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Case 109: Meigs Syndrome¹

¹ From the Departments of Radiology (G.R.V., D.L.) and Obstetrics and Gynecology (D.L.), Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. Received April 29, 2004; revision requested July 12; revision received July 21; accepted August 18; final version accepted September 29.

Correspondence: Address correspondence to D.L. (e-mail: dlevine{at}caregroup.harvard.edu).

	History

TOP History Imaging Findings Discussion References

 
A 50-year-old postmenopausal woman presented to the emergency department with worsening right lower quadrant pain, vomiting, and diarrhea. Her medical history included diabetes, hypertension, and cardiovascular disease; prior myocardial infarction was treated with angioplasty. She had experienced intermittent bouts of similar pain for 3 months before she sought treatment. Physical examination revealed obesity and mild tenderness in the right lower quadrant, with focal guarding. Bowel sounds were normal. Pelvic examination was limited owing to patient body habitus. White blood cell count was 23.2 x 10⁹/L (normal range, [4 to 11] x 10⁹/L).

The initial imaging examination was contrast material–enhanced computed tomography (CT). Pelvic sonography was performed owing to CT findings. Magnetic resonance (MR) imaging was performed for better characterization of pelvic organs. The CA-125 level was 463 U/mL (normal level, <35 U/mL).

	Imaging Findings

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CT scanning (Figs 1–3) revealed a large, slightly heterogeneous, solid adnexal mass in the right side of the pelvis adjacent to the fundus of the uterus. There was no distinct plane of cleavage between this mass and the uterus. Adjacent to this mass was a small amount of fluid. The appendix was normal. Images obtained through the lung bases revealed small bilateral pleural effusions.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Transverse CT image of the lower part of the thorax after administration of oral and intravenous contrast materials. Small bilateral pleural effusions (arrows) are more prevalent in the left side of the thorax than in the right side.

View larger version (206K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Transverse CT image of the pelvis after administration of oral and intravenous contrast materials. There is a large mass (M) in the right lower quadrant adjacent to the uterine fundus (U). The mass is slightly heterogeneous and does not enhance to the same degree that the uterus does. Note the adjacent fluid (*).

View larger version (172K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Coronal reformatted CT image of the abdomen and pelvis demonstrates the normal appendix (arrow), as well as the pelvic mass (M) and ascites (*).

View larger version (68K): [in this window] [in a new window] [Download PPT slide]   Figure 4: Transabdominal sagittal sonogram of the pelvis shows a large heterogeneous solid mass in the pelvis (calipers, + and x) with multiple regions of edge shadows. The uterus is not depicted owing to patient body habitus, as well as attenuation and shadowing from the mass. A transvaginal sonogram (not shown) revealed a normal-appearing uterus; however, normal ovaries were not depicted.

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 5: Sagittal T2-weighted MR image (repetition time msec/echo time msec, 5100/138; 28-cm field of view; 5-mm section thickness; 512 x 174 matrix; one signal acquired) of the pelvis. The mass (M) is well defined, separate from the uterus (U), and of predominantly low signal intensity, with patchy areas of high signal intensity (large arrow) that suggest hemorrhage or edema. Note the normal appearance of the endometrium (small arrows).

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 6a: Transverse T1-weighted (a) in-phase and (b) out-of-phase (160/5.3 and 2.7, respectively; 42-cm field of view; 512 x 106 matrix; 8-mm section thickness; one signal acquired) MR images of the pelvis. The mass (M) is well circumscribed, is predominately of low signal intensity, and does not show any darkening on b to suggest the presence of fat.

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 6b: Transverse T1-weighted (a) in-phase and (b) out-of-phase (160/5.3 and 2.7, respectively; 42-cm field of view; 512 x 106 matrix; 8-mm section thickness; one signal acquired) MR images of the pelvis. The mass (M) is well circumscribed, is predominately of low signal intensity, and does not show any darkening on b to suggest the presence of fat.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 7: Coronal T1-weighted MR image of the pelvis after administration of intravenous contrast material (4.2/1.3, 42-cm field of view, 160 x 140 matrix, 2.5-mm section thickness, one signal acquired). A normal right ovary was not seen on this or any other image. The mass (M) shows less enhancement than does the uterus (U). The normal left ovary (arrow) is also seen.

	Discussion

TOP History Imaging Findings Discussion References

In a postmenopausal woman with a solid adnexal mass, diagnostic considerations include a solid ovarian neoplasm (either primary or secondary) and a pedunculated fibroid (2). Sonography is typically the imaging modality of choice for evaluation of adnexal masses (3), which is why sonography was performed after CT scanning. In this case, sonographic findings of a solid mass with variable attenuation and multiple edge shadows suggested a fibrous nature of the mass (1); however, the findings were not sufficient to determine whether the mass was of uterine or ovarian origin.

MR examinations are helpful in assessing adnexal masses because of their excellent contrast resolution, usefulness in tissue characterization, and ability to depict organs in multiple planes to enable identification of the origin of a mass. In this patient, the mass was clearly separate from the uterus. It was of predominantly low signal intensity on T1- and T2-weighted images, which indicated it had a fibrous origin (2–4). Patchy increased signal intensity on T2-weighted images and the pain reported by the patient suggested that torsion and necrosis could have been contributing to the presenting symptoms. Exophytic fibroid was considered an unlikely diagnosis because no other fibroids were present and because the lesion was depicted separately from the uterus. A normal left ovary was depicted (Fig 7), but the right ovary was not seen. Lack of fat within the lesion made dermoid cyst an unlikely diagnosis.

Metastatic disease to the ovary was considered unlikely because the sonographic and MR characteristics of the mass were those of a fibrous lesion. Metastatic disease to the ovary typically is bilateral and is associated with the finding of moth-eaten cyst formation on sonograms (5).

Primary ovarian malignancy was also a possible diagnosis. Although this patient had fluid adjacent to the mass and pleural effusion, there was no other evidence of malignant disease, such as peritoneal implants or omental caking. Furthermore, the mass did not have the mixed solid and cystic appearance of a typical primary ovarian cancer (6).

The sonographic and MR appearances were those of a solid primary ovarian fibrous neoplasm, such as a fibroma, thecoma, or fibrothecoma. Fibromas, thecomas, and fibrothecomas are benign ovarian tumors that originate in the gonadal stroma. They are generally asymptomatic and appear as solid tumors that mimic a pedunculated fibroid or, because of their solid nature, a malignant neoplasm.

Ovarian fibroma accounts for 4% of all ovarian tumors, and it occurs most frequently in the 4th–6th decades of life (7). While fibromas are composed of spindle cells and lack any epithelial components, thecomas have abundant lipids in the cytoplasm of thecal cells and are responsible for the estrogenic effects of the tumor. The fibrous tissue that composes most of these tumors is responsible for the low signal intensity of the tumors on T1- and T2-weighted images. Thecomas are hormonally active and may have an associated widening of the endometrial stripe (3,4). In this case, the endometrial stripe was normal. Fibrothecomas have both spindle cells and thecal cells. Associated findings of ascites and bilateral pleural effusions raise the possibility of Meigs syndrome (8).

Meigs syndrome is defined as the presence of ascites and pleural effusion in association with a benign ovarian tumor (7–11). The ascites and pleural effusion disappear after the tumor is removed. While fibromas are the most common tumors associated with Meigs syndrome, the precise incidence of specific types of ovarian tumors associated with Meigs syndrome varies. In a review of 128 cases of Meigs syndrome by Majzlin and Stevens (11), the most common (91.4%) tumors were fibromas or fibrothecomas. Less common tumors included benign granulosa cell tumors (4.7%) and Brenner tumors (1.6%). Meigs syndrome complicates about 1% of fibromas. Ascites alone is present in 10%–15% of fibromas larger than 10 cm in diameter (9). The importance of Meigs syndrome is that the presence of ascites and pleural effusion does not necessarily indicate that a pelvic mass is malignant.

The pathogenesis of ascites and pleural effusion in patients with Meigs syndrome has not been clearly elucidated. Vasoendothelial and fibroblast growth factors and cytokines may play a role in third-space fluid accumulations (12). An alternative explanation is the pressure of the tumor on lymph vessels that causes fluid to escape through the surface lymphatics located just beneath the single-layered cuboidal cells covering the tumor. Tracking of this ascitic fluid through defects in the diaphragm explains the hydrothorax (13).

CA-125 is a tumor marker associated with ovarian carcinoma. There have been sporadic reports in the literature of elevated CA-125 levels in patients with Meigs syndrome (14,15). In this patient, the CA-125 level was elevated. However, it should be noted that elevation of the CA-125 level has been reported in a variety of processes and that it cannot be used to make a specific diagnosis.

Clinical signs of torsion include pain, fever, and an elevated white blood cell count. The finding of a well-defined low-signal-intensity mass on T1- and T2-weighted images, an absence of fat, and a few patchy areas of increased signal intensity on T2-weighted images suggested a diagnosis of torsion in the fibroma. The history of pain and lack of surrounding inflammatory changes in the fat around the lesion suggest that torsion was intermittent.

After the imaging evaluation was completed and a provisional diagnosis of Meigs syndrome was assigned, the patient underwent exploratory laparotomy. At surgery, a 16-cm-diameter solid right ovarian mass was found with torsion, and 300 mL of ascites was removed. Other than the ascites and ovarian mass, all other findings were normal. Histologic analysis revealed an ovarian fibroma. Additional findings were edema, necrosis, and infarction consistent with torsion. Five months after surgery, the patient was asymptomatic and doing well.

In summary, the findings of a fibrous ovarian lesion with ascites and pleural effusion suggest a diagnosis of Meigs syndrome. The patient's symptoms suggest that the adnexal mass had undergone torsion.

	FOOTNOTES

 

Part one of this case appeared 4 months previously and may contain larger images.

 

	References

TOP History Imaging Findings Discussion References

 

1. Dill-Macky MJ, Atri M. Ovarian sonography. In: Callen PW, ed. Ultrasonography in obstetrics and gynecology. 4th ed. Philadelphia, Pa: Saunders, 2000; 857–896.
2. Schwartz RK, Levine D, Hatabu H, Edelmann RR. Ovarian fibroma: findings by contrast-enhanced MRI. Abdom Imaging 1997;22:535–537.[CrossRef][Medline]
3. Jeong YY, Outwater EK, Kang HK. Imaging evaluation of ovarian masses. RadioGraphics 2000;20:1445–1470.[Abstract/Free Full Text]
4. Siegelman ES, Outwater EK. Tissue characterization in the female pelvis by means of MR imaging. Radiology 1999;212(1):5–18.[Abstract/Free Full Text]
5. Shimizu H, Yamasaki M, Ohama K, Nozaki T, Tanaka Y. Characteristic ultrasonographic appearance of the Krukenberg tumor. J Clin Ultrasound 1990;18:697–703.[Medline]
6. Brown DL, Zou KH, Tempany CM, et al. Primary versus secondary ovarian malignancy: imaging findings of adnexal masses in the Radiology Diagnostic Oncology Group Study. Radiology 2001;219:213–218.[Abstract/Free Full Text]
7. Dockerty MB, Masson JC. Ovarian fibromas: a clinical and pathologic study of two hundred and eighty-three cases. Am J Obstet Gynecol 1944;47:741–752.
8. Meigs JV. Fibroma of the ovary with ascites and hydrothorax: Meigs' syndrome. Am J Obstet Gynecol 1954;67:962–985.[Medline]
9. Samanth K, Black WC. Benign ovarian stromal tumors associated with free peritoneal fluid. Am J Obstet Gynecol 1970;107:538–545.[Medline]
10. Nemeth AJ, Patel SK. Meigs syndrome revisited. J Thorac Imaging 2003;18:100–103.[CrossRef][Medline]
11. Majzlin G, Stevens FL. Meigs syndrome: case report and review of literature. J Int Coll Surg 1964;42:625–630.[Medline]
12. Abramov Y, Anteby SO, Fasouliotis SJ, Barak V. Markedly elevated levels of vascular endothelial growth factor, fibroblast growth factor, and interleukin 6 in Meigs syndrome. Am J Obstet Gynecol 2001;184:354–355.[CrossRef][Medline]
13. McGee DM, Connolly SA, Young RH. A 10-year-old girl with recurrent bouts of abdominal pain, case 24-2003. N Engl J Med 2003;349:486–494.[Free Full Text]
14. Lin JY, Angel C, Sickel JZ. Meigs syndrome with elevated serum CA 125. Obstet Gynecol 1992;80:563–566.[Medline]
15. Patsner B. Meigs syndrome and "false positive" preoperative serum CA-125 levels: analysis of ten cases. Eur J Gynaecol Oncol 2000;21:362–363.[Medline]

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