Giant Ovarian Tumour

CEZAR LAURENTIU TOMESCU1,3, GABRIELA STANCIU2*, TEODOR STEFAN NITU3, MADALINA BOSOTEANU3, RODICA SIRBU4, DRAGOS MARIAN BREZEANU3, ANETA TOMESCU1,3* 1Ovidius University of Constanta, Faculty of Medicine, 1 Universitatii Alley, 900470, Constanta, Romania 2Ovidius University of Constanta, Department of Chemistry and Chemical Engineering, 1 Universitatii Alley, 900470, Constanta, Romania 3Second Department of Obstetrics and Gynecology, County Clinical Emergency Hospital Sf. Apostol Andrei, 145 Tomis Blvd., 900591, Constanta, Romania

mass is observed, with a predominance of hyperechoic content.
Based on the clinical examination, laboratory testing and imagistic results it is decided to admit the patient to the 2 nd Department of Obstetrics and Gynaecology with the following diagnosis: Voluminous abdominal-pelvic tumoural mass.
A CT scan is also performed in the same day, revealing an abdominal and pelvic cystic mass measuring 35/41/52 cm, apparently attached to the broad ligament of the uterus, which compresses the intestinal loops, the pancreas, the splenic and superior mesenteric veins and the right ureter, aspect compatible with an ovarian serous cystadenoma.
In what regards laboratory testing, we note a ROMA score of 22.47%, compatible with an increased risk for an epithelial ovarian cancer.
Preoperative laboratory testing showed mild anaemia (Hb=10.5g/dl), the remainder of tests being within normal limits.

Results and discussions
Surgical interventions are performed by a mixed gynaecology-general surgery team 25 th of April 2017. Upon opening of the peritoneal cavity, a giant white pearly tumoural mass, with thin walls and intact capsule, of approximately 60/40/45cm is noted. The capsule is incised Intraoperative frozen section examination Cystic transformation of the ovary with a diameter of 40 centimetres, with microscopic lesions compatible with the diagnosis of borderline mucinous cystadenoma of the ovary -atypical cystic mucinous tumour. During surgery, the patient received 2 units of red cells and fresh frozen plasma. Postoperative evolution of the patient was favourable and she was discharged on the 3 rd of May 2017. Post surgical weight of the patients was 55 kg, the patient having lost a total of 50 kg as a result of surgery.
Discharge laboratory testing is within normal limits, with the exception of a mild hypochromic microcytic anaemia, for which she was recommended treatment with iron supplements.

Final histopathological examination and immunohistochemistry Final histopathological examination Macroscopic description
Open and drained cystic mass with a diameter of 40 centimetres, wall thickness of 0.3cm, with a smooth, white greyish external surface. The internal surface presents 3 exophytic lesions, 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 haemorrhagic areas, of slightly decreased consistency, friable.

Microscopic description
Borderline mucinous cystadenoma of the ovary (figures 7,8) which presents, at the stromal level, foci comprising glandular structures with architectural complexity and expansile pattern, lined by multistratified epithelial cells with moderate cytonuclear atypia, mitotic activity and minimal/absent stromal interposition (figures 9, 10, 11); the diameter of the described lesional areas varies between 3-5 mm. The adjacent stroma reveals desmoplastic appearance ( figure 12). Lympho-vascular and perineural invasion were not identified. The lesions are accompanied by areas of hemorrhagic necrosis, vascular thrombosis and chronic inflammatory infiltrate; the outer surface of the ovary is not affected.
All of the above-mentioned histological elements are compatible with the diagnosis of atypical proliferative mucinous tumour of the ovary, gastro-intestinal type, with microinvasion -expansile pattern.  A high specificity in the postoperative follow-up of a patient diagnosed with ovarian mucinous tumour is represented by the association between CA-125 and inhibin. Inhibin is a hormone involved in ovarian fertility, which decreases significantly in menopause. An increase in inhibin during menopause is associated with ovarian mucinous tumours [14].
In order to support the diagnosis, imagistic investigation, such as abdominal or transvaginal ultrasound can be performed. Ultrasound examination can attest, according to the characteristics of the tumoural mass, the benign or malignant features of the mass [15].
In ovarian dysgerminoma, which is a germ cell tumour, the prognosis is favourable, even without radical surgery. [16] Investigations of a higher reliability, such as CT scans or MRI can be used both before surger y and during postoperative follow-up. MRI examination can assess the starting point of the tumoural mass and can aid in its morphologic characterization, thus influencing therapeutic approach [17].

Conclusions
The particularities of the presented case rely in the size and weight of the tumour, with the patient having lost 50kg after the surgical intervention.
Postoperative evolution was favourable and follow-up is performed by a mixed gynaecologist-oncologist team every 6 months through the dosing of inhibin and CA-125, transvaginal ultrasound examination and abdominal-pelvic CT scan, which have, thus far, shown no sign of relapse. Immunohistochemistr y, correlated with histopathological examination and anatomical and clinical data support the diagnosis of borderline mucinous ovarian tumour/atypical proliferative mucinous tumour of the ovary, with microinvasion.

Postoperative follow-up
Since the surgical intervention and up to the present moment, the patient is followed-up every 6 months by the oncologist, which entails the dosing of CA-125 and inhibin as well as abdominal and pelvic CT scans. The last two native and contrast CT scans performed on the 17 th of January 2019 and 18 th of July 2019 respectively, show no signs of local or regional relapse.
The main symptom of mucinous ovarian tumours is represented by pain. This is present in up to 42.7% of patients [9].
In what regards laboratory testing, CA-125 alone is less useful in discovering mucinous ovarian tumours. In order to diagnose this type of tumour, CA19-9 is more useful [10]. CA-125 has a sensitivity rate of 51.9% for the diagnosis of mucinous tumours and up to 68.2% in epithelial nonmucinous tumours. CA19-9 has a specificity rate of 51.5% in serous tumour and up to 44.7% in mucinous tumours [11].
In the postoperative period, the combined dosing of CA-125 and CA19-9 has shown a much higher sensitivity in long term follow-up compared to CA-125 alone [10].
The association between CA-125 and HE4, known as the ROMA score has a higher sensitivity compared to CA-125 [12]. A 2016 study performed by Su Wei has shown a much higher sensitivity of the ROMA score in detecting ovarian tumours compared to CA-125 alone [13].