Central Medical Journal of Obstetrics and Gynecology

Case Report *Corresponding authors LászlóHodoniczki, Department of Obstetrics and Gynecology, University of Szeged, Hungary. H-6725, Szeged, Semmelweis u. 1, Hungary, Tel: 36-62-545499; Primary Extra Ovarian Fax: 36-62-545711; Email: Submitted: 10 November 2014 Associated with Accepted: 04 December 2014 Published: 05 December 2014 . Case Report ISSN: 2333-6439 Copyright László Hodoniczki*, Alexandra Tóth, and Attila Keresztúri © 2014 Hodoniczki et al.

Department of Obstetrics and Gynecology, University of Szeged, Hungary OPEN ACCESS

Abstract Keywords • Endometriosis Background: To report a rare case of primary extra ovarian dysgerminoma • Malignant transformation associated with endometriosis. • Extra ovarian Case presentation: A 34-year-old woman with known endometriosis had pelvic • Dysgerminoma mass and underwent laparoscopy followed by . The final pathological • Surgery finding was primary extra ovarian dysgerminoma. There was a second operation. The patient got parametrectomy, omentectomy, right salpingectomy, sigma and ileum resection. The and the uterus remained free of disease. She got only one cycle of BEP , because she did not agree to participate in further chemotherapy. She gets now LhRH analogue therapy for endometriosis caused as cites, and she is in good condition. Conclusion: The primary extra ovarian dysgerminoma is rare. There is no evidence on the treatment protocols, but surgery is essential.

ABBREVIATIONS most frequent tumors are endometrioid tumors and endometrial stromal sarcoma (ESS) [3]. ESS: Endometrial Stromal Sarcoma; GnRH: Gonadtropin Releasing Hormone; LHRH: Luteinizing Hormone Releasing Malignant ovarian tumors account for less than Hormone; FNAC: Fine Needle Aspiration Cytology; BEP: 5% of ovarian tumors. The peak incidence occurs in the mid and -- based chemotherapy late teens. are the most frequently occurring malignant . Primary extra genital INTRODUCTION dysgerminoma is rare and mostly occur in young man [4]. Endometriosis is an estrogen-dependent chronic common There is no data found in the literature of dysgerminoma and gynecological disorder in which endometrial tissue (glandular endometriosis. epithelium and stroma) is found at locations outside of the uterine cavity [1]. It affects 15% of women in childbearing age and 2-5% CASE PRESENTATION of postmenopausal women. Its incidence has been improving due A 34-year-old woman presented with left lower abdominal to widely used laparoscopic operations. Although this disease is pain and infertility. In the medical history there were two a benign condition, it has some malignant features, e.g. invasion laparoscopic operations performed at age 30 and 31 due to of other tissues and organs, recurrence, appearance in distant chronic pelvic pain. Results of both operations were histological locations. The etiology is not known, but the widely accepted mechanism is the adhesion and growth of endometrial fragments received GnRH analogue therapy for six months, following deposited into the peritoneal cavity via retrograde menstruation. theconfirmed second endometriosis. operation she remainedAfter the first asymptomatic operation for the 2 patient years. Then came back. The ultrasound was negative. suspected malignant transformation of endometriosis. Since The patient received oral dienogest therapy for 6 months. then,[2]. In several 1925, studies Sampson have was focused the first on the to relationship document a between case of After the therapy the pain improved, control ultrasound endometriosis and gynecological , especially ovarian revealed an inhomogeneous mass of 25x30 mm size in the cancer. Data from large studies indicate that endometriosis pouch of Douglas. There were no further investigations before the operation, like tumor markers and CT or MRI, because the risk of endometrioid and clear cell . All types of patient has endometriosis in the history and it was thought, malignantpatients have tumors an were approximately described in 3-foldectopic significantly endometriosis. higher The that this is a recurrence. We decided to perform a laparoscopy

Cite this article: Hodoniczki L, Tóth A, Keresztúri A (2014) Primary Extra Ovarian Dysgerminoma Associated with Endometriosis. Case Report. Med J Obstet Gynecol 2(4): 1045. Hodoniczki et al. (2014) Email: Central

Table 1: The results of the immunohistopathologic markers. DISCUSSION Immunhistopathologic marker Result CD 10 focalpositive of endometriosis. Patients often have elevated blood CA125 positive concentrations,There is no but specific normal marker HE-4 level. for malignant Imaging does transformation not enable actin negative us to diagnose transformational forms. There are some suspect signs, eg fast-growing endometriomas with size more than CK negative 10 cm. Carcinoma is suggested in case of an exclusively solid Ki 67 5-10% positive mass or detection of papillary excrescences or focal solid areas. CD 30 weakpositive PLAP positive it needs more immune histopathologic examinations. Immuno histochemistryDiagnosing endometriosis-associated is extremely valuable cancersfor determining can be difficult the origin and again. A tumor mass in the Douglas cavity was found. of the tumor [5]. Women most likely represent a different class The operation was converted into laparotomy and removal of of patients than traditional ovarian cancer patients and may the tumor was performed. The intra-operative histopathology require different therapeutic options. The surgical procedure and proposed hematologic , therefore the operation was maximal cytoreduction is necessary. Further therapy depends on the correct histopathologic diagnosis. Some of the symptoms are The CT scan of the showed a heterogeneous mass in the caused by the endometriosis therefore we need to remember regionfinished. of Thethe right final pathologic of 80 resultmm size. confirmed The uterus dysgerminoma. and the left treating these separately from the tumor. Further investigation ovary were normal, there was no lymphadenomegaly. The CT scan must focus on delineating the genetic, immune histochemical of the chest, the bone scintigraphy was without abnormalities. differences between women with endometriosis-associated Tumor maker were done, the NSE and CA-125 were elevated, extra-ovarian and endometriosis-associated ovarian cancer. [4- 16,7ug/l (normal range <16,3) and 72,57 U/ml (normal range 5]. There is no evidence on the treatment options, but the surgery <35,0) respectively, CEA was normal. The patient underwent is essential. a second operation. During surgery extensive adhesions were REFERENCES found. After dissection of the adhesions parametrectomy, omentectomy, right salpingectomy, sigma and ileum resection 1. Somigliana E, Vigano’ P, Parazzini F, Stoppelli S, Giambattista E, Vercellini P. Association between endometriosis and cancer: were performed. The ovaries and the uterus remained free of a comprehensive review and a critical analysis of clinical and epidemiological evidence. Gynecol Oncol. 2006; 101: 331-341. endometriosis with extra genital dysgerminoma. The immune disease. The final pathologic result showed deep infiltrating 2. Munksgaard PS, Blaakaer J. The association between endometriosis histopathology showed vimentin and PLAP positive, actin and CK and ovarian cancer: a review of histological, genetic and molecular negative tumour (Table 1). alterations. Gynecol Oncol. 2012; 124: 164-169. Two years later, following the operation and one cycle adjuvant 3. Booth C, Zahn CM, McBroom J, Maxwell GL. Retroperitoneal müllerian BEP chemotherapy the patient has worsening as cites during carcinosarcoma associated with endometriosis: a case report. Gynecol menstruation, caused by recurrent peritoneal endometriosis. Oncol. 2004; 93: 546-549. She did not agree to participate in further chemotherapy. She is 4. Yoo S , Kim KR, Hong SJ, Cho KJ. Primary retroperitoneal dysgerminoma now receiving LHRH analogue therapy, she is in good physical presenting as an adrenal tumor: a case report and literature review. condition, has amenorrhea, and has FNAC and cytologically Pathol Int. 2011; 61: 248-251. documented recurrent disease in the abdominal wall. The last 5. Benoit L , Arnould L, Cheynel N, Diane B, Causeret S, Machado A, Collin F. Malignant extraovarian endometriosis: a review. Eur J Surg Oncol. no unequivocal tumorous lesion in the and abdomen. 2006; 32: 6-11. abdominal MRI showed some fluid in the abdominal cavity with

Cite this article Hodoniczki L, Tóth A, Keresztúri A (2014) Primary Extra Ovarian Dysgerminoma Associated with Endometriosis. Case Report. Med J Obstet Gynecol 2(4): 1045.

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