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|Year : 1987 | Volume
| Issue : 1 | Page : 39-40
Massive oedema of the ovary (a case report).
Pandit AA, Deshpande RB, Vora IM, Rawal MY
|How to cite this article:|
Pandit A A, Deshpande R B, Vora I M, Rawal M Y. Massive oedema of the ovary (a case report). J Postgrad Med 1987;33:39-40
In 1969, Kalstone et al first time describe 4 cases of 'massive edema of the ovary simulating fibroma.' Since then, this lesion has come to be accepted as a distinct clinicopathological entity. In 1980, Chervenak et al, reviewing the world literature, could count 22 cases, including 2 of their own. Since then, a few more cases have been reported. Majority of the reported cases were mistaken at laparotomy for primary ovarian neoplasms and excised. The morphological features are fairly characteristic, and the awareness of the entity makes its recognition simple.
The rarity of the lesion has prompted us to report this case. A brief note on the previously reported cases, and a short discussion on the probable etiopathogenesis are added.
A 25 year old, married, nulliparous woman was admitted for pain in the abdomen and- a huge pelvic mass, of 4 months' duration. Her menstural history was unremarkable. No signs of virilization were noted. On examination, a large, firm, pelvic mass extending upto the xiphi sternum was palpable. The liver and spleen were not palpable. Ultrasound examination revealed a large, mixed echogenic pelvic mass probably arising from the right ovary. At laparotomy a large, firm, right sided, ovarian mass was seen. The mass was thought to be a primary solid ovarian tumour and excised. There was no mesovarian torsion, or any obvious blockage of the lymphatic or venous drainage. The uterus and both fallopian tubes were normal. The left ovary appeared normal. A wedge biopsy was taken from the left ovary. Post-operative recovery was uneventful.
Gross appearance of the mass was fairly characteristic, and an impression of massive ovarian oedema was entertained. The large, oval ovarian mass measured 20 x 20 x 10 cm and weighed 1.570 kg. It was soft, pale pink and well encapsulated. The cut surface appeared pale pink, soft and very wet [Fig. 1]. Microscopic examination of several sections showed similar features all over. The mass was essentially composed of thin, spindle-shaped cells widely separated by abundant interstitial, eosinophilic oedematous fluid [Fig. 2]. The spindle cells resembled the ovarian stromal cells and showed no cellular atypia. There was no particular pattern of cellular arrangement. Primordinal follicles, corpora lutea or albicans were not identified in any of the sections. However, periphery of the mass showed a thin band of compressed ovarian stroma. Blood vessels in the oedematous areas appeared dilated. There were no areas of haemorrhage or necrosis. No stromal luteinization was seen in any of the sections. The wedge biopsy of the left ovary was normal. There was no stromal oedema or any other pathology.
Massive oedema of ovary is a predominantly unilateral lesion occuring most often in young nulliparous women. Invariably the patients present with pelvic mass and abdominal pain. Most of them, at laparotomy, are mistaken for primary ovarian neoplasms and excised.
Of the 22 cases reviewed by Chervenak et al in 1980, the average age was 20 years, the range being 6 to 33 years. Five of these were premenarchal. Except for 3 patients, all were nulliparous. Three patients had signs of virilization at presentation, and one patient, a 6 year old girl, had precocious puberty. In 19 of the 22 cases, the lesion was unilateral.
Morphological recognition of the lesion is fairly simple. The cut surface of the specimen appears wet and soft, and thin oedema fluid oozes out. Microscopically, the ovarian stromal cells are widely separated by copious oedema fluid. Atretic follicles may at times be recognised. Characteristically, a thin rim of compressed cortical stroma is recognised at the periphery of the mass. Necrosis and haemorrhage are unusual.
Focal stromal luteinization has been, noted in 7 of 22 cases and 3 of these patients showed signs of virilization. Stromal luteinization is thought to be a mechanical process induced by the stretching of the stromal cells.
The exact mechanism of massive ovarian oedema is not clear. The most obvious explanation appears to be obstruction to the venous and/or lymphatic blockage due to partial torsion of the mesovarian. Such mesovarian torsion was seen in 8 of the 22 cases. Since torsion of normal tube and ovaries is known to occur in childhood, it is hypothesized that partial torsion causes blockage of lymphatic or venous drainage., thereby resulting in collection of interstitial oedema fluid. Chung et al studied a case ultrastructurally, and found that the over-whelming majority of the endothelial cells were normal and showed tight junctions. These features, according to the authors, indicate failure to reabsorb the oedema fluid, resulting in excess interstitial fluid.
A hormonal etiology for the massive oedema has not gained much support, especially since the majority of the cases were unilateral.
Considering the massive size of the oedematous ovary and the bulk of stromal cell mass as judged subjectively under the microscope, we feel there occurs stromal cell hyperplasia of some degree associated with massive oedema. Though the obvious cause of the massive oedema appears to be due to distal blockage of venous and/or lymphatic blockage, this is yet to be conclusively proved.
|1.||Chervenak, P. A., Castadot, M., Wiederman, J. and Sedlis, A.: Massive ovarian oedema: Review of world literature and report of two cases. Obstet. Gynecol. Surv., 35: 677-684, 1980. |
|2.||Chung, H. R., Riccio, J. A., Brown, T. F. and Sama, J. C.: Massive edema of the ovary. (Letter). Arch. Pathol. Lab. Med., 106: 692-694, 1982. |
|3.||Kalstone, C. E., Jaffe, R. B. and Abell, M. R.: Massive edema of the ovary simulating fibroma. Obstet. Gynecol., 34:564-571, 1969. |
|4.||Schultzi, L. R., Newton, W. A., Jr. and Clatworthy, H. W., Jr.: Torsion of previously normal tube and ovary in children. New Engl J. Med., 268, 343-346, 1963. |