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Struma Ovarii

Ovarian Cancer Struma Ovarii

Struma ovarii is an infrequent type of dermoid ovarian tumor that is usually benign and composed of at least 50% thyroid tissue. It may be part of a teratoma or cystadenoma and may also have a malignant character (papillary thyroid carcinoma). Thyroid tissue may be also found in the peritoneal cavity as in benign strumosis. In strumal carcinoid, the carcinoid tissue is present in the struma ovarii.


Presentation

Struma ovarii patients, often aged 40 to 60, more frequently present with ovarian, rather than thyroid hyperfunction complaints [1]. Ovarian symptoms include metrorrhagia, abdominal or pelvic pain or palpable abdominal mass that has no specific traits on clinical examination, making diagnosis difficult. All these signs are nonspecific and overlap with those caused by an ovarian malignancy. Abnormal liquid accumulation like ascites [2] (leading to the presence of a positive fluid wave test) and hydrothorax with ascites (leading to crackles on pulmonary auscultation and dyspnea), known as the pseudo-Meigs syndrome may also be encountered. Ascites occurs in 17 to 33% of patients [3] and may spontaneously disappear after tumor excision. Thyroid tumors may also be present [4]. Struma ovarii may be completely asymptomatic [5] and discovered on pelvic imaging studies or surgery performed for other complaints [1]. Hyperthyroidism signs are present in 5 to 8% of patients [6] [7]. Some of the women affected by the condition also have a goiter [8] due to Graves' disease [9].

Lymphadenopathy
  • A 38-year-old woman with metastatic malignant struma ovarii, including massive liver metastases and retroperitoneal lymphadenopathy, underwent ovarian resection and retroperitoneal lymph nodes excision, partial hepatectomy, and radiofrequency ablation[ncbi.nlm.nih.gov]
  • On examination, no pallor or supraclavicular lymphadenopathy. Abdominal examination was normal. Bimanual examination revealed 8 cm 10 cm cystic mass felt through left and anterior fornix.[jmidlifehealth.org]
  • There was no suspicious lymphadenopathy seen on bilateral central, lateral or posterior compartments. Fine needle aspiration biopsy of these suspicious nodules indicated benign findings.[gs.amegroups.com]
Peritoneal Disease
  • Patient underwent total thyroidectomy followed by radioactive iodine therapy for metastatic omental and peritoneal disease.[ncbi.nlm.nih.gov]
Aggressive Behavior
  • Because of its harmless histological appearance, this form of follicular carcinoma characteristically cannot be diagnosed until the neoplasm spreads beyond the ovary, thus, showing evidence of aggressive behavior.[ncbi.nlm.nih.gov]
Fine Tremor
  • One patient presented to hospital with palpitations, mild fine tremors, and proptosis. Her heart rate was 110 beats per minute. No diffuse goiters were apparent on inspection, and no abnormal masses were palpable in the thyroid gland.[journals.lww.com]
Dysarthria
  • Twenty-four hours later, patient experienced left hemiparesia, dysarthria, anosognosia and hemianopsia. A brain CT ruled out hematoma, and a second cerebral ischemic event was diagnosed.[elsevier.es]

Workup

Struma ovarii diagnosis is aided by blood workup and imaging modalities. Aside from complete blood cell count, the cancer antigen, although non-specific, may sometimes be useful [2]. However, its presence does not necessarily signify struma ovarii is present, as it is elevated in numerous other physiological and pathological instances. Although hyperthyroidism symptoms may be absent, the serum thyroid-stimulating hormone may be low and free thyroxine and/or triiodothyronine levels may be increased. However, they are not commonly ordered if increased thyroid function signs are absent. Also, despite the fact that clinical examination usually does not describe an enlarged thyroid, serum thyroglobulin level may be increased.

In the attempt to characterize the nature of the pelvic tumor, several methods may be applied. Pelvic ultrasound is usually the first study performed and offers limited information. Triple-contrast computed tomography (CT) scan describes the cystic aspect of the pathological mass and evaluates if lymph nodes and neighboring structures are also implicated [10]. Thoracic radiography is used when lung metastasis or hydrothorax are suspected. If pleural effusion is present, a diagnostic puncture may be useful. Fluid is evaluated to rule out adenocarcinoma. The true thyroid glandular nature of the tumor is highlighted by the sodium iodide I-123 uptake of the pelvic tumor.

After excision, strumal tissue is examined in order to determine if it is malignant or benign. Malignancy is suggested by cellular hyperplasia and atypia, increased mitotic activity, and invasion of underlying structures and consists of thyroid carcinoma or stromal carcinoid [11]. However, there seems to be a thin line between malignant and benign cases concerning histology traits, therefore the end result of therapy cannot be predicted by this method [12]. However, carcinoid variant, even if present, is usually not aggressive and cured by surgical excision [11]. Metastasis can be found in the mesentery, brain, liver, bone, contralateral ovary, peritoneum or lungs.

Multiple Pulmonary Nodules
  • We report the case of a 42-year-old woman who presented with multiple pulmonary nodules. Surgical resection of 3 nodules revealed differentiated thyroid carcinoma. Thyroid and neck ultrasound was normal.[ncbi.nlm.nih.gov]
Ischemic Changes
  • Hemorrhage and ischemic changes were seen. Other elements were not recognized. No malignant transformation was noted. These two elements were separately present, and no mergers between them were recognized.[ncbi.nlm.nih.gov]

Treatment

  • Malignant struma ovarii (MSO) is a rare malignant ovarian germ cell tumor that has been scarcely reported by thyroid surgeons focusing on treatment. There are no golden standards for its treatment.[ncbi.nlm.nih.gov]
  • METHODS: We report the clinical history, imaging studies, laboratory and pathologic data, and treatment in a patient with persistent hyperthyroidism after surgical treatment of Graves' disease.[ncbi.nlm.nih.gov]
  • Standardized treatment of malignant struma ovarii still remains undefined; currently the laparoscopic removal of the tumor may be a treatment option, and thyroidectomy and radiotherapy with 131I should be offered.[ncbi.nlm.nih.gov]
  • We review a series of four patients from a single institution and 53 cases from the literature, comparing the extent of treatment and outcomes.[ncbi.nlm.nih.gov]
  • Although this treatment strategy is well established for thyroid cancer, long-term outcomes of this treatment for struma ovarii are still unknown.[ncbi.nlm.nih.gov]

Prognosis

  • Clear cell carcinomas are considered as high-grade tumor often with poor prognosis. We describe 2 cases of clear cell carcinomas of the ovary mimicking benign or less aggressive tumors encountered in the female genital track.[ncbi.nlm.nih.gov]
  • Close follow-up was proposed and her prognosis is excellent.[ncbi.nlm.nih.gov]
  • The prognosis of patients with thyroid cancer in a struma ovarii is generally poor. In our patient, as in those who undergo ablative radioactive iodine therapy, this was not the case.[ncbi.nlm.nih.gov]
  • Thyroid-type carcinomas arising in struma ovarii, especially the newly recognized entity-highly differentiated follicular carcinoma of ovarian origin-have a favorable prognosis.[ncbi.nlm.nih.gov]
  • Activating mutations in KIT play an important role in diagnosis and prognosis of multiple malignancies including mastocytosis, gastrointestinal stromal tumors, and a subset of melanoma and acute myeloid leukemia.[ncbi.nlm.nih.gov]

Etiology

  • Possible etiologies include residual ovarian tissue after oophorectomy, ectopic thyroid, or metastatic thyroid cancer.[ncbi.nlm.nih.gov]
  • Rosenberg SA (eds): AIDS: Etiology, Diagnosis. Treatment, and Prevention. ‏ الصفحة 190 - Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. ‏ الصفحة 193 - Henson D, Tarone R.[books.google.com]
  • Unexpectedly, a new onset of hyperthyroidism prompted us to look for a second etiology.[eje.bioscientifica.com]
  • In November 2008, she was admitted for right transverse sinus thrombosis and multiple cerebral infarction from which she recovered completely; no etiology was found.[elsevier.es]
  • Etiology Risk factors Genetic predisposition BRCA1 / BRCA2 mutation HNPCC syndrome Peutz-Jeghers syndrome Hormonal imbalance and menstrual cycle Elevated number of lifetime ovulations (the contraceptive pill appears to have a protective effect) Infertility[amboss.com]

Epidemiology

  • PATIENTS AND METHODS: We analyzed the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2011 to follow-up all the cases of malignant struma ovarii in an effort of calculate the occurrence of SPTs in this cohort of patients.[ncbi.nlm.nih.gov]
  • Diagnostic criteria and microbial and epidemiologic associations. Am J Med. ‏ الصفحة 193 - Henson D, Tarone R. An epidemiologic study of cancer of the cervix, vagina, and vulva based on the Third National Cancer Survey in the United States.[books.google.com]
  • The report, which utilized the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute, also determined that the risk of aggressive thyroid cancer in patients with malignant struma ovarii is high.[emedicine.medscape.com]
  • Jump to: navigation, search Struma ovarii Microchapters Home Patient Information Overview Historical Perspective Classification Pathophysiology Causes Differentiating Struma ovarii from other Diseases Epidemiology and Demographics Risk Factors Screening[wikidoc.org]
  • The primary objective of this study was to examine the survival rate of women diagnosed with MSO using data from the Surveillance, Epidemiology, and End RESULTS (SEER) database.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Jump to: navigation, search Struma ovarii Microchapters Home Patient Information Overview Historical Perspective Classification Pathophysiology Causes Differentiating Struma ovarii from other Diseases Epidemiology and Demographics Risk Factors Screening[wikidoc.org]
  • The findings of hyperthyroidism disappeared over several weeks after surgery.9 The pathophysiology of hyperthyroidism in malignant struma ovarii is unknown.[archivesofpathology.org]

Prevention

  • Secondary Prevention Cost-Effectiveness of Therapy Future or Investigational Therapies Case Studies Case #1 Struma ovarii On the Web Most recent articles Most cited articles Review articles CME Programs Powerpoint slides Images American Roentgen Ray[wikidoc.org]
  • As for treatment, we think laparoscopy could be successful for struma ovarii, but the surgeon must be careful not to rupture the tumor intra-abdominally in order to prevent dissemination, which could lead to malignancy.[ncbi.nlm.nih.gov]
  • Treatment, and Prevention. ‏ الصفحة 190 - Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. ‏ الصفحة 193 - Henson D, Tarone R.[books.google.com]
  • 2018 19 Struma Ovarii: A Report of Three Cases and Literature Review. ( 30692823 ) Singh P...Khera P 2018 20 Struma Ovarii With Hyperthyroidism. ( 28394842 ) Ang LP...Esfandiari NH 2017 21 Hyperthyroidism due to struma ovarii: Diagnostic pitfalls and preventing[malacards.org]
  • Synchronous papillary carcinoma thyroid with malignant struma ovarii: A management dilemma 1 Department of Surgical Oncology, Cancer Institute, Womans India Association, Chennai, Tamil Nadu, India 2 Department of Preventive Oncology, Cancer Institute,[ijnm.in]

References

Article

  1. Yoo S, Chang K, Lyu M, et al. Clinical characteristics of struma ovarii. J Gynecol Oncol. 2008;19(2):135-138.
  2. Mui M, Tam K, Tam F, et al. Coexistence of struma ovarii with marked ascites and elevated CA-125 levels: case report and literature review. Arch Gynecol Obstet. 2009;279(5):753-7.
  3. Kim S, Pak K, Lim H, et al. Clinical diversity of struma ovarii. Korean J Obstet Gynecol. 2002;45:748–752.
  4. Zalel Y, Seidman DS, Oren M, et al. Sonographic and clinical characteristics of struma ovarii. J Ultrasound Med. 2000;19:857–861.
  5. March D, Desai A, Park C, et al. Struma ovarii hyperthyroidism in a postmenopausal women. J Nucl Med. 1998;29:263–265.
  6. Kraemer B, Grischke E, Staebler A, et al. Laparoscopic excision of malignant struma ovarii and 1 year follow-up without further treatment. Fertil Steril. 2011;95(6):2124.e9-e12.
  7. DeSimone CP, Lele SM, Modesitt SC. Malignant struma ovarii: a case report and analysis of cases reported in the literature with focus on survival and I131 therapy. Gynecol Oncol 2003;89:543.
  8. Young R. New and unusual aspects of ovarian germ cell tumors. Am J Surg Pathol. 1993;17:1210.
  9. Teale E, Gouldesbrough DR, Peacey SR. Graves' disease and coexisting struma ovarii: struma expression of thyrotropin receptors and the presence of thyrotropin receptor stimulating antibodies. Thyroid. 2006;16:791.
  10. Jung S, Kim Y, Lee MW, et al. Struma ovarii: CT findings. Abdom Imaging. 2008;33(6):740-743.
  11. Wei S, Baloch Z, LiVolsi V. Pathology of Struma Ovarii: A Report of 96 Cases. Endocr Pathol. 2015;26(4):342-348.
  12. Shaco-Levy R, Peng R, Snyder M, et al. Malignant struma ovarii: a blinded study of 86 cases assessing which histologic features correlate with aggressive clinical behavior. Arch Pathol Lab Med. 2012;136(2):172-178.

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Last updated: 2019-07-11 22:15