Sep 28, 2016 - amenorrhoea and the ultrasound did not demonstrate intrauterine pregnancy but bHCG was ... Some fluid and a piece of echogenic material of 1.8 x ... in nearly all premenopausal women and in up to 18% of postmenopausal ...
26th World Congress on Ultrasound in Obstetrics and Gynecology sac was measured in three planes to obtain a volume, which was initially 8.3 cm3. Methotrexate at 50 mg/m2 was administered intramuscularly. The patient was followed at regular interval with a sharp drop in the beta HCG but with only mild variation of the volume of gestational sac and the distance with bladder. Trophoblast aspect changed slightly overtime with a heterogeneous aspect of the trophoblast. Mild episodes of bleeding were noted over this period. The persistent vascular image on Colour Doppler led to suspicion of an arteriovenous malformation. This was confirmed by angio-MRI. The patient had then arteriography with embolisation. Conclusion: In the case of a scar pregnancy treated by methotrexate where ultrasound parameters change less than biological parameters, vascular malformations should be suspected and treated accordingly.
Supporting information can be found in the online version of this abstract
EP25.16 Pitfalls in the diagnosis of interstitial/cornual pregnancy: case report J. Zhi Ping Ho, S. Lee, L.K. Tan, H. Tan Department of Obstetrics and Gynecology, Singapore General Hospital, Singapore Case report: Patient was a 30-year old female, para 2. She has no medical history of note. She had a full-term normal vertex delivery complicated by 4th-degree tear with rectovaginal fistula. For the index pregnancy, she saw a private obstetrician at 4 weeks’ amenorrhoea and the ultrasound did not demonstrate intrauterine pregnancy but bHCG was 64000. Concerns were raised about the possibility of molar pregnancy. Dilatation and curettage was performed and it was confirmed that there was no mole. She had spotting for a week after the procedure; bHCG was 2000. She was also told to have a 6 cm fibroid on the ultrasound scan. She was otherwise asymptomatic and well with no pain, per vaginal bleeding or fever. She presented at our hospital’s emergency department for a second opinion. On examination, the abdomen was soft, non-tender; there was no per vaginal bleeding or discharge. Uterus was 12 weeks’ size, there was no adnexal tenderness. Investigations revealed bHCG to be 1392, Hb 13.1 TW 5.39 Plt 233. Ultrasound pelvis revealed a 5.0 x 4.9 x 4.0 cm echogenic mass in right lateral wall. Some blood flow was noted within this mass. Findings were suggestive of a fibroid. Some fluid and a piece of echogenic material of 1.8 x 0.5 cm were seen in the endometrial cavity. Impression: RPOC. She was reviewed one week later. bHCG was 672. An ultrasound scan which was performed revealed a 4.4 x 3.2 x 4.5 cm heterogeneous echogenic mass with cystic spaces in the right lateral wall. Colour and power Doppler did not detect intratumoural flow. The endometrial midline echo was impinging onto the central region of the above mentioned mass. Findings were suggestive of an interstitial ectopic pregnancy. A repeat ultrasound one month later showed the mass to be measuring 3.8 x 2.5 x 3.3 cm. She underwent wedge resection of cornual pregnancy. Conclusion: The rudimentary horn was not demonstrated on the ultrasound and hence, it was of great difficulty to confirm a cornual pregnancy.
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Electronic poster abstracts
EP26: MANAGING OVARIAN MASSES EP26.01 Dermoid cyst on remaining ovarian tissue six months after cystectomy for a complex ovarian mass A. Corpade2 , F. Olaru2 , C. Olaru1 1 Dr
Dumitru Popescu Hospital Timisoara, Timisoara, Romania; 2 Department of Obstetrics and Gynecology, SCMU Timisoara, Timisoara, Romania Introduction: Ovarian cysts are found on transvaginal sonography in nearly all premenopausal women and in up to 18% of postmenopausal women. Most of these cysts are functional in nature and benign. Mature cystic teratomas, or dermoids, represent more than 10% of all ovarian neoplasms. Complex ovarian cysts occur less frequently and are not related to the normal menstrual cycle. These are generally benign. There are three types of complex ovarian cysts: dermoid cysts, cystadenomas, and endometriomas. In complex, multiloculated cysts, the risk of malignancy climbs to 36%. Case description: We present the case of a 29-year old woman, who accused pelvic pain and dyspareunia. On physical examination a mass could be palpated in the left lower quadrant of the abdomen. Transvaginal ultrasound showed a triloculated ovarian mass on the left ovary of aprox. 12 cm, each lobule with different echogenicity. CT of the pelvis was performed, with similar result. CA-125 was in the normal range. The patient agreed to exploratory laparoscopy and cystectomy of the ovarian mass was performed. The histopathological result proved the complex nature of the ovarian cyst: dermoid, cystadenoma and hemorrhagic. Six months later the patient returns with similar symptomatology. Ultrasound shows a left ovarian mass of aprox. 10 cm diameter, uniloculated, with hyperchoic solid components within the mass. Exploratory laparoscopy was performed and we found a dermoid cyst on remaining ovarian tissue from the prior cystectomy. Oophorectomy was performed. Histopathological examination confirmed the dermoid nature of the cyst. Discussion: The particularity of this case was the rapid growth of the dermoid cyst on the remaining ovarian tissue, just six months after surgery for a complex ovarian mass. This wouldn’t have occurred, if oophorectomy was performed in the initial laparoscopy, but given the young age of the patient and the desire to have more children, a fertility-sparing approach was preferred.
EP26.02 Primary ovarian leiomyoma: a rare entity A.T. Marujo1 , R. Torres1 , C. Barros1 , M.D. Bernardo2 1 Department of Gynecology, Centro Hospitalar Lisboa Central-Maternidade Dr Alfredo Costa, Lisbon, Portugal; 2 Dona Estefania Hospital, Lisbon, Portugal
Introduction: Ovarian leiomyoma accounts for 0,5-1% of all benign ovarian tumours. Generally they occur in premenopausal women, are unilateral and small sized. Given its rarity and the nonexistence of specific sonographic characteristics, differential diagnosis can be difficult in the preoperative period. Case Report: A 35 year old nul´ıpara was referred to our hospital after the diagnosis of adnexal tumor in routine pelvic ultrasound. She was asymptomatic and had no special medical history. Gynecological examination revealed a solid mass at right iliac region, painless with mobilisation. Transvaginal ultrasound revealed a right adnexal solid mass, with 62x42x47mm in diameter that was well circumscribed and homogeneously isoechoic with no suspicious blood flow pattern. Her Ca125, AFP, CEA, CA 19–9 were normal. A staging laparoscopy was performed. A right adnexal solid mass with 6 cm in diameter was confirmed with
© The Authors 2016 © Ultrasound in Obstetrics & Gynecology 2016; 48 (Suppl. 1): 270–393.
25–28 September 2016, Rome, Italy no adhesions to surrounding structures. The uterus, left ovary and pelvic cavity were grossly normal. Unilateral salpingo-oophorectomy was performed and frozen sectioning revealed a benign tumour suggesting thecoma or fibroma. Histological examination revealed a tumour composed of interlacing bundles of fusiforme cells, with no atypia or pleomorphism and mitotic count and necrosis were absent. Immunohistochemical staining showed positive staining for smooth muscle actin, resulting in the diagnosis of primary ovarian leiomyoma. Postoperative period was uneventful. Conclusions: Ovarian leiomyomas are very rare and usually difficult to diagnose. Histological and Immunohistochemical diagnosis are essential for correctly distinguish them from other ovarian tumours.
EP26.03 Use of IOTA terms, definitions and models to describe ovarian mass with elevated β-hCG in 35-years-old patient: case report N. Abdalla, R. Piorkowski, M. Pazura, K. Cendrowski, W. Sawicki Department of Obstetrics, Gynecology and Oncology, II Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland A 35-year-old Caucasian patient was admitted to our Clinic for surgical intervention because of right ovarian mass and mild abdominal pain lasting for 3 months. Ultrasound examination was performed according to the terms and definitions of International Ovarian Tumor Analysis (IOTA) group. Ultrasound examination showed irregular unilocular-solid mass with dimensions of 116x89x71 mm. The largest diameter of the solid area was 35 mm. There was no vascularisation of the mass in colour Doppler ultrasound. The mass was considered as benign according to simple rules of IOTA. The results of IOTA logistic regression model 1 and 2 were 22,1% and 32,4% respectively, classifying the mass as malignant. Serum level of CA125 and β-hCG was 44 U/ml and 59,9 mIU/ml respectively. The IOTA-ADNEX model revealed 40,9% probability of malignancy. The probability of being borderline, stage I ovarian cancer, stage II-IV ovarian cancer or metastatic disease was 19,4%, 14,7%, 4,7% and 2,1% respectively. Macroscopic inspection of the right adnexa during operation revealed an 11 cm mass, with the oviduct being slightly dilated and stretched around the mass. Right adnexectomy was performed. The final histological examination revealed struma ovarii and right tubal ectopic pregnancy. The simple rules classified correctly the mass as non-malignant before histological diagnosis was made. Other IOTA models failed to classify the mass as benign. Individual management of each patient may help to classify the ovarian mass before surgical management.
EP26.04 Extra ovarian primary peritoneal carcinoma – a form of early ovarian cancer? R. Torres1 , A.T. Marujo1 , A. Lacerda1 , M.D. Bernardo2 1
Department of Gynecology, Centro Hospitalar Lisboa Central-Maternidade Dr Alfredo Costa, Lisbon, Portugal; 2 Dona Estefania Hospital, Lisbon, Portugal Extra ovarian primary peritoneal carcinoma is a rare type of adenocarcinoma of the pelvic and abdominal peritoneum. This neoplasia’s gross examination and histological aspect virtually overlaps with that of ovarian carcinoma. We report a case of a 77 year-old patient refered to our clinic for a recurring abdominal pain, constipation and an adnexal mass. The ultrasound and CT scan performed at our institution revealed a 69x52x55mm, single, smooth, solid mass without accoustic shadows, and with a high vascularisation index, close to the left ovary occupying the Douglas Pouch. CA 125 and CEA levels were
Electronic poster abstracts normal. The patient was operated through a midline abdominal incision and the uterus, adnexa and mass were removed. No primary tumor was found anywhere else in the abdomen or in the pelvis. Post-operative course was normal and the patient was discharged three days later. The histological exam and immunohistochemical analysis of the neoplasia revealed positivity for CK7 and estrogen receptors, and negativity to CA 125, CEA, CK20 and GCDFP15, which supported a final diagnosis of an indiferenciated extra ovarian primary peritoneal carcinoma. Conclusion: Epithelial ovarian cancer’s cellular origin has long been debated. Recent molecular and clinicopathologic studies have provided evidence that epithelial ovarian cancer stems ¨ from Mullerian-derived extraovarian cells that involves the ovary secondarily. This case can rise the question whether early detection of ovarian cancer can be a reality in the near future. Are we looking in the right direction?
EP26.05 Massive ovarian edema in a neonate following fetal torsion A. Kennedy Department of Radiology and Imaging Sciences, University of Utah, Salt Lake, UT, USA A biophysical profile was ordered to evaluate a noon-reactive NST at 38 weeks. Whilst looking for breathing the sonographer noted a fetal abdominal mass superior to the bladder. On closer evaluation the mass had tiny peripheral follicles and no internal flow consistent with ovarian torsion. After delivery imaging of the infant showed a similar-sized mass that looked like an ovary with a hemorrhagic cyst but there was some internal flow present. The diagnosis of massive ovarian edema from intermittent torsion was suggested. The infant was transferred to our neighboring pediatric hospital and, although she was well, surgical exploration was undertaken. A hemorrhagic cyst was removed but the ovary was salvaged. This is an improvement in care as previously all intraabdominal masses were removed by general pediatric surgeons even if the imaging characteristic were suggestive of benign ovarian etiology. The infant is 3 month of age and doing well. Long term follow up will be required to see if there is any residual function in the right ovary.
Supporting information can be found in the online version of this abstract
EP27: PELVIC PAIN AND ENDOMETRIOSIS EP27.01 Rectal endometriotic nodule volume (RENV) and angle of infiltrating endometriotic rectal nodule (AIERN): ultrasonographic markers of severity for DIE ´ 2 , H. Sovino3 , J. Martinez2 , A. Iturra2 , M. Leon M. Yamamoto1 1
Department of Maternal Fetal Medicine, Clinica Alemana y Hospital Padre Hurtado, UDD, Vitacura, Santiago, Chile; 2 Department of Obstetrics and Gynecology, Ultrasound Unit, Clinica Indisa, Santiago, Chile; 3 Reproduction Unit, Clinica Indisa, Santiago, Chile Objectives: The lesions of the rectum, with or without involvement of rectovaginal septum, is a major surgical problem whose decision on the type of surgery is, in most cases, intraoperative. Two simple methods of ultrasound measurement for predicting severe DIE: angle of infiltrating endometriotic rectal nodule (AIERN) and Rectal endometriotic nodule volume (RENV) proposed.
© The Authors 2016 © Ultrasound in Obstetrics & Gynecology 2016; 48 (Suppl. 1): 270–393.
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