Malignant Ovarian Lesion Complicated by a Rare Entero-Ovarian Fistula

Abstract

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 [Figures 1-3]. 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 Malignant Ovarian Lesion Complicated by a Rare Entero‐Ovarian Fistula Gynecology and Minimally Invasive Therapy 8 (2019) 89-90