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Table of Contents
LETTER TO THE EDITOR
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 89-90

Malignant ovarian lesion complicated by a rare entero-ovarian fistula


Department of Radiology, Holy Family Hospital, Thodupuzha, Kerala, India

Date of Submission19-Dec-2018
Date of Decision02-Jan-2019
Date of Acceptance03-Jan-2019
Date of Web Publication29-Apr-2019

Correspondence Address:
Dr. Reddy Ravikanth
Department of Radiology, Holy Family Hospital, Thodupuzha - 685 605, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GMIT.GMIT_127_18

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How to cite this article:
Ravikanth R, Kamalasekar K. Malignant ovarian lesion complicated by a rare entero-ovarian fistula. Gynecol Minim Invasive Ther 2019;8:89-90

How to cite this URL:
Ravikanth R, Kamalasekar K. Malignant ovarian lesion complicated by a rare entero-ovarian fistula. Gynecol Minim Invasive Ther [serial online] 2019 [cited 2019 Aug 24];8:89-90. Available from: http://www.e-gmit.com/text.asp?2019/8/2/89 /257334



To the Editor,

A 78-year-old elderly woman presented to the Gynecology Department with the complaints of chronic left lower-quadrant pain lasting for 1 year and bleeding per rectum for 1 month. She attained menopause at 42 years of age. Physical examination revealed a left adnexal mass. CA125 level was elevated with a value of 62 U/mL consistent with malignant epithelial ovarian tumor. Magnetic resonance imaging (MRI) of the pelvis was performed on a 1.5-Tesla scanner, which showed a lobulated, complex, and the left ovarian solid-cystic mass lesion with few of the cystic components showing fluid-fluid levels– consistent with hemorrhage. The lesion showed loss of fat planes with the posterior wall of the uterus and is noted to have a fistulous communication with the rectum posteriorly [Figure 1], [Figure 2], [Figure 3]. There was no free fluid or adjacent pelvic lymphadenopathy. Diagnostic imaging has a pivotal role in detection, characterization, and staging of adnexal mass lesions. Surface epithelial-stromal tumors represent 85% of all ovarian malignancies.[1] CA125 is considered the “gold standard” tumor marker and is most widely used in ovarian cancer, first identified by Bast et al. in 1981.[2] Ultrasound is often the first-imaging study performed in the evaluation of a suspected ovarian lesion since it is widely available, noninvasive, and of low cost. A combination of grayscale and color Doppler features done using transabdominal and endovaginal methods helps to assess the morphological structure and vascularity of the ovarian mass. Sonological features suggestive of ovarian malignancy include irregular walls and septa with a thickness of >2–3 mm, the presence of solid areas and papillary projections, peritoneal nodules, ascites, and metastatic lesions.[3] Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis is important in the evaluation of spread of malignancy, detection of recurrence posttherapy, and fat-containing lesions like mature teratoma. However, CECT has a limited value in the primary detection and characterization of an ovarian mass.[4] Role of 18F-fludeoxyglucose positron-emission tomography/CT in the evaluation of ovarian tumors appears to be crucial in the postoperative follow-up of patients with suspected recurrence. MRI serves as a problem-solving tool in patients with indeterminate lesions and helps to determine the site of origin of the ovarian lesion, characterization of adnexal masses, and assessing local invasion. A mixed solid-cystic appearance has a high suspicion of malignancy as seen in surface epithelial tumors and metastatic lesions. The presence of septations (>3 mm), thick-irregular walls (>3 mm), papillary projections, and enhancing soft tissue with a necrotic component is highly suggestive of malignant lesions and are better appreciated on dynamic contrast-enhanced MRI.[5] However, benign lesions such as mature cystic teratoma may also have an appearance of a complex mass. In conclusion, imaging plays a pivotal role in the evaluation of malignant adnexal lesions and their complications such as rare entero-ovarian fistula which we have described in this report.
Figure 1: Sagittal T2-weighted magnetic resonance image demonstrating a complex solid-cystic ovarian lesion (red circle) in a 78-year-old elderly woman with elevated CA125 consistent with malignant epithelial ovarian tumor. Loss of fat planes with the posterior uterine wall is demonstrated (pink arrow). Few cystic components are seen demonstrating fluid-fluid levels (blue arrow) consistent with hemorrhage into the cyst. Note the central T2 hypointensity (yellow arrow) consistent with air due to fistulous communication with rectum. Furthermore, note the anteriorly displaced urinary bladder (green star) due to mass effect from the lesion

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Figure 2: Axial T2-weighted magnetic resonance image demonstrating a complex solid-cystic left ovarian mass lesion (red circle) showing fistulous communication with the rectum posteriorly consistent with an entero-ovarian fistula (blue arrow)

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Figure 3: Sagittal T2-weighted magnetic resonance image demonstrating the cystic components (red stars) and solid component (green stars) of the complex ovarian lesion. Note the entero-ovarian fistula (blue arrow) with the rectum posteriorly

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Holschneider CH, Berek JS. Ovarian cancer: Epidemiology, biology, and prognostic factors. Semin Surg Oncol 2000;19:3-10.  Back to cited text no. 1
    
2.
Bast RC Jr., Feeney M, Lazarus H, Nadler LM, Colvin RB, Knapp RC, et al. Reactivity of a monoclonal antibody with human ovarian carcinoma. J Clin Invest 1981;68:1331-7.  Back to cited text no. 2
    
3.
Jeong YY, Outwater EK, Kang HK. Imaging evaluation of ovarian masses. Radiographics 2000;20:1445-70.  Back to cited text no. 3
    
4.
Iyer VR, Lee SI. MRI, CT, and PET/CT for ovarian cancer detection and adnexal lesion characterization. AJR Am J Roentgenol 2010;194:311-21.  Back to cited text no. 4
    
5.
Togashi K. Ovarian cancer: The clinical role of US, CT, and MRI. Eur Radiol 2003;13 Suppl 4:L87-104.  Back to cited text no. 5
    


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