Meigs' syndrome with elevated serum cancer antigen 125 levels in a case of ovarian sclerosing stromal tumor

ObjectiveMeigs’ syndrome presenting as an ovarian tumor with elevated serum cancer antigen 125 (CA 125) levels is unusual. Only 37 cases have been reported, including three cases of ovarian sclerosing stromal tumor (SCT). Many reports have suggested that the presence of ascites is the major factor inducing mesothelial expression of CA 125.Case ReportAn 18-year-old woman presented with massive ascites, elevated serum CA 125 levels, and radiographic evidence of ovarian tumor. The histological and immunohistochemical examinations revealed a benign SCT.ConclusionSCT is a benign ovarian tumor and complete excision is curative. We also review all 37 cases and discuss possible mechanisms of Meigs’ syndrome and elevated serum CA 125 level.     

Pseudo-Meigs syndrome and elevated CA125 associated with struma ovarii

BACKGROUND: Struma ovarii is a rare form of ovarian neoplasm composed entirely and predominantly of thyroid tissue. The association of pseudo-Meigs syndrome, elevation of CA125 and hyperthyroidism to struma ovarii is a rare condition. CASE: We report an unusual presentation of a postmenopausal woman with benign struma ovarii associated with pseudo-Meigs syndrome, hypertiroidism, and elevated CA125 serum level, and a large complex right pelvic mass thereby mimicking an ovarian cancer. CONCLUSIONS: Struma ovarii is a rare cause of ascites, hydrothorax, elevated CA125, and hyperthyroidism. This rare condition should be considered in the differential diagnosis in patients with ascites and pleural effusions but with negative cytology.     

Struma ovarii showing clinical characteristics of ovarian malignancy

Struma ovarii is a rare form of ovarian neoplasm, composed entirely or predominantly of thyroid tissue and generally a benign germ cell tumor of the ovary. Ascites have been reported in approximately 15-20% of all cases. However, the combination of struma ovarii and elevated CA125 has rarely been reported. We experienced a rare case of a postmenopausal woman with benign struma ovarii associated with massive ascites, a complex pelvic mass. There was marked elevation of her CA125 level. The clinical impression was ovarian malignancy. Surgical excision of the ovarian mass induced immediate resolution of the ascites and a normalization of the serum CA125 level. No recurrence of the ascites or of the tumor has been observed during the 10-month follow-up. Struma ovarii can mimic ovarian malignancy clinically, particularly if complex and associated with ascites and an elevated CA125 level.     

Ovarian Thecoma Associated with a Large Quantity of Ascites and Elevated Serum CA 125 and CA 15-3

Background: Elevation of tumour marker CA (cancer antigen) 125 associated with Meigs’ or atypical Meigs’ syndrome is widely recognized. Other tumour markers are available to assist in distinguishing between benign and malignant ovarian masses in the preoperative diagnosis.Case presentation: A 57-year-old woman presented with a suspicious pelvic mass and abundant ascites. Preoperative tumour markers CA 125 and CA 15-3 were elevated at 1750 U/mL and 60 U/mL, respectively. The woman underwent surgery, and 9 L of straw-coloured ascites were drained along with a solid-cystic ovarian mass. The final pathology disclosed an ovarian thecoma. Six months later, both tumour markers were normal.Conclusion: This first report of 2 elevated tumour markers associated with atypical Meigs’ syndrome cautions us not to rely on tumour markers to differentiate benign from malignant masses.     

Mesovarian hemangioma presenting as massive ascites, pelvic mass, and elevated CA125

Abstract.   Abu J, Brown L, Ireland D, Sizeland E. Mesovarian hemangioma presenting as massive ascites, pelvic mass, and elevated CA125. Int J Gynecol Cancer 2006; 16(Suppl. 1): 412–414.
We present the case of a 48-year-old woman with pelvic mass, ascites, and an elevated CA125 mimicking advanced-stage ovarian cancer. She underwent laparotomy, drainage of ascites, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and infracolic omentectomy. Histology confirmed this to be mesovarian hemangioma, a benign condition.     

Peritoneal tuberculosis with pelvic abdominal mass, ascites and elevated CA 125 mimicking advanced ovarian carcinoma: A series of 10 cases

Abstract. Bilgin T, Karabay A, Dolar E, Develioğlu OH. Peritoneal tuberculosis with pelvic abdominal mass, ascites, and elevated CA 125 mimicking advanced ovarian carcinoma.
Ten patients with peritoneal tuberculosis who were operated on for suspected advanced ovarian cancer during a 5-year period were analyzed. These 10 cases constituted 1.4% of the 728 new gynecologic cancer cases diagnosed and treated at our department during the same time period. Data were obtained from patients' files and pathology reports. The mean age of cases was 40.6 ± 6.1 (median 37; range 18–72). Ascites was present together with ill-defined nodularities or thickening in the Douglas pouch and/or in the adnexal areas on pelvic examination in all patients but three, who presented with well-demarcated adnexal masses of about 5 cm in diameter. All patients had elevated serum CA 125 levels with a median of 331 U/ml, (40–560 U/ml). Ultrasound and abdominopelvic CT examinations revealed omental and mesenteric thickening in addition to ascites in all patients, cystic ovarian masses or ovarian enlargement in five, and peritoneal implants in two. Abdominal paracentesis performed in the six cases in whom the findings were felt to be most inconclusive for the diagnosis of ovarian cancer revealed clear exudative fluid with benign cells. Mycobacteria could not be demonstrated on direct preparations. Tuberculosis was diagnosed at laparotomy in all. Patients received antituberculous therapy and serum CA 125 levels returned to normal within 2 months after the beginning of treatment. This case series demonstrates a high rate of misdiagnosis between advanced ovarian cancer and peritoneal tuberculosis. Whereas abdominal paracentesis is useless in ruling out peritoneal tuberculosis, and serum CA 125 levels are not helpful in the differential diagnosis, the latter marker may be useful in the follow-up of patients.     

Struma Ovarii Presenting as Acute Pseudo-Meigs Syndome with an Elevated CA125 Level

Summary: A 62-year-old woman presented with acute hydrothoraces and ascites. The CA 125 level was greatly elevated and pelvic ultrasound revealed an adnexal mass with solid and cystic components. At surgery a benign pure struma ovarii was diagnosed and following removal of the tumour the patient had immediate and complete resolution of her symptoms. This is the first report of struma ovarii causing both pseudo-Meigs syndrome and a marked elevation of CA 125.     

Coexistence of struma ovarii with marked ascites and elevated CA-125 levels: case report and literature review

Introduction  Struma ovarii is a rare form of ovarian neoplasm and consists mainly of thyroid tissue. Ascites has been reported in approximately one-third of all the cases. However, the combination of struma ovarii and elevated CA-125 has rarely been reported. Materials and methods  We described a case of benign struma ovarii, presenting with the clinical features of ovarian cancer: large complex pelvic mass, gross ascites and markedly elevated serum CA-125 levels. Surgical excision of the ovarian mass was followed by rapid resolution of the ascites and reduction of the serum CA-125 level. Conclusion  Struma ovarii can mimic ovarian malignancy clinically, when presented with ascites and an elevated CA-125 level.     

Pseudo-Meigs' syndrome caused by a hydropic degenerating uterine leiomyoma with elevated CA 125

BACKGROUND: Uterine leiomyomas rarely cause pseudo-Meigs' syndrome with elevated serum CA 125 levels. CASE: A 39-year-old patient with a large uterine leiomyoma is described. The associated massive ascites, pleural fluid, and increased CA 125 level all seemed to be related to the uterine tumor. Hydropic degenerating leiomyomas are characterized by focal accumulation of edema and collagen deposition. Marked degrees of hydropic degeneration may have resulted in cystic degeneration, leading to large myometrial cysts. A presumed direct relation between the abundance of intratumoral fluid and presence of ascites seemed justified. The increased level of CA 125 most probably resulted from the peritoneal mechanical irritation from the large leiomyoma or from a large volume of ascites. Having accumulated a sufficient volume and pressure, the ascites finds it way through the diaphragm through intercellular gaps and diaphragmatic apertures, as well as through small bilateral areas where muscular tissue of the diaphragm is replaced by areolar tissue, resulting in the presence of pleural fluid. CONCLUSION: The pathophysiology of a uterine leiomyoma mimicking a pelvic malignancy is described.     

Meigs' syndrome with high blood levels of CA 125. Clinical case and review of the literatureø

A case of Meigs' syndrome is reported. The patient presented with: hydrothorax, ascites, benign ovarian tumor (thecoma) and increased serum levels of CA 125. Ovarian thecoma is a rare tumor, accounting for less than 1% of all ovarian tumors. When associated with Meigs' syndrome, it can produce a clinical picture similar to that of ovarian carcinoma, but the prognosis is much more favourable. The condition was managed by bilateral salpingo-oophorectomy and hysterectomy. The ascites and hydrothorax disappeared spontaneously after removal of the ovarian tumor and CA 125 level decreased.     

Struma ovarii associated with pseudo-Meigs' syndrome and elevated serum CA 125: a case report and review of the literature

The association of pseudo-Meigs' syndrome, elevation of CA 125 to the struma ovarii is a rare condition. So far only nine cases have been reported in English literature through MEDLINE search. Here we report a 46-year-old case of the struma ovarii, presented with ascites, hydrothorax, right ovarian mass and elevated serum CA 125 level. These findings were misdiagnosed for an ovarian malignancy at the first impression. Immediate resolution of the ascites, hydrothorax and normalization of the serum CA 125 level were followed by ovarian mass removal. Struma ovarii could be a rare cause of ascites, hydrothorax, ovarian mass and elevated CA 125. This rare condition should be considered in the differential diagnosis in patents with ascites and pleural effusions but with negative cytology.     

Meigs' syndrome with elevated CA125: case report and review of the literature

A 51-year-old woman presented with acute ascites and hydrothorax is reported. Pelvic ultrasound showed two pelvic solid masses and serum CA125 level was elevated (577 IU/ml). Pathology revealed bilateral ovarian fibromas. We present this case of Meigs' syndrome and discuss its diagnostic problems and a review of the literature.     

Guidelines for referral of the patient with an adnexal mass

Gynecologists have to differentiate between benign and malignant adnexal masses. We review the evidence supporting to the specialty care of a gynecologic oncologist on the basis of the physical examination, imaging studies, family history, and CA 125 determination. We recommend adherence to the ACOG/SGO Joint Opinion guidelines. Specifically, referral to a gynecologic oncologist seems warranted for postmenopausal women with elevated CA 125, nodular or fixed pelvic mass, metastatic disease, ascites, or family history of breast or ovarian cancer. Premenopausal women should be referred if the CA 125 is elevated above 200 U/mL, there is an evidence of metastatic disease or ascites, or strong family history of breast or ovarian cancer.     

Elevated CA125 level associated with Meigs' syndrome: case report and review of the literature

Abstract.   Morán-Mendoza A, Luna GA, Ruiz GC, Olvera AS, López Graniel CM, Rincón DG. Elevated CA125 level associated with Meigs' syndrome: case report and review of the literature. Int J Gynecol Cancer 2006; 16(Suppl. 1): 315–318.
Meigs' syndrome is the association of ovarian fibroma, pleural effusion, and ascites. Meigs' syndrome with marked elevation of CA125 is an unusual clinical condition reported in 27 cases in the literature. The patient was a 46-year-old woman with right pleural effusion, ascites, ovarian tumor, and CA125 level of 1808 U/mL. Tomography revealed ascites and bilobate pelvic tumor of approximately 25 cm. The diagnosis of advanced epithelial ovarian cancer was considered, and the patient was treated with chemotherapy. Three chemotherapy schemes were applied due to the total lack of response in tumor volume; however, CA125 decreased to 90 U/mL. Thus, surgery was performed with resection of 25 cm of the left ovarian tumor, with intact capsule and without implants; the result of histopathologic analysis was fibroma. Postoperative CA125 was 11 U/mL. Patients with elevated CA125 and ascites cytology positive for malignancy must be cautiously treated due to the possibility of false positives, even if the probability is low. Therefore, minimally invasive surgery for biopsy collection must be considered. Although the association between ovarian tumor, pleural effusion, ascites, and marked elevation of CA125 is highly indicative of epithelial ovarian cancer, Meigs' syndrome must be considered in the differential diagnosis.     

Evaluation of CA 125 levels in differentiating malignant from benign tumors in patients with pelvic masses

Serum CA 125 levels were assayed from 44 normal healthy women, 153 patients with benign pelvic masses, and 58 patients with malignant pelvic masses. CA 125 levels were less than 35 U/mL in 42 of the 44 normal women and were greater than 35 but less than 65 U/mL in the other two women. Among 153 patients with benign pelvic masses, CA 125 levels greater than 35, 65, or 194 U/mL were detected in 61 (39.9%), 31 (20.3%), and eight (5.2%) patients, respectively. Of 58 patients with malignant pelvic masses, CA 125 results were greater than 35, 65, or 194 U/mL in 48 (82.8%), 45 (77.6%), and 38 (65.5%), respectively. Among the latter group, the positivity rates of 30 patients with epithelial ovarian cancers were 100, 93, and 80%, respectively. This study suggests that defining positive serum CA 125 levels as those greater than 35 U/mL is of limited clinical value because there is a 39.9% false-positive rate in patients with benign disease. However, serum CA 125 values greater than 65 U/mL may be considered positive in clinically normal women. Serum CA 125 greater than 194 U/mL, representing the units at the 95th percentile for 153 patients with benign pelvic masses, is defined as a new positivity criterion, and could be used to differentiate malignant tumors from benign pelvic masses.     

A patient presenting with a pelvic mass, elevated CA-125, and fever

BACKGROUND: Tuberculous peritonitis is a rare event which can mimic advanced stage ovarian cancer. A pelvic mass and an elevated CA-125 is suggestive of an ovarian malignancy; however, benign conditions may be discovered, especially in the premenopausal patient. CASE: A patient with a pelvic mass, ascites, and an elevated CA-125 underwent an exploratory laparotomy for presumed ovarian cancer. Final pathology revealed pelvic tuberculosis without any pulmonary involvement. Acid-fast bacilli were confirmed with polymerase chain reaction in the surgical specimen. DISCUSSION: Pelvic tuberculosis is an uncommon gynecologic condition that presents with ascites, a pelvic mass, and fever. An elevated CA-125 is not specific for ovarian malignancy.     

Ovarian cancer identified through screening with serum markers but not by pelvic imaging

Abstract. Woolas RP, Oram DH, Jeyarajah AR, Bast RC Jr, Jacobs IJ. Ovarian cancer identified through screening with serum markers but not by pelvic imaging.
This study evaluated the possible role of 3 additional tumor markers to CA 125 among postmenopausal volunteers participating in a sequential multimodal ovarian cancer screening study. In 82 asymptomatic women the finding of a serum CA 125 level of > 30 U/ml precipitated pelvic ultrasound examination. Levels of CA15–3, CA72–4 and CA19–9 were subsequently determined in sera stored from the time of the CA 125 assay. Following ultrasound 29 women underwent surgery for benign conditions. The remaining 53 women underwent 2 years of surveillance. In 5 of these women a diagnosis of ovarian cancer was established between 6 and 10 months after their initial investigation. Elevated levels of at least one of the 3 additional tumor markers were present in the serum, prior to ultrasound abnormalities being detected, in 4 (80%) of the women who developed cancer. At least one of this 3-marker panel was elevated in 29% of the 48 women who have not developed cancer and 14% of the 29 women undergoing surgery for benign conditions. Information complementary to pelvic ultrasound examination for the preclinical detection of ovarian cancer could be obtained through multiple marker assay. Coordinated elevated serum levels of tumor markers could increase the sensitivity of this sequential screening protocol.     

Preoperative evaluation of serum CA 125 levels in patients with primary epithelial ovarian cancer

Serum CA 125 levels were measured preoperatively in 100 women undergoing diagnostic laparotomy for palpable adnexal masses. All 11 patients with frankly malignant nonmucinous ovarian carcinoma had serum CA 125 levels greater than 35 U/mL and nine of the 11 had serum CA 125 levels greater than 65 U/mL. If patients with mucinous and borderline lesions were included, serum CA 125 was greater than 35 U/mL in 11 of 18 and greater than 65 U/mL in nine of 18 patients. Among 14 individuals with pelvic masses and CA 125 greater than 65 U/mL, 13 had some form of gynecologic malignancy. These results suggest that CA 125 assay can be used as a diagnostic adjunct for discriminating benign from malignant pelvic masses.     

Benign ovarian fibroma associated with free peritoneal fluid and elevated serum CA 125 levels

This paper reports the clinical case of a patient with ovarian neoplasia, ascites effusion, and elevated serum CA 125 levels (411 U/ml). This condition simulated a malignant pathology on the grounds of preoperative diagnostic examinations. Surgical investigation diagnosed an ovarian fibroma and ascites. Ascites was resolved rapidly and the serum CA 125 levels decreased after surgical neoplasia removal. An ovarian neoplasia associated with ascites effusion and elevated serum CA 125 levels (also in the presence of suspect ecographic and tomographic features) do not necessarily imply a malignant neoplasia.     

Preoperative serum tumor-associated antigen levels in women with pelvic masses

Preoperative sera were assayed for tumor-associated antigens CA 125, TAG 72, and CA 15-3 in 100 women with pelvic masses. Serum CA 125 levels were elevated above 65 U/mL in 83% of 42 patients with ovarian malignancies, in 58% of 12 patients with nonovarian malignancies, and in 17% of 46 patients with benign pelvic masses. Elevations of TAG 72 and CA 15-3 levels occurred less frequently in all groups of patients. Serum CA 125 levels distinguished most effectively between patients with malignant pelvic masses and those with benign pelvic masses, having a sensitivity of 78% and a specificity of 83% at a threshold level of 65 U/mL. When comparing 33 patients with epithelial ovarian carcinomas to 46 patients with benign masses, the CA 125 level alone yielded a sensitivity of 88% with a specificity of 83%. Coordinate elevations of CA 125 (above 65 U/mL) and TAG 72 (above 10 U/mL) or CA 15-3 (above 30 U/mL) distinguished ovarian epithelial carcinomas from benign masses with a sensitivity of 73% and a specificity of 98%, which improved to 81 and 100%, respectively, among patients over 50 years of age. Given the marked increase in specificity observed with this panel of three serum tumor-associated antigens, use of multiple markers might facilitate screening for ovarian carcinoma and appropriate referral of patients with pelvic masses for cytoreductive operations.