Intresting Case

Case report of a huge symptomatic Brenner tumor of ovary simulating uterine fibroid Author : Dr. T. Hema MD., DGO., DNB (OG), Dr. R. Annapoorani, MBBS., MS., (OG) Presenting Author : Dr. R. Annapoorani, MBBS., MS., (OG)

Ovarian tumours are common forms of neoplasia in women and it accounts for about 30% of female genital cancers. Ovarian carcinoma is the fourth most common female cancer and the fourth leading cause of death among cancer deaths in female. These tumours behave in diverse ways and usually they are detected after attaining a larger size. The ovarian lesion constitutes the major burden in gynaecology practices due to anatomical location of the tumour and also due to the fact that these tumours may remain asymptomatic for a longer period of time.

Transitional cell tumours of the ovary, described for the first time by Brenner in 1907, are rare neoplasms and account for about 2% of all ovarian tumours. Brenner tumours are uncommon solid fibro-epithelial neoplasm, in which the proliferating epithelial element has a transitional cell appearance, representing metaplasia. The average age at presentation is 50 years with 71% of the patients being more than 40 years. It constitutes 1.4-2.5% of all ovarian tumours and has a predilection for the postmenopausal woman. Although over 98% of these tumours are benign, and nearly 95% cases are unilateral, tumours of borderline malignancy (Proliferative Brenner Tumours), malignant and bilateral forms of these tumours have occasionally been reported. They are frequently so small as to be incidental findings at laparotomy, however very rarely it may grow up to 5-20cm in diameter and present as a pelvic mass at vaginal examination.

Case Report

A 27 year old female presented to our gynecology op with compliants of abdominal pain for one month. She was a nulligravida, married for 6 years. She had irregular menstrual cycles once in 2 months. She had felt a mass in the right lower abdomen for past one month. Her past medical and surgical history was not significant. There was no family history of systemic disease.On physical examination, she was a healthy looking woman, who was not febrile, pale or jaundiced. There was no peripheral lymphadenopathy. Her chest was clinically clear. Her radial pulse rate was 80 beats per minute, regular and of full volume. The blood pressure was 130 / 80mmHg. Her heart sounds we renormal. On abdomen examination, there was an Irregularly shaped, Hard, Non-tender, Mobile mass, The size of a 14 weeks pregnancy. The Liver, Spleen and Kidneys were not palpably enlarged. `There was no demonstrable ascites. The vulva and the vagina were normal.On vaginal examination mass was felt through right fornix,  exact uterine size was not made out.

When she was previously investigated for infertility 2 years ago, USG abdomen showed a 4×5 cm subserious fibroid. USG abdomen and pelvis taken now showed a 11×11 cm solid mass lesion in right adnexa. CA125 was done and found to be normal. MRI abdomen and pelvis showed a well defined oval mass lesion in right adnexa with mild internal cystic changes measuring 11×8.5×11.5 cm, right ovary was not separately visualised and the lesion was causing smooth indendation over the fundus of uterus. A diagnosis of ovarian tumour was made with a close differential diagnosis of subserious fibroid. Other tumour markers like beta HCG and Alpha Feto Protein were found to be normal.

She was planned for laporotomy and proceed. She was admitted in the ward. Two units of compatible blood were grouped and cross-matched for her. Her fasting blood sugar, liver and renal function test results were all normal. The urine analysis and chest radiograph were also normal. Aninformed consent was obtained.

Intraoperative findings
  • No ascites
  • Uterus was normal
  • 12×12 cm solid tumor of  right ovary present
  • Left ovary was normal
  • Omentum and other abdominal organs were normal

We proceeded with right ovariotomy, left ovarian wedge biopsy and omental biopsy.

The specimen was sent for histopathological examination. Her recovery from anaesthesia was uneventful. She received intravenous fluids,  parenteral antibiotics and analgesics for 48hours. The drugs were converted to the oral forms on the 2 post-operative day when her bowel sounds returned. Her post-operative packed cell volume was 35%. One unit of compatible packed cells was transfused. The rest of her post-operative period remained uneventful and was discharged home 4 post-operative day in satisfactory clinical condition with a 2 week appointment.

Histopathology on macroscopy showed an irregularly shaped multinodular mass with attached fallopian tubes. The surface was riddled with numerous nodules. The cut surface was nodulated, whorled and gritty. The right ovary showed nests of transitional cells within the ovarian stroma.  A histopathological diagnosis of Brenner tumour of the ovary was made.

Discussion

Brenner tumors are an uncommon subtype of the surface epithelial-stromal tumour group of ovarian neoplasms. The majority are benign, but some can be malignant. Brenner tumors were originally known as transitional cell tumors because of their histologic similarity to the urothelium. They are found incidentally on pathologic examination for oophorectomy performed for other reasons. Common symptoms include vaginal bleeding, a palpable pelvic mass, and pelvic pain. At pathologic examination, Brenner tumors are composed of epithelial nests (Walthard cell nest) surrounded by proliferating dense stromal tissue. The fibrous component is less prominent in borderline or malignant tumors than in benign lesions. Benign tumors are generally solid at pathologic examination. Size also correlates with histologic grade: most benign tumors are smaller than 5 cm, and those with borderline or malignant histologic findings are larger than 5 cm at diagnosis. Brenner tumor in our case was begin.

The cut section is sharply circumscribed and pale yellow-tan in colour. 90% are unilateral (Arising in one ovary, the other is unaffected). The tumours can vary in size from less than 1 centimetre to 30 centimetres. Borderline and malignant Brenner tumours are possible but each is rare. Tumor markers of the malignant neoplasms though useful to monitor the therapy and detect recurrences but because of the rarity and variable histological criteria, there is no established tumor marker for malignant Brenner tumors. Brenner tumors of the ovary usually have no hormonal activities, although there are reports of steroid hormone-producing Brenner tumors. Biochemical and immunohistochemical studies on estrogen and progesterone receptors in ovarian cancer correlated with the clinical outcome have given varying results. The CA 125 antigen was 06.40U / ml in this case (Normal < 35.0 U/ml).

Imaging characteristics of benign Brenner tumors are generally resembles other solid ovarian masses such as fibroma, fibrothecoma, and pedunculated leiomyoma. Sonography, although helpful in differentiating solid from cystic masses, is of more limited utility in detecting small tumors. Athey and Siegel identified 3 of 4 tumors prospectively on sonography; Moon et al reported that 5 (63%) of 8 patients had either a predominantly solid or at least a partly solid appearance on CT. Magnetic resonance imaging may show a T1 and T2 – weighted hypointense solid component containing fibrous tissue, mimicking a fibroma. By definition, transitional cell carcinoma of the ovary and malignant Brenner tumors are composed of epithelial cells morphologically resembling urothelium. At matched stage, transitional cell carcinoma of the ovary has a worse prognosis compared to malignant Brenner tumor, therefore, transitional cell carcinoma of ovary should be differentiated from malignant Brenner tumors.

First case of malignant Brenner tumor was described in 1945 by von Numbers. The criteria for a malignant Brenner tumor proposed by Hull and Campbell in 1973 are as follows: (i) Frankly malignant histological features must be present, (ii) There must be intimate association between the malignant element and a benign Brenner tumor, (iii) Mucinous cystadenomas should preferably be absent or must be well separated from both the benign and the malignant Brenner tumor and (iv) Stromal invasion by epithelial elements of the malignant Brenner tumor must be demonstrated.

Most Brenner tumors are candidates for surgical resection. Malignant Brenner tumors may affect surrounding tissue and metastasize into other structures, but this is so rare that a standard treatment has not been developed. Even malignant Brenner tumors, if diagnosed early, are candidates for complete surgical resection.21

CONCLUSION

Ovarian tumours are fairly common neoplasms. However, the incidence of Brenner tumours is very rare (1.4-2.5%) of which only 2-5% is malignant. Histopathological examination remains the gold standard for diagnosis of this entity.

Case Report Of A Triplet Pregnancy With Good Maternal And Foetal Outcome Authors : Dr. T. Hema MD., DGO., DNB(OG), Dr. R. Annapoorani, MBBS., MS.,(OG) Presenting Author : Dr. R. Annapoorani, MBBS., MS., (OG)

When more than one fetus simultaneously develops in the uterus, it is called multiple pregnancy. Simultaneous development of two foetuses (twins) is the commonest; although rare, development of three foetuses (triplets), four foetuses (quadruplets), five foetuses (quintuplets) or six foetuses (sextuplets) may also occur. According to Hellin’s rule, the mathematical frequency of multiple birth is, twins 1 in 80 pregnancies, triplets in 1 in 802, quadruplets 1 in 803 and so on.  Multiple pregnancy has always been a subject of interest to obstetricians and paediatricians alike. Since 1980, there has been 65% increase in the frequency of twins and a 500% increase in triplet and higher order births. Multifetal gestations also are associated with significantly higher maternal morbidity and associated health care costs.

The incidence of multiple gestations in developed world has increased over recent decades. There are two major reasons for high incidence of multiple pregnancies. First, the trend of child-bearing at an older age, which in itself is associated with increased risk of multiple births and, secondly, the increased availability and use of assisted reproduction technology. Multiple-pregnancy births are associated with major medical problems for both mother and infants such as Preterm delivery, Preeclampsia, Intrauterine growth retardation, Increased caesarean rates, Prematurity complications, Disabilities and Death.  We had a patient with triplets where we saved all the three babies.

Case Details

A 30 year old antenatal lady with 8 months pregnancy reported to our antenatal opd. She had one previous spontaneous abortion at 2 months amennorhoea. In this pregnancy she was given  ovulation induction with clomiphene citrate by a local practionner. She had a triamnniotictrichorionic triplet gestation now at 33 weeks. She was booked and immunised. She was not anemic, had mild pedal edema. Her Pulse rate was 80/min and blood pressure was 130/90 mm Hg. Chest was clear. Abdomen was overdistended with multiple fetal parts and all three fetal heart sounds were good. She was admitted for safe confinement. Serial ultrasounds was done. On follow up she developed non-severe preeclampsia, for which she was started on T.Labetalol 100 mg twice a day. Injection Betamethasone 12 mg intramuscular two doses was given for lung maturity.

Investigations showed Haemoglobin was 10.8, Liver function and renal function tests  were normal. Urine albuminuria was negative. Viral markers were negative. Her blood group was O positive. Last ultrasound showed triple viable foetuses. Fetus A was cephalic in presentation, measured around 32 weeks, EFW was 1631 gm. Fetus B was also cephalic, measured 33-34 weeks, EFW was 1937 gm. Fetus C was in breech presentation, measured 31-32 weeks, EFW was 1712 gm.Amniotic fluid was adequate in all three sacs.Seperating membrane was visualized in all three sacs. Doppler flow parameters was normal for all three foetuses.

She was planned was Elective caesarean section at 34 completed weeks. Two units of compatible blood was cross matched and kept. Under spinal anaesthesia LSCS was done. First baby was delivered by breech extraction, second and third were cephalic. Trichorionictriamniotic triplets.Uterus contracted well.  There was no post partum haemorrhage. Uterine wound was closed in layers. After getting  completehemostasis, instruments and pad counts were checked. Abdomen was closed in layers. Clear urine was draining in adequate amount.

Triplet A was an alive, preterm, female baby weighing 1.75 kg Triplet B was an alive, preterm, male baby weighing 1.8 kg Triplet C was an alive, preterm, female baby weighing 1.5 kg

All three babies cried immediately after birth. They were shifted to Neonatal intensive care unit for preterm care.Post-operatively mother received intravenous fluids, parenteral antibiotics and analgesics for 48hours. The drugs were converted to the oral forms on the 2 post-operative day when her bowel sounds returned. Her post-operative packed cell volume was 35%. One unit of compatible packed cells was transfused. The rest of her post-operative period remained uneventful. Babies were shifted to mother side after 48 hours. Breast feeding was established. Mother and three babies were discharged in good condition on 6th post-operative day.

Dealing with a multiple pregnancy involves more than the economic, emotional, and parental challenges of having several babies at once. There are serious medical risks and complications associated with carrying more than one fetus and giving birth to more than one infant at the same time.A multiple pregnancy is considered high risk; it requires early detection, specialized, extensive clinical management and monitoring, and awareness of possible complications. Complications for the mother and infants can be very serious—and the risks increase with the number of fetuses.

Maternal Risks and Complications

Multiple fetuses pose health risks to the mother that can compromise her health during pregnancy and childbirth. In a multiple pregnancy, fetal requirements are proportionately greater and maternal blood volume is approximately 500 mL greater than in a singleton pregnancy. Prenatal (before birth) screening and care is critical in order to detect complications early so they can be properly managed.

 

  • Miscarriages — They are at least twice as common in multiple pregnancies.
  • Hyperemesis gravidarum —”Morning sickness” is common in multiple pregnancies and is characterized by excessive nausea and vomiting.
  • Pregnancy-induced high blood pressure—Hypertension is 3 times more common in multiple pregnancies, and it is more severe.
  • Increased incidence of preeclampsia—This is a toxic condition that can develop in late pregnancy. It is characterized by a sudden rise in blood pressure, excessive weight gain, swelling, severe headache, visual disturbances, and excessive protein in the urine (proteinuria). Severe preeclampsia can be life threatening.
  • Gestational diabetes—This form of diabetes develops for the first time during pregnancy as a result of hormones produced by the placenta. The condition usually subsides after delivery.
  • Iron- and folate-deficiency anemias—It is generally recommended that women take 60–80 mg of iron and 1 mg of folic acid supplementation daily to prevent anemia. A high-protein diet is also recommended.
  • Acute polyhydramniosAn excessive amount of amniotic fluid, the liquid inside the sac that holds the fetus, occurs in about 5 – 8% of women who have a multiple pregnancy.
  • Operative delivery– incidence of caesarean section in triplets is around 90%
  • Heamorrhage—This condition is characterized by antepartum (before childbirth) heavy or uncontrollable bleeding.
  • Preterm labor and delivery—The average length of pregnancy is 39 weeks for singletons, 35 weeks for twins, 33 weeks for triplets, and 29 weeks for quadruplets. Multiple pregnancy is, on average, 12 times more likely to be preterm. Preterm labor often requires prolonged bed rest or hospitalization. Generally, once the pregnancy reaches about 32 weeks, the complications associated with premature delivery are significantly reduced.
  • Prolonged hospitalization and surgical delivery(i.e., caesarian section)—Caesarian section is often necessitated by malpresentation (abnormal position of the fetuses) that makes a vaginal delivery difficult, if not impossible.
  • During puerperium, anaemia continues, inadequate lactation, infections of urinary and genital tract may occur.
Fetal Complications

Neonatal morbidity and mortality increase with the number of foetuses in a pregnancy, but simultaneously the term of the pregnancy decreases so that problems associated with premature birth gain importance.

 

  • Prematurity – The incidence of preterm delivery in triplet pregnancies has been reported in literature to be approximately 90%.The optimal gestational age at birth for triplet pregnancies is reported to be 34-35 weeks, at a weight of 1,900 – 2,200 g.
  • Prelabour rupture of membranes – more common, adds to risk of perinatal infections and cord prolapse
  • Congenital malformations – more in monozygotic triplets
  • Fetal growth restriction – due to placental insufficieny, anaemia and preeclampsia
  • Intra uterine hypoxia leading to intrauterine death
Neonatal complications – about ¾ of infants of triplet gestation require NICU admission
  • Respiratory distress syndrome
  • Intra ventricular haemorrhage
  • Necrotizing entero colitis
  • Patent Ductus Arteriosus
  • Mechanical ventilation
  • Jaundice
  • Anaemia
  • Sepsis
  • Hypoglycaemia

Management

There is ample scope for the active management of multiple pregnancies, both antenatally as well as postnatally. In multiple pregnancy, both mother and fetuses count. As both of them are at a higher risk of morbidity and mortality. Each patient of multiple pregnancy presented with unique complication and hence, each of them were treated as different individual cases. Antenatal care plays a major role in the final outcome of multiple pregnancy. Also the age at which the patient conceived, for this multiple gestation and the parity for the present multiple gestations reflected the socioeconomic status and awareness among the patients. The role of antenatal registration among multiple pregnancies ismore pronounced which concludes the importance of regular follow up for clinical status and prevention of complications. The most common being preterm birth and prematurity. Regular follow up, along with prevention of preterm labour and adequate bed rest, and tocolysis helps in improving the neonatal outcome at birth and prevents neonatal NICU admissions and mortality. All patients with threatened preterm in between 28 – 34 weeks of gestation received 2 doses of Inj. betamethasone for fetal lung maturity. The most maternal common complication is PIH, followed by anaemia and PPH, which lead to adverse maternal outcome can be prevented. The active and timely intervention during delivery and strict vigilance in the progress of labour, definitely improves maternal and perinatal outcome. The pros and cons of the mode of delivery should be weighed and individualized. Not all multiple pregnancies can deliver vaginally, as also not all of them can be delivered by caesarean section.

Conclusion

Multiple pregnancies were associated with higher maternal and fetal/neonatal adverse outcomes. Early detection of high risk cases, timely referral, frequent antenatal visits and early hospitalization with good neonatal care set up are necessary to improve maternal and neonatal outcomes.

Successful Limb Salvage Reconstruction Surgery For Thigh Bone Tumor

Surgical Team: Prof. Dr. R. Sivakumar D. Ortho., M.S., Ortho. (Orthopaedic Surgeon) Dr.Somashekar M.S., Ortho. (Orthopaedic Surgeon) Dr.Prahalad Kumar Singhi D.Ortho DNB Ortho (Orthopaedic Surgeon) Dr.RajasekaranMD., DM., (Medical Oncologist) Dr.Balaji M.S., Mch. (Vascular Surgeon) Dr.Santhosh MD., FIPM., (Intensivist) Dr.L. MukunthakrishnanDA., DNB.,(Anaesthetist)

Introduction: Musculoskeletal oncology is an evolving field in orthopaedic surgery and surgical management for patients with osteosarcoma has changed fundamentally over the past three decades.

Osteosarcoma is a rare tumour, but it is the most common type of primary bone cancer with a biomodal peak. Primary cases tend to occur within the first two decades of life and secondary osteosarcomas affect older patients. Common causes of secondary osteosarcoma include Paget’s disease of bone and radiation exposure. Due to advances in chemotherapeutic regimes, imaging modalities, surgical techniques, material and prosthesis designs, amputation is no longer considered as treatment of choice for most patients.

Limb salvage surgery including endoprosthetic reconstructions is also constantly evolving, addressing surgical challenges such as margin control, reconstructive procedures and soft tissue management.

Historically the musculoskeletal oncology division has made long strides In the past 3 decades, which is considered as the medical wonder to the Mankind. “Limb Salvage” has been the milestone in the treatment of “Orthopaedic Oncology”. In this ,the affected neoplastic tissues were identified and removed enmass totally along with the neo adjuvant chemotherapy in the Multi Modality approach. We have followed this Multi Modality approach In managing OsteoSarcoma (the 2 nd commonest malignant tumor of bones) of the distal femur In a 21 year old college going student In Our multispeciality hospital in Madurai. After making proper investigation biopsy, imaging of the lesion along with preoperative neoadjuvant chemotherapy the tumor was totally excised and the limb was fitted with custom mega prosthesis giving her a mobile pain free joint and aiding her walk on her own, through proper rehabilitation therapy and continuation of chemotherapy post operatively providing a complete care for her. Case Report: History • 21 year old female • swelling and pain over left thigh for past 6 months. • She developed pain over distal thigh followed by swelling. • Patient had pain even at rest • Swelling was initially small in size, gradually increased in size, limiting her activities of daily living. • Initially treated at local hospitalTrucut biopsy taken and diagnosed as Osteosarcoma left distal femur, two cycles of Neo Adjuvant Chemotherapy was given Examination Finding • Clinically diffuse swelling of about 10*8 cm was present over lower thigh . • Local warmth was present. • Swelling was fixed to bone. • Knee movements were painful and restricted. • Surgical Procedure • Through anterior midline incision over the left knee joint extending proximally with lazy curved incision over the distal third femur and by careful soft tissue dissection along with the soft tissue extension of tumor mass , neurovascular bundle explored and isolated from the mass and intoto excision of the tumor along with approximately 6cm above the lesion distal femur was osteotomised. • Femoral canal preparation done and custom mega femoral prosthesis of 18 cm and tibia prepared , trial implantation done , cementing done and tibial component of size 1.5 with extension stem of 10*75 mm inserted with hinged rotating platform joint reduced and joint found stable. Thorough wash given and patella tracking done and joint and wound closure done with drain insitu. • Per-operative Picture • Fig.3, Surface Marking • Fig.4, Deep Dissection and Tumour mass exposure • Fig.4, Osteotomy of distal femur proximal to Tumour • Fig.5, Excised Tumour mass • • Fig.6, Femoral canal preparation • • Fig.7, After excision of tumour mass • Fig.8, Trial Prosthesis • Fig.9, Hybrid Custom made Hinged Megaprosthesis • • Fig.10, Hybrid Custom made Hinged Megaprosthesis • Immediate post operative • Immediate post operative period patient haemodynamicaly stabilized by blood transfusions and further postoperative period was uneventful and is on rehabilitation programme. Excised mass send for histopathological examination and found consistent with the previous biopsy report . • Report • Medical management, surgical techniques and prosthetic design have improved significantly during the last three decades. • Amputation is no longer considered as standard of care in patients with osteosarcoma in most cases. • However, limb salvage with megaprosthesis remains challenging. • Complication rates are high, with infection occurring most commonly • A good interaction within a multidisciplinary team in a preferably high-volume centre is required for optimal management. • Historically the osteosarcoma being a highly malignant, potential killer disease with pain and sufferings with a very low five years survival rate in spite of sacrificing the limb along with the tumor . • The innovations and advances in management of such tumors with the Combination of NeoAdjuvant Chemotherapy and Limb Salvage Reconstruction surgery and rehabilitation -a multi disciplinary approach as brought back their smiles mobility and better longevity . • Today the girl is able to walk with both lower Limbs pain free and her “smile” brings great rejoice to her family and great Success to Our Institute.