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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 54-56

Case report of ovarian edema – A diagnostic dilemma


1 Department of Gynecology, Apollo Hospitals, Hyderabad, Telangana, India
2 Department of Pathology, Apollo Hospitals, Hyderabad, Telangana, India

Date of Submission07-Oct-2021
Date of Decision11-Dec-2021
Date of Acceptance20-Jan-2022
Date of Web Publication24-Feb-2022

Correspondence Address:
Rooma Sinha
Department of Gynecology, Apollo Hospitals, Hyderabad - 500 033, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_111_21

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  Abstract 


Ovarian edema is a rare solid tumor-like condition, usually seen in women of reproductive age. It occurs due to the accumulation of interstitial fluid in the stroma of the ovary, because of partial or complete torsion of the ovary causing interference with the venous or lymphatic flow but not the arterial flow. It is a misleading condition, difficult to diagnose visually and can lead to oophorectomy resulting in loss of fertility and hormonal function. We report the case of a 13-year-old girl who presented with acute abdomen. The ovary gave a visual impression of malignancy at laparoscopy and a frozen section was done. The frozen section ruled out malignancy and reported as ovarian edema which is a benign condition. The patient underwent ovarian detorsion and the ovary was conserved. Ovarian conservation is important in young girls and oophorectomy should not be done on visual suspicion. When possible frozen section should be done to confirm a benign pathology intraoperatively before taking a decision of surgical removal of the ovary.

Keywords: Benign, laparoscopy, oophorectomy, ovarian edema


How to cite this article:
Sinha R, Rupa B, Modi T, Sampurna S. Case report of ovarian edema – A diagnostic dilemma. Apollo Med 2022;19:54-6

How to cite this URL:
Sinha R, Rupa B, Modi T, Sampurna S. Case report of ovarian edema – A diagnostic dilemma. Apollo Med [serial online] 2022 [cited 2022 May 22];19:54-6. Available from: https://www.apollomedicine.org/text.asp?2022/19/1/54/338425


  Introduction Top


Massive ovarian edema is a rare solid tumor-like condition presenting as adnexal mass and occurs due to marked accumulation of interstitial fluid in the stroma of the ovary. It was first described by Kalstone in 1969.[1] Ovarian edema is defined by the WHO as a clinicopathological entity with an accumulation of edema within the ovarian stroma separating the normal follicular structures. This condition may involve one or both ovaries. Commonly affects young women in the reproductive age group, but it has been reported in a 6-month-old infant,[2] a postmenopausal woman[3] and even during pregnancy.[4] The etiology of ovarian edema is not clear but usually occurs as a result of interference with the venous and lymphatic flow secondary to partial or complete torsion of the mesovarium, with preservation of the arterial blood flow. This results in stromal cell luteinization in the edematous ovary, as a response to torsion and subsequent ischemia. The stromal cells have estrogen and progesterone receptors and undergo stimulatory changes responsible for the hormonal-related symptoms often found with ovarian edema.[5],[6] Clinical presentations include pain, abdominal distension, mass per abdomen, infertility, and in some cases irregular vaginal bleeding. The acute presentation may prompt an emergency action. This condition is often misdiagnosed with malignancy resulting in surgical removal of the ovary in young patients resulting in loss of hormonal function and fertility. There are multiple reports of oophorectomy due intraoperative suspicion of malignancy.[7],[8],[9],[10]


  Case Report Top


A 13-year-old girl presented with severe pain abdomen associated with nausea and giddiness for 1 day. She complained of intermittent abdominal pain for the past 6 months. She attained menarche 2 years ago and had regular menstrual cycles lasting for 3 − 4 days with the average flow and congestive dysmenorrhea. Her last menstrual cycle was 7 days ago. She underwent laparoscopic cholecystectomy 8 months ago. There was no history of any comorbidities or significant history of cancer in the family. On arrival to the hospital, she was conscious, coherent, and her vitals were stable, Abdominal examination revealed tenderness in the suprapubic region. There was no evidence of free fluid or ascites. On evaluation with ultrasound, uterus was of normal size and echotexture, the right ovary was enlarged (5 cm × 3 cm) and the left ovary was normal in size. However, the pelvic scan repeated after 12 h, reported an increase in the size of the right ovary (7.9 cm × 4.3 cm). The serum levels of cancer antigen-125 (CA-125), carcinoembryonic antigen, alpha-fetoprotein (AFP), lactate dehydrogenase (LDH) were within the normal limits. With a presentation of acute onset of pain with nausea, a clinical diagnosis of torsion of the right ovary was made. On laparoscopic evaluation, there was single torsion of the right ovarian ligament. The ovary did not have necrosis but looked enlarged edematous and had petechial hemorrhagic spots on the surface [Figure 1]. The ovary was inspected for any cyst and a wedge biopsy sent for the frozen section. The frozen section was reported as benign. Detorsion of the ovary was done and the right ovary was left in situ. No further intervention was done. The postoperative recovery was uneventful. She was discharged in 48 h. An ultrasound examination at 6 months' follow-up reports a normal right ovary of 2 cm × 3 cm. Final histopathology of the wedge biopsy showed massive ovarian edema with hypocellular stroma, vessels, and few luteinized cells. Adjacent compressed ovary shows hemorrhage with primordial follicles. There was no evidence of malignancy [Figure 2],[Figure 3],[Figure 4].
Figure 1: Appearance of ovarian edema on laparoscopy

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Figure 2: Ovarian mass with stromal edema (H and E, ×200)

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Figure 3: Ovarian mass with compressed peripheral stroma with primordial follicle (H and E, ×200)

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Figure 4: Ovarian mass with few luteinized cells (H and E, ×400)

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  Discussion Top


Massive ovarian edema is an uncommon clinical entity. It can be primary or secondary.[1] Primary ovarian edema which is more common type occurs with incomplete or intermittent torsion of the ovarian pedicle leading to interference in the venous blood supply without compromising the arterial blood flow. Secondary ovarian edema occurs secondary to a diseased ovary, where there is a preexisting ovarian pathology like ovarian capillary hemangioma, mucinous or serous cystadenomas, mature cystic teratomas, Meig's syndrome, ovarian fibrothecoma, PCOD, or malignancies (causing metastatic lymphatic permeation). Such pathology can be sometimes seen secondary to drugs used for ovulation induction. Patients may present with pain abdomen (acute pain if torsion occurs), menstrual irregularities, infertility, and abdominal distension.[6] Adults may present with androgenic features secondary to abnormal hormones.[11] Natrajan reported precocious puberty and drew attention to the fact that this differential diagnosis should be considered in prepubertal girls presenting with precocious puberty.[2] Similar to our case, the diagnosis in most reported cases was made on pathology and not on visual diagnosis. The presence of ovarian stromal cells which are separated by copious edema fluid with the presence of atretic follicles without any involvement of tunica albuginea and the superficial cortical zone are seen characteristically involved during the pathological examination. A thin rim of compressed cortical stroma at the periphery of the mass can be seen with necrosis and hemorrhage. There is also the presence of focal stromal luteinization. The edema of the stroma may provoke the activation of fibroblasts.[12] Peripherally placed follicles and preservation of blood flow may be suggestive of this condition on ultrasound scan.[13] Tumor markers such as serum beta-HCG, LDH, CA-125, and AFP in preoperative evaluation can help differentiate ovary with benign edema from tumors such as dysgerminomas and mixed germ cell tumors. Most cases at diagnosis have unilateral ovarian edema and usually result in unilateral salpingo-oopherectomy. Intraoperative frozen section if available should be utilized to diagnose correctly and prevent unwarranted oophorectomy and subsequent compromised ovarian function and fertility. Detorsion and wedge resection for confirmation of the diagnosis should be the surgical treatment. Plication of the ovarian ligament can be considered if the pedicle is found to be long; however, this is not universally followed.


  Conclusion Top


Benign ovarian edema is a rare condition and poses a diagnostic dilemma. It is important to keep this possibility in mind while operating in suspected ovarian torsion cases in the reproductive age group. Intraoperative frozen section can confirm a benign pathology and prevent loss of ovary and subsequent compromised ovarian function and fertility.

Ethics Committee– EC/NEW/INST/2020/519.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kalstone CE, Jaffe RB, Abell MR. Massive edema of the ovary simulating fibroma. Obstet Gynecol 1969;34:564-71.  Back to cited text no. 1
    
2.
Natarajan A, Wales JK, Marven SS, Wright NP. Precocious puberty secondary to massive ovarian oedema in a 6-month-old girl. Eur J Endocrinol 2004;150:119-23.  Back to cited text no. 2
    
3.
Shirk JO, Copas PR, Kattine AA. Massive ovarian edema in a menopausal woman. A case report. J Reprod Med 1996;41:359-62.  Back to cited text no. 3
    
4.
Saito S, Yamamoto M, Iwaizumi S, Yoshida H, Shigeta H. Laparoscopic surgery for massive ovarian edema during pregnancy: A case report. Case Rep Womens Health 2021;31:e00318.  Back to cited text no. 4
    
5.
Mahajan N, Khatri A, Khan NA, Gupta N. Massive ovarian edema: An extremely rare cause of ovarian mass in a 7-year-old girl. J Indian Assoc Pediatr Surg 2020;25:256-7.  Back to cited text no. 5
  [Full text]  
6.
Geist RR, Rabinowitz R, Zuckerman B, Shen O, Reinus C, Beller U, et al. Massive edema of the ovary: A case report and review of the pertinent literature. J Pediatr Adolesc Gynecol 2005;18:281-4.  Back to cited text no. 6
    
7.
Tazion S, Hafeez M, Manzoor R. Massive ovarian edema mimicking malignancy. J Coll Physicians Surg Pak 2020;30:1111-2.  Back to cited text no. 7
    
8.
Shrestha S, Homagain S, Kandel S, Jha P, Gurung G. Bilateral ovarian edema with unilateral ovarian leiomyoma and double inferior vena cava: A case report. J Med Case Rep 2020;14:97.  Back to cited text no. 8
    
9.
Singh S, Surampudi K, Swain M. Benign ovarian edema masquerading as malignancy: A case report. J Obstet Gynaecol India 2019;69:92-4.  Back to cited text no. 9
    
10.
Johannesen E, Nguyen V. Massive ovarian edema in a girl with hemoglobin SC disease. Case Rep Pathol 2018;2018:4193248.  Back to cited text no. 10
    
11.
Siller BS, Gelder MS, Alvarez RD, Partridge EE. Massive edema of the ovary associated with androgenic manifestations. South Med J 1995;88:1153-5.  Back to cited text no. 11
    
12.
Machairiotis N, Stylianaki A, Kouroutou P, Sarli P, Alexiou NK, Efthymiou E, et al. Massive ovarian oedema: A misleading clinical entity. Diagn Pathol 2016;11:18.  Back to cited text no. 12
    
13.
Karaca SY, İleri A. Ovarian Torsion in Adolescents with and without ovarian mass: A Cross-sectional Study. J Pediatr Adolesc Gynecol. 2021;34:857-61.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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