Abstract
Objective
We present an intriguing case of simultaneous, bilateral, complete ovarian torsion with synchronous endometrial adenocarcinoma in a previously healthy patient with a reported history of unilateral oophorectomy. This unique case demonstrates the limitations of pelvic imaging and patient history.
Case report
A 32-year-old woman with a history of unilateral oophorectomy, presented to the emergency department with worsening left lower abdominal pain concerning for ovarian torsion. A pelvic ultrasound showed an 8-cm heterogeneous right ovarian cyst with preserved arterial flow. The left ovary appeared absent. The endometrium appeared irregular with scant anechoic intracavitary fluid. She underwent a diagnostic laparoscopy, revealing large bilateral ovarian masses, each with torsion along its infundibulopelvic ligament. Concurrent hysteroscopic sampling demonstrated endometrial adenocarcinoma.
Conclusion
This unique case of simultaneous bilateral ovarian torsion with synchronous endometrial adenocarcinoma emphasizes the vigilance required to pursue a diagnosis when a clinical presentation conflicts with reported patient history and imaging findings.
Introduction
Ovarian torsion is a gynecologic emergency that requires prompt surgical intervention in cases where fertility preservation is desired [ ]. Typically, patients present with severe, unilateral abdominopelvic pain and may have transvaginal ultrasound findings consistent with reduced blood flow within the ovarian vessels. Simultaneous torsion of both ovaries is exceedingly rare, with fewer than 20 cases reported in the literature [ ]. Here, we present the first and only case of simultaneous, bilateral, complete torsion of fused adnexal masses and synchronous endometrial adenocarcinoma, which created a significant diagnostic challenge.
Case presentation
A nulliparous 32-year-old woman with a BMI of 35.7 kg/m 2 presented to the emergency department as a transfer from a nearby hospital with worsening left lower quadrant pain initially concerning for ovarian torsion. She reported episodic, sharp, left lower quadrant pain over the past month that acutely worsened the night prior. She had associated nausea and vomiting. The pain was not alleviated with acetaminophen. She denied any other gastrointestinal or genitourinary symptoms. The patient reported a similar episode three years prior. At that time, she was diagnosed with a presumed ovarian teratoma and underwent a laparoscopic oophorectomy, per her report, as her medical records from Mexico were not available for review. She did not recall on which side the tumor was found but remembered that the tumor contained hair and teeth. She began menstruating at age 12 with subsequent irregular cycles. She had no history of any other illnesses or known allergies. She was not on any medications. Her family history was unremarkable. She denied tobacco or illicit drug use and endorsed occasional social alcohol consumption.
Physical examination revealed normal vital signs. She was in no acute distress with non-labored respirations on room air. Her pelvic exam was notable for cervical motion tenderness, a palpable right adnexal mass, and mild tenderness of the left adnexa without signs of peritonitis. Initial laboratory testing was remarkable only for a leukocytosis of 15.1 k/μL.
An ultrasound was performed and showed an 8-cm heterogeneous right ovarian cyst with preserved arterial flow. An irregular endometrium was also visualized with a small volume of nonspecific anechoic fluid in the endometrial canal. The left ovary was not visualized.
The patient’s pain and nausea improved after receiving morphine and ondansetron. Though the left ovary could not be visualized with transvaginal ultrasonography, this was consistent with the patient’s reported prior oophorectomy. The right ovary was found to have preserved arterial flow, and torsion was thought to be unlikely due to the location of the pain. It was felt that there was no active torsion as the patient’s pain had resolved, and serial abdominal exams were benign. She was discharged from the emergency department in stable condition, with close follow-up recommended.
She presented two days later at our clinic, again feeling intermittent left lower quadrant pain without identified triggers. At this point, we were most concerned about intermittent torsion of the right ovary with pain referred to the left pelvis. Additionally, we were concerned about endometrial hyperplasia, given the patient’s history of abnormal uterine bleeding and irregular-appearing endometrium with intracavitary fluid.
The patient was amenable to surgical management and was not concerned with fertility preservation. She consented to a diagnostic laparoscopy with possible right ovarian detorsion, possible right ovarian cystectomy, possible salpingectomy, and possible oophorectomy with concomitant hysteroscopy with dilation and curettage.
Upon abdominal entry, large bilateral ovarian masses were noted that prevented visualization of the uterus [ Fig. 1 ]. The masses both appeared to be torsed along their respective infundibulopelvic ligaments. Furthermore, a vascular adhesion connected both adnexal masses, which were twisted [ Fig. 2 ]. Notably, the left adnexal mass appeared to be necrotic compared to the right.
