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A Rare Case of Torsion Ovarian Fibroma
eMediNexus,  30 March 2019
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#Obstetrics and Gynecology

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Abstract

Ovarian fibroma is a benign solid tumor, which accounts for 1-4% of ovarian neoplasms. This is commonly seen in postmenopausal women. A 40-year-old para 3 live 3, who had undergone tubectomy and was having regular cycles, was admitted to our hospital with pain abdomen and a 16 weeks pelvic mass. Preoperatively, she was misdiagnosed as pedunculated fibroid with torsion. On table, she was found to have ovarian fibroma with torsion. Total abdominal hysterectomy with bilateral salpingo-ovariotomy was done. Ovarian fibroma cannot be diagnosed accurately in preoperative period. Excision of tumor is the treatment of choice.

Keywords

Ovarian fibroma, postmenopausal women, pedunculated fibroid, torsion, abdominal hysterectomy, bilateral salpingo-ovariotomy

Introduction

Ovarian fibroma is a type of sex cord cell tumor of ovary. It is a solid tumor which accounts for 1-4% of benign ovarian tumors.1 This tumor commonly occurs in elderly patients, 80.9% were above 40 years and 40.9% were postmenopausal.2 Rarely, it is reported in young females as Gorlin syndrome (ovarian fibroma with nevoid basal cell carcinoma).3 Sometimes it is associated with ascites and pleural effusion, when it is known as Meigs’ syndrome. It is difficult to diagnose preoperatively; may be misdiagnosed as uterine myoma or if it is associated with ascites it may be mistaken for ovarian malignancy.

We are reporting one such case of ovarian fibroma operated with misdiagnosis of uterine myoma with torsion.

Case Report

 

A 40-year-old para 3 live 3, who had undergone tubectomy and was having regular cycles, was admitted to Mandya Institute of Medical Sciences, Mandya, Karnataka with pain in the lower abdomen, on and off, since 1 week and which became more severe since past2 days. Patient was conscious and oriented, afebrile, pallor was present, pulse - 94 beats/min and blood pressure (BP) - 100/70 mmHg.

On abdominal examination, a firm and irregular pelvic mass of 16 weeks size was palpable per abdomen. Bimanual examination revealed a pelvic mass of 16-18 weeks, irregular in shape, firm in consistency and tender. Other systemic examinations were normal. Ultrasound pelvis showed a normal-sized uterus with solid mass of 12 × 9.0 × 8.0 cm? Pedunculated fibroid; right side ovary was not seen and left ovary showed a small cyst of 3 cm. Urine pregnancy test was negative, chest X-ray was normal, USG abdomen was normal with no ascites.

Preoperatively a diagnosis of a pedunculated subserous fibroid with torsion/ovarian cyst with torsion was made. Her hemoglobin (Hb) was 8.2 g/dL and since pain was increasing after admission

she was planned for emergency laparotomy.Peroperatively, uterus of parous size with a right- sided solid ovarian mass of 15 × 10 × 10 cm was seen with torsion three times around itself, and appeared inflamed. There was no ascites (Fig. 1 a and b).

Left ovary revealed a cyst of 3 × 3 cm size; total abdominal hysterectomy with bilateral salpingo-ovariotomy was done. Postoperative period was uneventful and the patient was discharged on 7th postoperative day.

Histopathology report shows single grey-brown mass 14 × 12 × 10 cm cut section shows solid grey-brown to dark-brown hemorrhagic areas. Microscopy section from ovarian mass showed features of fibroma with hemorrhage consistent with torsion (Fig. 2).

Discussion

Ovarian fibromas account for 1-4% of ovarian neoplasms; 10-15% of these are associated with ascites and 1% have both ascites and pleural effusion.4 Ovarian fibromas are seen in middle-aged women, largely asymptomatic unless they undergo torsion. They are solid ovarian tumors and they are benign, so detection of fibroma is important to decrease patient anxiety and unnecessary extensive surgical procedure. Ovarian fibromas cannot be diagnosed accurately either clinically or by ultrasound.5 Magnetic resonance imaging (MRI) is an excellent modality for detection of ovarian fibroma as they enhance less than myometrium and fibroids.6

In rare cases, carcinoembryonic  antigen-125  may  be raised.7 But ovarian fibroma is a benign tumor with extremely low malignant potential. It may be misdiagnosed as uterine fibroma, torsion ovarian cyst, ectopic pregnancy and ovarian malignancy. Development of ascites is attributed to inefficient lymphatic drainage through small-sized pedicle and lack of real tumor capsule to the tumor and hydrothorax is secondary to ascites due to transdiaphragmatic passage.8

Treatment is excision of tumor by open or laparoscopic surgery, and life expectancy is same as in general population. Laparoscopy can be a diagnostic tool in detection of tumor and for resection of tumor or for ovariotomy. It can be converted into laparotomy in malignant cases.2 Complete resolution of ascites and pleural effusion takes place after surgery. In young patients with Gorlin syndrome, ovarian preservation can be done by resecting only fibroma.3

Conclusion

 

Ovarian fibromas are benign tumors accounting for 1-4% of ovarian neoplasms, seen in elderly patients, generally asymptomatic and cannot be diagnosed accurately preoperatively; excision of tumor is the choice of treatment.

References

 

  1. Chechia A, Attia L, Temime RB, Makhlouf T, Koubaa Incidence, clinical analysis, and management of ovarian fibromas and fibrothecomas. Am J Obstet Gynecol. 2008;199(5):473.e1-4.
  2. Son CE, Choi JS, Lee JH, Jeon SW, Hong JH, Bae Laparoscopic surgical management and clinical characteristics of ovarian fibromas. JSLS. 2011;15(1):16-20.
  3. Ball A, Wenning J, Van Eyk N. Ovarian fibromas in pediatric patients with basal cell nevus (Gorlin) J Pediatr Adolesc Gynecol. 2011;24(1):e5-7.
  4. Abad A, Cazorla E, Ruiz F, Aznar I, Asins E, Llixiona Meigs’ syndrome with elevated CA125: case report and review of the literature. Eur J Obstet Gynecol Reprod Biol. 1999;82(1):97-9.
  5. Najmi Z, Mehdizadehkashi A, Kadivar M, Tamannaie Z, Chaichian S. Laparoscopic approach to a large ovarian fibroma: a case J Reprod Infertil. 2014;15(1):57-60.
  6. Shinagare AB, Meylaerts LJ, Laury AR, Mortele KJ. MRI features of ovarian fibroma and fibrothecoma with histopathologic AJR Am J Roentgenol. 2012;198(3):W296-303.
  7. Morán-Mendoza A, Alvarado-Luna G, Calderillo-Ruiz G, Serrano-Olvera A, López-Graniel CM, Gallardo-Rincón Elevated CA125 level associated with Meigs’ syndrome: case report and review of the literature. Int J Gynecol Cancer. 2006;16 Suppl 1:315-8.
  8. Nigam A, Jain S, Lal Twisted ovarian fibroma mimicking as an ectopic pregnancy. J Case Rep. 2013;3:64-7.
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