Giant Ovarian Tumour CEZAR LAURENTIU TOMESCU1,3 , GABRIELA STANCIU2 *, TEODOR STEFAN NITU3 , MADALINA BOSOTEANU3 , RODICA SIRBU4 , DRAGOS MARIAN BREZEANU3 , ANETA TOMESCU1,3 * 1 Ovidius Unive rsity of Constanta, Faculty of Me dicine , 1 Unive rsitatii Alle y, 900470, Constanta, Rom ania 2 Ovidius Unive rsity of Constanta, De partm e nt of Che m istry and Che m ical Engine e ring, 1 Unive rsitatii Alle y, 900470, Constanta, Rom ania 3 Se cond De partm e nt of Obste trics and Gyne cology, County Clinical Em e rge ncy Hospital Sf. Apostol Andre i, 145 Tom is Blvd., 900591, Constanta, Rom ania Abdom inal-pe lvic m asse s are an im portant part of the fe m ale pe lvic pathology. The y can be long e ithe r to the ute rus, ovarie s or the fallopian tube s. The m ain sym ptom s are re pre se nte d by abdom inal and pe lvic pain, and in ce rtain case s significant abdom inal diste nsion. The se can som e tim e s be accom panie d by se condary sym ptom s, according to the ne arby organs involve d. He re in, we pre se nt the case of a 42-ye arold patie nt with an im pre ssive ovarian tum our m ass (50kg). Ke ywords: m ucinous ovarian tum our, ovarian cance r, borde rline tum our, inhibin, CA-125, CA 19-9 Ova ria n tu m o u rs re p re se n t a n in c re a sin gly m o re fre que nt pathology in re ce nt ye ars. Re fe rring strictly to m alignant ovarian m asse s, the se have an incide nce of a p p ro xim a te ly 239.000 c a s e s p e r ye a r w o rld w id e , accounting for 152.000 de aths annually [1]. In th e US, a p p ro xim a te ly 21.290 n e w c a s e s a re re giste re d e ach ye ar, with a ye arly de ath rate of 14.180 [2]. By contrast, China re giste rs approxim ate ly 52.100 ne w case s e ach ye ar, 22.500 of the m le ading to de ath [3]. A histological variant is re pre se nte d by the m ucinous ovarian tum our, which can e ithe r be be nign, borde rline or m alignant [4]. Borde rline tum ours re pre se nt approxim ate ly 10-20% of all ovarian tum ours [5]. Until 2004, m ucinous ovarian tum ours we re conside re d a s be longing to the e pithe lia l ova ria n tum ours group. Nowadays, the y are conside re d a se parate group and are sim ply calle d m ucinous ovarian tum ours [6,7]. Borde rline tum ours have the highe st incide nce of all m ucinous tum ours, re pre se nting up to 67% of this type of tum our [8]. Expe rime ntal part Case pre se ntation 42-ye a r-old pa tie n t D.F pre se n ts to th e Em e rge n c y De partm e nt of the County Clinical Em e rge ncy Hospital Sf. Ap. Andre i Constanta on the 20th of April 2017, com plaining of inte nse abdom inal and pe lvic pain for approxim ate ly 24 hours, as we ll as progre ssive e nlarge m e nt of the abdom e n ove r the pre vious ye ar. Fro m th e p a tie n t’s m e d ic a l h isto r y, w e n o te o n e pre gnancy de live re d via Cae sare an-se ction in 1994 and a m iscarriage at 7 w e e ks’ ge stational age . Patie nt de nie s any othe r he alth issue s, alcohol consum ption or cigare tte sm oking. Clinical e xam ination re ve als e nlarge d, te nse abdom e n, painful upon palpation. We ighing of the patie nt re ve als a we ight of 105kg. Pe lvic and spe culum exam ination do not re ve al any pathological abnorm alitie s. An abdom inal ultrasound is perform ed on the 20th of April 2017, which re ve als a giant tum our m ass occupying the entire abdom en with dim ensions of 50/70/60cm , stretching from the xiphoid proce ss to the pubic sym physis and both flanks of the abdom e n. An inhom oge ne ous aspe ct of the * e m ail: GSTANCIU@univ-ovidius.ro, Phone : +40241600488; tom e scu.ane ta@gm ail.com , Phone : + 40 722 331 961 REV.CHIM.(Bucharest) ♦ 70 ♦ No. 11 ♦ 2019 Fig. 1. Pre ope rative aspe ct Fig. 2. Pre ope rative aspe ct m ass is obse rve d, with a pre dom inance of hype re choic conte nt. Base d on the clinical exam ination, laboratory te sting and im agistic re sults it is de cide d to adm it the patie nt to the 2nd De partm e nt of Obste trics and Gynae cology with the follow ing dia gnosis: Volum inous a bdom ina l-pe lvic tum oural m ass. A CT scan is also pe rform e d in the sam e day, re ve aling an abdom inal and pe lvic cystic m ass m e asuring 35/41/52 cm , a ppa re ntly a tta che d to the broa d liga m e nt of the u te ru s , w h ic h c o m p re s s e s th e in te s tin a l lo o p s , th e pancre as, the sple nic and supe rior m e se nte ric ve ins and the right ure te r, aspe ct com patible with an ovarian se rous cystade nom a. In w hat re gards laboratory te sting, w e note a ROMA score of 22.47%, com patible with an incre ase d risk for an e pithe lial ovarian cance r. Pre ope rative laboratory te sting showe d m ild anae m ia (Hb= 10.5g/dl), the re m ainde r of te sts be ing within norm al lim its. Re s ults and dis cus s io ns Su rgic a l in te rve n tio n s a re p e rfo rm e d b y a m ixe d gynae cology-ge ne ral surge ry te am 25th of April 2017. Upon ope ning of the pe ritone a l ca vity, a gia nt w hite pe a rly tum oura l m a ss, w ith thin w a lls a nd inta ct ca psule , of approxim ate ly 60/40/45cm is note d. The capsule is incise d All authors are conside re d m ain authors with e qual contributions http://www.revistadechimie.ro 3957 Fig. 6. Intraope rative m acroscopic aspe ct of the intracystic e xophytic le sions Fig. 3. Skin le ve l incision Fig. 4. Macroscopic aspe ct of the tum our afte r e vacuation of 40l of se rous fluid and 40 litre s of liquid are aspirate d, of which a sam ple is pre se rve d for cytological exam ination. Left adnexe ctom y and right salpinge ctom y is pe rform e d. Sam ple s are se nt to in tra o p e ra tive fro ze n s e c tio n e xa m in a tio n w h ic h established the diagnosis of m ucinous proliferative ovarian tum our. The final diagnosis w ill be ce rtifie d by paraffin histopathology e xam ination. Intraope rative froze n se ction e xam ination Cystic transform ation of the ovary with a diam e te r of 40 centim etres, with m icroscopic lesions com patible with the dia gnosis of borde rline m ucinous cysta de nom a of the ovary - atypical cystic m ucinous tum our. Microscopic de scription Borde rline m ucinous cystade nom a of the ovary (figure s 7,8) which pre se nts, at the strom al le ve l, foci com prising glandular structure s w ith archite ctural com ple xity and e xpansile patte rn, line d by m ultistratifie d e pithe lial ce lls w ith m ode ra te cytonucle a r a typia , m itotic a ctivity a nd m inim al/abse nt strom al inte rposition (figure s 9, 10, 11); the diam eter of the described lesional areas varies between 3-5 m m . Th e a d ja c e n t stro m a re ve a ls d e sm o p la stic appe arance (figure 12). Lym pho-vascular and pe rine ural invasion we re not ide ntifie d. The le sions are accom panie d by areas of hem orrhagic necrosis, vascular throm bosis and chronic inflam m atory infiltrate ; the oute r surface of the ovary is not affe cte d. All of the above -m e ntione d histological e le m e nts are com pa tible w ith the dia gnosis of a typica l prolife ra tive m ucinous tum our of the ovary, gastro-inte stinal type , with m icroinvasion - e xpansile patte rn. Fig 7. Borde rline m ucinous ovary cystade nom a Hae m atoxylin Eosin stain X100 Fig. 5. Postope rative aspe ct - e xce ss skin tissue During surge ry, the patie nt re ce ive d 2 units of re d ce lls and fre sh froze n plasm a. Postope rative e volution of the patie nt was favourable and she was discharge d on the 3rd of May 2017. Post surgical we ight of the patie nts was 55 kg, the patie nt having lost a total of 50 kg as a re sult of surge ry. Discharge laboratory testing is within norm al lim its, with the e xce ption of a m ild hypochrom ic m icrocytic anae m ia, for w hich she w as re com m e nde d tre atm e nt w ith iron supple m e nts. Final histopathological e xam ination and im m unohistoche m istry Final histopathological e xam ination Macroscopic de scription Ope n and draine d cystic m ass with a diam e te r of 40 ce ntim e tre s, wall thickne ss of 0.3cm , with a sm ooth, white gre yish e xte rnal surface . The inte rnal surface pre se nts 3 e xophytic le sions, of 6/3.5/2.5 cm , 4.5/3/1 cm and 3/2.5/ 1.5 cm respectively, grey pink in colour, with haem orrhagic are as, of slightly de cre ase d consiste ncy, friable . 3958 http://www.revistadechimie.ro Fig 8. Borde rline m ucinous ovary cystade nom a Hae m atoxylin Eosin stain X200 Fig 9. Microinvasion foci Hae m atoxylin Eosin stain 200X REV.CHIM.(Bucharest)♦ 70♦ No. 11 ♦ 2019 Fig 10. Microinvasion foci Hae m atoxylin Eosin stain 100X Fig 11. Microinvasion foci Hae m atoxylin Eosin stain 100X Im m unohistoche m istry Ova r y fra gm e n ts s h o w in g tu m o ra l p ro life ra tio n com pa tible w ith borde rline m ucinous tum our/a typica l p ro life ra tive m u c in o u s tu m o u r w ith m ic ro in va s io n , accom panie d by hae m orrhagic and ne crotic are as. Table 1 IMMUNOHISTOCHEMISTRY Im m u n o h is to c h e m is tr y, c o r re la te d w ith h is to pathological exam ination and anatom ical and clinical data support the dia gnosis of borde rline m ucinous ova ria n tum our/atypical proliferative m ucinous tum our of the ovary, with m icroinvasion. Postope rative follow-up Since the surgical inte rve ntion and up to the pre se nt m om e nt, the patie nt is followe d-up e ve ry 6 m onths by the oncologist, which e ntails the dosing of CA-125 and inhibin as we ll as abdom inal and pe lvic CT scans. The last two native and contrast CT scans pe rform e d on the 17th of January 2019 and 18th of July 2019 re spe ctive ly, show no signs of local or re gional re lapse . The m ain sym ptom of m ucinous ovarian tum ours is re pre se nte d by pa in. This is pre se nt in up to 42.7% of patie nts [9]. In what re gards laboratory te sting, CA-125 alone is le ss use ful in discove ring m ucinous ovarian tum ours. In orde r to diagnose this type of tum our, CA19-9 is m ore use ful [10]. CA-125 has a se nsitivity rate of 51.9% for the diagnosis of m ucinous tum ours a nd up to 68.2% in e pithe lia l nonm ucinous tum ours. CA19-9 has a spe cificity rate of 51.5% in se rous tum our and up to 44.7% in m ucinous tum ours [11]. In the postope rative pe riod, the com bine d dosing of CA125 and CA19-9 has shown a m uch highe r se nsitivity in long te rm follow-up com pare d to CA-125 alone [10]. The association be twe e n CA-125 and HE4, known as the ROMA score has a highe r se nsitivity com pare d to CA125 [12]. A 2016 study pe rform e d by Su We i has shown a m uch highe r se nsitivity of the ROMA score in de te cting ovarian tum ours com pare d to CA-125 alone [13]. REV.CHIM.(Bucharest) ♦ 70 ♦ No. 11 ♦ 2019 Fig 12. Microinvasion foci Hae m atoxylin Eosin stain 200X A high spe cificity in the postope rative follow -up of a p a tie n t d ia gn o se d w ith o va ria n m u c in o u s tu m o u r is re p re se n te d b y th e a sso c ia tio n b e tw e e n CA-125 a n d inhibin. Inhibin is a horm one involve d in ovarian fe rtility, which de cre ase s significantly in m e nopause . An incre ase in inhibin during m e nopause is associate d with ovarian m ucinous tum ours [14]. In order to support the diagnosis, im agistic investigation, such a s a bd om ina l or tra nsva gina l ultra sound ca n be pe rform e d. Ultrasound e xam ination can atte st, according to the characte ristics of the tum oural m ass, the be nign or m alignant fe ature s of the m ass [15]. In ovarian dysge rm inom a, which is a ge rm ce ll tum our, the prognosis is favourable , e ve n without radical surge ry. [16] Inve stigations of a highe r re liability, such as CT scans or MRI c a n b e u s e d b o th b e fo re s u rge r y a n d d u rin g postope rative follow-up. MRI e xam ination can asse ss the sta rting point of the tum oura l m a ss a nd ca n a id in its m orphologic characterization, thus influencing therapeutic approach [17]. Co nclus io ns The particularitie s of the pre se nte d case re ly in the size and we ight of the tum our, with the patie nt having lost 50kg afte r the surgical inte rve ntion. Postope rative e volution was favourable and follow-up is pe rform e d by a m ixe d gynae cologist-oncologist te am e ve ry 6 m onths through the dosing of inhibin and CA-125, transvaginal ultrasound exam ination and abdom inal-pelvic CT scan, which have , thus far, shown no sign of re lapse . Re fe re nce s 1. REID, B.M., PERMUTH, J.B., SELLERS, T.A., Cance r Biol Me d., 14 , no. 1, 2017, p. 9. 2. Am e rican Cance r Socie ty. Cance r Facts &am p; Figure s 2015. Atlanta: Am e rican Cance r Socie ty, 2015. 3. CHEN, W.Q., ZHENG, R.S., BAADE P.D., ZHANG, S.W., ZENG H.M., BRAY F., CA Ca nce r J Clin., 66 , 2016, p. 115. 4. BROWN, J., MICHAEL FRUMOVITZ,M., Curr. Oncol. Re p., 16 , no. 6, 2014, p. 389. 5. SUH-BURGMANN, E., Gyne col Oncol., 103, 2006, p. 841. 6. FRUMOVITZ, M., SCHMELER, K.M., MALPICA, A., SOOD, A.K., GERSHENSON, D.M., Gyne col Oncol., 117, 2010, p. 491. 7. HESS, V., A’HERN, R., NASIRI, N., J. Clin. Oncol., 22, 2004, p. 1040. 8. 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SAYASNEH, A., EKECHI, C., FERRARA, L., KAIJSER, J., STALDER, C., SUR, S., TIMMERMAN, D., BOURNE, T., Int. J. Oncol., 46 , no. 2, 2015, p. 445. 16. TOMESCU, A., MOCANU, L., BREZEANU, D., STANCIU, G., SIRBU, R., TOMESCU, C., Re v. Chim . (Buchare st), 70 , no. 5, , 2019, p. 1731. 1 7 . FO TI, P.V., ATTINA, G. , SPADOLA, S. , CALTABIANO , R., FARINA, R., PALMUCCI, S., ZARBO, G., ZARBO, R., D’ARRIGO, M., MILONE, P., ETTORRE, C.E., Insights Im aging., 7, no. 1, 2016, p. 21. Manuscript re ce ive d: 4.11.2019 3960 http://www.revistadechimie.ro REV.CHIM.(Bucharest)♦ 70♦ No. 11 ♦ 2019