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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 4  |  Page : 523-524
Ovarian fibroma: An unusual morphological presentation with elevated CA-125


Department of Pathology, VMMC and Safdarjung Hospital, New Delhi, India

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   Abstract 

This paper reports a case of a 42 year old female patient who presented with a large multi septate, predominantly cystic ovarian mass with elevated CA-125 levels. A diagnosis of malignant ovarian tumour was made on grounds of pre operative investigations and radical surgery was planned. Histopathological examination however revealed an ovarian fibroma with cystic change reinforcing the non specificity of CA-125 as a marker of ovarian malignancy and establishing the importance of a proper histopathological examination even in the most obvious of cases.

Keywords: CA-125, fibroma, ovary

How to cite this article:
Arya A, Rao S, Agarwal S, Arora R, Gupta K, Dhawan I. Ovarian fibroma: An unusual morphological presentation with elevated CA-125. Indian J Pathol Microbiol 2008;51:523-4

How to cite this URL:
Arya A, Rao S, Agarwal S, Arora R, Gupta K, Dhawan I. Ovarian fibroma: An unusual morphological presentation with elevated CA-125. Indian J Pathol Microbiol [serial online] 2008 [cited 2020 Sep 19];51:523-4. Available from: http://www.ijpmonline.org/text.asp?2008/51/4/523/43748



   Introduction Top


Ovarian fibroma is a stromal tumor, which accounts for 4% of all ovarian tumors. It usually occurs in patients over 40 years of age. Ovarian fibromas usually present as unilateral, solid, hard masses with a bosselated external surface. Edematous tumors may be soft in consistency and cyst formation is common. The cut surface is grey-white and homogeneous with a whorled pattern and occasional areas of calcification. Ovarian fibroma is almost always benign in nature. It may be associated with ascitis and hydrothorax known as Meig's Syndrome. We report a case of ovarian fibroma with an unusual morphological presentation and elevated CA 125.


   Case Report Top


A 42-year-old female presented to the Surgical Out-Patient Department with complaints of pain and heaviness in the right lower abdomen for the past 15 years that had suddenly increased during the 3 days prior to reporting to the hospital. She gave a history of increased menstrual flow with passage of clots. She had no complaints of fever, vomiting, or bowel or bladder dysfunction. Her general physical examination was unremarkable. An abdominal examination showed a 16-18 week size, tender supra-pubic mass arising from the pelvis and reaching up to the right iliac region. A vaginal examination revealed an irregular, firm mass non separable from the uterus and felt through all fornices. Routine laboratory tests were within normal limits.

An abdominal ultrasonography was suggestive of a left adnexal solid and cystic mass measuring 110105180 mm. The right adnexa and uterus were unremarkable. A subsequent magnetic resonance image (MRI) revealed a large multiseptate predominantly cystic mass arising from the pelvis, possibly ovarian mass with mild ascitis. The patient's blood CA-125 levels were raised to 154 U/ml (normal < 35 U/ml). Based on the clinical presentation and investigations, a provisional clinical diagnosis of malignant ovarian tumor was considered and the patient underwent a total abdominal hysterectomy with bilateral salpingo-oopherectomy and omentectomy. An exploration of the abdominal cavity did not yield any other abnormalities.

Pathological findings

A gross examination revealed a pan hysterectomy specimen with uterus and cervix measuring 852.5 cm. The left ovarian mass measured 18128 cm with attached  Fallopian tube More Details measuring 4 cm. The capsule covering the mass was intact and the outer surface was smooth and bosselated. On sectioning, the mass was predominantly multicystic and filled with yellowish mucoid material. The cystic spaces varied in sizes from 0.5-3.0 cm. Solid areas were grey-white and firm. No areas revealing papillary projections, necrosis, or hemorrhage were identified. Normal ovarian tissue was not identified. The right ovary and right Fallopian tube were unremarkable [Figure 1]. The omentum received separately measured 1510 cm and was grossly unremarkable. A gross examination suggested a benign/borderline epithelial tumor of mucinous origin. However, on microscopic examination, multiple sections taken from the ovarian mass revealed a tumor composed of spindle shaped cells with uniform bland nuclei and scant cytoplasm arranged in fascicles. The tumor showed a variable degree of edema and cystic change.

There were no mitotic figures. Tumor cells were vimentin-positive. Multiple sections were evaluated to rule out any focus of epithelial differentiation. Histological features were consistent with a fibroma ovary with cystic change [Figure 2]. Sections from the cervix showed chronic cervicitis. The myometrium, both Fallopian tubes, the right ovary and the omentum were unremarkable.


   Discussion Top


Ovarian fibromas are stromal tumors composed of spindle, oval or round cells producing collagen. [1] Fibromas are usually solid, spherical, slightly lobulated, encapsulated, grey-white masses covered by a glistening, intact ovarian serosa. [2] Fibromas occur at all ages, most frequently during middle age, with an average age of 48 years. [3] Ovarian fibromas are almost always benign. Very rarely, fibromas without any atypical features are associated with peritoneal implants. [4] Surgical removal of these solid ovarian tumors is recommended because of the low probability of malignancy. [5]

CA-125 as an ovarian carcinoma tumor marker has been suggested as a valuable tool to assist in distinguishing between benign and malignant neoplasms. Unfortunately, it has not proved to be a reliable predictor of ovarian cancer as normal values do not exclude the presence of carcinoma and elevated levels can be associated with a benign diagnosis. [6] Spinelli, et al. [7] also reported a case of benign ovarian fibroma with elevated CA-125 levels.

In our case, there was a strong clinical, radiological and serological suspicion of malignancy, so radical surgery was planned. Unlike the guarded prognosis encountered for advanced cases of ovarian carcinoma, the surgical option in this case proved to be curative with an uneventful post-operative course. The patient's CA-125 level fell to 14 U/ml within 14 weeks of surgery.

The present case report emphasizes the varied presentation and unique gross morphology of ovarian fibroma. It also reinforces the non specificity of CA-125 as a marker of ovarian malignancy. It beckons us to re evaluate the presumption that thorough clinical examinations supported by laboratory investigations and imaging modalities are fool proof in themselves. The role of a histopathological diagnosis should not be underestimated even in cases with a strong suspicion of malignancy.

 
   References Top

1.Tavassoli FA, Mooney E, Gersell DJ, McCluggage WG, Konishi I, Fujii S, et al. Sex-Cord Stromal Tumors. In: World Health Organisation Classification of Tumors. Pathology and Genetics of Tumors of the Breast and Female Genital Organs. Lyon, France: IARC Press; 2003. p. 149-51.  Back to cited text no. 1    
2.Crum CP. The Female Genital Tract. In: Kumar V, Abbas AK, Fausto N, editors. Robbins and Cotran Pathologic basis of disease. 7 th ed. Philadelphia: WB Saunders Company; 2004. p. 1059-117.  Back to cited text no. 2    
3.Dockerty MB, Masson JC. Ovarian fibroma-A clinical and pathological study of two hundred and eighty three cases. Am J Obstet Gynecol 1944;47:741-52.  Back to cited text no. 3    
4.Young RH, Scully RE. Sex Cord-Stromal, Steroid Cell and other ovarian tumors with Endocrine, Paraendocrine and Paraneoplastic manifestation. In: Kurman RJ, editors. Blausteins Pathology of the Female Genital Tract. 5 th ed. India: Springer Private Limited; 2004. p. 923-5.  Back to cited text no. 4    
5.Leung SW, Yuen PM. Ovarian fibroma: A review on the clinical characteristics, diagnostic difficulties and management option in 23 cases. Gynecol Obstet Invest 2006;62:1-6.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Walker JL, Manetta A, Mannel RS, Shu-Yuan L. Cellular fibroma masquerading as ovarian carcinoma. Obstet Gynecol 1990;76:530.  Back to cited text no. 6    
7.Spinelli C, Gadducci A, Bonadio AG, Berti P, Micolli P. Benign ovarian fibroma associated with free peritoneal fluid and elevated serum CA 125 levels. Minnerva Ginecol 1999;51:403-7.  Back to cited text no. 7    

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Correspondence Address:
Anupama Arya
8/32 A East Punjabi Bagh, New Delhi 110 026
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.43748

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    Figures

  [Figure 1], [Figure 2]

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