Fibrothecoma with pseudo-carcinomatosis in a young woman: The radiologic pitfalls of Meigs syndrome and the importance of fertility-sparing surgery

Ovarian fibrothecomas are uncommon benign sex cord-stromal tumors that may rarely present with ascites and pleural effusion, constituting Meigs syndrome. In young women, this presentation may mimic advanced ovarian malignancy with peritoneal carcinomatosis, potentially leading to unnecessarily aggressive surgery and avoidable loss of fertility. We report the case of a 38-year-old nulliparous woman presenting with progressive abdominal distension. Contrast-enhanced computed tomography (CT) demonstrated a giant right ovarian mass measuring 198 × 179 mm associated with abundant ascites and left pleural effusion. Multiplanar reconstructions revealed a solid ovarian lesion with suspicious peritoneal nodularity initially interpreted as carcinomatosis. Serum CA-125 level was elevated (275 U/mL), further increasing suspicion for ovarian malignancy. Surgical exploration demonstrated a large right ovarian mass without diffuse peritoneal carcinomatosis. The contralateral adnexa appeared normal. Right adnexectomy with omental and peritoneal biopsies was performed as a fertility-preserving strategy. Cytologic analysis of ascitic fluid showed hemorrhagic inflammatory fluid without malignant cells. Histopathological examination confirmed ovarian fibrothecoma without evidence of malignancy. This case highlights a major diagnostic pitfall in gynecologic imaging: benign ovarian fibrothecoma associated with Meigs syndrome may closely simulate advanced ovarian cancer, particularly in the presence of ascites, pleural effusion, elevated CA-125, and suspicious peritoneal nodules. Increased radiologic awareness of this entity is essential in young women to avoid unnecessarily radical surgery and preserve reproductive potential.