; p.523-51. kins; 2000. Chapter 12, Non epithelial ovarian and cology. 3rded.UK:Li Berek JS, HackerNF. Practical GynecologicOn-

ppinkot Williams and Wil- ppinkot Williams and

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