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A Rare Case of Torsion Ovarian Fibroma

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Dr Pradeep Musale Ramamchandra, Dr Lalitha Shivanna, Dr Mamatha Siddappaji    24 November 2017

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 past 2 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 Temine RB makhlout T Koubaa A Incidence clinical analysis and management of ovarian fibromas and fibrothecomas. Am J obstet gynecol 2008 199 473.e1 4 2. Son CE choi JS lee J.H. Jeon SW Hong JH Base JW 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 syndrome.J pediatric Adolesc Gynecol 2011 24 1 e5 7 4. Abad A Cazorla E Ruiz F Aznar I Asin E Lcixiona J Meigs syndrome with elevated CA 125 case report and review of literature Eur J obstet Gynecol Reprod Biol 1999 82 97 9 5. Zahra Najmi1 Abolfazl mehdizadehkashi2 marya kadivar3 zeinab tamannaie4 shahala chai chian2 4 laparoscopic approach to a large ovarian fibroma A case report J Reprod Infertil 2014 15 1 57 60 6. Atul B shingare1 lies beth J meylaerts2 Anna R lavry3 and koenard J mortele1 MRI features of ovarian fibroma and fibrothecoma with histopathologic correlation. Mar 2012 vol 198 no 3 American journal of Roentgenology 2012 198 w296 w303 7. Moran mendoza A Alvarado luna G calderillo ruiz G serranu olvera A Lopez Graniel CM Galcaredo Rincon D Elevated CA 125 level associated with meigs syndrome case report and review of literature Int J Gynecol cancer 2006 16 suppl 1 315 8 8. Nigam A Jain s lal pe twisted ovarian fibroma mimicking as an ectopic pregnancy. Journal of case reports 2013 3 64 67

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