B. Meigs syndrome
Discussion
Figure 1 - CT chest, abdomen and pelvis (Coronal image) – Red arrow
shows right sided pleural effusion and blue arrow shows bilateral
ovarian masses. Minimal amount of intraperitoneal fluid also seen.
Figure 2 – CT of chest (axial image) – Red arrow re-demonstrates the large right sided pleural effusion in Figure 1
This patient was ultimately diagnosed with Meigs’ syndrome, which
refers to the association of an ovarian fibroma or granulosa cell tumor
with ascites and/or pleural effusion (1). In contrast, Pseudo-Meigs
syndrome, refers to the association of ascites and/or pleural effusion
with an ovarian tumor that is not a fibroma [choice C is incorrect].
Pseudo – Meigs could be due to a benign or malignant tumor . “Ovarian
hyperstimulation syndrome occurs in the setting of an exaggerated
ovarian response to fertility treatments resulting in ascites” [choice A
is incorrect]. Luteinized thecoma is a benign tumor sometimes
associated with sclerosing peritonitis causing large ascites [choice D
is incorrect].
Given this patient’s advanced age, persistent symptoms and recurrence
of her effusion, a CT scan of chest, abdomen and pelvis was ordered to
rule out malignancy. Imaging showed a right sided pleural effusion, mild
ascites and bilateral ovarian masses. Gynecological oncology was
consulted. A CA 125 was ordered which was elevated up to 163 u/ml. She
underwent hysterectomy and bilateral salpingo-oophorectomy. Histologic
examination of the bilateral ovarian masses showed ovarian fibroma.
Thus, the patient was diagnosed with Meigs’ syndrome. The patient’s
clinical manifestations subsided after removal of the tumor and she
remained asymptomatic during subsequent follow-up visits over the course
of several months.
Meigs’ syndrome is a benign condition which can mimic an ovarian
malignancy (2). The fluid accumulation is probably related to substances
like vascular endothelial growth factor that increase capillary
permeability (3). Removal of the tumor results in symptomatic relief in
patients(1). There are many case reports that have described the
association of Meigs’ syndrome with elevation of the tumor marker CA 125
(4). The patient mentioned in this case also had an elevated CA 125
despite the fact that her tumor was ultimately determined to be benign.
Thus, in a post-menopausal female with a pelvic mass, the association
of ascites, pleural effusion or elevated CA-125 may not always indicate
an advanced ovarian cancer. Surgery and histopathologic examination are
crucial because pathology aids in both diagnosis and treatment.
References
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Meigs JV. Fibroma of the ovary with ascites and hydrothorax; Meigs' syndrome. Am J Obstet Gynecol. 1954;67(5):962-85.
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Brun JL. Demons syndrome revisited: a review of the literature. Gynecol Oncol. 2007;105(3):796-800.
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Ishiko O, Yoshida H, Sumi T, Hirai K, Ogita S. Vascular endothelial
growth factor levels in pleural and peritoneal fluid in Meigs' syndrome.
Eur J Obstet Gynecol Reprod Biol. 2001;98(1):129-30.
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Timmerman D, Moerman P, Vergote I. Meigs' syndrome with elevated
serum CA 125 levels: two case reports and review of the literature.
Gynecol Oncol. 1995;59(3):405-8.