PMC7418455_01
Sonographic findings of 03/2018: possible, small endometriotic lesions in the (A) right (yellow arrow) and (B) left (green arrows) ovaries.
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Four months later, however, in the subsequent follow-up ultrasound scan, both of the ovaries as well as the rectovaginal septum showed newly developed, possible endometriotic lesions (Figure 1).
Sonographic findings of 11/2018: (A and B) large, septated cystic lesion with mostly ground glass echogenic content and signs of fresh hemorrhages in the right ovary; (C and D) left ovary with endometrioma-like cystic lesions with ground glass echogenic content with a possible papillary structure in one of them (yellow arrow).
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Between two subsequent scans in July and November 2018, made in the process of regular follow-up at our clinic, and under continuation of the prescribed hormonal treatment, a large, partially septated, endometriotic cyst had developed in the right ovary measuring a maximum diameter of 8 cm, showing a content of ground glass echogenicity as well as signs of fresh hemorrhages (Figure 2A and B). There had also been an increase in the size of the left ovary, with multiple cystic findings with ground glass echogenic content (Figure 2C), one of which had a possible papillary structure lining the cyst wall (Figure 2D).
Intraoperative findings 11/2018: (A) chocolate like fluid spilling from the endometriotic cyst of the right ovary; (B) papillary structures found lining the bottom of the endometriotic cyst.
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During enucleation of the endometriotic cyst on the right side (Figure 3A), unexpected papillary structures were found lining the bottom of the cyst (Figure 3B).
Histological findings of the endometrioid borderline ovarian tumor (eBOT): (A) overview including the ovarian capsule; (B) transition from the endometriotic cyst wall (green arrow) to the proliferated part with borderline malignancy (yellow arrow); (C) section with proliferated part; (D) detailed view with mitotic figures (red arrows).
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Definitive histological examination revealed an endometrioid borderline ovarian tumor, pT1c2 (rupture of the cyst preoperatively), without stromal invasion (Figure 4).
Ultrasound study of the left ovary 4 weeks postoperatively showing progressive enlargement of the ovary itself as well as the cystic structures. (A) the left ovary now measures 64 mm in the maximum diameter (in the previous exam it measured 51 mm, see Figure 2) with cystic lesions with ground glass echogenic content, suggestive of endometriomas; (B) no blood flow is detected within the cystic lesions; (C) in the center of the left ovary a solid part can be distinguished; (D) the solid center shows no increased vascularization (yellow arrow).
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Unfortunately, after this period of 4 weeks, sonographic imaging showed further enlargement of the left ovary itself as well as the cystic lesions, along with a more prominently appearing central solid part, all in all suspicious of contralateral borderline malignancy entailing further surgical investigation (Figure 5).
PMC7418455_02
Intraoperative findings 01/2019: (A and B) show the intraoperative appearance of the left ovary, with the impression of cystic enlargement and induration on palpation; (C) shows the right ovary after cystectomy 2 months earlier; (D) shows the greater omentum.
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Thus, suspecting bilateral involvement of the ovaries in this now 26-year-old patient, the decision was made to complete the staging operation by laparoscopic reevaluation of the right ovary (Figure 6C), cystectomy of the left ovary for histological diagnosis (Figure 6A and B) as well as peritoneal washing cytology, omentectomy (Figure 6D), peritoneal biopsies and endometrial sampling.