EP24.01: Polypoid endometriosis: clinical presentation and ultrasound findings

Polypoid endometriosis is a rare form of endometriosis that may present as a lesion of rapid growth mimicking ovarian malignancies. We present the patient case of a 43-year-old woman who had worked in Singapore for 5 years. There was no past medical or surgical history of note. She went for 6 month employment review which reported ovarian cyst of 7.7 x 10cm. Ca 125 was raised above 400, and she was told by GP to go to Emergency Department to be admitted as it might be cancer. On examination, she had no pain, vomit or fever, only intermittent pain x 4 months(only pre menses); No LOW, no LOA. Patient was alert, abdomen was soft, non-tender. Bedside scan revealed a 6.9cm loculated clear cyst with echogenic nodules, regular margins, no papillary projection, no ascites. Clinician's impression was suspicious right adnexal cyst. Patient went for formal ultrasound scan. A 9.3 x 8.2 x 8.7cm septated cystic-solid mass noted in midline of the pelvis and slightly towards the right adnexal region. It contained mid-grey level internal echoes and at least two echogenic areas measuring up to 4.2 x 3.4 x 1.6cm. Both echogenic areas contained multiple echogenic specks and demonstrated moderate vascularity. It was probably of right ovarian origin. Another ovary-like mass measured 2.4 x 1.3 x 1.3cm and was noted posterior to the above mentioned mass in right adnexal region, and was probably the left ovary. IOTA scoring for likelihood ratio of malignancy was 5.2%. She underwent CT scan for staging. Findings: Large circumscribed cystic lesion in the right adnexa with enhancing solid components was suspicious for primary ovarian malignancy. No evidence of distant metastasis. Patient underwent Laparotomy THBSO FS KIV PLND and omentectomy. Histopathology: Polypoid endometriosis involving the right ovary. In conclusion, the diagnostic workup on polypoid endometriosis may pose challenges, but IOTA scoring on ultrasound observations would provide results with high sensitivity.