Decidualized ovarian endometriosis mimicking malignancy.

Abstract

Becausesonography is nowcapable of achieving increased resolution, ovarian tumors are more fre quently found in early pregnancy. In this case, we describea patientin the secondtrimester with ovarian endometriosis, which enlarged and was accompanied by structural changes inside the tumor. Case ReportA 28-year-old primigravidawas first seen in our antenatal clinic at 5 weeks of gestation. She had a history ofovarian endometriosis and had been treated with a gonadotropin-releasing hormone analogue before the pregnancy. A sonographic examination showed an intrauter me gestationsac and a right ovariantumor.The tumor was a unilocular cyst with fine in ternal echoesand a maximum diameter of 45 mm (Fig. 1A). Because the patient had a his tory of endometriosis, the tumorwasbelieved to represent an endometrial cyst and was treated conservatively.At 16 weeks ofgestation, sonographic exam ination revealeda fetus appropriatefor the ges tational age and showed an increase in size of the ovariancyst, which had reacheda maximum diameter of 85 mm. On transvaginalsonogra phy, irregularhyperechogenicrepresentingpap illary excrescences structures were seen inside the cyst. Color-flow Doppler sonography de picted vascularity within the solid irregular ar eas (Fig. 1B). These sonographic changes became more remarkable at i8 weeks of gesta flon. For further evaluation of a possible malig nancy, MR imaging was performed.The high signalintensityon TI-andT2-weightedimages was in the cystic portion of the tumor, suggest ing blood products. The solid portion was dark on Tl-weighted images and bright on 12-weighted images, suggesting malignancy that may have arisenfrom the endometriosis (Figs. lCand lD).On exploratory laparotomy performed at 20 weeksof gestation,a right ovariantumor adher ingtotheposterior wall ofthe uteruswasfound. A smallamountof asciteswasalsonoted.The tumor, which contained chocolatelike bloody fluid,hadalreadyraptured. After suctioning the fluid from the tumor, a right salpingo-oophorec tomy was performed.Papillaryexcrescences werefoundprotruding intothelumenof thetu mor. Final histopathologicexamination re vealed ovarian endometnosis with marked decidual changes and hemorrhage and without evidenceof malignancy (Fig. 1E). The patient recovered promptly and delivered a 3704-g healthymale infant at 40 weeksof gestation. during human pregnancy;thus, we did not use this contrast material in our patient. The clinical findings were indicative of malig nancy;however,final histopathologic exami nation of the tumor merely revealed solid tissue representing massive decidualization and hemorrhage. To our knowledge, ovarian endometriosisincreasingin size and accom panied by marked decidual bleeding during pregnancyis a rareoccurrence. The malignant transformation of endometri osis has been well documented, and persistent estrogenic stimulation has been implicated as a cause [4,5]. Becauseof this,ovarianendometri osis in pregnant women should be treated with special attention to structural changes that occur during pregnancy. Disc...

Decidualization of Ovarian Endometriosis during Pregnancy Mimicking Malignancy: Report of Three Cases with a Literature Review

“…Decidualization occurs not only in the uterine but also in the extrauterine endometrium during pregnancy [1,4,6] , especially in endometrial stromal cells of ovarian endometriotic cysts [1,4] . This study revealed that decidualized ovarian endometriotic cysts showed papillary excrescences mimicking malignancy during pregnancy.…”

“…This phenomenon also occurred in histologically confirmed ovarian endometriotic cysts without preoperative ultrasound/MRI findings; however, no previous reports have described it. Although to our knowledge, 6 cases were hitherto reported in which decidualized ovarian endometriotic cysts showed ultrasound features mimicking malignancy, necessitating surgery during pregnancy [1][2][3][4][5] ( table 1 ), the clinical features such as MRI findings, Doppler findings, or the serum CA125 level, were not fully described in some cases. The present report adds 3 further cases with detailed descriptions.…”

“…Although a few recent reports indicated that decidualized ovarian endometriotic cysts occasionally showed excrescence mimicking malignancy [1][2][3][4][5] , only one report [5] provided all the following data: clinical course, MRI findings, Doppler findings, and serum CA125 levels, all of which may be important to characterize this condition. Here, we report 3 pregnant women with decidualized ovarian endometriotic cysts showing excrescence, which obliged us to perform surgery during pregnancy.…”

Perfusion fraction of diffusion‐weighted MRI for predicting the presence of blood supply in ovarian masses

“…However, not all the enhanced ovarian lesions are malignant (12,13). Some benign lesions also have contrast enhancement effect; for instance, polypoid endometriosis (14), decidualized endometriotic cysts during pregnancy in endometriosis (15) or even normal endometriotic tissue itself (12), mature cystic teratoma (13), and many sex cordstromal tumors (1,16). Although we did not evaluate if the PF contributed to the differentiation between malignant and benign tissues, knowing if a lesion has blood supply will be helpful in their characterization.…”

Clinical Management of Ovarian Endometriotic Cyst (Chocolate Cyst): Diagnosis, Medical Treatment, and Minimally Invasive Surgery

“…One of the difficulties in diagnosing malignancy in endometriosis is a decidualized endometriosis during pregnancy, which presents as a rapidly growing nodular portion or wall thickening with abundant vascularity in the endometriotic cyst. This finding can be easily misdiagnosed as a malignancy [10][11][12]. In such cases, expectant management with careful serial follow-up is needed.…”