BMJ Case Reports

Uretero-Iliac artery fistula: a rare cause of haematuria

A woman in her mid-forties with a history of cervical cancer requiring chemoradiation presented with bilateral ureteral strictures secondary to radiation therapy. The ureteral obstruction was initially relieved with bilateral percutaneous nephrostomy tubes, and subsequently, bilateral ureteral stents. Over the course of 8 months, she presented with multiple episodes of severe gross haematuria. This persisted even after stent removal and conversion back to percutaneous nephrostomy tubes. The initial evaluation, done with concern for an uretero-iliac artery fistula, which included bilateral retrograde pyelograms and CT angiography was non-diagnostic. Given continued haematuria, repeat endoscopic evaluation was undertaken; on retrograde pyelogram, brisk contrast was seen to pass into the arterial system, consistent with a left ureteroarterial fistula. The patient underwent endovascular iliac artery stent placement. Subsequently, the patient underwent resection of the iliac artery with endovascular graft in situ, left distal ureterectomy with proximal ureteral ligation following femoral-to-femoral bypass. This allowed for complete resolution of the patient’s gross haematuria episodes.

Cervical bronchogenic cyst in a toddler

Bronchogenic cyst is a congenital abnormality arising from the tracheobronchial system. Localisation of such cysts in the head and neck region is rare. We report a girl in her early childhood with a painless enlarging right lateral neck mass diagnosed with a branchial cleft cyst based on clinical and radiological MRI findings. An incidental finding of a cervical bronchogenic cyst was made on the final histopathological specimen. Although rare, bronchogenic cysts should be considered as differential diagnoses for paediatric patients’ lateral and midline cervical masses.

Ovarian luteoma masses in pregnancy: an uncommon cause of virilisation

Pregnancy luteoma is a benign ovarian tumour that presents during pregnancy and regresses spontaneously post partum. The mass may secrete androgenic hormones which can result in virilisation of mother and female foetus. Clinical presentation of pregnancy luteoma is varied from asymptomatic to significant virilisation. We present two cases of ovarian luteomas identified incidentally at caesarean section. The first case had marked hirsutism, while the second case had mild acne. Both foetuses were male and appeared unaffected at birth. Where maternal virilisation is identified during pregnancy, differential diagnoses including pregnancy luteoma should be considered.

Occult ovarian adenocarcinoma manifesting as dermatomyositis

A woman in her 60s presented with erythematous lesions predominantly over the joints. After evaluation by dermatology and rheumatology, she was diagnosed with dermatomyositis and initiated on oral steroids and immunosuppressants. She was subsequently referred to gynaecology services for further evaluation of possible malignancies. On pelvic examination, a firm, mobile mass was noted in the right adnexa which was confirmed on imaging. A decision for staging laparotomy was taken. Intraoperatively, a solid mass was observed in the right ovary with no adjacent tumour deposits. Histopathology indicated high-grade serous carcinoma. Following surgery, her dermatological condition improved drastically, and she is currently off medications. She has received postoperative chemotherapy. Five years on, she is doing well.

Spontaneous subcapsular and perirenal haemorrhage with retroperitoneal haematoma in a patient with ovarian melanoma metastases

A 47-year-old woman was admitted to our clinic for intensive pain in the left flank region. The transvaginal ultrasound showed a left adnexal solid mass with ascites. She had undergone surgical removal of skin melanoma in 2008, but in September 2019, intracardiac metastasis resulting from it had been discovered. CT performed in March 2020 had been negative for other metastases. A full abdomen ultrasound was not performed. During the night, the patient began to show signs and symptoms of hypovolaemic shock. The patient was urgently transferred to the operating room for a video laparoscopy. A vast left retroperitoneal haematoma was diagnosed along with voluminous enlargement of the left ovary. We proceeded with a left adnexectomy and blood transfusion. Subsequent contrast-enhanced CT revealed a left subcapsular, perirenal haematoma and a voluminous retroperitoneal haematoma. Kidney metastasis was also seen. The final histological diagnosis was metastatic amelanotic malignant melanoma of the ovary.

Cervicovaginal cellular angiofibroma

Cellular angiofibroma is a rare type of benign mesenchymal tumour that arises mostly in middle-aged women. It needs to be distinguished from other neoplasms and has a predilection for the vulvovaginal region. To our knowledge, this is the first case of a cervical cellular angiofibroma. A 34-year-old nulligravid woman was referred with a large mass bulging in the fornix posterior. Ultrasound scanning and MRI showed a large solid mass projecting in the pouch of Douglas. Laparoscopic surgical excision was performed. Histopathological examination showed a well-demarcated, unencapsulated tumour, consisting of short fascicles of spindle cells in-between thick-walled medium-sized vessels. On immunohistochemistry, there was strong reactivity with antibodies against CD34 and oestrogen receptor. Angiofibromas are benign mesenchymal tumours mostly occurring in middle-aged women. They can cause abnormal swelling and uterine bleeding and need to be distinguished from other (malignant) neoplasms.

Prolapsing vaginal fibroepithelial polyp

Although uncommon, vaginal fibroepithelial polyps can present as prolapsing vaginal tissue, causing discomfort and anxiety. Surgical excision of the polyps can provide a minimally invasive solution. In this case, we describe a nulliparous female in late adolescence who presented for evaluation of tissue protruding through the vagina. On exam, a 5×4 cm fibroepithelial polyp was extending from the distal posterior vagina on a broad stalk. Successful transperineal surgical excision was performed. Fibroepithelial polyps, although uncommon, can be a cause for prolapsing vaginal tissue and should be part of the differential diagnosis, especially in patients who have no risk factors for pelvic organ prolapse. They can be excised vaginally, alleviating symptoms and distress. Because they sometimes recur, continued surveillance with gynaecological exams is recommended.

Eclampsia, HELLP and PRES in a 16-week partial molar pregnancy

Eclampsia spectrum disorders are a set of serious complications of pregnancy that commonly present after 20 weeks of gestation. There is an association between molar pregnancy, a gestational trophoblastic disease resulting from abnormal fertilisation and gametogenesis, and eclampsia spectrum disorders which can result in manifestation of pre-eclamptic symptomatology earlier than 20 weeks of gestation. We report a case of a gravida 1 para 0 in her mid 20s at 16-weeks gestation presenting with partial hydatidiform mole who developed eclampsia, haemolysis, elevated liver enzymes and low platelets syndrome and posterior reversible encephalopathy syndrome. Ultrasound findings were consistent with molar pregnancy and pathology confirmed partial molar pregnancy with triploid 69, XYY karyotype. This case highlights the early onset potential of eclampsia spectrum disorders in molar pregnancies while suggesting screening such patients for hypertensive disorders.

Treatment for SMARCA4-deficient carcinoma of uterine cervix

SMARCA4-deficient undifferentiated cervical carcinoma is an extremely rare and aggressive malignancy, and effective treatment options are lacking. We experienced a rare case involving a patient with SMARCA4-deficient undifferentiated cervical carcinoma who was successfully managed in the long term. A woman in her 40s presented with a chief complaint of abnormal vaginal bleeding. A cervical biopsy revealed adenocarcinoma; thus, radical hysterectomy was performed with R0 tumour resection. Histopathological examination of the resected tumour showed rhabdoid features under (H&E) staining and negativity for SMARCA4 under immunohistochemical staining. Given the poor prognosis associated with SMARCA4-deficient carcinoma, adjuvant radiotherapy was added. Follow-up for more than a year revealed no evidence of recurrence. For undifferentiated cervical carcinoma with rhabdoid features on H&E staining, SMARCA4 immunostaining may be considered for risk classification and recurrence prevention. R0 resection and postoperative adjuvant radiotherapy may contribute to a good prognosis for patients with SMARCA4-deficient carcinoma.

Unilateral Roth spots secondary to uterine leiomyoma

We report a rare case of a female patient in her early 50s who presented with unilateral transient visual symptoms that resolved shortly. On examination, the anterior segment exam was unremarkable bilaterally; however, her fundus examination showed unilateral anaemic retinopathy, including Roth spots. Her blood tests showed iron deficiency anaemia due to chronic menorrhagia, and her abdominal ultrasound scan showed large uterine fibroids. The gynaecology team was involved; medical therapy failed to control her heavy menstrual bleeding and subsequently correct her anaemia; thus, surgical management was advocated. After undergoing hysterectomy with bilateral salpingectomy and left oophorectomy, her blood testing normalised, and the anaemic retinopathy completely resolved.

Development of endometrial cancer after long-term usage of the levonorgestrel-releasing intrauterine system

A 52-year-old long-term user of the levonorgestrel-releasing intrauterine system (LNG-IUS) presented with vaginal bleeding. Endometrial biopsy was performed and revealed endometrioid adenocarcinoma. The patient had a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Endometrial cancer is rare in women with LNG-IUS as only seven cases have been published in the literature. Although scientific evidence shows LNG-IUS has a protective effect on the endometrium from developing cancer, our report highlights the importance of clinicians to be vigilant in cases of women with LNG-IUS who develop intermittent vaginal bleeding.

Giant serous adenofibroma of the fallopian tube

Serous adenofibroma of the fallopian tube is a rare, benign tumour of the female genital tract. They are usually small, asymptomatic and incidentally diagnosed during a surgery for another gynaecological condition. This report presents an atypical case of a 17-year-old girl with a tubal serous adenofibroma that presented with a palpable mass occupying the entire abdomen accompanied by urinary symptoms. She underwent a laparoscopic surgery with drainage of 1800 mL of yellow, citrine liquid from the cyst and left salpingectomy with no complications.

Metastatic clear cell endometrial carcinoma: an unusual cause of a common clinical presentation

A 60-year-old woman presented with melena for 2 weeks. She had undergone hysterectomy and bilateral salpingo-oophorectomy to treat clear cell endometrial carcinoma 10 months before the presentation. She was anaemic and tachycardic; abdominal CT scan revealed a large duodenal mass. Her gastrointestinal bleed was not amenable to endoscopic intervention, so she had emergent laparotomy, pancreaticoduodenectomy with duodenal mass excision. Histopathology confirmed that the duodenal mass was a metastatic deposit from her clear cell endometrial cancer. Postoperatively, she was frail and chose hospice care and she died 90 days postoperatively. Clear cell endometrial cancer is a rare subtype of endometrial cancer, that has a worse prognosis compared with the more common endometrioid subtype. The duodenum is a rare site for metastatic endometrial cancer, and we report this case to alert clinicians to the possibility of metastases to the small intestine in patients with clear cell endometrial cancer.

Primary extranodal marginal zone B-cell lymphoma in a macroscopically normal fallopian tube

Primary extranodal marginal zone lymphomas (EMZL) of the fallopian tube are rare. The few published case reports suggest a causal relationship between chronic inflammation and tubal EMZL, with associated abnormal macroscopy noted intraoperatively. We present a woman in her 50s with postmenopausal bleeding and endometrial hyperplasia who underwent a laparoscopic total hysterectomy and bilateral salpingectomy. Macroscopy of the specimen was unremarkable. Microscopy of the right fallopian tube showed dense infiltrate of monomorphous lymphocytes with mild nuclear membrane irregularity. Immunohistochemical stains found a marked increase in CD20 B cells with Ki-67 <5%. Postoperative positron emission tomography was negative for multifocal involvement. This was consistent with a primary low-grade EMZL of the right fallopian tube. We present a case of a macroscopically normal primary tubal EMZL with no evidence of preceding antigenic stimulus, thus challenging its well-established role in the lymphomagenesis of EMZL.

Internal bowel herniation through a peritoneal defect between the right fallopian tube and right ovarian vessels

Second trimester semi-elective abdominal myomectomy to manage severe systemic inflammatory response syndrome secondary to fibroid degeneration

Although leiomyomata are common, it is rare for them to be associated with severe complications in pregnancy. We describe the case of a primigravida with a known multifibroid uterus. She presented at 16 weeks’ gestation with abdominal pain, distension, raised serum inflammatory markers and features of a gastrointestinal ileus. The patient was initially managed conservatively; however, her clinical condition deteriorated and she developed a severe systemic inflammatory response syndrome (SIRS). Imaging demonstrated red degeneration of two large leiomyomata, small bowel obstruction and ascites. Following a multidisciplinary team meeting, the patient was offered an antenatal abdominal myomectomy, or a termination of pregnancy plus deferred elective myomectomy. She underwent a successful abdominal myomectomy at 17+4 weeks’ gestation and subsequently had an uncomplicated elective Caesarean section at 39 weeks’ gestation. This report highlights the importance of multidisciplinary team management and informed consent in a surgically complex patient in the second trimester of pregnancy.

Expectant management of missed miscarriage in a post-trachelectomy patient with permanent cervical cerclage

A woman in her 30s with a history of simple trachelectomy and permanent cervical cerclage for stage IA1 cervical cancer presented with a missed miscarriage at 9 weeks gestation following IVF pregnancy. After a review of the literature and a failed medical management of miscarriage, a multidisciplinary decision was made to continue a prolonged expectant management protocol. The patient’s primary priority was the preservation of her fertility potential to facilitate future IVF following miscarriage resolution. Surgical approach to miscarriage management was considered with a high risk of complications including perforation, removal of cerclage and hysterectomy; therefore, this option was to be avoided unless absolutely necessary. Over a 7-month period with regular ultrasound follow-up we demonstrated gradual resolution with clearance of all products of conception 7 months from initial diagnosis. She remained clinically well throughout this process. This case highlights the challenges of managing early pregnancy failure in patients with a history of trachelectomy and supports the role of prolonged conservative management and individualised care plans.

Live birth in a twin pregnancy with a complete hydatidiform mole and a coexisting normal fetus

Co-presentation of complete mole with live pregnancy is very rare, few cases with live birth were reported. The diagnosis requires a high index of suspicion, which is important to set the management plan antenatal, intrapartum, postnatal and neonatal. Our patient conceived during follow-up for previous partial molar pregnancy. Early pregnancy scan showed a gestational sac with cystic spaces. Ultrasound scans by fetal medicine specialists revealed a normally developing fetus with partly multicystic placenta. She was delivered by caesarean section at 31 weeks due to abdominal pain and increasing size of the theca lutein cysts. Placental histology and cytogenetics confirmed the diagnosis. Further course of care was uneventful. Incidence of the above-mentioned condition is 1 in 20 000 to 100 000. This is a high-risk pregnancy with multiple maternal, fetal and neonatal complications. The suggested management plan involves a multidisciplinary team and individualised care with close maternal and fetal monitoring.

Intrauterine expulsion of a submucosal fibroid following transcervical radiofrequency fibroid ablation

A woman in her 40s presented with complaints of watery discharge (sloughing). These symptoms developed three months after treatment of her Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) type 2 fibroid with the transcervical use of intrauterine ultrasound-guided radiofrequency ablation, the Sonata system (Gynesonics). Previous symptoms of heavy menstrual bleeding significantly decreased three months after transcervical ablation. In spite of this, the patient presented with complaints of sloughing. Examination by transvaginal ultrasound revealed an intracavitary fibroid. Additional hysteroscopy identified a FIGO type 0 fibroid with a necrotic aspect. Eventually, the intracavitary fibroid was removed by hysteroscopic myomectomy, and complaints of sloughing vanished completely. The necrotic fibroid tissue was confirmed by the pathologist. Intrauterine expulsion of a (submucosal) fibroid after treatment with the Sonata system should be discussed with patients during pre-treatment counselling as a possible consequence of this treatment. Thus, patients can recognise symptoms of intrauterine expulsion of the ablated fibroid in a timely manner.

Ruptured uterine pyomyoma with multiorgan dysfunction syndrome

A woman with a history of chronic hypertension, no previous pregnancies and a recent myomectomy presented to the emergency department with fever, vomiting, diarrhoea and abdominal pain. She showed signs of septic shock, acute kidney injury and respiratory failure. Imaging revealed a large necrotic fibroid, hydrosalpinx, ascites and pleural effusion. Blood cultures showed Escherichia coli growth. She underwent emergency surgery for total abdominal hysterectomy, bilateral salpingoophorectomy and hysteroscopy. Intraoperatively, purulent discharge was found, and cultures confirmed E. coli infection. Pathology revealed leiomyomata with degenerative changes, benign endometrial polyps and endometriosis. Postoperatively, she received intensive care and showed gradual improvement, eventually being discharged in a stable condition. Follow-up appointments showed resolution of symptoms, wound healing and no infection recurrence. Antibiotics were discontinued, and the pleural drain was removed. Overall, the patient had a successful recovery with no complications noted during follow-up.

Yolk sac ovarian cancer with mesenteric metastases

We present a rare case of mesenteric metastases of yolk sac ovarian cancer in an early adolescent girl. The patient initially presented with abdominal distension. The patient underwent physical and diagnostic testing, which yielded findings indicative of a malignant ovarian tumour (solid cystic mass and increased levels of tumour markers). Surgery was performed and histological examination revealed a yolk sac tumour that had spread to the mesentery. Chemotherapy was administered. Yolk sac ovarian cancer metastases usually occur in nearby structures; however, mesenteric metastases are rare.

Cutaneous leiomyosarcoma in a case of hereditary leiomyomatosis and renal cell carcinoma syndrome

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome is an autosomal-dominant disorder that results from a germline pathogenic variant in the fumarate hydratase (FH) gene on chromosome 1, characterised by renal cell carcinoma (RCC), cutaneous leiomyoma and uterine leiomyoma. Leiomyosarcomas are reported in less than 1% of those with HLRCC. We report a case of a man in his 30s who had a long-standing plaque excised from the left upper arm after undergoing a radical nephrectomy for a fumarate-deficient RCC, with histological exam revealing a grade 1 leiomyosarcoma. Genetic testing confirmed a heterozygous pathogenic variant in the FH gene. This is a rare case of leiomyosarcoma associated with HLRCC, and our patient remains under surveillance with interval abdominal imaging and skin examination. Leiomyosarcomas are difficult to distinguish clinically from their benign counterpart; therefore, histopathological examination is paramount with a low threshold for excision.

Extranodal diffuse large B-cell lymphoma involving the uterine cervix

This is a case of primary diffuse large B-cell lymphoma involving the uterine cervix which presented with irregular vaginal bleeding. The diagnosis was confirmed following multiple cervical biopsies. Treatment with a combination of immunotherapy, chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP)) and radiotherapy produced a good response.

Emergency hysterectomy following iatrogenic injury to the descending branch of the uterine artery during colposcopy

Large loop excision of the transformation zone is an extremely common procedure routinely carried out in a gynaecology or colposcopy outpatient setting under local anaesthetic. Here, we present a rare case resulting in emergency hysterectomy. A healthy para 3, who had been diagnosed with microscopic cancer of the cervix, attended colposcopy for repeat excision. The colposcopy revealed a normal cervix, and diathermy loop excision was performed. During the procedure, heavy bleeding from the anterior cutting edge was noted. Despite the best attempts to manage the haemorrhage conservatively in outpatients, the bleeding persisted, and the patient was transferred to theatres. Examination under anaesthesia revealed an injury to the descending branch of the uterine artery, and emergency hysterectomy was performed. Immediate recognition of an extremely rare complication, fast decision-making and a cross-disciplinary approach led to a satisfactory outcome.

Cervical cancer in a transgender man: lessons learnt to improve care

We describe a case of rapid progression of cervical dysplasia to stage IVB cervical cancer in a previously healthy transgender young adult man on testosterone therapy. The cancer diagnosis came 7 months after routine pap smear showed low-grade dysplasia with high-risk human papillomavirus in preparation for gender-affirming hysterectomy/bilateral-salpingo-oophorectomy. After diagnosis, our patient faced unique challenges as a transgender man receiving gynecologic oncology care. This case highlights the challenges of and barriers to cervical cancer screening and treatment that transgender men confront. This case also considers whether gender-affirming testosterone therapy is associated with cervical cancer risk. We offer suggestions on how to improve cervical cancer screening and treatment for the transgender population.

Tuberculous peritonitis diagnosed following laparoscopic examination for suspected advanced ovarian cancer

Laparoscopy for intra-abdominal exploration and tissue sampling is useful in advanced ovarian cancers, in which it is presumed to be difficult to achieve complete tumour reduction in the initial surgery. This is a report of a case of suspected advanced ovarian cancer in a patient, who underwent laparoscopic screening and was later pathologically diagnosed with tuberculous peritonitis. A woman in her 50s visited her local doctor with constipation. Since imaging showed massive ascites she was referred for further evaluation. We initially suspected advanced ovarian cancer due to the presence of massive ascites and multiple peritoneal nodules. However, histopathological examination indicated that the nodules were tubercles, and the patient was subsequently diagnosed with tuberculous peritonitis. It is important to be aware that tuberculosis peritonitis can be misdiagnosed or mistaken for advanced ovarian cancer. Preoperative diagnosis of tuberculous peritonitis is often difficult. Tuberculous peritonitis should be considered if intraoperative findings show diffuse nodular disseminated lesions.

Antenatal myomectomy of huge pedunculated fibroid

A female patient in her 20s presented at 10 weeks of pregnancy with abdominal pain. She was known to have a 17-cm fibroid a year ago, which, on repeat imaging, was found to have increased in size to 29 cm. A 12-cm increase in size over a year therefore led to concerns that it would increase in pregnancy, causing risk of thrombosis, decrease in venous return, miscarriage, fibroid torsion, fibroid necrosis, preterm labour and uterine rupture. Following a multidisciplinary team review with obstetricians, neonatologists, gynaecologists and radiologists, the patient opted to proceed with an open myomectomy at 14 weeks gestation, which was performed successfully. The pregnancy continued uneventfully until term when she delivered a healthy girl infant at 38+2 weeks via an elective caesarean section.

Vulvar reconstruction in post-RT case using the versatile VRAM flap: reporting the rare extrapelvic approach

Although primary vulvovaginal reconstruction following vulvectomy has a significant chance of improving patient outcomes, flap reconstruction is not a recognised component of the accepted standard of care for vulvar cancer. We provide a case of a patient who underwent successful vulvar reconstruction using the extrapelvic vertical rectus abdominis myocutaneous (VRAM) flap. This musculocutaneous flap offers adequate coverage and bulk to the perineal defect after excision in post-irradiated vulvar cancer. To proceed with sphincter-saving surgery, she was scheduled for neoadjuvant chemoradiation, as the lesion involved the urethra and perineal body. However, she experienced severe grade IV dermatitis after receiving 37 Gy of radiation. Though the lesion had reduced in size, it was still large enough to cause significant perineal deformity. We performed a vulvar reconstructive surgery using the uncommon but reliable extrapelvic VRAM flap. This well-vascularised VRAM flap is particularly useful in irradiated areas prone to poor healing. Postoperatively, the wound healed well and the patient underwent adjuvant therapy 6 weeks later. We emphasise the advantages of well-perfused muscle for the primary repair of prior irradiated perineal lesions.

Xanthogranulomatous endometritis with unilateral salpingo-oophoritis in a postmenopausal woman masquerading as a malignancy

Xanthogranulomatous endometritis (XGE) is a rare pathological entity which is characterised by sheets of foamy histiocytes and lymphoplasmacytic infiltrates. This condition can mimic endometrial carcinoma. We report a case, clinically suspected as carcinoma of the endometrium/ovary, which was diagnosed as XGE with left salpingo-oophoritis on histopathology.

Treatment-induced sarcoidosis in a patient with metastatic clear cell ovarian cancer

Sarcoidosis is a granulomatous disease that commonly presents with lung or lymphatic system manifestations. Diagnosis is often delayed due to variable clinical presentation. This is a case of a patient with metastatic clear cell ovarian cancer who developed disease reoccurence after definitive treatment with surgery and adjuvant chemotherapy. She was treated with multiple lines of therapy, including investigational agents. During this time, she developed mediastinal lymphadenopathy and hypercalcaemia. Due to suspicion that her presentation was not a manifestation of her malignancy, she underwent two lymph node biopsies revealing granulomatous disease. She was initiated on prednisone for management of sarcoidosis, which led to radiologic, laboratory and symptomatic improvement. Although the precipitating factor for this patient’s sarcoidosis cannot be definitively determined, nivolumab is a possible culprit. This case highlights the importance of a broad differential diagnosis when a patient undergoing antineoplastic treatment develops mediastinal lymphadenopathy or hypercalcaemia.

Paediatric cystic ovarian torsion masquerading appendicitis

A 7-year-old girl presented with a 2-day history of right iliac fossa pain, fever and elevated inflammatory markers. Clinical examination supported a diagnosis of appendicitis. The patient was taken to theatre for an open appendicectomy the following morning. Intraoperatively, a right-sided ovarian haemorrhagic cyst with 360 degrees torsion was discovered. The ovary was torted along with the cyst. Both were detorted and the abdomen was closed. The patient was discharged 48 hours later, with gynaecology outpatient follow-up 6–8 weeks later. Paediatric ovarian torsions caused by a haemorrhagic cyst greater than 2 cm are rare. Here, we discuss an atypical presentation of ovarian torsion and how the clinical presentation can mimic appendicitis.

Androgen receptor amplification in mesonephric remnants

Mesonephric remnants (MRs) are embryonic vestiges most commonly found in female pathology specimens from the lateral wall of the cervix. The highly regulated genetic programme of mesonephric duct development has been well characterised in animals based on traditional surgical castration and knockout mouse experiments. However, the process is incompletely understood in humans. MRs are believed to give rise to mesonephric neoplasms, which are rare tumours with uncertain pathophysiology. There is a dearth of molecular studies on mesonephric neoplasms in part due to their rarity. Here, we report the results of next-generation sequencing of MR, which identified amplification of the androgen receptor gene for the first time to the best of our knowledge and discuss the potential implications in the context of the literature.

Hyperandrogenism caused by ovarian Leydig cell tumour: finding the needle in a haystack

Leydig cell tumours (LCTs) of the ovary are rare ovarian tumours that usually present with hyperandrogenism. Conventional radiological imagings are helpful in localising these tumours. However, some tumours may be too small to be localised before curative surgical removal. It is important to identify these androgen-secreting neoplasms which originate mostly from adrenals or ovaries because they are potentially malignant and require specific treatment. When conventional imagings are unrevealing, selective ovarian and adrenal venous sampling (SOAVS) is the next option. We report a case of LCT that was localised by SOAVS after results from other imaging modalities remained inconclusive.

Unexpected borderline ovarian tumours (BOT) in late pregnancy: challenges in management and review of literature

This case report describes a right-sided borderline ovarian tumour diagnosed unexpectedly following suspected torsion in the third trimester of pregnancy. The patient had had a right mucinous cystadenoma and left serous cystadenoma in her previous pregnancy and underwent bilateral ovarian cystectomy at the time of her first elective caesarean section. The management of borderline ovarian tumours is generally difficult in younger women of reproductive age and is made more complex by pregnancy. The authors share the challenges of managing this condition in pregnancy together with a review of the literature.

Ovarian torsion and laparoscopy in the paediatric and adolescent population

A 9-year-old girl attended the emergency department with right-sided abdominal pain and vomiting. Due to history and following examination, an ultrasound was requested which demonstrated a large complex midline mass. The most likely diagnosis was ovarian torsion, for which the patient underwent laparoscopy, detorsion and ovarian cystectomy. Histology revealed a mature cystic teratoma. Although less common than in the adult population, it is important to consider ovarian torsion in children and adolescents. Presentation is usually with pain accompanied by vomiting and fever, although these symptoms are not always present. Current management is organ-sparing, with laparoscopy±cystectomy. We discuss the adaptations for this procedure with regard to the paediatric and adolescent population. Differences in the anatomy and physiology must lead to consideration for alterations in surgical technique and positioning to ensure the safest and best quality care for these young patients.

Subcutaneous drainage of refractory lower limb oedema at the end of life

Severe, refractory lower limb oedema can be a significant burden for patients with advanced metastatic malignancy. Despite this challenge, management strategies are often limited to analgesia, as well as pressure care and nursing care with positioning and dressings. The evidence for subcutaneous drainage in this setting largely consists of case reports, and it is infrequently practised in palliative care units (PCUs). In this case report, a patient with advanced metastatic ovarian cancer in her final weeks of life is discussed. Her severe lower limb oedema resulted in frequent pain and severe limitations on her mobility. The symptoms resulted in a multidisciplinary approach from the palliative care team, part of which included the use of subcutaneous drainage. The process of initiating this procedure in the PCU, details of the procedure and the benefit from it are described.

Impact of luteoma during pregnancy on fetal development and its long-term effects into adulthood

A woman in her 30s presents to the Differences in Sexual Development Programme at a tertiary care academic medical centre with vaginal stenosis and scarring. Her medical history is significant for virilisation in utero due to a maternal luteoma of pregnancy. Laboratory investigations at the time of birth showed elevated androgens in both mother and daughter. During infancy, she underwent clitoroplasty and vaginoplasty for correction of posterior vaginal fusion. She represented as an adult with vaginal stenosis, with associated physical and psychosocial implications. She was not able to insert a tampon or have penetrative intercourse. After examination and shared decision-making, the patient underwent cystoscopy, vaginoscopy and posterior vaginoplasty with the goal to create a normal calibre vagina. Postoperative dilator use was recommended to prevent restenosis of the introitus. In clinic follow-up, the patient was observed to have a normal calibre vagina.

A complex case of a granulosa cell tumour

This is a case of a 73-year-old woman who first presented in 2020 with a fullness in her abdomen. After several thorough investigations and unforeseen complications, the fullness was diagnosed as a granulosa cell tumour. In 2003, she had been diagnosed with a granulosa cell tumour of the ovary. Complete excision was performed, however she was not given a follow-up appointment after the procedure. This case highlights the importance of frequent follow-up of these tumours, the high recurrence rate, the severe complications which may result and the awareness of possible variations in this tumour’s histologic appearance.

Anti-NMDAR encephalitis presenting after immature teratoma resection

This is a case of a young woman who developed neurological and psychiatric symptoms 3 days after resection of an immature teratoma. She was diagnosed with anti-NMDA receptor encephalitis via positive serum antibody titres, which was later confirmed with cerebrospinal fluid antibody titres. Given her cancer diagnosis, she underwent treatment with bleomycin, etoposide and cisplatin chemotherapy in addition to 5 days of high-dose steroids (1 g of intravenous methylprednisolone) for the encephalitis. This treatment regimen led to significant clinical improvement 3 weeks after completion of one cycle of chemotherapy.

Peritoneal lesions caused by Enterobius vermicularis suspected to be metastases of ovarian malignancy

Enterobius vermicularis, also known as pinworm, is a helminth that commonly causes intestinal parasitic infestation. E. vermicularis can also cause extraintestinal infestations. We report a case of lower abdominal pain and intermittent vaginal bleeding in a 45-year-old woman who was referred to our gynaecology department. On investigation, a transvaginal ultrasound showed a multilocular cyst in the left ovary, along with elevated levels of cancer antigen 125. Consequently, a laparoscopic salpingo-oophorectomy was performed. A biopsy of atypical peritoneal lesions revealed remains of E. vermicularis. Peritoneal lesions are a rare complication of enterobiasis, and the diagnosis of this complication is usually delayed by limitations in diagnostic options. Although extraintestinal enterobiasis does not require treatment because it is the last stage of the parasitic cycle, primary intestinal infestation requires treatment with mebendazole.

Triple-hit high-grade B-cell lymphoma presenting with ovarian torsion

We report a case of a previously healthy woman in her early 70s who presented with 2 weeks of episodic abdominal pain and significant weight loss. Imaging of her abdomen revealed acute right ovarian torsion associated with bilateral ovarian enlargement and an indeterminant pelvic mass. An urgent laparoscopic bilateral oophorectomy was performed with pathological results consistent with triple-hit high-grade B-cell lymphoma. She was successfully treated with dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin and rituximab, intrathecal methotrexate and venetoclax with complete remission after three cycles. Ovarian lymphoma is a rare entity and its genetic features have not been well described. We performed a literature review, describe the current knowledge regarding ovarian lymphoma and its therapeutic implication in the genomic age.

High-grade serous cancer of undetermined primary origin presenting as solitary inguinal lymph node enlargement

A 62-year-old woman presented with unilateral inguinal lymphadenopathy, existing for several months. As it was initially thought to be lymphoma, the lymph node was resected. Pathology, however, revealed a metastasis of a high-grade papillary serous cancer, according to its stainings, most likely ovarian in origin. Further staging showed lymphadenopathies in the inguinofemoral, para-aortic and mediastinal regions. Consequently, the multidisciplinary oncologic meeting advised a diagnostic laparoscopy which showed no macroscopic spread within the abdomen. Pathological examination of biopsies as well as both ovaries showed no sign of ovarian cancer. The patient received standard chemotherapy, that is, carbo-Taxol-Avastin, to which she showed complete response after three cycles as shown on positron emission tomography–CT. A review of existing literature showed that this is a very unusual case of high-grade serous carcinoma, where no site of origin could be found.

A rare cause of postmenopausal hyperandrogenism

We present an unusual case of mucinous cystadenoma presenting with severe virilisation in a postmenopausal woman. A 71-year-old woman was referred to our outpatient endocrinology clinic because of rapidly progressive androgenic alopecia, clitoromegaly and male pattern pubic hair growth for 1 year. Her medical history was unremarkable. The serum testosterone level was 3.35 µg/L (normal range, <0.4 µg/L), and the dehydroepiandrosterone sulfate level was 267 µg/L (normal range, 100–800 µg/L). MRI of the abdomen revealed a 4×4 cm cystic ovarian mass. A bilateral salpingo-oophorectomy was performed, and histopathology showed a unilocular cystic structure with a yellowish content, compatible with mucinous cystadenoma. Postoperative testosterone levels quickly normalised (<0.4 µg/L). Rapidly developing postmenopausal hyperandrogenism easily turns into a diagnostic challenge for the clinician. Hormone-secreting neoplasms of the ovary are most commonly of sex cord stromal derivation, but atypical causes must be recognised as well. Cystadenomas are among the most common benign ovarian neoplasms and are classically considered ‘non-functional’ tumours. Most of these tumours are asymptomatic and found incidentally on pelvic examination or with ultrasound. To date and to the best of our knowledge, there are only five cases of mucinous adenoma causing virilisation in postmenopausal women identified in the literature. This sixth case adds strength to the link between ovarian mucinous cystadenoma and severe, rapidly progressive hyperandrogenism during menopause. In this case, surgical resection is the treatment of choice.

Papillary thyroid carcinoma in struma ovarii: management after surgery

A woman in her 40s presented with a 3-month history of lower abdominal pain and intermenstrual bleeding. Ultrasound of the pelvis disclosed a 4 cm left adnexal mass. An MRI of the pelvis revealed a 2.2×3.6×2.4 cm solid, enhancing left ovarian mass. Due to high suspicion for malignancy, she underwent laparoscopic left salpingo-oophorectomy and resection of the tumour. Histopathology revealed papillary thyroid carcinoma in the background of struma ovarii as confirmed by thyroglobulin and thyroid transcription factor-1 positivity on immunohistochemistry. BRAF mutation analysis was negative. An ultrasound of the thyroid gland showed two low-risk nodules. An iodine-123 whole-body scan showed normal uptake in the thyroid gland. Thyroid-stimulating hormone (TSH) was 1.070 mcIU/mL (0.450–4.500), and thyroglobulin was 6.8 ng/mL (1.5–38.5). We risk-stratified this patient as low risk for recurrence. Risk stratification of malignant struma ovarii is essential to determine suitable thyroid targeting adjuvant therapy and reduce the risk of recurrence.

Takotsubo cardiomyopathy caused by infusion reaction to paclitaxel

Takotsubo cardiomyopathy (TCM) secondary to an infusion reaction is extremely rare in the literature. Here, we present an unusual case of TCM in a patient with cervical squamous cell carcinoma who presented with acute hypoxic respiratory failure following the initiation of the first-cycle paclitaxel infusion therapy.

Squamous cell carcinoma of uterine cervix metastatic to the axillary lymph node

We report a case of an elderly woman, presenting with vesicouterine fistula and enlarged axillary lymph nodes. She had been diagnosed with cervical squamous cell carcinoma (SCC) in April 2015, for which she had received brachytherapy and concurrent chemoradiation therapy. The presence of enlarged axillary lymph nodes raised a suspicion for breast cancer with axillary metastases, but the bilateral mammograms did not show any discrete lesion in both breasts. The biopsy from axillary lymph node showed metastatic SCC, with block positivity for P16, confirming the origin from known cervical primary. Axillary lymph nodes are the least likely to be involved by tumours arising in the pelvis, as the lymphatic drainage of this region goes directly to the systemic circulation via the para-aortic lymph nodes and thoracic ducts. A complete clinical history is essential in such cases, to avoid misdiagnosis. Positron emission tomography CT helps in this regard.

Bilateral massive leiomyomas in a bicornuate uterus, with torsion of the right horn

Uterine leiomyomas are the most common benign tumours of the female reproductive system, often asymptomatic, but can cause significant clinical issues such as abdominal pain. This case report highlights the rare occurrence of a unilateral uterine horn torsion in a bicornuate uterus caused by a massive subserosal leiomyoma. Surgical intervention with myomectomy revealed a previously undiagnosed bicornuate uterus, and the patient’s recovery was uneventful. This finding shows the need for clinicians to consider leiomyoma torsion as well as uterine horn torsion in their differential diagnosis of acute abdominal pain.

Adult granulosa cell tumour of the testis: an uncommon tumour

A male patient in his late 20s was admitted to the hospital after presenting with left abdominal, back and scrotal pain that had begun approximately 2 weeks earlier. He had a history of a stable left testicular mass for 3 years, and a physical exam revealed a non-tender, firm left testicular mass and a mild left varicocele. Testicular tumour markers were normal, but a scrotal ultrasound revealed a 2 cm hypoechoic left testicular lesion. Staging imaging showed no retroperitoneal adenopathy or pulmonary metastases. The patient underwent left radical inguinal orchiectomy with no evidence of extratesticular or spermatic cord involvement. His surgical pathology revealed a left pT1a 2.3 cm adult granulosa cell tumour of the testis with no lymphovascular invasion. The tumour was positive for inhibin and negative for OCT3/4, supporting the diagnosis.

Role of an IUCD in managing patients with post-LLETZ cervical stenosis

Large loop excision of the transformation zone (LLETZ) is one of the fertility sparing treatments for people with high-grade cervical intraepithelial neoplasia, however, this procedure is known to increase the risk of postoperative cervical stenosis by 1.3%–5.2%. We present a case demonstrating the successful use of a copper intrauterine contraceptive device to manage a patient with cervical stenosis secondary to three LLETZ procedures for severe dyskaryosis.

Seronegative autoimmune encephalitis associated with ovarian teratoma and uterine STUMP tumour

This case report details a case of probable seronegative autoimmune encephalitis (AE) secondary to either an ovarian teratoma or a uterine smooth muscle tumour of uncertain malignant potential (STUMP). AE is a neurological disorder often associated with specific autoantibodies. However, cases can occur without identifiable antibodies, necessitating a broader diagnostic approach. We present a woman in her 30s who exhibited sudden-onset acute behavioural disturbance and psychiatric symptoms. Initial investigations, including both infective and autoimmune screening, returned negative. Further investigations revealed an adnexal mass and raised ovarian tumour markers. Both an ovarian teratoma and a uterine STUMP were resected. Postoperatively, the patient demonstrated significant clinical improvement, with resolution of neurological symptoms and normalisation of cognitive function.

Massive serous cystadenofibroma with incidental umbilical endometriosis in a morbidly obese patient presenting as acute respiratory compromise

We present a case of a woman in her 50s with a rapidly expanding giant serous cystadenofibroma of the ovary. The 40-kg mass displaced her bowel and splinted her diaphragm, causing mass effect and acute respiratory compromise worsening over a 6-week period. Due to complex features on imaging and raised tumour blood markers, suspicion of malignancy was raised. Therefore, surgical cytoreduction was necessary. In this case, complex multiple comorbidities, including morbid obesity with a BMI of 62.7, posed significant surgical and anaesthetic challenges. This case highlights the complex diagnostic, intraoperative and perioperative challenges in managing giant ovarian cysts in multimorbid obese patients.

Sotorasib provides a durable response in high-grade metastatic ovarian serous adenocarcinoma harbouring KRAS G12C mutation

Metastatic ovarian cancer patients who have recurrent disease after multiple lines of prior treatment have dismal prognosis. The Kristen rat sarcoma viral oncogene homologue (KRAS) G12C mutation is very rare in ovarian cancers and no approved KRAS G12C targeted treatment options exist for ovarian cancer. Here we present a case of metastatic ovarian serous adenocarcinoma in a female patient in her late 70s who was heavily pretreated with multiple lines of treatment before, showing an excellent durable response to KRAS G12C inhibitor sotorasib at reduced dose of 240 mg oral daily for over 26 months and ongoing. Our case highlights KRAS G12C as a driver mutation in ovarian cancer patients that is potentially targetable in certain subgroups of patients.

Ovarian metastasis from Klatskin tumour

Hilar cholangiocarcinoma, a rare bile duct malignancy, typically metastasises to the liver, lungs or lymph nodes, with ovarian involvement being exceedingly rare. We present a case of a South Asian woman in her mid-30s with abdominal pain, constipation, right upper quadrant discomfort and fever. Imaging and histopathological analysis of biopsy confirmed a hilar mass with ovarian metastasis, supported by elevated CA 19-9 levels. Palliative biliary stenting was performed, but the patient succumbed 6 months postdiagnosis. This case highlights the importance of recognising atypical metastatic patterns in hilar cholangiocarcinoma to guide diagnostic and therapeutic strategies.

Anaesthetic management of a patient with giant ovarian tumour and multiple deep venous thrombosis for gynaecologic surgery

Patients with giant tumours encompassing the abdominopelvic cavity are predisposed to multiple complications due to increased intra-abdominal pressure from compression by the tumour. Patients with the said condition have the risk of developing deep venous thrombosis (DVT) which increases their risk for further thromboembolic events, perioperatively. This report describes the anaesthetic management of a woman in her 30s with a giant ovarian tumour and multiple DVTs, who underwent exploratory laparotomy, decompression of right ovarian mass and right salpingo-oophorectomy under general endotracheal anaesthesia. It highlights complex anaesthetic and perioperative challenges posed by giant ovarian tumours. A carefully individualised anaesthetic plan was developed aimed at minimising the patient’s elevated risk for thromboembolic, respiratory and haemodynamic complications without standard prophylactic options such as inferior vena cava filter placement due to surgical inaccessibility. The favourable outcome, despite the patient’s high-risk profile, affirms the value of a multidisciplinary approach and tailored anaesthetic strategies—particularly in light of the limited literature describing effective anaesthetic management to prevent fatal outcomes in such complex cases.

Pseudo-Meigs syndrome: a rare cause of abdominal ascites in a patient with an ovarian mass

Meigs syndrome is a rare phenomenon seen in approximately 1% of patients diagnosed with ovarian tumours. It is defined as a triad of a benign ovarian tumour, pleural effusion and ascites with complete resolution of symptoms following surgical intervention. This constellation of findings can be confused with several diagnoses, ranging from metastatic ovarian cancer to decompensated cirrhosis. Herein, we present a young woman presenting with new ascites, initially thought to be due to cirrhotic portal hypertension and found to have an atypical presentation of pseudo-Meigs syndrome, in the setting of a benign ovarian teratoma.

Does surgery to preserve fertility in Sertoli-Leydig cell tumours increase the likelihood of spontaneous conception?

A nulligravida in her 30s presented with primary infertility and secondary amenorrhoea. General examination revealed virilisation; sonological examination detected a right ovarian solid mass. International Ovarian Tumour Analysis (IOTA) was suggestive of malignancy and serum testosterone was raised. A strong clinical suspicion and negative tumour markers pointed towards androgen producing sex cord stromal ovarian neoplasm. MRI excluded pelvic lymphadenopathy. Given the patient’s desire for conception, fertility sparing staging laparotomy was done. Histopathology confirmed Sertoli-Leydig cell tumour (SLCT) International Federation of Gynaecology and Obstetrics stage IA. Serum testosterone fell drastically by day 10. Spontaneous menstruation resumed within 30 days. The significance of SLCTs as a differential diagnosis in young women with secondary amenorrhoea and virilising features underscores the role of fertility-preserving surgery in certain circumstances. Here we discuss the clinical features, diagnostic challenges and management strategies for SLCTs, emphasising the need for multidisciplinary collaboration and option of fertility preservation in early stages.

Total neoadjuvant therapy and abdominoperineal resection with sigmoid colon vaginoplasty for locally advanced rectal adenocarcinoma invading the vagina

This report presents a woman in her 70s with locally advanced rectal adenocarcinoma invading the posterior vaginal wall. She received total neoadjuvant therapy (TNT) consisting of six cycles of capecitabine–oxaliplatin followed by long-course chemoradiotherapy, resulting in significant tumour downstaging. Definitive surgery involved extralevator abdominoperineal excision with near-total vaginectomy and reconstruction using a sigmoid colon flap vaginoplasty. Histopathology confirmed an R0 resection, with two of 17 lymph nodes positive for metastasis. The patient recovered uneventfully, with a viable neovagina, preserved lubrication and no stricture formation. Transient urinary retention resolved with conservative management. This case demonstrates that TNT can facilitate curative resection of complex T4b rectal cancers and enable successful functional reconstruction. The use of a sigmoid colon flap provides a versatile and well-vascularised option for vaginal reconstruction, supporting both oncologic safety and quality of life in extensive pelvic resections.

Vaginal myomectomy of multiple cervical myomas

Cervical myomas are rare and pose a treatment challenge, particularly in childbearing years. We describe a case of a woman in her 30s with symptomatic multiple cervical myomas, two of them intramural, who desired a future pregnancy. She was successfully submitted to vaginal myomectomy, an unusual approach in intramural cervical myomas, which allowed uterine preservation and a normal appearing cervix on speculum and ultrasound examinations on follow-up.

How can we best manage ovarian sebaceous carcinomas arising from mature cystic teratomas?

Sebaceous carcinoma arising from ovarian mature cystic teratomas (MCTs) is exceedingly rare, with only 19 cases reported in the literature. We present a novel case of a woman in her 60s who experienced lower abdominal pain and a large pelvic mass. She underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection, omentectomy and peritoneal washings. Intraoperative frozen section analysis confirmed a malignant tumour, favouring squamous cell carcinoma, possibly arising from an MCT. Postoperative recovery was uneventful, and she remains disease free after 28 months. Our review revealed that most cases presented at early International Federation of Gynecology and Obstetrics (FIGO) stages (70%), with unilateral tumours averaging 16.7 cm. Surgery was the mainstay of treatment, with salpingo-oophorectomy performed universally. Adjuvant chemotherapy was infrequent (20%), and mismatch repair deficiency was noted in 57.1% of tested cases. The median disease-free interval was 19 months. This case underscores the rarity of sebaceous carcinoma in MCTs and highlights the critical need for further research to establish evidence-based guidelines for optimal management and prognosis.

Diagnosis and management dilemma in leiomyoma of the anterior vaginal wall

Vaginal leiomyomas, rare benign tumours arising from the vaginal wall, present a diagnostic challenge due to their varied clinical manifestations. We report the case of a woman in her mid-40s who sought medical attention for heavy menstrual bleeding and abdominal pain. Initial examinations revealed a palpable mass within the vaginal canal, prompting further investigation with imaging modalities that confirmed a solid lesion suggestive of leiomyoma. A Tru-Cut biopsy was performed to rule out malignancy, after which surgical excision was carried out. Subsequent histopathological analysis confirmed the diagnosis. The case underscores the importance of considering leiomyomas in the differential diagnosis of vaginal masses and highlights the successful management through appropriate surgical strategies with excellent postoperative outcomes.

Diverse nature of ovarian tumours: Van Wyk-Grumbach syndrome

Van Wyk-Grumbach syndrome is a unique condition where a medical illness like hypothyroidism manifests as large ovarian masses, ascites and precocious puberty. This is a treatable condition and warrants a suitable and timely recognition. This study includes a series of three cases over 3 years where despite the myriad of apparently grave symptoms and signs, they resolved on treatment with thyroxine. The investigations included serum TSH levels to rule out hypothyroidism, serum FSH and LH levels, X-ray wrist bones to ascertain onset of precocious puberty and tumour markers including serum CA 125 and LDH for ovarian tumours in the young. The follow-up included an ultrasound after 3 months of Tab Eltroxin to see resolution of ovarian masses which miraculously disappeared. Awareness of such a condition avoids any unnecessary and unwarranted surgical intervention which would hamper the young girls’ fertility.

Partial molar pregnancy as ruptured tubal ectopic

Tubal molar pregnancy is extremely rare, and less than 200 cases have been reported in the literature. The incidence is approximated at 1.5 per 1 000 000 pregnancies. We report a case of ruptured tubal pregnancy in a woman, whose postoperative histopathology diagnosis showed partial molar pregnancy in the ruptured fallopian tube. The presence of abnormal, non-polar trophoblast proliferation, which is circumferential with vacuolation, along with sheets of pleomorphic extravillous trophoblast, is the main diagnosing feature, and it carries the risk of malignant potential.

Uterine preservation in pyomyoma complicating uterine artery embolisation

Pyomyoma, a rare complication of uterine artery embolisation (UAE) for symptomatic fibroids, can closely mimic post-embolisation syndrome (PES), which typically presents with pain, fever and leucocytosis within the first week. Differentiating PES from pyomyoma is critical, as pyomyoma carries a higher risk of severe complications. We report a case of an unmarried nulliparous woman who developed pyomyoma following UAE for fibroids. Initially suspected to have PES, her persistent high-grade fever, purulent discharge and imaging findings of gas pockets within a necrotic fibroid led to the diagnosis of pyomyoma. Despite initial treatment with broad-spectrum antibiotics, emergency laparotomy was required, revealing a necrotic, pus-filled fibroid. The infected tissue was excised, and careful surgical reconstruction of the uterus was performed, successfully preserving her fertility. This case underscores the importance of timely intervention and uterine-preserving approaches in patients with prolonged or worsening symptoms after UAE to optimise both clinical and reproductive outcomes.

Round ligament fibroid presenting as a huge pedunculated vulvar tumour

A woman in her early 20s presented with a huge pedunculated tumour of the vulva which had progressively increased in size over the course of 10 years. Clinical examination revealed a pedunculated solid mass arising from the right labia majora measuring 15×15 cm. CT scan showed a multilobulated mass arising from the right round ligament suggestive of an extrauterine fibroid. Tumour excision, vulvoplasty and inguinal repair were performed, and histopathological examination confirmed fibroid of lipoleiomyoma variant. This article reports a rare case of round ligament fibroid presenting as a huge pedunculated vulvar tumour.

Paraneoplastic anti-TIF1-gamma-positive dermatomyositis as expression of cervical squamous cell carcinoma recurrence

Idiopathic inflammatory myopathies are neuromuscular disorders characterised by muscle weakness and histologically inflammation within the muscle. Dermatomyositis and polymyositis are highly associated with a wide range of cancers, especially in antitranscriptional intermediary factor-1 (TIF1)-gamma-positive myositis. We present a case of paraneoplastic dermatomyositis in a patient with a medical history of a FIGO stage 1B1 cervical squamous cell carcinoma. Anti-TIF1-gamma autoantibodies were detected by myositis lineblot analysis and a PET-CT scan revealed an abnormality positioned at the right ovary. She underwent laparoscopic exploration and pathological analysis of the PET-positive abnormality showed a lymphogenic metastasis of a squamous cell carcinoma, competitive with cervical carcinoma recurrence. She started chemoradiation as curative oncological treatment. The dermatomyositis was successfully treated with high-dose corticosteroids. Physicians should be aware of the association between myositis and the increased risk of malignancies.

Uterine carcinosarcoma showing immature teratoid-like differentiation

A carcinosarcoma is a rare form of cancer characterised by the presence of both carcinomatous and sarcomatous components. Here, we present our experience with an extremely rare case of an uterine carcinosarcoma with immature teratoid-like differentiation. The patient was a woman in her 60s. She was referred for the evaluation of a uterine tumour. She underwent total abdominal hysterectomy with bilateral adnexectomy and received postoperative treatment with paclitaxel and carboplatin. On microscopic examination, the tumour had a heterogeneous appearance with a combination of carcinomatous and sarcomatous elements, and teratoid features. The tumour included immature squamous epithelial cells and immature epithelial glands, and focal atypical fused glands, which are consistent with endometrioid carcinoma, were identified in the endometrium. Pathological differentiation from extrarenal Wilms’ tumour and teratocarcinosarcoma was challenging. The final pathological diagnosis was uterine carcinosarcoma with immature teratoid-like differentiation. At 14 months after the surgery, the patient has not experienced recurrence.

Familial recurrent molar pregnancy: positive for KHDC3L gene mutation

Recurrent hydatidiform moles are defined by the occurrence of two or more molar pregnancies in the same patient. These can be sporadic or familial where familial recurrent hydatidiform mole is rare and inherited as an autosomal recessive condition. Here, we present a case of four consecutive complete molar pregnancies with similar history in the sisters, who was diagnosed with fourth complete molar pregnancy. She underwent suction and evacuation followed by weekly serum β-hCG. On genetic analysis, she was found to be homozygous for KHDC3L gene mutation. She was advised for evaluation of her sisters and to consider In vitro fertilization (IVF) with donor ovum or adoption. Prompt suspicion and diagnosis along with counselling of the couple regarding the fertility options available to them are the main aspects of this disease to protect them from repeated physical as well as psychological trauma.

Acute abdomen caused by internodular bleeding from a multiple myoma pseudocapsule in a postmenopausal woman

A woman in her 50s presented with lower abdominal pain. She had a diagnosis of multiple uterine myomas 3 years earlier, followed by menopause. CT showed a pelvic mass of 19.5×9.4×10.2 cm in size, containing a haemorrhagic component. It was assumed that the tumour was the previously diagnosed myoma, and that it had increased to 150% of the size noted 3 years ago. An emergent hysterectomy was performed, and the pathological diagnosis was a uterine leiomyoma, with no components suggestive of sarcoma or degeneration. We witnessed a rare case of acute abdomen caused by internodular bleeding of multiple myomas. We assumed that the source of bleeding was the vessels of the myoma pseudocapsule. These cases may be more likely to occur in patients with multiple myomas presenting around the commencement of menopause. For symptomatic relief, emergent hysterectomy is considered to be the best treatment.

Transcatheter aortic valve replacement for pure native aortic regurgitation

We report the case of a female patient in her 60s with advanced ovarian cancer and Trousseau’s syndrome, who presented with a stroke. An unusual biphasic femoral flow led to transthoracic echocardiography that revealed a severe aortic regurgitation (AR) secondary to a prolapsed right coronary aortic valve leaflet. An initial echocardiography missed the diagnosis due to tachycardia. Transcatheter aortic valve replacement (TAVR) resulted in symptom improvement. She was readmitted 2 years later with prosthetic valve thrombosis, ultimately succumbing to oncological complications. This case highlights challenges in diagnosing AR and the potential role of TAVR in patients with native pure AR (NPAR). While TAVR for NPAR poses technical challenges, newer generation transcatheter heart valves (THVs) offer promising outcomes. The Acurate NEO 2 valve was successfully used in this case. TAVR with off-label THVs can be considered for selected NPAR patients, and we can expect increased utilisation of on-label devices when availability issues are solved.

Autoamputated ovarian mass causing a partial bowel obstruction in an infant with literature review

An autoamputated ovary (AO) is an extremely rare circumstance with a few reports in the literature. We present a case of a 3-month-old girl with a history of vague abdominal symptoms as well as a known ovarian mass, which was initially suspected to be benign and regressing. On laparoscopy for pain and obstructive symptoms, she was found to have an AO. The pathology was consistent with necrotic and torsed ovarian tissue with superimposed infection and possibly a cystic non-malignant teratoma. AOs are thought to originate from a torsion and are typically diagnosed incidentally. This is an interesting case of an AO causing a partial small bowel obstruction.

Primary ovarian synovial sarcoma

Synovial sarcoma (SS) has a rare occurrence in the female genital tract. Only three prior reports of primary ovarian sarcoma could be retrieved after a thorough literature review. We are reporting a case of primary ovarian SS in a young woman. The tumour showed monophasic spindle cell morphology, and there was a wide list of differential diagnosis to consider. We confirmed the diagnosis by cytogenetics Flourescent Insitu Hybridisation (FISH) technique to identify the classical translocation. The diagnosis of this disease can be challenging especially if the tumour is of monophasic type. Morphology and immunohistochemistry are not enough to confirm the diagnosis in many cases. A confirmatory molecular pathology test is paramount. We have discussed the differential diagnosis of spindle cell tumours in ovary. We suggest that SS should be in the differential diagnoses when facing any atypical spindle cell tumour in the ovary. Molecular pathology techniques can help to confirm the diagnosis.

Hypercalcaemia due to ovarian small cell carcinoma of the hypercalcaemic type

A 37-year-old woman presented with a few days’ history of lower abdominal pain and an incidental finding of hypercalcaemia. A thorough workup ensued, and the cause was found to be an exceptionally rare ovarian tumour—ovarian small cell carcinoma of the hypercalcaemic type. Acute treatment of hypercalcaemia consisted of aggressive intravenous fluids and bisphosphonates. She underwent surgery to remove the tumour and is currently receiving systemic platinum/etoposide chemotherapy combination to be followed by pelvic radiotherapy. This case highlights the wide range of differential diagnosis for hypercalcaemia and the importance of a stepwise and thorough approach during investigations. We discuss the pathophysiology of malignancy-related hypercalcaemia, focusing especially on parathyroid hormone-related peptide-associated hypercalcaemia.

Primary peritoneal mucinous cystadenocarcinoma mimicking possible recurrent ovarian mucinous cystadenoma: coincidental pathology or a spectrum of disease?

We present the case of a 32-year-old woman with a previous surgical history of benign mucinous cystadenoma resected in 2012 who underwent magnetic resonance cholangiopancreatography following her second pregnancy in 2020. This demonstrated a large cystic mass in the left subdiaphragmatic space. Histopathology confirmed a well-differentiated primary peritoneal mucinous cystadenocarcinoma displaying cells of a Mullerian origin. We subsequently discuss the aetiology of these conditions separately and explore the possibility of a connection between the two regarding origin or potential malignant transformation that may otherwise have occurred coincidentally in this young patient. We also acknowledge a paucity of evidence regarding subsequent management strategies.

Radiation-induced glioblastoma of the conus medullaris from radiation treatment of cervical cancer

Radiation-induced spinal glioblastoma is an extremely rare disease with only four previously published reports in the literature. We report the fifth case, a 69-year-old woman who previously underwent treatment with brachytherapy for cervical cancer, and thereafter presented with neurologic deficits from a conus medullaris tumour. Biopsy and histopathology confirm glioblastoma, not otherwise specified. Treatment of spinal glioblastoma consists of surgery, either biopsy or excision and chemoradiation. However, results are still unsatisfactory and prognosis remains poor.

Anti-NMDA receptor encephalitis in an adolescent with a cryptic ovarian teratoma

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disease frequently associated with ovarian teratomas. In cases where an ovarian teratoma is identified, treatment involves prompt removal of the ovarian teratoma, resulting in significant clinical improvement and decreased incidence of relapse. We present the case of a 14-year-old female patient admitted for progressively worsening psychiatric and neurological status, diagnosed with anti-NMDAR encephalitis, and negative initial imaging for ovarian pathology. She was in the hospital for 8 months requiring admission to the intensive care unit and multiple courses of immunotherapy before clinical improvement. Three months after discharge, she was readmitted with clinical relapse and repeat imaging showed an ovarian teratoma. Removal of the teratoma resulted in sustained clinical improvement with return to baseline and no further relapse. Our case report highlights the importance of maintaining a high suspicion for an underlying ovarian teratoma in a female patient with anti-NMDAR encephalitis, even when initial imaging is negative. Currently, there are limited data on recommendations for repeat imaging. Therefore, we recommend repeat imaging in patients resistant to multiple lines of treatment or presenting with clinical relapse.

Radiological features of multifocal embryonal rhabdomyosarcoma affecting the vagina and the urinary bladder in a pediatric patient

Rhabdomyosarcomas are the most common soft-tissue sarcomas, found usually in the younger age group. Histologically, they are subdivided into embryonal, alveolar, pleomorphic and not otherwise specified. They have a heterogenous appearance on imaging with few additional characteristic features based on the subtype. Botryoid variant of embryonal rhabdomyosarcoma commonly involves the genitourinary and the biliary system. They can be multifocal. Most of these lesions have a heterogenous appearance on imaging with areas of necrosis and haemorrhage. On ultrasound, they are polypoidal with cystic areas and are vascular. The lesions are hyperintense on T2 sequences, isointense to the skeletal muscle on T1 sequences and show heterogenous enhancement. Surgery is the mainstay of treatment along with radiotherapy or chemotherapy depending on the site and the stage of the tumour. We report a case of botryoid variant of rhabdomyosarcoma involving the vagina and the urinary bladder.

Adamantinoma: metastatic disease masquerading as a gynaecological malignancy

Adamantinoma is a rare low-grade malignancy of the appendicular skeleton with unclear histogenesis. We present the case of a 65-year-old woman with known recurrent and metastatic right tibial disease despite clear resection margins. On further investigation, a positron emission tomography–CT scan identified a primary breast lesion and an 11 cm mass in the right iliac fossa of suspected ovarian malignancy amenable to surgical resection. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and resection of a retroperitoneal mass arising from the pelvic sidewall encompassing the iliac vasculature. The patient made an uneventful recovery with histology confirming disease metastasising to the pelvis. Currently, clinical management guidelines are not available. We present an overview of adamantinoma and highlight a previously undocumented gynaecological oncology surgical approach to this novel disease location. Regarding metastases, we acknowledge the challenges of investigation pertaining to disease site and origin as well as a paucity of recommendations for surveillance and follow-up.

Resolution of hyperthyroidism and thyroid antibodies following struma ovarii resection: an uncommon entity

We report a case of 34-year-old clinically asymptomatic woman who had been followed for 6 years for hyperthyroidism with thyroid stimulating hormone <0.006 uIU/mL, free T4 1.98 ng/mL, free T3 5.3 pg/mL, elevated thyroid stimulating immunoglobulin 1.70 IU/L, thyroid peroxidase antibody 38 IU/mL and thyroglobulin antibody 9.3 IU/mL. Radioiodine thyroid scan showed minimal uptake in both thyroid lobes (24-hour uptake was 0.3%). She subsequently underwent evaluation for lower abdominal pain and menstrual irregularities, which revealed a large left ovarian cyst measuring 15.9 cm × 10.8 cm × 13.2 cm and right-sided ovarian cyst measuring 2.7 cm × 3.3 cm × 3.5 cm. Laparoscopic bilateral ovarian cystectomy was performed and the final pathology revealed struma ovarii of the left ovarian cyst with the entire ovarian tumour made up of benign thyroid tissue. Thyroid function tests performed 3 months after surgical removal of struma ovarii showed euthyroidism. We present a rare case with detailed laboratory and immunological data before and after ovarian extirpation with resolution of hyperthyroidism associated with functional struma ovarii.

Proptosis and ovarian masses: extramedullary manifestations of acute myeloid leukaemia

Aggressive anaplastic ovarian carcinoma in a young nulliparous patient

Ovarian tumours harbouring foci of anaplastic carcinoma are extremely rare. With just a handful of cases reported in the literature, understanding of the disease and optimal management remains limited. A 38-year-old woman was referred to the gynaeoncologists with a multiloculated complex ovarian mass. High-grade mucinous ovarian carcinoma with mural nodules of anaplastic carcinoma was found on biopsy. Furthermore, an umbilical Sister Mary Joseph nodule signalled advanced metastatic disease. The patient underwent primary debulking surgery and was referred for adjuvant chemotherapy. High-quality radiological and surgical images are included to illustrate the approach taken to preoperative diagnosis and described surgical technique. Our case demonstrates the aggressive and rapidly progressive nature of mucinous ovarian carcinoma bearing anaplastic components. Sharing experience of such cases generates awareness and highlights the need for early detection and thorough investigations to guide subsequent management.

Radiation-induced sarcoma presenting as a gluteal abscess: a diagnostic and therapeutic challenge

Sarcomas are a rare and fatal treatment complication following radiotherapy. Radiation-induced sarcomas (RISs) presenting as a gluteal abscess is a rarity, accounting for its varied presentation. We present a case of a middle-aged woman, post-chemo-radiation for carcinoma cervix 5 years ago, who presented with gluteal abscess. Achieving haemostasis post incision and drainage under anaesthesia was a challenge. On further evaluation, she was diagnosed with radiation-induced gluteal soft tissue sarcoma. Haemostasis was achieved after radiation following failed attempts of surgical and radiological interventions. She is currently planned for chemotherapy. Cancer survivors have an increased risk of developing a second malignancy following radiation treatment. RISs are highly aggressive, exhibit a varied clinical presentation and pose a challenge in early diagnosis; thus, have a poor outcome. RISs pose a diagnostic challenge; any dubious lesion in the previously irradiated field should raise suspicion and prompt aggressive management.

Meigs syndrome presenting with severely elevated CA-125 level

A 64-year-old woman referred to Gynaecological Oncology secondary to the finding of pelvic mass and ascites. Imaging showed multiple pelvic masses, with the largest mass measuring 20 cm in diameter, as well as bilateral pleural effusions and abdominal ascites, suspicious for ovarian carcinoma. Laboratory findings included elevated cancer antigen 125 (CA-125) of 2124 units/mL. The patient underwent an exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy for pathological evaluation. Postoperatively, the patient had resolution of ascites and pleural effusion. Surgical pathology revealed a 26 cm right ovarian fibroma, confirming the diagnosis of Meigs syndrome. Despite the high suspicion for ovarian carcinoma in patients presenting with elevated CA-125 level, pelvic mass, ascites and pleural effusion, the diagnosis of Meigs syndrome cannot be excluded without pathological evaluation of mass.

Cerebral venous sinus thrombosis in a patient with concomitant Graves’ disease and squamous cell carcinoma of the cervix

Cerebral venous sinus thrombosis (CVST) is caused by either acquired or inherited pro-thrombotic states. Hyperthyroidism is a less recognised predisposing factor of CVST, and the causality has been debated. We report a case of a life-threatening CVST in a 40-year-old woman, with uncommon dual risk factors: hyperthyroidism and advanced squamous cell carcinoma of the cervix. CVST should be considered as a differential diagnosis when a patient with hyperthyroidism presents with new-onset headache or other neurological symptoms. Further assessment to elucidate other covert risk factors may need to be continuously carried out, when the causal relationship of one apparent cause has not been well established.

Rare case of coexisting ovarian Brenner tumour and ovarian stromal hyperplasia presenting with persistent endometrial hyperplasia following treatment with levonorgestrel-intrauterine system

Endometrial hyperplasia (EH) is a precursor of endometrial cancer. It arises in an environment of unopposed oestrogen. Treatment is based on a combination of weight management, diet and exercise, and the use of progestogens either via a levonogestrel-intrauterine system (LNG-IUS) or orally. The LNG-IUS is the first-line recommendation for EH without atypia. Recurrences are rare, and any recurrences despite prolonged treatment and control of risk factors necessitate a thorough consideration of other oestrogenic sources. This case report presents a rare case of a coexisting ovarian Brenner tumour and ovarian stromal hyperplasia in a menopausal patient in her 50s with recurrent EH despite earlier regression. The above histology may have provided the additional oestrogenic influence. This patient subsequently underwent a definitive hysterectomy and bilateral salpingo-oophorectomy (BSO). It is important to maintain a high index of suspicion for potential oestrogenic influences in cases of refractory EH that are not identifiable on imaging. BSO should be considered at the time of hysterectomy in such cases of unidentified oestrogenic foci.

Large Gartner cyst of the posterior vaginal fornix

International classifications of congenital anomalies do not extensively describe vaginal cysts. For this reason, clinicians who deal with such conditions can only rely on their personal or other colleague’s experience, and only a few case reports are present in the literature. This paper illustrates the clinical scenario due to a particular Gartner cyst, the diagnostic workup followed for its diagnosis and its surgical management.

Uncommon presentations of common variable immunodeficiency

Common variable immunodeficiency (CVID) is a primary immunodeficiency disorder that causes decreased immunity and increased susceptibility to infections. It affects B lymphocyte differentiation, resulting in predominantly bacterial and less frequently viral, fungal, and protozoal infections. The respiratory and gastrointestinal tracts where antibody defences are essential are usually affected. Individuals with CVID are also predisposed to developing lymphoid and gastrointestinal malignancies. We present two cases with rare infectious and oncological complications of CVID, including a patient with Mycobacterium avium complex-intracellular infection and ovarian cancer, and another patient with group B Streptococcus empyema of the lung with acute myeloid leukaemia. The main objective of this study is to highlight how CVID-induced hypogammaglobulinaemia can lead to rare infections and malignancies. The management of these complications can vary according to severity, but an awareness of their existence is crucial to diagnose them promptly in an already immunocompromised CVID patient.

Evaluation of a microperforate hymen leading to the incidental diagnosis of a borderline ovarian tumour

Microperforate hymens are rare anatomical variants with an unknown incidence and very few reported cases. Borderline ovarian tumours are similarly uncommon, with an incidence of approximately 0.002%–0.006%. The concurrent presence of a microperforate hymen and a borderline ovarian tumour is therefore exceedingly unique with no documented cases to date. In this report, we review the case of a nulliparous woman in her late 20s who initially presented with an inability to have penetrative intercourse. A subocclusive hymenal variant was noted on examination and further imaging work-up resulted in the incidental discovery of a large ovarian mass subsequently noted to be a borderline ovarian tumour. Herein, we review contemporary approaches to the diagnosis and management of both hymenal variants and borderline ovarian tumours, and discuss fertility-sparing strategies for young women diagnosed with ovarian neoplasms.

Primary ovarian leiomyosarcoma in a woman with uterovaginal prolapse

Primary ovarian leiomyosarcoma is a very uncommon and aggressive neoplasm. We presented a right-sided ovarian leiomyosarcoma in a woman in her late 40s. No case has been described in the literature till now of primary ovarian leiomyosarcoma in a woman with uterovaginal prolapse. A total abdominal hysterectomy with bilateral adnexectomy, metastasectomy, excision of large tumour deposit over small intestine followed by resection with ileo-ileal anastomosis and omentectomy was performed. The diagnosis was made based on morphology along with immunohistochemistry. The patient was given adjuvant chemotherapy during postoperative period. Due to rarity, there is a dearth of information on the clinical behaviour and best treatment options for these tumours. This case report highlighted the importance of clinical awareness and aimed to provide a baseline to guide clinical practice as well as future research.

Carcinoid ovary with synchronous carcinoid tumour of the appendix: report of a rare occurrence with review of literature

Carcinoid tumours are present in a wide range of organs but most frequently involve the gastrointestinal tract and rarely reported in gynaecological organs. Literature reports that the prevalence of ovarian carcinoid is 0.3%–1% of ovarian neoplasms and accounts for only 5% of ovarian teratomas. The pathogenesis of neuroendocrine tumours associated with synchronous primaries is undetermined and many theories have been proposed, such as existence of a common carcinogenic effect or a common stem cell undergoing similar genetic mutation. Paracrine or autocrine growth loop effect by the secretory peptides of the neuroendocrine cell tumours is also suggested. Since carcinoids are variably positive in neuroendocrine and organ-specific markers, there are no immunohistochemistry markers to delineate the definite primary site of origin versus metastasis. We report a rare case of carcinoid ovary with synchronous carcinoid tumour of the appendix. In our case, the presence of contralateral teratomatous elements may hint primary struma carcinoid instead of being metastatic from the appendix. A strumal carcinoid component was also highlighted by PAX8 positivity. This led us to conclude the case as concurrent appendix carcinoid with struma carcinoid as two independent primaries with uncertain pathogenesis. Histologically, as both tumours are well differentiated with Ki-67 of less than 3%, the decision of the joint tumour board was to keep the patient on surveillance, with no adjuvant treatment needed. The patient is currently on surveillance and the follow-up period of 24 months to date has been uneventful.

Extramedullary haematopoiesis presenting as an adnexal mass in a patient with β-thalassaemia

Solid masses of the ovaries raise the suspicion of malignancy or metastasis and require histological diagnosis. Extramedullary haematopoesis (EMH) is a rare histological finding of a mass of the adnexa. The sonographic pattern of EMH has rarely been described in the literature. Transvaginal biopsy of EMH has not been reported in the literature. We present a case of adnexal EMH in a patient affected with β-thalassaemia, and we performed a narrative review. Only in our case, the sonographic pattern was described, and a transvaginal ultrasound-guided core biopsy was used. Assessing patients’ medical history and correlating it to the findings of diagnostic imaging is of paramount importance when evaluating patients with adnexal masses. The correct interpretation of sonographic images can avoid unnecessarily invasive procedures. A transvaginal biopsy could be a safe, easy and well-tolerated method to gain definite histological diagnosis in cases where a primary ovarian malignancy is not suspected.

Xanthogranulomatous salpingo-oophoritis presenting as an ovarian tumour

Xanthogranulomatous salpingo-oophoritis (XGSO) is an exceptionally rare entity. Its clinical manifestations and imaging modalities can mimic benign and malignant adnexal diseases, making it difficult to diagnose. Here we report a case of XGSO in a young woman who was operated with suspicion of a borderline ovarian tumour. Preoperative diagnosis of XGSO should be considered to avoid radical surgical treatment, especially in young patients.

Ovarian steroid cell tumour inducing virilisation in a postmenopausal woman

Hyperandrogenism with virilisation de novo in postmenopausal women is exceedingly rare, with aetiology oscillating between ovarian tumours, adrenal tumours, ovarian hyperthecosis and, less frequently, Cushing’s syndrome. We report a case of a postmenopausal woman in her late 60s, referred from her primary healthcare physician to a gynaecology appointment due to hirsutism and vasomotor symptoms. At physical examination, clitoromegaly was also identified. Blood tests revealed severe hyperandrogenemia, with total testosterone above 200 ng/dL, but transvaginal ultrasound and abdominal CT were unremarkable. Three months later, abdominal CT was repeated, revealing a moderate heterogeneous enhancement with 18 mm on the left ovary, which was confirmed by transvaginal ultrasound. Total laparoscopic hysterectomy with bilateral adnexectomy was performed. Histopathological examination reported an ovarian steroid cell tumour not otherwise specified on the left ovary and bilateral ovarian hyperthecosis. Two months later, the patient had normal total testosterone and the hirsutism complaints were completely absent.

Microcystic stromal tumour of testis

Within the group of gonadal sex cord-stromal tumours, microcystic stromal tumour (MCST) is a rare entity. In the literature, most case series and reviews discussed MCST arising in the ovary, only one case-report concerned a testicular MCST. We present a Caucasian man in his late 30s, who presented with an MCST in his right testis. The tumour was encapsulated and composed of vaguely lobulated cellular nodules and cystic spaces with bland spindle cells and hyalinised fibrous stroma. By immunohistochemistry, the tumour cells expressed cluster designation 10, androgen receptor, steroidogenic factor-1 and nuclear beta-catenine, and there was focal nuclear expression of cyclin D1. Molecular diagnostics confirmed the presence of an exon 3 mutation (c.98C>T) in the CTNNB1 gene. These features are similar to MSCT described in the ovary. Clinical follow-up (more than 1 year) was uneventful. Although the clinical and radiological presentation was that of a possible malignant testicular lesion, this entity is benign.

Abdominal tuberculosis masquerading as ovarian carcinoma in a Caucasian woman: a diagnostic challenge

We present a case of a 37-year-old Caucasian woman with abdominal distension and loss of weight. She was initially presumed to be a case of ovarian malignancy due to an elevated serum cancer antigen 125 (CA 125) level and imaging of abdomen and pelvis that showed ascites and bulky ovaries. However, histological examination of biopsy later revealed it to be a case of abdominal tuberculosis (AbT). Ascitic fluid was also found to be positive for Mycobacterium tuberculosis by whole genome sequencing. The patient was started on antituberculosis treatment following which she showed a significant improvement in her symptoms.

High-grade B-cell lymphoma with MYC and BCL6 rearrangements presenting as a cervical mass

Lymphoid malignancies represent 0. 008% of all cervical tumours. While uncommon, lymphoid malignancies of the gynaecological tract require careful diagnosis and classification to ensure appropriate treatment. We present a case of a 54-year-old woman with HIV who presented with urinary and faecal incontinence for 2 weeks, associated with the feeling of a mass in her vagina. A smooth flesh-coloured pelvic mass was seen on physical examination, and a transvaginal biopsy revealed infiltration of atypical lymphoid cells with fluorescence in situ hybridisation positive for MYC and BCL6, and negative for IGH/BCL2. Bone marrow and cerebral spinal fluid analysis also showed involvement by atypical lymphocytes. She was diagnosed with stage IV high-grade B-cells lymphoma (HGBLs) with MYC and BCL6 rearrangements. She was given R-CODOX-M plus IVAC with no evidence of disease at 4-month follow-up. To our knowledge, this is the first literature report of a HGBL with MYC and BCL6 rearrangement presenting as a cervical mass.

Benign tumour of the vulva: vulvar schwannoma

Schwannoma is usually a solitary, slowly progressing, benign tumour. It arises from the Schwann cells of peripheral, cranial and autonomic nerve sheaths and rarely affects the external female genitalia. We treated a patient in her late 30s with vulvar schwannoma with complete excision. A histological examination showed an encapsulated proliferation of bland spindle cells positive for S100 and SOX10 on immunohistochemistry, negative for desmin. A diagnosis of vulvar schwannoma was made. It carries a good prognosis with complete excision.

When Word fails: a misdiagnosed vulvar leiomyoma mimicking a Bartholin’s cyst

Vulvar leiomyomas are exceedingly rare benign tumours, with fewer than 300 cases reported to date. We report a case of a woman in her 20s with a long-standing vulvar swelling. Clinical suspicion was initially for a Bartholin’s cyst, prompting treatment with oral antibiotics and referral for a Word catheter insertion. After an unsuccessful attempt at a Word catheter, the mass was instead enucleated. Histopathology confirmed a benign vulvar leiomyoma. Vulvar leiomyomas should be considered in the differential diagnosis of persistent vulvar masses and atypical Bartholin’s cysts/abscesses. Surgical excision remains the definitive treatment and is usually curative, as well as allowing histological analysis for definitive diagnosis.

Giant vulvar acrochordon (skin tag) presenting in second trimester of pregnancy

Fibroepithelial polyps (FEPs), or skin tags or acrochordons, are benign, hormone-responsive lesions commonly found on mucosal and cutaneous surfaces of females of reproductive age. However, it is not very widely reported during pregnancy, with only four cases of vulvar FEP reported in the literature to date in pregnant females. Herein, we present a case of giant FEP of the vulva measuring 10 cm × 10 cm in the second trimester of pregnancy. The lesion was successfully excised without any complications, and histopathological examination confirmed its benign nature.

Recurrent ectopic primary breast adenocarcinoma of the vulva with a 19-year follow-up period

We present a case of an ectopic breast adenocarcinoma of the vulva with metastatic local recurrence and a total follow-up period of 19 years, the longest documented in the literature to our knowledge. Following surgical excision, radiation therapy and hormonal treatment after the recurrence, the patient has remained disease free. This case demonstrates the potential for malignant transformation in accessory breast tissue and highlights the importance of close surveillance and regular physical examinations in patients with a history of ectopic breast malignancy.

Vulvar leiomyoma in a postmenopausal woman

Leiomyomas of the uterus are the most common benign tumours of women in the reproductive age group, affecting up to 40%–50% of women older than 35. In postmenopausal women, the incidence is much lower with an estimated incidence of 1%–2% in women in the 60–80 years old age group. Vulvar leiomyomas are much rarer than their uterine counterparts, accounting for only 0.03% of all gynaecological neoplasms and 0.07% of all vulvar tumours. These tumours are well-circumscribed, painless, solitary growths that affect females of all ages. Given the presentation and rarity of vulvar leiomyomas, they are often misdiagnosed as a Bartholin gland cyst, abscess or even cancer preoperatively. We present a case of a woman in her 70s with a 1.5 cm firm mass that was palpated on the left lower vaginal side wall and was initially suspected to be a Bartholin gland cyst or abscess. Initial treatment included antibiotics and an incision and drainage. Two weeks later, the mass had grown to 3 cm in size. Wide excisional biopsy revealed the mass to be a vulvar leiomyoma.

Large vulvar fibroepithelial polyp and review of differentials

Vulval fibroepithelial polyps (FEPs) are a rare type of vulval fibroblastic tumour commonly found in premenopausal women. It is important to obtain an accurate pathological diagnosis because, despite being benign, the condition shares some characteristics with malignant vulva lesions in its differential diagnosis. We present a case of young woman in her 20s with a giant FEP. After surgical excision, the patient did not manifest any signs of recurrence after 1-year follow-up. Our review focuses on the distinguishing characteristics of these rare neoplasms as we explore their differential diagnosis.

Deep (aggressive) angiomyxoma of the vulva in a pregnant woman

Aggressive angiomyxoma is a rare mesenchymal tumour, which usually appears in the pelvic region of women in their reproductive age. Although benign, it is a locally infiltrative tumour with frequent recurrence. We report a case of a pregnant woman in her 30s with a vulvar aggressive angiomyxoma which was initially misdiagnosed. Features of this case are discussed, highlighting the difficulty in its diagnosis and the challenge of the follow-up and treatment of recurrences.

Twisted aggressive angiomyxoma of the vulva presenting as an emergency with severe pain and impending gangrene

Vulval leiomyoma: a rare clinical entity

Vulvar condyloma of Buschke and Löwenstein: an unusual tumour in developed countries

Vulvar aggressive angiomyxoma: a surgical challenge

Aggressive angiomyxoma is a rare and locally aggressive mesenchymal tumour, predominantly occurring in women of reproductive age group. The term aggressive is attributed to the infiltrative nature and frequent local recurrences. They arise commonly from the vulvovaginal region, perineum or pelvis and are usually misdiagnosed as other common entities in these regions. Radiological investigations aid in the diagnosis and planning of surgery. However, the final diagnosis in most of the cases is established by histopathological examination. We herein report a case of a middle-aged woman presenting with recurrent large right vulvar mass highlighting the surgical challenges posed by its intrapelvic extension.

Extrarenal rhabdoid tumour of the vulva: diagnostic and management challenges

Extrarenal rhabdoid tumour (ERT) of vulva is a rare gynaecological neoplasm with an aggressive course and no clear management guidelines. We present the case of a 25-year-old woman with a rapidly increasing mass in right vulva suggestive of sarcoma. Wide local excision was done. Histopathology examination revealed ERT of vulva. Six weeks later she manifested lung metastases. Despite adjuvant chemotherapy, the disease progressed and she died 8 months later. We review the literature and briefly discuss the epidemiology, treatment approaches, prognostic factors and expected outcomes of this rare disease.

Multidisciplinary management of patients with pubic osteomyelitis, a rare but serious complication after surgery and radiation therapy for advanced gynaecological cancer

Pubic osteomyelitis is a rare and often late-onset complication of radiation therapy and surgery for vulvar and vaginal carcinoma. It typically presents with vulvar pain, fever, vaginal discharge and/or gait disorders. Pubic osteomyelitis is often accompanied by fistulas or wound dehiscence in the pelvic area. Its accurate diagnosis and treatment are challenging and require a multidisciplinary team effort. In our patients, multiple combined surgical procedures, long-term antibiotic treatment and days to weeks of hospital admission were necessary to treat pubic osteomyelitis. We emphasise the importance of timely and adequate diagnosis and multidisciplinary approach resulting in a course of treatment that is as effective as possible, limiting the impact on quality of life, which is generally high in this group of patients.

Giant fibroepithelial vulvar polyp in a pregnant woman

Fibroepithelial polyps are benign lesions that may appear in the vulvovaginal region. They usually occur in women of reproductive age and tend to grow up to 5 cm, but there are some rare cases in which they grow up to 20 cm. We report a case of a 22-year-old woman in the third trimester of her first pregnancy with spontaneous bleeding from a pedunculated mass measuring 15 cm in the widest diameter on the right side of the vulva. Features of this case are discussed as well as its implications, especially regarding the decision of labour. Due to the big size of the mass and its propensity to bleed, we decided to perform an elective caesarean section as well as its excision.

Small cell neuroendocrine tumour of the cervix in pregnancy: the importance of multidisciplinary management

A woman in her mid-20s presented with bleeding at 18 weeks gestation from a cervical ‘polyp’. Histopathology demonstrated a rare small cell neuroendocrine of the cervix. There were only 18 cases of neuroendocrine tumours of the cervix in and around pregnancy in the literature, so the evidence base for treatment was scarce. She was treated with neoadjuvant chemotherapy, using a regimen used for small cell neuroendocrine tumours of the lung, to allow for fetal lung maturity. Disease initially responded, then progressed and she was delivered at 32 weeks by caesarean radical hysterectomy. Adjuvant treatment included further chemotherapy and radical pelvic radiotherapy. The woman and her child are doing well over 6 years after treatment, although the woman has significant side effects of both radical surgery and radiotherapy. This case emphasises the need for excellent communication between multidisciplinary professionals, patients and their families and using external colleagues to help with rare clinical problems.

En bloc resection of cervical adenocarcinoma with late recurrence to the iliopsoas

This is a case of a 50-year-old woman diagnosed with recurrent cervical adenocarcinoma presenting with chronic and persistent low back pain. She underwent myomectomy for myoma uteri 8 years prior. Histopathology report revealed cervical cancer. She underwent chemotherapy, brachytherapy and external beam radiotherapy. All surveillance work-up, over the years, were negative until she was found to have a solitary recurrent lesion in the right iliopsoas muscle on CT scan. A multidisciplinary team of surgeons collaborated to perform wide excision of pelvic recurrence en bloc right internal hemipelvectomy, right hemicolectomy en bloc resection of external iliac artery and vein, external ilio-iliac artery interposition graft and external iliac vein–common femoral vein bypass. Final histopathologic results showed adenocarcinoma with endometrioid features with associated poorly differentiated high-grade carcinoma involving the iliopsoas, cecum and terminal ileum. Two months postoperatively, the patient is ambulating with minimal assistance.

Complete pelvic organ prolapse associated with cervical cancer

Rare complications of complete hydatidiform molar pregnancy: the ‘hook effect’ and thyrotoxicosis

A multiparous woman in her 40s presented with a positive pregnancy test, vaginal bleeding, abdominal distention and shortness of breath, 8 weeks after her last menstrual period. A serum human chorionic gonadotrophin (hCG) was reported 900 mIU/ml, and a transvaginal ultrasound (TVUS) diagnosed a pregnancy of unknown location. The patient deteriorated re-presenting 6 days later with features of thyrotoxicosis. TVUS demonstrated a 198×110×165-mm intrauterine mass with features of a complete hydatidiform mole (CHM), and a serum hCG was reported as 440 mIU/ml. Due to the discrepancy between hCG level and suspicion of CHM, the hCG was thought to be falsely low secondary to the ‘hook effect’. Following appropriate dilution, the hCG was reported as 4 573 344 mIU/mL. She underwent an uncomplicated surgical evacuation of molar pregnancy and was discharged 3 days postoperatively with resolution of her symptoms and follow-up in a regional gestational trophoblastic disease centre.

Allergy testing for Cremophor in a patient with cervical cancer with infusion reactions to paclitaxel and docetaxel

A woman in her 30s with cervical cancer underwent postoperative chemotherapy and showed allergic reactions to multiple taxanes. As the patient had infusion reactions to both paclitaxel and docetaxel, a prick test with Cremophor was conducted. In the absence of an allergic reaction to etoposide, we determined that the patient was allergic to pure taxane compounds. Among infusion reactions caused by taxanes, Cremophor allergy is reported in 3% of cases. Therefore, a prick test with Cremophor performed on a taxane infusion reaction will be useful in diagnosing allergy. In addition, allergy due to docetaxel may be managed by adequate premedication and continuous intravenous chlorpheniramine administration.

Cervical carcinosarcoma: approach of a rare tumour in a rare location

Cervical carcinosarcoma is a very rare tumour, with less than 70 cases described in the literature. We report a case of a woman in her 60s, with an atypical presentation: a single episode of high volume serous vaginal discharge. A carcinosarcoma of the uterine cervix was diagnosed and, after exclusion of distant disease, the patient was submitted to radical surgery. Due to surgical complications adjuvant treatment was not performed.

Serous endometrial cancer with an elusive preoperative diagnosis

Uterine serous carcinoma (USC) is an aggressive histological subtype of endometrial cancer that frequently presents with early extrauterine spread, often without uterine symptoms. We report a diagnostically challenging case of a postmenopausal woman presenting with malignant ascites, peritoneal metastases and deep vein thrombosis, but no abnormal uterine bleeding. Preoperative imaging and biopsies were inconclusive, suggesting a possible leiomyoma or ovarian malignancy. Exploratory laparotomy revealed widespread peritoneal disease, and histopathology demonstrated serous carcinoma confined to an endometrial polyp with lymphovascular space invasion but no myometrial invasion. Immunohistochemistry showed p53 and p16 positivity, focal WT1 (Wilms tumor 1 protein) positivity, weak ER (estrogen receptor) expression and MMR (mismatch repair) proficiency, confirming primary USC (International Federation of Gynaecology and Obstetrics (FIGO) stage IVB). The patient was initiated on paclitaxel–carboplatin chemotherapy. This case highlights the diagnostic difficulties of USC, its potential to mimic ovarian carcinoma and the importance of integrating surgical, pathological and molecular evaluation for accurate diagnosis and management.

Dysgerminoma of the ovary presenting as acute abdomen with intratumoural gas image: a diagnostic challenge suspected as a gastrointestinal stromal tumour

A woman in her 20s presented with acute abdomen, manifesting as a palpable abdominal mass, left lower quadrant pain and vomiting. Imaging revealed a large pelvic mass containing multiple linear air pockets, which complicated the differentiation from gastrointestinal tumours (such as gastrointestinal stromal tumour) or abscesses. Emergency surgery revealed a left ovarian tumour with 360-degree torsion and associated congested change. Pathological diagnosis confirmed dysgerminoma, characterised by positive immunohistochemistry for Sal-like protein 4, placental alkaline phosphatase and octamer-binding transcription factor 4 (OCT-4). We hypothesise that the intratumoural gas was intravascular gas associated with the torsion, entrapped within the dysgerminoma’s characteristic fibrovascular septa, thereby mimicking an enterogenous mass. This case highlights the importance of considering ovarian torsion as an aetiology of unusual gas images and underscores the challenge in diagnosing rare ovarian malignancies presenting acutely.

Enigma of postmenopausal virilisation: bilateral Leydig cell tumours as the culprit

A postmenopausal woman in her 50s presented with progressive hirsutism, virilisation and markedly elevated serum testosterone levels (>1500 ng/dL). Routine laboratory, adrenal and imaging evaluations were largely unremarkable except for a small left adnexal mass on MRI. With normal dehydroepiandrosterone sulphate (DHEAS) and cortisol levels, an ovarian source of androgen excess was suspected. The patient underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Histopathology revealed bilateral Leydig cell tumours, an exceptionally rare finding. Postoperatively, serum testosterone normalised, and virilisation regressed significantly. This case highlights the importance of considering androgen-secreting ovarian tumours in postmenopausal women with rapidly progressive virilisation, even when imaging is inconclusive. Bilateral Leydig cell tumours are exceedingly uncommon but should be suspected when severe hyperandrogenism is present. Surgical removal remains the definitive diagnostic and therapeutic approach, ensuring hormonal normalisation and symptom resolution while preventing prolonged morbidity associated with delayed diagnosis.

Deciphering a diagnostic enigma from ovarian malignancy to disseminated peritoneal leiomyomatosis

Disseminated peritoneal leiomyomatosis (DPL) is a rare benign disorder of uncertain aetiology that often mimics advanced ovarian or peritoneal malignancy, both clinically and radiologically. The majority of reported cases have been associated with prior laparoscopic uterine myomectomy, particularly when uncontained morcellation was used. Here, we present a case of a nulliparous woman in her 20s who presented with a large abdominopelvic mass and radiological findings suggestive of ovarian carcinoma. However, further history-taking revealed a laparoscopic myomectomy with morcellation performed 2 years earlier for primary infertility due to a large intramural fibroid. Subsequent ultrasound-guided biopsy and immunohistochemistry confirmed the diagnosis of disseminated peritoneal leiomyomatosis (DPL). The objective of this case report is to highlight the diagnostic challenge DPL poses by mimicking malignancy and to emphasise the importance of eliciting prior surgical history—particularly involving morcellation—as a crucial clue in correctly identifying this benign entity.

Myomatous erythrocytosis syndrome with unusually normal serum erythropoietin levels

Myoma uteri is the most common benign tumour in women, but myomatous erythrocytosis syndrome (MES) is rare. MES is characterised by erythrocytosis, a myomatous uterus and blood normalization after hysterectomy or myomectomy. It increases the risk of thromboembolic events, making early recognition crucial. A premenopausal, nulliparous woman in her 50s with dyslipidaemia and obesity presented with a 20-week-sized abdominopelvic mass but no abnormal uterine bleeding. CT imaging revealed a large right adnexal mass. Lab tests showed isolated erythrocytosis with normal tumour markers and serum erythropoietin (Epo). Hysterectomy and bilateral salpingo-oophorectomy confirmed multiple uterine myomas, the largest measuring 19.5 cm, along with a right ovarian haemorrhagic cyst. Postoperatively, her blood levels normalised, confirming MES. The exact mechanism remains unclear but may involve Epo production. While Epo is often linked to myomas, some cases, like ours, show normal levels, highlighting the need for further research to understand MES and develop targeted treatments.

Incidental tubal pathology from pelvic organ prolapse surgery

Incidental gynaecologic malignancies are detected in up to 1.3% of pelvic organ prolapse (POP) surgeries. There is limited data on the incidence of fallopian tube pre-malignancies, such as serous tubal intraepithelial lesion (STIL) and carcinoma (STIC), which progress to ovarian cancer in 10.5% of patients over 5 years. We report two new cases of incidental tubal pathology after POP surgery. Patient one is a woman in her 70s who underwent a laparoscopically assisted vaginal hysterectomy and bilateral salpingectomy with sacrocolpopexy, revealing STIC and STIL in the left adnexa. Follow-up laparoscopic bilateral oophorectomy with peritoneal biopsies was benign. Patient two is a woman in her 70s who underwent vaginal hysterectomy, left salpingectomy, uterosacral ligament suspension and enterocele repair and was found to have STIL. Follow-up robotic bilateral oophorectomy, right salpingectomy and peritoneal biopsies were benign. Patients with incidental tubal carcinoma should be monitored by gynaecologic oncology to prevent progression to ovarian cancer.

Salvage cytoreductive surgery and HIPEC in chemoresistant juvenile granulosa cell tumour

Juvenile granulosa cell tumours (JGCTs) are rare ovarian neoplasms with aggressive potential and limited responsiveness to chemotherapy. We present a case of a female in early adolescence with chemoresistant JGCT and extensive peritoneal recurrence following initial surgery and systemic therapy. The patient underwent cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin, resulting in a favourable postoperative course. This report highlights the role of aggressive surgical management combined with HIPEC as a promising approach for selected cases of chemoresistant peritoneal JGCT. Further studies are needed to establish standardised treatment protocols.

Xanthogranulomatous oophoritis: malignant appearance, benign pathology

Xanthogranulomatous oophoritis (XO) is a rare inflammatory condition of the female genital tract that closely mimics malignancy due to its non-specific clinical presentation and mass-like appearance on imaging. It is histologically characterised by lipid-laden macrophages, chronic inflammatory cells and necrosis. We report the case of a woman in the late 60s referred to the gynaecologic oncology clinic for evaluation of a newly identified complex ovarian mass on CT. She underwent surgical intervention with histopathological examination confirming the diagnosis of XO with extension into the uterine wall and peri-appendicitis. Postoperative recovery was uneventful, and intraoperative cultures grew Bacteroides fragilis , suggesting a potential infectious aetiology. XO remains a diagnostic challenge due to its resemblance to ovarian malignancy. This case underscores the importance of considering XO in patients presenting with adnexal masses, particularly those with a history of chronic pelvic inflammation or infection. Awareness of this rare entity can help prevent unnecessary radical surgeries, improve patient outcomes, and guide future research into its pathogenesis and management strategies.

Malignant peritoneal mesothelioma mimicking ovarian cancer: a diagnostic challenge

Malignant peritoneal mesothelioma (MPM) is a rare and aggressive cancer associated with a poor prognosis. Its presentation mimics a spectrum of conditions, making diagnosis and management particularly challenging. This case highlights the difficulties in managing MPM under the constraints of diagnostic uncertainty. A nulliparous woman in her early 20s was initially diagnosed with ovarian cancer based on CT imaging, leading to laparotomy for tumour debulking with fertility-sparing procedures. However, the postoperative diagnosis of MPM necessitated reoperation for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), which resulted in favourable outcomes. This case underscores several important points: (1) The limitations of imaging in distinguishing MPM from ovarian cancer, (2) The critical role of pathological diagnosis, including immunohistochemical staining, in differentiating between benign and malignant mesothelioma, (3) The utility of grading MPM risk using clinical findings, the peritoneal cancer index and pathological results to guide decisions regarding subsequent neoadjuvant chemotherapy and (4) The challenges in managing a rare and aggressive malignancy, which demonstrated a favourable response to CRS-HIPEC.

Clear cell borderline tumour of the ovary: a rare entity

Borderline clear cell tumours of the ovary are exceedingly rare, with limited cases documented in literature. We present a case of a woman with primary infertility who presented with abnormal uterine bleeding and a history of bilateral endometriotic cysts. Abdominal examination revealed a mass of 17×12 cm. CT imaging showed a heterogeneous solid-cystic mass measuring 16.6×10.8 cm in the right adnexa with elevated cancer antigen 125 (CA-125) levels (761.9 IU/mL). Staging laparotomy was performed due to high suspicion of malignancy. Intraoperatively, a right ovarian mass of 18×14 cm size, with intact capsule, and a 3×3 cm left ovarian endometriotic cyst were found. Microscopically, the mass showed a multiloculated cyst wall lined by cuboidal epithelium, without significant nuclear atypia or stromal invasion, and was positive for Napsin A. The overall features were suggestive of clear cell borderline tumour. Postoperative CA-125 level was normalised and the patient was placed under regular follow-up.

The blue bloater: a tale of cyanosis, platypnoea and right heart failure in a patient with an abdominal mass

An elderly woman in her 60s presented with generalised anasarca due to right heart failure, platypnoea and central cyanosis. On investigation, she was found to have dilatation of the right ventricle and right atrium, thickened and non-coapting tricuspid valve leaflets with severe organic low pressure tricuspid regurgitation and a small patent foramen ovale shunting right to left. Further evaluation revealed elevated serum chromogranin levels and 24-hour urinary 5-hydroxy indole acetic acid levels which suggested the possibility of a carcinoid-secreting tumour. A whole body PET scan revealed an ovarian mass with high uptake of the tracer, thus confirming the diagnosis of ovarian carcinoid with carcinoid heart disease. We discuss the intricacies of this case and then briefly review the literature on carcinoid heart disease. After initial decongestion, she underwent left salpingo-oophorectomy with tricuspid valve replacement and aortic valve repair in the same session and at a follow-up of 4 years is doing well and is disease free (Summary Figure).

PALB2 c.3106G>C (p.Val1036Leu) in a familial cancer setting suggesting potential pathogenicity

The case is a woman in her 60s with a heterozygous germline variant in PALB2 (c.3106G>C, p.Val1036Leu) who developed ovarian cancer. Tumour somatic analysis revealed a 24.7% loss of heterozygosity, commonly associated with homologous recombination deficiency. No other pathogenic DNA damage repair gene mutations were identified, although ATR amplification was observed. The proband has four siblings, all of whom tested positive for the PALB2 c.3106G>C variant. Both of her brothers were diagnosed with prostate cancer. One of her sisters was diagnosed with breast cancer at age 62, while the other sister has no cancer history. The patient’s two children have not been tested and have no reported history of cancer. Her father had prostate cancer at age 67 and died due to melanoma at age 75. No history of cancer was found on her mother’s side. Segregation analysis of the PALB2 c.3106G>C variant with multiple cancer diagnoses suggests a pathogenic role.

Paraneoplastic hypercalcaemia induced by ovarian clear-cell carcinoma in a young nullipara: implications for early detection and management

Paraneoplastic hypercalcaemia, an uncommon manifestation in ovarian malignancies, exhibits the commonest association with clear cell carcinoma among epithelial ovarian neoplasms. Patients presenting with severe hypercalcaemia of malignancy are considered oncological emergencies, necessitating prompt and aggressive intervention. We present a case of ovarian clear-cell carcinoma (OCCC) that manifests with severe hypercalcaemia as one of its primary clinical features, posing significant challenges to precise diagnosis and preoperative optimisation. The necessity for aggressive fluid resuscitation, calciuresis and meticulous electrolyte monitoring led to an arduous course in perioperative management. Normalisation of the serum calcium levels was promptly noted following primary cytoreductive surgery. This case underscores the importance of including OCCC in the differential diagnosis of unexplained hypercalcaemia, particularly in women presenting with symptoms suggestive of ovarian malignancy. This also emphasises the critical need for early recognition of these paraneoplastic manifestations, facilitating timely diagnosis and treatment initiation, potentially improving prognostic outcomes.

Mixed germ cell tumour in pregnancy: clinical insights and challenges

A young 24 weeks pregnant woman in her 20s presented with abdominal pain and distension and was diagnosed to have an ovarian mixed germ cell tumour (GCT). She received chemotherapy with weekly paclitaxel and carboplatin with a good clinical response, which was followed by the delivery of a healthy child. Subsequently, she underwent cytoreductive surgery and completed chemotherapy. She is currently disease-free for 7 years and there are no treatment-related sequelae in either the patient or her child. This case report aims to highlight the intricacies of managing ovarian GCT during pregnancy, illustrating that positive outcomes are possible even in the face of significant medical challenges.

Treatment of breast cancer in a patient with sickle cell disease

We present a woman in her 30s with sickle cell disease (SCD) treated with monthly exchange transfusions who had suffered cerebrovascular complications, presented with a 4-cm left breast mass and was ultimately diagnosed with Estrogen receptor-positive, human epidermal growth factor receptor 2 positive (ER+HER2/Neu+) invasive ductal carcinoma with axillary metastasis. She was treated with neoadjuvant trastuzumab-based chemotherapy, followed by a left-modified radical mastectomy and had residual invasive disease. She received postmastectomy radiation followed by adjuvant trastuzumab emtansine. Given the ER positivity, she also began adjuvant ovarian suppression (OS) and an aromatase inhibitor (AI). Throughout treatment, her SCD remained well-controlled, highlighting the potential for effective and tolerable cancer therapy in patients with SCD and the importance of interdisciplinary collaboration. This case underscores the importance of tailored oncological management and the need for further research on chemotherapy safety in this population.

Meigs syndrome mimicking ovarian carcinoma: a diagnostic pitfall

Meigs syndrome, characterised by a pelvic mass, ascites and pleural effusion, is commonly associated with benign ovarian fibromas. It can mimic ovarian carcinoma both clinically and radiologically, leading to potential misdiagnosis. Early recognition of Meigs syndrome is crucial to prevent unnecessary interventions, such as chemotherapy or extensive surgery. This is a case summary of a woman in her early 50s who presented with abdominal pain, shortness of breath and a pelvic mass, suggestive of ovarian malignancy. Imaging and elevated CA-125 levels raised suspicion for ovarian cancer. However, histopathological examination of the mass revealed an ovarian fibroma, confirming Meigs syndrome. Meigs syndrome should be considered as part of the differential diagnosis in cases of pelvic masses with ascites and pleural effusion, helping to guide appropriate management and avoid unnecessary treatments.

Fertility-preserving approach in growing teratoma syndrome with repeated ovarian surgeries

Growing teratoma syndrome (GTS) is an extremely rare complication of malignant ovarian germ cell tumours. Repeated ovarian surgeries may be required in the case of GTS, which might pose a challenge for fertility preservation and may necessitate assisted reproductive techniques. A nulligravida in her early 20s with infertility presented with bilateral benign ovarian cysts, which appeared to be benign on initial workup but were diagnosed as left immature teratoma (stage IC1) after surgical staging and histopathological examination. She underwent bilateral ovarian cystectomy followed by chemotherapy as she was keen on fertility preservation. In her mid-20s, she had a left-sided benign serous cystadenoma removed, and 2 years later, a left ovarian dermoid cyst was removed by laparoscopy, which made us diagnose GTS. Assisted reproductive technique was pursued later, leading to a successful pregnancy. A healthy male baby was delivered at 37 weeks.

Role of immunohistochemistry in the fertility-sparing management of Sertoli Leydig cell tumour

Ovarian Sertoli Leydig cell tumours (SLCTs) are rare and occur predominantly in young females. Categorised as less common ovarian cancers, they have a favourable prognosis, and fertility preservation is an option in early-stage disease, where fertility is desired. Here, we describe a case of a late adolescent girl, who presented after tumour excision of left ovarian mass. Her initial histopathology report showed mucinous adenocarcinoma of left ovary. Slide review and immunohistochemistry suggested stage IC, intermediate grade Sertoli Leydig cell tumour and the patient was kept on observation. Six months later, she underwent re-surgery with fertility preservation for suspected recurrence. Final histopathology showed no residual tumour. The girl has been disease-free for 4 years. This case highlights the importance of immunohistochemistry and extensive pathology review for diagnosis of this rare tumour. It emphasises that SLCT can masquerade as other poor-grade malignancies owing to histopathological overlap.

Bilateral malignant struma ovarii with concurrent thyroid carcinoma

Malignant struma ovarii (MSO) is a rare ovarian tumour. The co-occurrence of MSO and thyroid carcinoma is even rarer. There is no established treatment for these patients. We report a postmenopausal woman in her 60s who presented with left hip pain, increased urinary frequency and fatigue. Imaging showed a left adnexal cystic lesion 8.8 cm in diameter and an incidental 12×8 mm right ovarian cyst. She underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy, and findings were significant for bilateral stage IA MSO. The metastatic workup showed concurrent papillary thyroid carcinoma. She underwent total thyroidectomy with neck dissection and radioactive iodine (RAI) adjuvant therapy. While thyroid carcinoma management is more standardised, a literature review yielded a wide range of MSO treatments. Recent literature favours conservative management with unilateral salpingo-oophorectomy. RAI therapy in these cases is controversial. We will discuss the literature findings on the optimal treatment of MSO with concurrent thyroid cancer.

Anaesthetic management of laparotomy in a patient with anti-NMDA receptor antibody-mediated encephalitis

Management of cases of anti-N-methyl-D-aspartate (NMDA) antibody-mediated encephalitis is very challenging to anaesthesiologists as this receptor is the target of many anaesthetics. We report a woman diagnosed with anti-NMDA antibody-mediated encephalitis posted for laparotomy. She presented with generalised tonic-clonic seizures. Testing revealed anti-NMDA antibodies and anti-SOX antibodies. Ultrasonography of the abdomen showed a right adnexal cystic lesion; hence, the patient was taken up for right ovarian cystectomy after obtaining high-risk consent. A combination of total intravenous anaesthesia with endotracheal intubation under bispectral index monitoring and bilateral transversus abdominis plane block for postoperative analgesia was administered. Postoperatively, there was no excessive drowsiness or hypoventilation. Prioritising careful monitoring and tailored anaesthesia techniques to minimise the risk of triggering neurological exacerbations while ensuring optimum surgical conditions are met is of paramount importance. Meticulous planning and careful use of resources enabled the administration of safe anaesthesia.

Laparoscopic approach to inguinal hernia with incarcerated ovary in a patient with endometrial neoplasia

Ovarian inguinal herniation is a rare clinical entity. It can be safely managed laparoscopically, even in patients with concurrent gynaecological malignancies requiring radical hysterectomy. We present the case of a middle-aged woman admitted for severe anaemia and progressive weakness. Imaging revealed endometrial cancer and a right inguinal hernia containing an 8 cm lesion of indeterminate origin. MRI identified strangulated ovarian tissue within the hernia, and histopathology confirmed a low-grade endometrioid adenocarcinoma. The patient underwent a planned laparoscopic procedure, including radical hysterectomy, sentinel lymph node biopsy and simultaneous inguinal hernia repair. The hernia was repaired using the transabdominal preperitoneal approach after excision of the right adnexa, with polyvinylidene fluoride mesh fixation. The patient experienced an uneventful recovery and was discharged on the second postoperative day. Histopathological analysis confirmed low-grade endometrioid carcinoma with clear margins and metastasis in two lymph nodes, demonstrating the feasibility of managing both conditions concurrently.

Male ductal carcinoma in situ (DCIS) at a young age

In this case, a man in his late 20s visited his general practitioner with unilateral left nipple discharge. Initially, he was treated with antibiotics and the nipple discharge stopped. When the discharge recurred after a few weeks, the patient was referred to the multidisciplinary breast centre in UZ Leuven. Clinical examination revealed an otherwise healthy but obese man (body mass index of 31 kg/m²). On examination, we were able to evacuate bloody discharge from a single duct by mild compression of the left nipple. The bilateral mammography and ultrasound showed an irregular retroareolar density of 40×50 mm with adjacent, multiple clustered microcalcifications over a total distance of 20 mm on the left side. The histopathological report after core needle biopsy revealed a poorly differentiated ductal carcinoma in situ. Genetic testing for hereditary breast–ovarian cancer genes was negative. A simple left mastectomy with sentinel lymph node biopsy was performed. There was no indication for adjuvant chemotherapy or radiotherapy, nor for adjuvant endocrine therapy.

Giant cell carcinoma resembling the lung in the ovary: challenges and treatment approaches

Giant cell carcinoma (GCC) resembling the lung in the ovary is a rare and aggressive tumour with no established standard treatment options. In this case, a postmenopausal woman in her 50s with hypothyroidism underwent surgery for a left ovarian mass. Due to dense adhesions to the sigmoid colon, the procedure was abandoned, and she was referred to our centre. Imaging showed a necrotic pelvic mass involving adjacent organs, omental nodules and para-aortic lymphadenopathy. Her initial biopsy showed an undifferentiated carcinoma with giant cells, resembling GCC of the lung, which was confirmed by immunohistochemistry. Three cycles of carboplatin and paclitaxel reduced the tumour, enabling successful interval debulking surgery. The patient completed three more cycles and has been recurrence-free for 18 months. In this case, the use of neoadjuvant chemotherapy likely contributed to better disease control, facilitating a complete resection during the interval surgery.

Non-bacterial thrombotic endocarditis in a patient with high-grade serous ovarian carcinoma: diagnostic challenges and management insights

Non-bacterial thrombotic endocarditis (NBTE) is characterised by sterile vegetations on heart valves and often emerges in hypercoagulable states like malignancy. It is frequently underdiagnosed and only comes to light during postmortem examination. Early diagnosis and treatment with anticoagulation can help lower mortality. We present a case of a woman in her 60s with marantic endocarditis, secondary to ovarian malignancy. She presented with a 4 week history of headache, confusion and abdominal discomfort. Examination revealed cyanosis, splinter haemorrhages and abdominal tenderness. Echocardiogram showed impaired left ventricular function and suspicion of a small vegetation at the tip of the anterior mitral valve. Further investigation revealed multiple cerebellar infarcts, pulmonary embolism, splenic infarct, ascites and a pelvic mass. A biopsy of the pelvic mass and analysis of ascitic fluid was consistent with high-grade serous carcinoma of tubo-ovarian origin. Following discussion at the gynaecology multidisciplinary team meeting, she was scheduled for chemotherapy treatment.

Gemcitabine-induced myositis in a patient with pancreatic cancer

Gemcitabine, a cytosine analogue, is a cytotoxic agent commonly used in the treatment of patients with a variety of solid tumours, including non-small cell lung cancer, cholangiocarcinoma and breast, pancreatic, testicular and ovarian cancers. Although generally well-tolerated, several reports suggest that it can rarely cause myositis. We present a case of gemcitabine-induced myositis in a patient with pancreatic adenocarcinoma and review the literature on this topic.

Small cell carcinoma of the ovary, hypercalcaemic type causing an acute kidney injury

Summary We report a case of small cell carcinoma of the ovary, hypercalcaemic type, a rare and aggressive form of ovarian cancer, causing an acute kidney injury. A woman in her mid-30s presented with a large pelvic mass and abdominal distention, this was associated with rapidly deteriorating renal function, which did not improve with standardised kidney injury treatment. There was a high suspicion of ovarian cancer. She deteriorated and underwent emergency cytoreductive surgery, followed by systemic chemotherapy. Her presentation, acute kidney injury and electrolyte disturbance preoperatively and postoperatively suggest this was caused by her cancer. Renal dysfunction, due to paraneoplastic syndromes, is a rare oncological emergency seen with solid tumours. Awareness of the condition can lead to early recognition and timely management.

Unusual presentation of an aggressive ovarian malignancy in a young pregnant woman

Cancer during pregnancy is uncommon. Symptoms caused by new cancers in pregnancy can be difficult to recognise leading to a delay in diagnosis and treatment. Ovarian cancer during pregnancy poses a further diagnostic challenge due to the vague symptoms that it can present, along with difficulty in the interpretation of tumour markers. Presentation with acute abdominal pain, in the presence of an ovarian cyst, can be misdiagnosed as benign conditions such as ovarian torsion or haemorrhage. We present a case of a highly aggressive small-cell ovarian carcinoma diagnosed in the third trimester of pregnancy. Ultrasound and MRI scans provided some information on the complex nature of the ovarian cyst. She underwent laparotomy with salpingo-oophorectomy, which was followed by Caesarean birth 2 weeks later at 34+ weeks’ gestation. There was a rapid progression of disease between the two surgeries. Despite starting chemotherapy soon after, she became unwell after two cycles due to disease progression and suspected sepsis. She was unable to continue further treatment. She spent her last few days at home with her family. The final histology with specific stains confirmed the diagnosis of ovarian small cell carcinoma hypercalcaemic type.

Unusual recurrence in advanced ovarian cancer after interval cytoreductive surgery and HIPEC

Ovarian cancer is the second most fatal gynaecological malignancy. The relapses after treatment of ovarian cancer usually occur within 2 years after completion of the first-line therapy. Recurrent ovarian cancer commonly presents as peritoneal surface deposits in the abdomen with or without ascites. A delayed relapse presenting as a solitary lesion in the urinary bladder wall is unusual in patients treated for advanced ovarian cancer. We report the successful management of a case of solitary metastasis of ovarian cancer in the urinary bladder wall, which occurred more than 6 years after achieving a complete remission state.

Acute embolic infarcts of bilateral cerebellar lobes, cerebral peduncles, thalami and left parietal lobe cortex following HIPEC surgery

Cytoreductive surgery and intraoperative, intraperitoneal hyperthermic chemoperfusion (hyperthermic intraperitoneal intraoperative chemotherapy) are commonly used for the management of peritoneal surface metastases. We describe a case of acute embolic infarcts in bilateral cerebellar lobes, cerebral peduncles, thalamus and left parietal lobe cortex in a postmenopausal woman in her 50s diagnosed with bilateral ovarian mucinous adenocarcinoma with peritoneal metastasis under general anaesthesia.

Early-stage serous fallopian tube carcinoma

Primary fallopian tube carcinoma (PFTC) is a rare disease. Its location, close association with epithelial ovarian carcinoma, and lack of specific signs and symptoms make diagnosis challenging especially in its early stages. We report a postmenopausal patient who presented with a 2-month history of abdominopelvic pain with watery vaginal discharge. Imaging findings showed a 7 cm complex left adnexal mass. The patient underwent a robotic-assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy and surgical staging. Findings were significant for stage IA serous fallopian tube carcinoma. PFTC is sometimes missed preoperatively and intraoperatively. Available literature review has focused on the clinical and imaging characteristics of PFTC to aid in timely disease diagnosis. Minimally invasive surgery is a viable option in the diagnosis and management of early-stage ovarian cancer due to improved visualisation of pelvic structures, decreased length of hospital stay, decreased estimated blood loss and lower postoperative complication rates compared with laparotomy.

LAMN port-site metastasis after laparoscopic oophorectomy for a presumed ovarian tumour treated with CRS and HIPEC

Low-grade appendiceal mucinous neoplasm (LAMN) may culminate as a mucin-secreting disease known as pseudomyxoma peritonei (PMP). Once the diagnosis of LAMN and PMP is made, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC) are indicated. Herein, we present a female patient in her 50s who was diagnosed with an ovarian mass for which she underwent laparoscopic oophorectomy. As the pathology of the ovary showed a tumour of gastrointestinal origin, she then underwent CRS and HIPEC with a final pathology of LAMN. Six weeks later, a mucinous lesion confined to the abdominal wall was detected on a postoperative CT. Suspected for port-site metastasis at the laparoscopic trocar site, we treated this lesion using the same principles of treatment as the intra-abdominal disease. The abdominal wall mass was surgically resected, and the cavity created was irrigated with mitomycin C. On 30 months of follow-up, the patient had no evidence of disease.

Synchronous skull base and spinal metastases in a patient with treatment-resistant, high-grade serous adenocarcinoma of tubo-ovarian origin

Brain metastases (BMs) arising from ovarian cancer remain rare. Spinal cord metastases are even rarer, accounting for just 0.4% of total metastatic spinal cord compressions. In this report, we describe a case of a woman in her 70s who developed sequential brain and spinal cord metastases during her treatment for high-grade serous ovarian cancer, without a germline or somatic BRCA mutation. Following completion of neoadjuvant chemotherapy, interval debulking surgery and adjuvant chemotherapy, relapsed disease was ultimately identified as a single BM, curiously mimicking an acoustic neuroma. Subsequently, spinal cord metastases rapidly developed. Throughout, multidisciplinary team meetings guided decisions on patient management. In this report, we highlight the rarity of such a presentation and discuss the possible role of disease pathophysiology, associated systemic anticancer therapy resistance, and treatment possibilities for both cerebral and spinal metastases.

Ovarian tumour-cutaneous fistula as a primary presentation of pelvic malakoplakia coexisting with a benign ovarian tumour mimicking advanced ovarian cancer

Malakoplakia is a rare granulomatous, chronic inflammatory disease generally affecting the urogenital organs, though it can arise in other organs. The clinical manifestations of malakoplakia vary depending on the affected organ. The final diagnosis is confirmed by the presence of Michaelis-Gutmann bodies on pathology. This report describes a case of pelvic malakoplakia accompanied by an ovarian tumour-cutaneous fistula, initially misdiagnosed as advanced ovarian cancer invading the anterior abdominal wall with left pleural effusion based on imaging studies and increased serum carbohydrate antigen 19-9. The patient underwent left thoracentesis and fluid collection from the fistula tract for cytology, which showed no malignancy. She underwent primary debulking surgery, including removal of the fistula tract from anterior abdominal wall. Histopathological examination revealed malakoplakia coexisting with mucinous cystadenoma of the left ovary. For postoperative management, she received prolonged oral antibiotics for 6 months. There was no evidence of disease recurrence at the 24-month follow-up.

Massive serous cyst adenoma with ovarian abscess causing fatal septicaemia

Isolated unilateral ovarian tumour without obvious concomitant tubal pathology is unlikely to cause intrabdominal abscess or septicaemia. Benign serous cystadenoma is a fairly common ovarian tumour but rarely causes fatality. We present a patient in mid-30s with massive ovarian serous cystadenoma presenting with abscess and septicaemia, leading to mortality. To our knowledge, no previous serous cystadenoma causing abscess formation has been reported before.

Borderline tumour recurrence: how quickly does the tumour grow?

This abstract describes a case of the growth of a serous borderline tumour recurrence and cyst to papillary projection ratio with associated ultrasound images. The aetiology, presentation and management of such cases are explored and compared to the literature.

Fertility-sparing approach in concurrent gliomatosis peritonei and growing teratoma syndrome in a young woman

Gliomatosis peritonei (GP) and Growing Teratoma Syndrome (GTS) are rare and clinically significant conditions often associated with ovarian teratomas. GP involves the development of benign glial implants on the peritoneal surface, while GTS is characterised by the growth of benign, yet enlarging peritoneal implants following chemotherapy for malignant germ cell tumours. These implants are typically histologically mature teratomas devoid of malignancy. Our report documents a unique case where both GP and GTS manifested in a patient undergoing treatment for an immature ovarian teratoma. This dual occurrence is scarcely reported in the existing literature. The patient, a nulliparous woman in her 20s, developed a tumour indicative of GTS immediately after completing three cycles of bleomycin, etoposide and cisplatin therapy. This chemotherapy regimen followed fertility-sparing surgery for a stage IIIb ovarian immature teratoma. Given that total tumour resection is pivotal in positively influencing the prognosis of GTS, early minimally invasive surgical intervention before significant tumour growth is essential. This approach is particularly crucial considering that ovarian germ cell tumours are commonly present in younger patients, necessitating a focus on fertility preservation in most cases.

Transgastric drainage for subdiaphragmatic abscess secondary to perforation of the sigmoid colon after cytoreductive surgery for advanced ovarian cancer

Drainage of subdiaphragmatic abscesses is difficult due to its anatomical location and it can result in adverse events, including organ damage and the spread of infection. In recent years, endoscopic ultrasonography (EUS) guided drainage for upper abdominal abscesses has become available. We report a case of successful infection control using this procedure for a subdiaphragmatic cyst secondary to perforation of the sigmoid colon after cytoreductive surgery for advanced ovarian cancer. A Japanese woman in her 60s underwent laparotomy for ovarian cancer, and then developed sigmoid colon perforation 6 days after surgery. The emergency reoperation was performed, and a cyst suspected to be an antibiotic-resistant fungal abscess appeared under the left diaphragm in the postoperative period. We adopted an EUS-guided route for diagnostic and therapeutic drainage method, which enabled shrinkage of the cyst and did not concur further adverse events. This procedure was effective as a minimally invasive drainage route for subdiaphragmatic cysts.

Ovarian teratoma-associated anti-NMDA receptor encephalitis with severe features

Anti-N-methyl-D-aspartame receptor (NMDAR) encephalitis is an uncommon clinical entity for the general intensivist or neurologist. Diagnosis can be made by the presence of cerebrospinal fluid IgG antibody against the GluNR1 and GluNR2 subunits of the NMDAR. We present a case of anti-NMDAR encephalitis in a young woman with an ovarian teratoma treated with surgical resection and multiple immunomodulatory therapies.

Psoriasis and psoriatic arthritis following use of dostarlimab for endometrial cancer

Immune checkpoint inhibitors (ICIs) are associated with immune-related adverse events (irAEs), but psoriasis and psoriatic arthritis (PsA) after use of dostarlimab have not been reported. We present a woman who received dostarlimab for endometrial cancer and subsequently developed rash and polyarthralgia, diagnosed as overlapping palmoplantar pustular and plaque psoriasis with PsA. She was treated with discontinuation of dostarlimab, topical steroids, oral methylprednisolone and methotrexate. This case highlights phenotypic heterogeneity in cutaneous irAEs influenced by malignancy and ICI type and underscores the need for multidisciplinary care in treating irAEs. We review three current professional society guidelines for managing irAEs, highlighting their emphasis on management based on severity grading, early initiation of systemic corticosteroids and steroid-sparing agents and discontinuation of ICI for severe events. Certain recommendations deviate from typical approaches to idiopathic rheumatologic disease. Further research is needed to support the ongoing development of approaches to irAE management.

Endoscopic full-thickness resection of a solitary ovarian carcinoma colorectal metastasis

A woman in her 70s with a medical history of recurrent ovarian carcinoma was referred to the gastroenterologist because of rectal blood loss. Colonoscopy revealed a spontaneously bleeding lesion, which was not a typical colorectal carcinoma by optical diagnosis. Biopsies confirmed the diagnosis of recurrence of the former ovarian carcinoma. The patient was not eligible for surgical resection due to former abdominal surgery and she declined chemotherapy due to severe side effects earlier. After a multidisciplinary team consultation, she was treated with endoscopic full-thickness resection (eFTR). This is a minimally invasive resection technique for removal of challenging colorectal lesions. The patient has recovered well and 2 years after the metastasis resection with eFTR there still have been no signs of recurrent malignancy.

Ovarian mass Presenting as Paraneoplastic cerebellar degeneration with peripheral neuropathy and anti-Yo antibody

Paraneoplastic neurological syndromes (PNS) are a group of disorders with diverse neurological manifestations that are observed in patients with various types of cancer. Any portion of the nervous system can be affected by these syndromes, which are brought on by processes other than metastasis, direct tumour spread or chemotherapy side effects. An immune-mediated attack on the cerebellar Purkinje cells and consequent cerebellar symptoms define paraneoplastic cerebellar degeneration(PCD), a subtype of the PNS. Axonal or demyelinating paraneoplastic peripheral neuropathies are both possible. Here, we describe the case of a middle-aged woman who presented with subacute-onset cerebellar symptoms and peripheral neuropathy, was discovered to have a positive anti-Yo antibody, and was later detected to have an ovarian mass. This case illustrates the significance of considering a paraneoplastic aetiology in patients with otherwise unexplained neurological manifestations and initiating an appropriate workup and early treatment for the primary malignancy.

Patient with concurrent anti-NMDAR autoimmune encephalitis and immature teratoma of the ovary

In young women with anti-N-methyl-D-aspartate receptor (anti-NMDAR) autoimmune encephalitis (AE), co-occurrence with ovarian teratoma is common. While the management of mature teratoma with AE is well documented, literature on managing immature teratoma (IT) in tandem with AE is relatively scarce. Here, we report a case of a female patient in her early adolescence who presented with abdominal pain and was diagnosed with grade 3 IT combined with anti-NMDAR AE after an ovarian tumour was discovered and resected. Postsurgery, the patient received immunotherapy, chemotherapy and antiepileptic therapy, and two follow-up evaluations showed no signs of recurrence or sequelae. This case highlights the importance of a high index of suspicion for concurrent AE in the presence of ovarian teratoma, particularly IT, and the crucial role of concurrent administration of immunotherapy and chemotherapy following tumour resection in impacting prognosis.

Rare case of steroid cell tumour presenting as resistant hypertension in early pregnancy

A woman 12 weeks and 3 days pregnant was referred to the emergency department with significant hypertension which, despite aggressive medical management, remained uncontrolled. Markedly elevated levels of renin and aldosterone beyond what is typical in early pregnancy were present, which together with the finding of a right ovarian cyst pointed to the possible diagnosis of an extrarenal reninoma.and the decision was made to perform a right-sided oophorectomy at 16 weeks gestation. Histology demonstrated a staining pattern most consistent with a steroid cell tumour leading to the diagnosis of refractory hypertension secondary to an ovarian steroid cell tumour. Post oophorectomy blood biochemistry rapidly returned to normal, and our patient’s hypertension slowly resolved allowing for a large reduction in antihypertensive agent requirements and a successful pregnancy outcome.

A rare case of infection and spontaneous rupture in ovarian mucinous cystadenoma

Ovarian cysts exhibit variable clinical presentations depending on their size, type and resulting sequelae. Rupture of ovarian cysts is infrequent, and cyst infections are even rarer. Here, we report an unusual case involving a young, non-pregnant woman who presented acutely with features of peritonitis and sepsis and was found to have a complex adnexal mass. Following a rigorous diagnostic evaluation, which included an urgent exploratory laparotomy and salpingo-oophorectomy, common diagnoses including tubo-ovarian abscess, endometriotic cyst and pelvic tuberculosis were ruled out. Instead, she was diagnosed with an ovarian mucinous cystadenoma that had become infected, possibly due to pelvic inflammatory disease, leading to spontaneous rupture. Such a presentation has rarely been reported, especially in a non-pregnant setting. Therefore, we emphasise the importance of considering this rare complication as a potential differential diagnosis in similar clinical presentations and discuss the management implications, including the importance of adequately treating pelvic inflammatory disease.

Digital ischaemia as a presenting feature in metastatic ovarian cancer

A woman in her 50s presented with acute pain and discolouration in the fingertips of both hands, without other features of connective tissue disease. The history was otherwise significant for abdominal bloating, altered bowel habit, urinary urgency and fatigue. Inflammatory markers, antinuclear antibodies, serum protein electrophoresis and complement levels were all normal. The tumour marker CA125 was significantly elevated, prompting a CT abdomen and pelvis, which revealed a large right-sided adnexal mass with multiple enhancing peritoneal and omental nodules and moderate ascites, suggestive of disseminated primary ovarian cancer. Digital ischaemia (DI) can be associated with cancer in up to 15% of cases. An underlying cancer should be suspected in patients presenting with new or worsening symptoms of DI. Prompt treatment with anticancer therapies can achieve complete resolution of DI.

Gastrointestinal stromal tumour: presenting as an ovarian cystadenoma

A gastrointestinal stromal tumortumour (GIST) is an uncommon gastrointestinal neoplasm that can arise from any part of the gastrointestinal tract. They can rarely present as a pelvic mass, which might result in a gynaecological condition being misdiagnosed in a female patient. A woman in her early 70s presented with a huge pelvic mass. Abdomen-pelvis CT scan showed a significant cystic mass in the left-sided pelvis with a mass effect on adjacent structures, which suggested a possibility of an ovarian cystadenoma. Her CA-125 was normal. She underwent an exploratory laparotomy with pelvic mass excision. A diagnosis of a gastrointestinal stromal tumour (GIST) arising from the ileum was made on a histopathology study.

Diagnostic and therapeutic challenges in a recurrent endometrial carcinoma in lung, 15 years after primary treatment

Endometrial carcinoma (EC) is the sixth most common cancer in females. Most ECs are detected in stage 1 and have a 5-year survival rate of more than 90%. Recurrence rates are highest within 5 years after treatment and are exceptionally rare after 10 years. Here, we describe a woman in her late 70s with endometrial cancer who was treated in 2008 and was diagnosed with a relapse in her left lung in 2023. Due to her advanced age and comorbidities, she was deemed inoperable. However, she received sequential chemotherapy and radiotherapy with a good partial response. She has now been started on hormonal therapy with an alternate megestrol and tamoxifen regime. There is a lack of follow-up imaging guidelines to detect late relapse, a dilemma in preferred treatment sequencing at relapse and an enigma in selecting chemotherapy or hormonal therapy.

From endometrium to fingernail bed: histological evaluation of a rare cutaneous metastasis

In the dermatological spectrum of oncologic manifestations, cutaneous metastases from endometrial carcinoma stand as a rarity, given the tumour’s predilection for neighbouring uterine regions. We present an exceptional case of a patient in her mid-50s, whereby an endometrial carcinoma, defying conventional pathways, manifested on the skin and nail of her distal fourth finger, an unusual site for cutaneous metastases, with a specific histology of the primary cancer.

Pulmonary embolism in a post laparoscopic hysterectomy for endometrial cancer: defying thromboprophylaxis

Pulmonary embolism (PE) is a rare but serious complication following gynaecological surgery, particularly in patients with underlying malignancy. We present a case of acute PE that occurred after a laparoscopic hysterectomy for early-stage endometrial cancer, despite thromboprophylaxis. This case report aims to highlight the persistent risk of venous thromboembolism in high-risk surgical patients and reviews current strategies for thromboprophylaxis in such scenarios.

Post-hysterectomy presentation of low-grade endometrial stromal sarcoma (LGESS): a clinical challenge in uterine malignancies

Endometrial stromal sarcoma (ESS) is a rare uterine malignancy originating from endometrial connective tissue. It is classified into benign and malignant subtypes. While it primarily affects perimenopausal women aged 45–55 years, younger patients may also be affected. ESS often presents with symptoms such as abnormal uterine bleeding, pelvic pain or pelvic mass, mimicking benign conditions like fibroids. Definitive treatment includes total hysterectomy with bilateral salpingo-oophorectomy, complemented by hormonal therapy for advanced cases. Despite its indolent nature, low-grade ESS (LGESS) requires long-term follow-up due to significant recurrence risk. We present a case of a woman in her late 20s, who underwent hysterectomy for severe bleeding and anaemia, with LGESS diagnosed later during a growing abdominal wall mass evaluation. Imaging and biopsy confirmed her diagnosis. She underwent extensive debulking surgery. Histological analysis revealed oval to spindle cells, low mitotic activity, no necrosis or atypical mitotic figures; Estrogen Receptor (ER), Progesterone Receptor (PR) and CD10 positivity, which were consistent with LGESS.

Acute myeloid leukaemia with endometrial involvement presenting as abnormal uterine bleeding

The spread of acute myeloid leukaemia (AML) outside of the blood or bone marrow is known as extramedullary involvement, and common sites include the skin, bone and lymph nodes. Here, we describe a case of AML presenting as abnormal uterine bleeding in a pre-menopausal patient. Complete blood count (CBC) was notable for anaemia, thrombocytopaenia and leucocytosis, prompting a stat blood smear that showed increased circulating blasts. Subsequent bone marrow biopsy and analysis confirmed an AML diagnosis, while histological examination of endometrial tissue revealed infiltrating cells positive for CD34, myeloperoxidase and CD117, consistent with AML. The patient was given oestrogen for uterine bleeding and chemotherapy, eventually achieving remission. She received additional chemotherapy following relapse and remains in her second round of remission. As shown in this case, physicians should be aware of potential leukaemic infiltration of non-haematopoietic tissues and maintain a low threshold for ordering a blood smear in the context of an abnormal CBC.

When imaging fails: surgical discovery of an occult ovarian teratoma in severe refractory anti-NMDA receptor encephalitis

Anti-N-methyl-D-aspartate (NMDA) encephalitis is marked by rapidly evolving and severe neuropsychiatric symptoms that can affect any age. This case illustrates a woman in her early 40s who was admitted with refractory headache, hallucinations and progressive encephalopathy. After imaging failed to detect a neoplasm, a left salpingo-oophorectomy was performed due to high clinical suspicion, which revealed a mature teratoma. Surgery and immunotherapy led to gradual recovery in physical function and improvement in consciousness. This case highlights the importance of aggressive multimodal therapy, thorough tumour evaluation and consideration of surgical exploration in imaging-negative, refractory anti-NMDA receptor encephalitis.

Leydig cell ovarian tumour: a rare cause of hyperandrogenism

We present a case of a postmenopausal woman with androgenic alopecia and very high testosterone levels of 16 nmol/L (normal range 0.4–1.2). CT showed an enlarged right ovary with a high-density nodule and an incidental adrenal nodule. She underwent bilateral salpingo-oophorectomy and pathology confirmed a benign Leydig cell tumour of the right ovary and Leydig cell hyperplasia of the left. Testosterone levels improved to near normal postoperatively. Adrenal investigations favoured a benign adenoma, although adrenal androgen production could not be ruled out. This case highlights the challenges in investigating hyperandrogenism in postmenopausal women; the most common causes are ovarian and adrenal in origin. Leydig cell tumours are rare androgen-secreting benign ovarian tumours. The treatment of choice is bilateral salpingo-oophorectomy and provides cure in most cases.

An unusual presentation of endometrial cancer—diagnostic challenges and management

This case report elucidates the atypical presentation of endometrial cancer in a postmenopausal woman, initially manifested by bladder symptoms only without postmenopausal bleeding. Imaging revealed a large cystic uterine mass suggestive of pyometra. Despite diagnostic hurdles, a total abdominal hysterectomy and bilateral oophorectomy were carried out to achieve a definitive diagnosis, which identified an endometrial adenocarcinoma, FIGO stage II on postoperative pathology. This case highlights the complexities in diagnosing and managing uterine masses, emphasising the value of thorough evaluation in cases of diagnostic uncertainty. Written informed consent was obtained from the patient for publication of this case report.

Ectopic ACTH-dependent Cushing syndrome due to mature ovarian teratoma

Ectopic adrenocorticotropic hormone (ACTH) secretion accounts for 10%–20% of ACTH-dependent Cushing syndrome, with ovarian teratomas being an exceptionally rare source. We present a female in her early 40s with severe Cushing syndrome due to ectopic ACTH secretion from a mature ovarian teratoma. She presented with progressive weight gain, moon facies, dorsocervical fat pad, proximal muscle weakness, hypertension and new-onset diabetes. Biochemical evaluation confirmed ACTH-dependent hypercortisolism with elevated cortisol, plasma ACTH, late-night salivary cortisol, urinary free cortisol and failure of dexamethasone suppression. Bilateral inferior petrosal sinus sampling (IPSS) confirmed an ectopic source. After negative pituitary and thoracoabdominal imaging, pelvic imaging identified a large right ovarian mass. Laparoscopic salpingo-oophorectomy was performed, and histopathology confirmed a mature cystic teratoma with ACTH-positive neuroendocrine cells. Postoperatively, the patient achieved complete clinical and biochemical remission with full hypothalamic-pituitary-adrenal axis recovery at 1 year follow-up. This case underscores the systematic diagnostic approach required for ectopic ACTH syndrome—including biochemical confirmation, IPSS to distinguish pituitary from ectopic sources and comprehensive imaging—as well as the importance of considering uncommon tumour sites, including ovarian teratomas, when standard thoracoabdominal imaging is unrevealing.

Malignant Brenner tumour of ovary causing ureteric obstruction

Malignant Brenner tumours (MBT) are extremely rare surface epithelial tumours of the ovary. We present a case of ovarian MBT, causing ureteric obstruction. A middle-aged female in her 40s, postabdominal hysterectomy, with a left percutaneous nephrostomy tube in situ, presented to the gynaecology department with lower abdominal pain for 6 months, radiating from the left flank to the groin. On evaluation, she was found to have a neoplastic left adnexal mass involving the distal left ureter. She underwent complete surgical staging with left distal ureter resection and ureteric reimplantation with a psoas hitch. Histopathological findings were suggestive of MBT stage IIIA1(i). She received six cycles of platinum-based adjuvant chemotherapy. Currently, she is in remission at a 1-year follow-up.

Pyoderma gangrenosum of the abdominal wall skin in a postoperative gynaecologic oncology patient

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis not only characterised by rapidly progressive skin ulceration, often triggered by trauma or surgery, but also associated with malignancy as a paraneoplastic condition. This case report describes a female patient in her early 70s who developed PG following a total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy for stage IVB high-grade serous carcinoma of the endometrium. This case highlights the diagnostic challenges, the role of early multidisciplinary involvement, investigation and appropriate therapeutic interventions.

Endometrial cancer recurrence presenting as anterior abdominal wall necrotising fasciitis

Endometrial cancer is the second leading cause of malignancy in women worldwide. Risk of recurrence and treatment depends on tumour grade, stage and more recently, molecular classification. This case details an atypical presentation of endometrial cancer recurrence. A postmenopausal woman presented to hospital in septic shock with anterior abdominal wall necrotising fasciitis. She was 5 years into her surveillance for FIGO (International Federation of Gynaecology and Obstetrics) Grade III, Stage IIIA mixed endometrioid and clear cell endometrial adenocarcinoma, treated by total abdominal hysterectomy, bilateral salpingo-oophorectomy, vaginal brachytherapy, radiotherapy and chemotherapy. Necrotising fasciitis was localised to a fluid collection associated with biological mesh on the anterior abdominal wall. Histopathology and cytology of the fluid collection revealed high-grade serous endometrial carcinoma. Recurrence in the incision has previously been described in the literature, however not as a fluid collection in association with biological mesh nor causing necrotising fasciitis of the anterior abdominal wall.

Severe thrombocytopenia after trastuzumab in a patient with HER2-positive serous endometrial cancer

Trastuzumab is a humanised, monoclonal antibody that interferes with the human epidermal growth factor receptor 2 (HER2)/neu receptor and binds selectively to the HERB2 protein. It has been shown to prolong survival of patients with HER2-positive advanced uterine serous carcinoma. We report the case of a woman in her 70s with HER2-positive metastatic papillary serous endometrial adenocarcinoma, who experienced severe thrombocytopenia related to trastuzumab administration. One week after the first dose of carboplatin/paclitaxel/trastuzumab combination chemotherapy, the patient was admitted to the hospital with vaginal bleeding, melena, petechiae and platelet counts of 0×109/L. The patient was suspected to have a severe trastuzumab-induced thrombocytopenia. A rapid and complete recovery was observed after multiple platelet transfusions, high-dose IV corticosteroids and immunoglobulin. Among the 13 reported cases of trastuzumab-induced thrombocytopenia, this is the first case reported in the literature occurring in a patient with a gynecologic malignancy.

Rare case of high-grade endometrial stromal sarcoma metastasising to inferior vena cava and right atrium

Endometrial stromal sarcomas (ESSs) are a rare form of uterine malignancy representing <10% of all uterine sarcomas and <1% of all primary malignant tumours of the uterus. Invasion of the vascular system by low-grade ESS has been reported in the literature. Here we report the first case of a high-grade ESS invading the pelvic and gonadal vein and extending through the inferior vena cava to the right atrium, the diagnostic challenges and multidisciplinary management of the case.

Radical abdomino-pelvic surgery in the management of uterine carcinosarcoma with concomitant para-aortic lymphadenopathy metastasising from anal carcinoma

Uterine carcinosarcomas are aggressive gynaecological cancers comprising less than 5% of uterine malignancies. We present the case of a woman in her 70s with a complicated history of advanced anal carcinoma treated with pelvic radiotherapy and multiple laparotomies, who was referred to gynae-oncology following MRI surveillance imaging showing evidence of endometrial carcinoma and para-aortic lymphadenopathy. Successful surgical excision required multidisciplinary teamwork between gynae-oncology, colorectal and urology surgeons. The patient underwent midline laparotomy, with adhesiolysis, ileum resection and side to side anastomosis, posterior exenteration, left kidney mobilisation and suspension, para-aortic lymph node debulking and left ureteric stent insertion. Significant challenge was posed by the extensive adhesions from previous laparotomies and the debulking of the para-aortic lymph nodes around the renal vessels. This case demonstrates the importance of a multidisciplinary approach in complex pelvic surgery and the vitality of good communication between colleagues in achieving effective patient care.

Preoperative screening endometrial cytology discovered incidental gynaecological malignancy in two patients undergoing risk-reducing salpingo-oophorectomy

Pelvic ultrasonography and measurement of serum cancer antigen 125 (CA-125) are recommended for preoperative evaluation before performing risk-reducing salpingo-oophorectomy (RRSO). We report our experience with two patients in whom an incidental gynaecological malignancy was found using endometrial cytology as a preoperative screening test for RRSO. Patient 1 was an early 50s woman with a pathologic variant of BRCA1. Transvaginal ultrasonography showed no endometrial abnormalities, but preoperative endometrial cytology revealed high-grade serous carcinoma. The patient underwent total hysterectomy, bilateral adnexectomy, pelvic and para-aortic lymph node dissection, and omentectomy. Patient 2 was a late 40s woman with a pathological variant of BRCA1. Transvaginal ultrasonography showed mild enlargement of the left ovary, and her CA-125 level was elevated. Preoperative endometrial cytology revealed high-grade serous cancer. She underwent total hysterectomy, bilateral adnexectomy and omentectomy. These case reports illustrate the importance of preoperative screening—including endometrial cytology—before performing RRSO.

Maintenance therapy for long-term control of high-grade endometrial stromal sarcoma

High-grade endometrial stromal sarcoma (HG-ESS) is a malignant uterine tumour with a poor prognosis. This study aimed to demonstrate the usefulness of maintenance chemotherapy with paclitaxel (PTX) and carboplatin (CBDCA) for HG-ESS recurrence, by examining a case of HG-ESS tumour progression as a result of maintenance therapy interruption because of the COVID-19 pandemic. The patient was a woman in her 60s who presented with lower abdominal pain, nausea and a pelvic tumour, which was diagnosed as HG-ESS. Chemotherapy with PTX (175 mg/m2 day 1) + CBDCA (area under the concentration-time curve 5 day 1) every 21–28 days (TC therapy) was administered for long-term maintenance of HG-ESS. After 26 cycles, chemotherapy had to be postponed because of the COVID-19 pandemic, thus leading to disease progression and eventually death. In conclusion, TC therapy can prolong survival in patients with HG-ESS, and maintenance chemotherapy should not be postponed.

Isolated ureteral extrauterine endometrial stromal sarcoma: an unusual presentation

Extrauterine endometrial stromal sarcomas (EUESSs) are rare tumours occurring without primary uterine involvement. They are classified as primary or secondary, depending on uterine involvement by stromal sarcomas. A 56-year-old woman who earlier underwent bilateral modified radical mastectomy for adenocarcinoma and total abdominal hysterectomy for endometrial stromal sarcoma, followed by tamoxifen therapy, presented with left loin pain. On evaluation, she had a left renal calculus with hydroureteronephrosis. Before percutaneous nephrolithotripsy, ureteroscopy revealed a polypoidal mass that was diagnosed as EUESS. The mass arose primarily within the ureteral lumen, with periureteric tissue uninvolved. She underwent left radical nephroureterectomy with adjuvant hormonal treatment. This is probably the first case of EUESS arising de novo from within the ureteral lumen without endometriosis, to be reported in medical literature. Immunohistochemistry facilitates earlier diagnosis. Cytoreductive surgery is the definitive treatment and multidisciplinary approach helps in overall survival of the patient.

Morbidly obese patient with endometrial cancer treated by bariatric surgery to enable cancer treatment

The case demonstrates the use of bariatric surgery to improve a patient’s candidacy for surgical treatment for endometrial cancer (EC). A 50-year-old morbidly obese woman with early-stage EC was initially treated with levonorgestrel-releasing intrauterine system (52 mg) . She had to reduce her body mass index (BMI) to become eligible for definite EC treatment. Using conservative methods, she was unable to lose weight effectively. She then underwent bariatric surgery that reduced her BMI from 71.3 to 54.3 kg/m2. She maintained her weight and was eligible for total hysterectomy and bilateral salpingo-oopherectomy. Her procedure was successful and had no complications. She has 6-monthly follow-ups, and the most recent review showed no evidence of recurrence.

Malignant peripheral nerve sheath tumour (MPNST) of the cervix: differential diagnosis and a favourable oncological outcome with multimodality treatment

Malignant peripheral nerve sheath tumours (MPNSTs) are aggressive sarcomas that occur rarely in the cervix. Considering the varied clinical features and the absence of a pathognomonic immunohistochemical marker, it is always challenging to diagnose these tumours. Treatment has not been standardised as yet, but a combination of surgery, radiotherapy and chemotherapy is used to treat MPNSTs of the cervix. Here, we report a case of a woman in her 40s with a 10×7 cm polypoidal lesion in the cervix, diagnosed as an MPNST. She was treated with surgery, ifosfamide-based chemotherapy and external beam radiotherapy before developing pulmonary metastases. She was treated with stereotactic body radiotherapy for the pulmonary metastases, and the patient has been on follow-up since then. We are also summarising the clinicopathological findings, surgical treatment and follow-up of all reported cases of cervical MPNSTs to date.

Emphysematous endometritis in stage III endometrial cancer

We report a case of emphysematous endometritis in a 65-year-old patient who has stage III, high-grade, poorly differentiated endometrial cancer; she was on chemotherapy. The patient developed pyogenic emphysematous endometritis complicated by hypovolemic shock and sepsis. She was admitted to the intensive care unit for treatment with vasopressors and antibiotics. The shock was successfully managed and her hospital course was otherwise unremarkable.

Benign metastasising leiomyoma with endometrial carcinoma, with a differential diagnosis of metastatic lung cancer

Benign metastasising leiomyoma (BML) is a rare disease in which histologically benign uterine fibroids spread throughout the body. It is thought to originate from the hematogenous metastasis of myoma cells following myomectomy. To date, BML has been noted in patients with respiratory symptoms, even during regular checkups. There are few case reports of co-occurrence with gynaecological cancer. We report the case of a suspected stage IVb carcinoma based on preoperative examination for endometrial cancer, that indicated lung metastasis. However, postoperative pathology revealed a grade 1, pT1a pN0 tumour. We suspected BML based on the discrepant findings and history of myomectomy, and this was confirmed by lung biopsy. In metastatic lesions of a carcinoma patient with a history of myomectomy, the co-occurrence of BML should be considered when there is discrepancy between the preoperative suspected stage and postoperative pathology.

Primary mixed large cell neuroendocrine and high grade serous carcinoma of the endometrium

Endometrial large-cell neuroendocrine carcinoma admixed with a high-grade serous (HGS) adenocarcinoma is extremely rare with only one reported case in the literature. We present the second reported case in a 47-year-old woman who presented with abdominal pain, distension and loss of weight. On examination she had a fixed pelvic mass and vascular left vaginal mass. Imaging confirmed a 13 cm solid cystic rectouterine pelvic mass, omental disease and retroperitoneal lymphadenopathy. She underwent a modified posterior exenteration, partial posterior vaginectomy, omentectomy and Hartmanns procedure with suboptimal debulking. Histopathology revealed a stage 4B mixed carcinoma with large cell neuroendocrine (70%) and HGS carcinoma (30%). Eight cycles of adjuvant cisplatin and paclitaxel were given with a complete radiological and biochemical response after 7 months. Unfortunately, she developed widespread recurrence at 9 month and was offered second line chemotherapy.

Multimodality therapy of endometrial glassy cell carcinoma: a rare type of cancer

Glassy cell carcinoma (GCC) is a rare histologically aggressive cancer subtype of the cervix that is associated with poor prognosis. Only 16 cases of endometrial GCC (EGCC) have been described in the literature to date. The data on prognostic factors and management of EGCC are limited and no optimal treatment protocol has been established. We describe a case of a 67-year-old woman who presented with postmenopausal bleeding and was diagnosed with stage IA EGCC. The patient’s risk factors included histology, age and lower uterine segment involvement. The patient was successfully treated with total hysterectomy and bilateral salpingo-oophorectomy with pelvic node dissection followed by adjuvant sandwich chemotherapy and radiotherapy. The patient has no evidence of disease recurrence for 18 months. This is the first case of EGCC management with adjuvant multimodality therapy.

Necrotising soft tissue infection following myomectomy: a devastating postoperative complication

This report describes a multiparous woman in her mid-40s who underwent an abdominal myomectomy for abnormal uterine bleeding due to fibroids and desire for fertility preservation which resulted in the rare consequence of uterine loss due to severe infectious complications postoperatively. Despite receiving prophylactic clindamycin at the index surgery, her postoperative course was complicated by an abdominal wall abscess as well as necrotising soft tissue infection involving the uterus. Management included parenteral antibiotics and a supracervical hysterectomy with bilateral salpingo-oophorectomy. There is a dearth of guidance regarding surgical site infection for myomectomy of any route. Limited data support a need for further high-quality clinical trials to develop decisive guidance regarding antibiotic prophylaxis at the time of myomectomy. As demonstrated in this case, the consequences have the potential to lead to infertility, menopause and even death.

Bowel perforation with generalised peritonitis secondary to recurrent primary fallopian tube carcinoma after 17 years

We describe a case of bowel perforation secondary to a recurrence of primary fallopian tube carcinoma treated more than a decade ago. A woman in her 70s presented to a rural centre with an acute abdomen. An abdominal CT showed a perforated ileum secondary to a pelvic mass. Emergency laparotomy identified the pelvic mass that was adherent to the side wall and invading the ileum at the site of perforation. Its adherence to the external iliac vessels posed a challenge to achieve en-bloc resection; therefore, a defunctioning loop ileostomy was created. Final histopathology and immunopathology were consistent with the recurrence of her primary fallopian tube carcinoma. The patient was further discussed in a multidisciplinary team meeting at a tertiary referral hospital. This case highlighted the importance of having a high index of suspicion for cancer recurrence, the utility of rapid source control laparotomy and multidisciplinary team patient management.

Unusual presentation of aggressive angiomyxoma arising from the posterior vaginal wall

A multiparous woman presented with a large bulge protruding from the posterior wall of the vagina, initially diagnosed as a rectocele. Imaging revealed a cystic lesion measuring 9 cm × 6 cm × 3.5 cm suspected to be a developmental cyst. The lesion underwent surgical excision with significant improvement in symptoms. Histological analysis reported an aggressive angiomyxoma (AAM); postoperative hormonal therapies were considered and rigorous follow-up initiated. The authors discuss challenges in investigating and managing AAM with proposals made for improving preoperative diagnosis and optimising postoperative management. Correlating tumour size with symptoms, judicious planning of surgery, rigorous postoperative follow-up and involving the patient in all aspects of decision-making will guide clinicians in providing the best care in the rare entity of AAM.

Rare diagnosis: the second documented report of primary diffuse large B-cell lymphoma of the fallopian tube

Primary non-Hodgkin’s lymphoma is a highly prevalent haematologic malignancy but contrarily, primary lymphoma of the female genital tract (PLFGT) is extremely rare. The most common histological subtype of PLFGT is diffuse large B-cell lymphoma (DLBCL), which most commonly arises from the ovary, cervix, uterus or vagina. It is rarer still for DLBCL to arise from the fallopian tube, and therefore, we present the second case ever reported. A woman in her 30s presented with abdominal pain and a pelvic mass on CT. The mass was laparoscopically excised, which allowed the histological diagnosis to be made, and the patient was subsequently treated with chemotherapy. This report aims to contribute to existing knowledge of this rare condition because, although unusual, PLFGT is a potential diagnosis to consider when managing pelvic masses.

Pulmonary multiple leiomyomas mimicking metastatic disease

Pulmonary benign metastasising leiomyoma is a rare condition characterised by multiple smooth muscle tumours in the lungs, typically in women with a history of uterine leiomyoma. We report a case of a woman with a previous hysterectomy who developed multiple pulmonary nodules, initially misdiagnosed as hydatid disease or metastatic cancer. Surgical resections and histopathological examination revealed benign leiomyomas composed of mature smooth muscle cells without necrosis or mitoses. Immunohistochemistry was positive for vimentin, desmin and smooth muscle actin, confirming the diagnosis despite a high Ki-67 index. The course was complicated by spontaneous pneumothorax, followed by staged thoracotomies with bilateral tumour removal and subtotal thyroidectomy. This case emphasises the diagnostic challenge of pulmonary leiomyomatosis, the importance of morphological and immunohistochemical verification and the role of individualised surgical management with long-term follow-up in selected symptomatic cases.

Primary uterine yolk sac tumour: a rare and aggressive malignancy – navigating diagnostic uncertainty and treatment pathway

This case report documents an extremely rare presentation of primary uterine yolk sac tumour (YST) in a premenopausal woman in her late 40s, who presented with heavy menstrual bleeding. Imaging was suggestive of a uterine tumour with rising serum germ cell markers. In the absence of preoperative histology, a surgical staging was performed, confirming pathological diagnosis and immunohistochemistry (SALL4 and alpha-fetoprotein (AFP) positive). She received adjuvant chemotherapy as per protocol. With a short disease-free interval, she had a rise in serum AFP with recurrence in the lungs, which was successfully treated with second-line chemotherapy. This case uniquely highlights the importance of comprehensive tumour marker assessment, the role of marker-guided surveillance in early relapse detection, and demonstrates the feasibility of successful salvage therapy. The case expands current knowledge of extragonadal YST management, encourages vigilance for atypical presentations and underscores the value of individualised multimodality care—even in aggressive, relapsed disease—for achieving complete remission.

Curious phenomenon of ‘hook effect’ in invasive mole

Gestational trophoblastic disease is a group of pregnancy-related trophoblastic tumours. Gestational trophoblastic neoplasia refers to its invasive and malignant forms: invasive mole, choriocarcinoma, placental site trophoblastic tumour and epithelioid trophoblastic tumour. Patients exhibit elevated beta human chorionic gonadotropin (β hCG) levels, sometimes exceeding 100 000 mIU/mL. When the serum levels of hCG surpass 500 000 mIU/mL, there is a possibility of encountering a phenomenon called ‘hook effect’ which causes erroneously low or negative value when using the immunometric hCG assays that are presently available in the commercial market. We present a rare case involving a female in mid-30s with an invasive molar pregnancy presenting with bleeding, an abdominal mass, hypertension and hyperthyroidism. Despite a negative urine β hCG test, her serum hCG, after dilution, was recalculated to over 850 000 mIU/mL. MRI confirmed invasive mole. Post-hysterectomy, she received methotrexate chemotherapy. Her β hCG normalised after two cycles, and she remains disease-free for 14 months.

Concomitant low-grade B-cell lymphoma and cervical intraepithelial neoplasia

Primary cervical lymphoma is a rare entity of cervical malignancy. The diagnostic pitfalls arise from the non-specific clinical presentation and poor sensitivity of cervical cytology in detecting the disease. Here, we present a case of extra-nodal marginal zone cervical lymphoma in a postmenopausal nulliparous woman. The patient underwent colposcopy due to an abnormal cervical smear and was found to have a large cervical lesion in keeping with high-grade cervical intraepithelial neoplasia (CIN). Cervical conisation was performed, and a low-grade B-cell lymphoma confined to the cervix was found underneath the surface CIN. As there was no established treatment for this uncommon disease, multidisciplinary involvement was required for optimal management and follow-up of the patient. The prognosis is generally favourable in comparison to the common cervical malignancies.

Small bowel intussusception as a rare presentation of metastatic uterine leiomyosarcoma

Uterine leiomyosarcoma (uLMS) is a rare and aggressive cancer, commonly metastasising to the lungs and liver. However, small bowel metastasis, especially causing intussusception, is exceedingly rare. We report a woman in her 60s who developed acute small bowel obstruction 22 months after her initial uLMS diagnosis and treatment for bone metastases. Despite being stable on adjuvant therapy, her CT scan confirmed bowel obstruction with intussusception-suggestive findings, though a clear neoplastic lead point was not initially identified. Emergency laparotomy subsequently revealed intussusception with a tumour as the lead point, which histopathology confirmed as metastatic leiomyosarcoma. This case underscores the importance for clinicians to maintain a high index of suspicion for metastatic disease, even at uncommon sites, in patients with a uLMS history presenting with acute abdominal symptoms, regardless of the time elapsed since the primary diagnosis.

Transfundal hysterotomy after an unsuccessful dilation and evacuation procedure due to uterine fibroids

A woman in her 20s, at 13 weeks gestation, presented to the emergency department (ED) for escalation of care after an incomplete second trimester termination. Imaging in the ED revealed multiple uterine fibroids up to 10 cm. She was admitted to Obstetrics and Gynaecology for completion of the evacuation via dilation and curettage; however, this could not be completed, as multiple fibroids were preventing visualisation and access to the cervical canal. Evacuation was successfully completed via mini-laparotomy and hysterotomy. The patient had no postoperative complications and was discharged 2 days later. This case illustrates a rare cause of unsuccessful abortion due to interfering fibroids and outlines hysterotomy as an effective secondary evacuation strategy for complicated second trimester abortions, particularly when products of conception are still present.

Non-gestational choriocarcinomas in postmenopausal period

Non-gestational choriocarcinomas (NGCCs) are extremely rare and aggressive tumours that can develop without pregnancy. We present three cases in postmenopausal women in their early 60s and 70s who presented with abdominal symptoms. Evaluation included imaging, histopathology, immunohistochemistry and elevated serum β-hCG. One patient showed a partial response to chemotherapy, while two had disease progression and died. The case series illustrates the need for consideration of NGCC in older women with elevated β-hCG and no recent pregnancy, and the crucial role of early immunohistochemical diagnosis.

Silent yet severe: inferior vena cava thrombosis associated with platypnoea–orthodeoxia. Is uterine sarcoma the culprit?

An elderly lady with a background of surgically treated uterine stromal sarcoma and deep venous thrombosis presented with exertional shortness of breath. On initial assessment, she was in type 1 respiratory failure and hypoxia was inconsistent with her symptoms and fluctuated with her position, demonstrating the features of platypnea–orthodeoxia. She was started on high flow nasal oxygen and treated as pulmonary embolism, although CT pulmonary angiography was normal. As there was a diagnostic dilemma, a repeat CT chest and abdomen was requested later which confirmed the presence of an extensive inferior vena cava thrombus extending from the right atrium to the left common iliac vein. She was managed conservatively following multidisciplinary discussions and succumbed to death later. Inferior vena cava thrombosis can rarely present with platypnea–orthodeoxia syndrome. This case highlights the importance of early recognition of symptoms with timely investigation and management to prevent life-threatening complications.

Ventricular electrical storm refractory to 250 defibrillations during myomectomy: the critical role of VA-ECMO and multidisciplinary management

Ventricular electrical storm (VES) is a critical cardiac emergency with high mortality, often refractory to treatment. They are typically associated with certain cardiovascular diseases, cardiac surgeries, hereditary arrhythmia syndromes or ICD shocks. Malignant intraoperative VES during non-cardiac surgeries represents a rare subset within cardiovascular medicine, yet their under-representation in clinical literature is disproportionate to the critical nature of the condition. This case report describes a previously healthy patient who developed sudden intraoperative ventricular fibrillation (VF) during an elective myomectomy, progressing to an overwhelmingly malignant VES. A family history of sudden cardiac death suggested a genetic arrhythmic syndrome. Management required over 250 defibrillations, veno-arterial extracorporeal membrane oxygenation (VA-ECMO), intra-aortic balloon pump (IABP) and a multidisciplinary approach. Despite poor prognostic indicators, the patient survived, an exceptionally rare outcome. This case underscores the importance of early mechanical circulatory support and highlights the potential for recovery even in critical scenarios challenging conventional prognostic expectations.

Red degeneration of fibroid presenting with abdominal pain in pregnancy

Uterine fibroids (leiomyoma) are a common presentation in women of reproductive age. However, during pregnancy, red degeneration and torsion of a subserosal fibroid may present with an acute abdomen, creating a diagnostic dilemma. Red degeneration of a fibroid during pregnancy responds to conservative management, whereas torsion of a subserosal fibroid requires emergency myomectomy. The authors present the case of a woman in her early 30s at 21 weeks gestation presenting with acute onset of right-sided abdominal pain. Ultrasound examination confirmed the diagnosis of fibroid degeneration. She was managed conservatively with analgesia and was discharged home uneventfully after 72 hours. This case report illustrates the diagnostic difficulties often encountered in managing abdominal pain during pregnancy complicated by a fibroid uterus.

Silent uterine torsion in pregnancy

Uterine torsion, although rare, can occur during pregnancy, especially in the presence of a uterine myoma. It is important to have a high level of suspicion and timely management to avoid maternal morbidity and perinatal mortality. We discuss a case of a primigravida with chronic hypertension at 31+6 weeks of pregnancy with imminent signs of eclampsia. An emergency caesarean was done. The intraoperative course was uneventful until the baby’s extraction, when it was observed that there was uterine torsion of 180°, and the uterine incision was in fact on the posterior uterine wall. One 6*5 cm International Federation of Gynaecology and Obstetrics type 6 fibroid on the right anterolateral wall was noted. Uterine torsion is unpredictable, with diagnosis mostly done intraoperatively. Although torsion was an incidental finding in our case, it can be associated with maternal and fetal complications if not managed on time.

Beyond the uterus: diagnostic puzzle unravelled as benign metastasising leiomyomatosis with retroperitoneal and pulmonary involvement

Benign metastasising leiomyomatosis (BML) is a rare entity characterised by the spread of benign smooth muscle cells, most commonly from uterine leiomyomas, to distant sites—most often the lungs. We present a case of a woman in her 40s who presented with abnormal uterine bleeding. Initial imaging revealed multiple uterine fibroids, a retroperitoneal mass mimicking gastrointestinal stromal tumour. HRCT chest showed thin-walled cystic lung nodules creating a suspicion of lymphangioleiomyomatosis (LAM). Following total abdominal hysterectomy with bilateral salpingo-oophorectomy and excision of the retroperitoneal lesion, histopathology and immunohistochemistry (IHC) confirmed a spindle cell tumour probably leiomyoma. Although the lung lesions were initially suggestive of LAM, the IHC study of the retroperitoneal lesion showed negative HMB-45 staining, and the genetic study also ruled out tuberous sclerosis complex mutations. Hence, we finally came to the diagnosis of BML. This case highlights the diagnostic challenges posed by cystic lung lesions in BML and underscores the need for a multidisciplinary approach incorporating histology, IHC and genetic testing to differentiate BML from mimickers like LAM or low-grade leiomyosarcoma.

Unintentional exposure to leuprolide acetate during early pregnancy with a huge intramural myoma

Leuprolide acetate is commonly used to reduce the size of myomas before surgery. Initially, it stimulates pituitary gonadotropin secretion, followed by sustained suppression of gonadal function. However, the impact on pregnancy outcomes from inadvertent exposure remains unclear. This case involves a woman in her 30s, multiparous, with a 20-week-sized leiomyoma, who received two doses of 3.75 mg subcutaneous leuprolide acetate, 15 days after menstruation, 4 weeks apart. An ultrasound, conducted 2 weeks after the last dose, accidentally revealed a viable intrauterine pregnancy at 8+6 weeks gestation. Her pregnancy progressed without complications, culminating in a term caesarean delivery without fetal anomalies. She opted for a total hysterectomy with bilateral salpingectomy 6 months later. Despite unclear teratogenic effects, evidence suggests that leuprolide acetate does not significantly impact pregnancy outcomes.

Cervical teratoblastoma in a paediatric patient: clinical presentation and management

Cervical teratoblastoma in paediatric patients is an extremely rare and aggressive malignancy, with limited documentation in the medical literature. Teratoblastoma is a malignant variant of germ cell tumours, distinguished by its invasive growth pattern and poor cellular differentiation. A female child in early adolescence presented to our oncology hospital with complaints of persistent lower abdominal discomfort and abnormal uterine bleeding. These symptoms had been progressively worsening over time. On physical examination and imaging, pelvic ultrasonography and MRI revealed a complex cystic mass with hypoechoic features, located in the region between the cervix and the hymenal ring. Histopathological evaluation of a biopsy specimen confirmed the diagnosis of malignant cervical teratoblastoma. A multidisciplinary tumour board recommended surgical intervention. The patient underwent transvaginal excision of the cervical mass, with care taken to preserve reproductive anatomy. Postoperatively, adjuvant chemotherapy was initiated with the bleomycin, procarbazine (Natulan) and cisplatin regimen to reduce the risk of recurrence and metastasis. This case highlights the importance of early recognition, accurate diagnosis and a coordinated treatment approach in managing rare paediatric cervical malignancies.

Rapidly recurring ovarian fibrosarcoma after optimal debulking surgery in a 46-year-old woman

Ovarian fibrosarcoma is an extremely rare tumour with no universally accepted guidelines for treatment. We present a 46-year-old nulliparous woman with ovarian fibrosarcoma who mainly presented with a painful abdominal enlargement. Optimal debulking surgery was performed, and a specimen of the tumour was examined. A frozen section examined during surgery revealed spindle cell morphology, raising the suspicion of ovarian fibrosarcoma, which was later confirmed by immunohistochemistry staining. Our patient refused to undergo chemotherapy and died 3 months after surgery due to tumour recurrence. Although no clear consensus exists for administering chemotherapy for fibrosarcoma, some published case reports have shown a lower chance of recurrence and better prognosis in patients who undergo chemotherapy compared with our patient.

Choriocarcinoma mimicking ectopic caesarean-scar pregnancy

Vaginal bleeding is one of the most common reasons for presentation to the early pregnancy unit. To aid in diagnosis, beta-human chorionic gonadotropin levels and ultrasound scan are commonly used. The most frequent diagnoses include miscarriage, ectopic pregnancy and cervical causes for bleeding; however, gestational trophoblastic disease (GTD) must always be ruled out. If left untreated, GTD can have fatal consequences. GTD is often associated with distinctive ultrasound findings, described as having a ‘cystic’ or ‘snowstorm’ appearance. However, it is important to consider GTD even in the absence of these features. Fewer than five cases of choriocarcinoma presenting as a caesarean-scar ectopic pregnancy have been reported. We described a rare but significant case of a patient with vaginal bleeding in early pregnancy, initially managed as a caesarean-scar ectopic pregnancy, with histology later confirming a diagnosis of choriocarcinoma.

Rapidly progressive pneumonitis days after receiving tisotumab vedotin: a new antibody–drug conjugate

The emergence of antibody–drug conjugates (ADCs) shows promise for treating a variety of tumours by using target-specific monoclonal antibodies to deliver cytotoxic substances directly to cancer cells. Their clinical development, however, is often hindered by significant toxicities. We report a case of a woman in her late 50s who developed grade 4 pneumonitis after receiving tisotumab vedotin (TV) for recurrent, metastatic squamous cell carcinoma of the cervix. 5 days post infusion, the patient exhibited severe respiratory distress, marked by hypoxaemia and diffuse ground-glass opacities on imaging. After careful ruling out of infection and alveolar haemorrhage via bronchoscopy, a presumptive diagnosis of drug-induced pneumonitis was established given the temporal relationship to receiving TV. The patient was treated with high-dose intravenous steroids and immunoglobulin, leading to eventual recovery. This case exhibits the potential for severe pulmonary toxicity associated with TV and highlights the need for greater awareness and investigation of adverse effects related to ADCs.

Non-traumatic avulsion of a leiomyoma

A patient in her 30s was referred to our Gynaecology Outpatient Department due to symptomatic leiomyoma which was first identified during her first pregnancy. An MRI performed postnatally confirmed a 10.5 cm leiomyoma. The patient was experiencing heavy menstrual bleeding and intermittent pelvic pain presumed to be secondary to a pressure effect. Treatment options were discussed, and it was decided to proceed with open myomectomy. On entry to the abdomen, the leiomyoma was free floating with no uterine attachment and only held loosely to the dome of the bladder, sigmoid colon and the left fallopian tube by filmy adhesions.

Large bowel obstruction as a rare complication of a uterine leiomyoma

Bowel obstruction occurs when the normal flow of intraluminal contents is interrupted. Large bowel obstruction secondary to mechanical compression from a uterine leiomyoma is a rare complication that can present significant management challenges, especially in the postpartum period. We present the case of a woman in her early 40s with a large uterine fibroid, who underwent a lower segment caesarean section and developed a bowel obstruction in the immediate postpartum period. Although extremely rare, it is important that clinicians be aware that large bowel obstructions in the immediate postpartum period can be a complication of uterine leiomyomas.

Navigating the challenge of high-grade cervical lesions (CIN3) in pregnancy: a near miss

In this case, a pregnant Indigenous woman presented with high-grade cervical lesions (high-grade squamous intraepithelial lesion (HSIL), cervical intraepithelial neoplasia grade 3 (CIN2–3) and was lost to follow-up for over 5 years, posing a unique management challenge. Despite higher regression rates in pregnant women, personalised care was crucial due to potential pregnancy-related intervention risks. This case underscores the complexities of managing high-grade cervical lesions in pregnancy and highlights the significant burden of cervical cancer within Aboriginal and Torres Strait Islander communities. It emphasises the urgent need for equitable screening access, patient-centred care and culturally sensitive education among vulnerable populations. Of particular note is the case’s uniqueness, with the patient’s CIN3 diagnosis persisting for over 5 years and spanning three pregnancies without definitive management. Post partum, a subsequent LLETZ revealed extensive HSIL (CIN3) involving ectocervical and endocervical margins. Due to margin involvement, the patient now requires ongoing surveillance, with continued risk of being lost to follow-up due to the factors described.

Intramyometrial ectopic pregnancy masquerading as intramural leiomyoma: a diagnostic challenge

One of the extremely rare locations for an ectopic pregnancy is myometrium. Intramyometrial ectopic pregnancy is characterised by an unusual form of implantation wherein the gestational sac is situated deep in the myometrium, separated from the endometrial cavity and fallopian tubes. It accounts for <1% of all ectopic pregnancies. The preoperative diagnosis based on ultrasound findings may mimic a degenerated leiomyoma, thereby posing further diagnostic challenges. We report a case of a woman in her late 20s presenting with abnormal uterine bleeding diagnosed ultrasonographically as posterior wall fibroid. Histopathological evaluation of the myomectomy specimen revealed chorionic villi lined by trophoblastic cells, thereby confirming the diagnosis. This case report aims to increase the awareness about the possibility of this potentially life-threatening rare entity even with normal serum beta-human chorionic gonadotropin levels.

Cotyledonoid dissecting leiomyoma with peritoneal dissemination

Cotyledonoid dissecting leiomyoma (CDL) is a rare benign uterine leiomyoma that macroscopically shows multinodular placenta-like growth. Its border with the myometrial layer is unclear, making it clinically difficult to differentiate from uterine sarcoma. CDL is often misdiagnosed. We report a case of CDL in which a subserosal myoma was suspected preoperatively and an abdominal myomectomy was performed. However, due to intraoperative findings and intraoperative rapid histopathological diagnosis, the procedure was changed to total hysterectomy. Peritoneal dissemination had also occurred and was resected simultaneously. It has been reported that CDL is generally a disease with good prognosis and that fertility preservation may be considered depending on the case. On the other hand, some cases of large tumours have caused peritoneal dissemination. We did a literature review of CDL and compared a group with peritoneal dissemination who underwent disseminated resection simultaneously and a group without peritoneal dissemination. We found that the tumour diameter was significantly greater in the peritoneal dissemination group.

Torsion of a large subserosal fibroid along with omental torsion adherent to it: a rare cause of acute abdomen

A woman in her 30s presented to emergency with complaints of acute lower abdominal pain for 3 days, not associated with any menstrual, bowel or urinary symptoms. Examination revealed an abdominopelvic mass corresponding to an 18-week gravid uterus with diffuse tenderness and guarding over her lower abdomen. The patient was a follow-up case of subserosal fibroid uterus, chronic kidney disease stage 4 and rheumatic heart disease on anticoagulants. Fibroid degeneration or torsion was suspected. Ultrasound revealed a large posterior wall subserosal fibroid with free fluid in the pelvis. As findings did not suggest degeneration or pedunculated fibroid, noncontrast CT was done, which showed a similar mass with a pedicle arising from the uterine fundus with free fluid with no other evident cause of acute abdomen. The patient was taken up for emergency laparotomy. Intraoperatively, it was found to be a case of subserosal fibroid with greater omentum adhered to it and twisted around its axis about eight times. This case is being reported to highlight a rare cause of acute abdomen.

Dermatomyositis: a debilitating paraneoplastic phenomenon following a diagnosis of localised squamous cell carcinoma of the cervix

This case report describes the management of a patient, recently diagnosed with Stage IIIC cervical cancer, presenting with significant proximal muscle weakness, dysphagia and cutaneous changes over the hands, knees and outer thighs bilaterally. Following multiple investigations, this clinical presentation was proven to be dermatomyositis as a paraneoplastic phenomenon, a rare diagnosis with cervical cancer. Improvement of the presenting symptoms followed commencement of radical chemoradiation to the primary tumour plus administration of high dose steroids and intravenous immunoglobulins. As demonstrated in this case, and accompanying literature review, dermatomyositis is a rare complication of cervical cancer but should be considered as urgent treatment of the underlying malignancy is imperative. Involving members of the multidisciplinary team, including dieticians and physiotherapists, is of utmost importance to optimise the patient’s recovery from such a debilitating diagnosis.

Late and unusual recurrences after minimally invasive cervical cancer surgery

Disseminated peritoneal leiomyoma: a diagnostic dilemma

Disseminated peritoneal leiomyomatosis (DPL) is a rare and benign clinical entity. It is also known as leiomyomatosis peritonealis disseminata (LPD). Here, we report and discuss a case of a primiparous woman in her early 40s who presented with heavy, prolonged, painful menses and heaviness in her lower abdomen. She underwent a laparoscopic myomectomy for a fibroid uterus, 12 months ago for similar complaints. On workup, she was diagnosed with DPL. We performed a total abdominal hysterectomy with bilateral salpingectomy, low anterior resection with stapled colorectal anastomosis and excision of peritoneal tumour deposits in consortium with the gastrosurgery team. Her postoperative period was uneventful, and the patient was discharged on postop day 6. Her histopathology report was consistent with leiomyoma; the follow-up period was uneventful.

Partial Molar Ectopic Pregnancy: A diagnostic challenge

Here, we present a rare case of a primigravida who presented to us with symptoms and signs suggestive of an ectopic gestation, which turned out to be a partial mole in histopathological examination. Since it is a very rare occurrence, we would like to publish the case details in this case report.

Aggressive precursor B cell ALL of cervix with obstructive uropathy

Involvement of the cervix with acute lymphoblastic leukaemia (ALL) is extremely rare. In this case report, we discuss an unmarried woman in her early 20s, who presented in the emergency with lower abdominal pain and irregular vaginal bleeding for 1 month. Clinical examination and imaging revealed a large cervical mass probably neoplastic with obstructive uropathy. On evaluation, she was diagnosed incidentally with CALLA-positive precursor B cell ALL in peripheral blood flow cytometry. Involvement of B cell ALL in cervical mass was confirmed by histopathological examination of cervical biopsy and immunohistochemistry markers. Her history was not suggestive of signs and symptoms pertaining to leukaemia. Literature is sparse with only a few cases reporting cervical leukaemic infiltration. The present case report is a rarest case where the primary/initial presentation of precursor B cell ALL was seen with cervical involvement and obstructive uropathy mimicking characteristics of advanced cervical malignancy.

Submucous leiomyoma: an uncommon cause of heavy menstrual bleeding in early adolescence

Uterine leiomyomas are rare in the paediatric population. This report describes a rare case of a submucous leiomyoma in an adolescent girl. The patient presented with a history of abnormal and painful period which was refractory to medical treatment. Sonographic findings revealed a uterine mass that protruded through the cervix until the upper third of the vagina. A hysteroscopic resection was performed, and a pathological examination confirmed a leiomyoma. 12 months after surgery, there were no signs of recurrence. Conservative sparing-fertility management, such as hysteroscopic resection, is the best option with a type 0 submucosal fibroid, especially in adolescents and young women.

Concurrent NMDAR and GFAP Antibody Encephalitis During Pregnancy

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune antibody encephalitis, commonly affecting young women with comorbid ovarian teratoma. It typically presents with alteration of consciousness, psychosis, movement disorders eventually deteriorating with seizures, dysautonomia and central hypoventilation requiring critical level of care that may last weeks to months. Removal of teratoma and immunosuppressant therapy support can led to a dramatic recovery. To our knowledge, this is the first illustrated case in the literature of a pregnant woman presenting with concurrent autoimmune NMDAR and anti-glial gibrillary acidic protein(GFAP) antibody encephalitis in the setting of an ovarian teratoma. Despite the teratoma removal and receiving various forms of immunosuppressant therapy, a meaningful neurological improvement was observed following the delivery. After a prolonged hospitalisation and recovery period, the patient and her offspring made an excellent recovery highlighting the significance of early diagnosis and management.

Myomatous erythrocytosis syndrome: a uterine fibroid associated with polycythaemia

Myomatous erythrocytosis syndrome (MES) is a rare form of secondary erythrocytosis seen with myomas. Here, we present a case of a postmenopausal, nulliparous woman in her 50s incidentally found to have asymptomatic erythrocytosis on routine laboratory work. She was found to have an 18.5 cm myoma and after surgical resection, the patient’s haematological values returned to normal ranges after a few weeks. This established the diagnosis as MES. The aetiology of MES continues to remain unknown but is most likely caused by an autonomous production of erythropoietin from the myomatous tissue. This case highlights obtaining a detailed history and physical examination to differentiate between the different causes of erythrocytosis, considering MES as a rare cause of secondary erythrocytosis and to prevent unnecessary procedures such as phlebotomy as surgery is the mainstay of treatment.

Spinal intramedullary uterine carcinosarcoma metastasis

Intramedullary spinal cord metastases (ISCM) are a rare and challenging manifestation of metastatic cancer that have devastating impacts on the individual’s neurological function, survival expectancy and overall quality of life. Given the rarity and poor prognosis, there is a lack of consensus in management. Uterine carcinosarcoma itself is a rare cancer, accounting for less than 3% of all uterine cancers. It carries a poor prognosis, with only one-third of patients surviving beyond 5 years. There are no previous reports of uterine carcinosarcoma metastases to the spinal cord. Here, we present the case of a woman in her late 70s with a uterine carcinosarcoma intramedullary metastasis that was refractory to radiotherapy treatment and responded favourably to surgical debulking.

Multiple cutaneous and uterine leiomyomatosis: Reed’s syndrome

Reed’s syndrome (RS) is a rare autosomal-dominant disorder characterised by multiple cutaneous and uterine leiomyomas, with a strong tendency for renal cell carcinoma (RCC) development. A woman in her 50s, who had previously undergone total abdominal hysterectomy due to multiple uterine leiomyomas, presented with painful nodules on her trunk and right arm for the past 6 years. These nodules were confirmed as leiomyomas through histopathology. Diagnosis of RS was established through clinicopathological correlation and positive family history, particularly her mother’s. Early-onset uterine leiomyomas in patients with a similar family history should raise suspicion for RS, necessitating vigilant long-term follow-up. RCC detection requires mandatory renal imaging. Screening family members and providing genetic counselling are crucial.

Management of a pregnant woman with a large cervical polyp and moderate genital bleeding in the first trimester

Polypectomy during pregnancy is known to be a risk for spontaneous late miscarriage or preterm delivery. We managed a pregnant woman in her 30s with a large cervical polyp without polypectomy, and we administered probiotics including Clostridium butyricum and 17-alpha-hydroxyprogesterone caproate. As a result, she delivered a healthy baby at 38 weeks.

Strangulated bowel obstruction caused by vaginal perforation due to vaginal cancer in a patient with chronic uterine prolapse

A woman in her 90s with chronic uterine prolapse presented with abdominal pain and a vaginal mass. The patient had generalised peritonitis and a strangulated bowel obstruction originating from a perforated posterior vagina. We performed partial intestinal resection and a total hysterectomy, including excision of the perforation of the vaginal site and the adnexa. The patient died on postoperative day 8 due to worsening systemic sepsis. The pathological diagnosis revealed an invasive carcinoma in the perforated area of the vagina. Obstetric factors are the most frequent cause of female genital tract perforation, and chronic uterine prolapse is associated with this condition; however, vaginal cancer has never been reported as a cause of perforation. Therefore, close collaboration in gynaecology should be considered to investigate whether vaginal perforation and uterine prolapse are related to cancer.

Metastatic spread of serous ovarian carcinoma to the bilateral breasts: a rare presentation

A woman presented with a mass in her right breast. She had previously been treated with carboplatin, paclitaxel and bevacizumab for serous ovarian carcinoma diagnosed 5 years previously and was currently on maintenance olaparib. A right breast mammogram demonstrated periareolar skin thickening and the physical examination revealed an erythematous, non-blanching cutaneous lesion. A punch biopsy revealed high-grade serous carcinoma of ovarian origin, positive for PAX-8, WT-1 and p53. Positron emission tomogram-CT scan showed diffusely increased fluorodeoxyglucose uptake in the right breast. She was treated with external beam radiation therapy to the right breast and regional lymphatics and received 5200 cGy in 20 fractions to the right breast and supraclavicular region with good response. Two weeks after completing radiation therapy, she presented with a new lesion inferior to her left areola, concerning for metastasis to the contralateral breast. Subsequent biopsy of the left breast identified metastatic serous ovarian carcinoma for which she received an additional 5200 cGy in 20 fractions to the breast.

Post-radiation uterine rhabdomyosarcoma

Benign multicystic peritoneal mesothelioma mimicking mucinous ovarian neoplasm with pseudomyxoma peritonei

Cystic mesothelioma, also known as benign multicystic peritoneal mesothelioma (BMPM), is a rare neoplasm and one of the five main histological types of peritoneal mesothelioma. Although it is usually considered benign histologically, it is increasingly accepted as a ‘borderline malignancy’ because the local recurrence rate is high. It is more common in middle-aged women and is generally asymptomatic. Considering that BMPM is often found in the pelvis, it is difficult to differentiate from other pelvic and abdominal lesions, such as cystic ovarian masses, especially mucinous cystadenoma–adenocarcinoma, pseudomyxoma peritonei, etc. Preoperative diagnosis is very difficult due to its rarity and lack of specific diagnostic imaging and clinical findings. Definitive diagnosis is made only by pathological evaluation. In this article, we aimed to present the imaging findings of a BMPM case in a woman who was diagnosed with mucinous ovarian neoplasm with pseudomyxoma peritonei preoperatively and underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

Extragastrointestinal stromal tumour of the transverse mesocolon mimicking giant ovarian cystic neoplasm

Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours which are most commonly found along the gastrointestinal tract. They are more rarely found in an extragastrointestinal location and typically present late due to only vague symptoms from mass effect. There are very few case reports of GIST arising within the transverse mesocolon. We report a case of a large cystic transverse mesocolic GIST which preoperative imaging concluded was likely of ovarian origin. This resulted in an abrupt change in the surgical management intraoperatively, but fortunately, an R0 resection was still achieved. This serves as an important lesson to keep the differential diagnosis broad when dealing with large cystic abdominal masses. The tumour was found to be KIT wild type, with a platelet-derived growth factor receptor alpha D842V mutation identified, conferring intrinsic resistance to imatinib.

Growing teratoma syndrome: a surgical conundrum

Growing teratoma syndrome (GTS) is a tumour growth, which contains mature teratomatous elements during or after chemotherapy for malignant germ cell tumours. Surgery is the only potential treatment option for GTS because these growing teratomas are resistant to chemotherapy and radiation therapy. Extensive surgeries may be needed in GTS with multivisceral resections to achieve no residual disease status. This report presents a case of GTS treated with multiple surgical resections in a woman with malignant immature teratoma ovary in her early thirties; she is disease free after 1 year of treatment.

Uterine incarceration: a rare diagnosis in non-pregnant women

Uterine incarceration (UI) is a rare complication in non-pregnant women. A woman in her 50s presented to the emergency department with acute urinary retention and paresis of the right inferior limb. A neurological exam suggested a decrease in the right lower limb strength. On gynaecological exam, the cervix was displaced anteriorly and the cul de sac was obliterated with a pelvic mass. CA 19.9 and CA 125 levels were increased. The MRI of the pelvis confirmed an elongated and anteriorly displaced cervix compressing the urethra and the vesical neck due to a uterine mass. A diagnosis of UI was made and an abdominal hysterectomy with adhesiolysis was suggested as the treatment option. Six months after surgery the patient had no urinary complaints and the neurological exam was normal. UI should be considered in women with urinary and neurological symptoms. A delay in diagnosis may lead to significant morbidity.

Complete double ureter in a case of carcinoma cervix: incidental intraoperative diagnosis and implications

Adult granulosa cell tumour camouflaged as mucinous neoplasm

This case report delves into the diagnostic intricacies and clinical management of adult granulosa cell tumour (AGCT) in a woman in her 50s, presenting with pain abdomen. Initial imaging investigations like ultrasound suggested diagnosis of benign cystadenoma. Further MRI revealed a large well-defined multiloculated lesion so a diagnosis of neoplastic aetiology/likely mucinous cystadenocarcinoma was offered. However, the definitive diagnosis was established through meticulous histopathological examination, revealing characteristic features of AGCT, a rare ovarian neoplasm. The case underscores the diagnostic challenges posed by AGCT, the importance of integrating clinical, radiological and histopathological data, and the necessity for a multidisciplinary approach for accurate diagnosis and optimal patient management.

Malignant struma ovarii with late recurrence harbouring high microsatellite instability

Struma ovarii (SO) is a rare ovarian teratoma containing abundant mature thyroid tissue. Malignant transformation is even less common and distant metastasis is documented in about 5%–10%. The time from diagnosis of primary SO to metastatic disease varies. As malignant SO is rare, there are no uniform diagnostic criteria or treatment guidelines. Management is usually extrapolated from that of thyroid malignancy. We report a patient who relapsed 12 years from the initial diagnosis and metastasised to the lungs 5 years after the first recurrence. Our patient was treated with total thyroidectomy followed by radioactive iodine, and retreated on progression in the lungs. The tumour harboured high microsatellite instability and treatment with programmed cell death protein 1 inhibitor was initiated. This case shows the long latency of SO with the rare phenomenon of metastasis. It also highlights the importance of molecular testing for rare cancers such as this.

Sertoli-Leydig cell ovarian tumour: a rare cause of virilisation and androgenic alopecia

Sertoli-Leydig cell tumours (SLCTs) represent a rare cause of hyperandrogenic state. SLCTs are sex cord ovarian neoplasms, accounting for <0.2% of all ovarian tumours. Most of the sex cord-stromal tumours have a benign clinical course, with 10%–20% of them at risk of aggressive course. We report a case of a woman in her 30s who presented with androgenic alopecia, virilisation and secondary amenorrhoea. The evaluation revealed an extremely high testosterone level. Imaging for the localisation of source of excess testosterone with contrast-enhanced CT of the abdomen revealed a right ovarian mass. Hence, a diagnosis of testosterone-secreting ovarian tumour was considered. The patient underwent right salphingo-oophorectomy, and histopathology was reported as Sertoli cell tumour. Postoperatively, there was normalisation of serum testosterone levels with decrease in virilisation and resumption of spontaneous menstrual cycles. The patient conceived spontaneously after 2 months of surgery.

Somatic gene mutations in malignant steroid cell tumours and response to multiple treatments

Malignant ovarian steroid cell tumours are a rare subgroup of sex cord-stromal tumours. There are no systematic reviews on the associated treatments, and little is known about their genomic profile. We describe a case of a pelvic malignant ovarian steroid cell tumour in a premenopausal woman in her 40s. She received cytoreductive surgery and six cycles of paclitaxel+carboplatin+bevacizumab. After recurrence, the tumour was surgically removed again, followed by radiation and hormone blockade therapy. Complete remission was achieved after treatment with bleomycin, etoposide and cisplatin. She remained in a platinum-sensitive relapse state and subsequently received maintenance therapy with olaparib. Since the tumour was initially refractory to treatment, tissue specimens were screened for gene mutations using a next-generation sequencing oncology panel and a somatic variant detection system, which revealed somatic gene mutations in ARID1A, PIK3CA, TERT and ATM, some of which are involved in DNA repair.

Double inferior vena cava in gynaecological oncology surgery

Bilateral microscopic Leydig cell ovarian tumors in the postmenopausal woman

A 64-year-old postmenopausal female patient presented with approximately 5 years of intermittent spotting, progressive hirsutism and significantly increased libido and clitoral hypersensitivity with spontaneous orgasms multiple times a day beginning a few months prior. Initial hormone work-up revealed elevated total serum testosterone, androstenedione and 17-hydroxyprogesterone. Luteinising hormone, follicle stimulating hormone, estradiol, dehydroepiandrosterone-sulfate, thyroid stimulating hormone and prolactin were all within normal limits. Initial suspicions suggested an androgen-secreting tumour, likely in the ovary. The lesion was undetectable on transvaginal ultrasound and abdominal–pelvic CT scan. Laparoscopic bilateral salpingo-oophorectomy was performed to remove the likely source of excess androgens. Visible gross lesions were not observed intraoperatively; however, bilateral Leydig (hilus cell) tumours were confirmed by histopathology. Serum testosterone, androstenedione and 17-hydroxyprogesterone levels were normalised postoperatively within 2 weeks and 1 month, respectively.

Anterior vaginal wall neurofibroma in neurofibromatosis type 1 causing lower urinary tract symptoms

Neurofibromatosis type 1 (NF1) is a rare autosomal dominant disorder primarily affecting the skin, nervous and skeletal systems. Vaginal involvement is exceptionally uncommon. We present a case of a woman in her 60s with NF1 who developed a neurofibroma in the anterior vaginal wall, accompanied by lower urinary tract symptoms including urgency and urge incontinence. Imaging and cystourethroscopy guided the diagnosis. The mass was excised and histopathology confirmed neurofibroma through S100 and SOX10 positivity. The patient experienced significant symptomatic improvement postoperatively and no recurrence was observed at 1 year follow-up. This case emphasises the importance of considering NF1 in atypical genitourinary presentations and supports surgical excision for symptom resolution and definitive diagnosis.

Rare aggressive solid pseudopapillary neoplasm of the ovary with metastatic disease following surgical resection

Extra-pancreatic solid pseudopapillary neoplasms (SPNs) are rare tumours with an overall favourable prognosis and low malignant potential. SPNs with metastatic spread, distant lymph node metastasis and extrapancreatic origin are exceedingly rare. Significant controversy regarding the treatment and the management of metastatic disease exists and, currently, there are no standardised guidelines or treatment recommendations for the use of adjuvant therapy. In this case report, the authors present a patient with widely metastatic SPN of likely ovarian origin with the invasion of the inguinal lymph nodes and multiple abdominal metastatic deposits. Using the currently available literature, the authors discuss treatment options for metastatic SPN of the ovary and highlight the need for continued research in this important field.

Patent foramen ovale presenting with platypnoea-orthodeoxia syndrome and stroke after multi-organ resection

Platypnoea-orthodeoxia syndrome (POS) is defined by oxygen desaturation and dyspnoea in upright position that improves by lying down. It results from a right to left shunt at the intracardiac or intrapulmonary level. A 53-year-old ovarian cancer patient presented with POS that was refractory to oxygen therapy. The symptoms began after an extensive abdominal and pelvic surgery as treatment of her cancer with a complex hospital course. A patent foramen ovale was found with the use of transoesophageal echocardiography. A percutaneous closure was done with positive outcome and dyspnoea disappearance. In this case with its challenging clinical setting, we present a unique clinical scenario of an immediate postoperative POS syndrome. We address the different therapeutic modalities and the need for a multidisciplinary medical approach.

46, XY complete gonadal dysgenesis with pubertal virilisation due to dysgerminoma/gonadoblastoma

Complete gonadal dysgenesis (CGD) or Swyer syndrome is characterised by sexual infantilism in a phenotypic female with 46, XY karyotype. Patients with gonadal dysgenesis and Y-chromosome material are at a high risk of developing gonadoblastoma and dysgerminoma. A 16-year-old girl presented with progressive virilisation, poor breast development and primary amenorrhea. On evaluation, she was found to have male-range serum testosterone, large abdominopelvic mass lesion, elevated germ cell tumour markers and 46, XY karyotype. She underwent surgical excision of left gonadal mass and right streak gonad, histopathology of which revealed dysgerminoma and gonadoblastoma, respectively. A diagnosis of virilising germ cell tumour arising in the setting of 46, XY CGD was, therefore, made. This case highlights a rare presentation of 46, XY CGD and the need to consider early prophylactic gonadectomy in patients affected with this rare condition. The presence of dysgerminoma/gonadoblastoma should be suspected if a hitherto phenotypic female with CGD undergoes virilisation.

Malignant Brenner tumour of the ovary manifesting as distal intestinal obstruction and perforation

A rare case of malignant Brenner tumour of ovary manifesting with intestinal perforation due to colonic infiltration is elaborated in the present report. Brenner’s tumour accounts for 1%–2% of all ovarian neoplasms and malignant Brenner tumour is even rarer and only about 5% of Brenner tumours are malignant. A 62-year-old woman came to surgical emergency with 1-month history of abdominal pain, vomiting and constipation with a palpable mass in right iliac fossa. Abdominal radiograph was suggestive of colonic obstruction. Contrast-enhanced CT of the abdomen revealed cystic right ovarian mass of 10.2×8.8 cm2 with pneumoperitoneum. Exploratory laparotomy was done, which revealed mass arising from right ovary involving terminal ileum, cecum and ascending colon. Possibility of ovarian malignancy was kept. Patient underwent debulking surgery along with ileostomy and descending colon mucous fistula was created. Histology was compatible with malignant Brenner tumour of the ovary.

Pseudo-Meigs’s syndrome

Yolk sac tumour of ovary with fever and overt hypothyroidism: rare clinical presentation

Yolk sac tumours of the ovary are rare and highly malignant germ cell tumours, which comprise of only 10%–15% of all malignant germ cell tumours. They have various clinical presentations most common being subacute pelvic pain and feeling of lump but sometimes high-grade fever can be one of the rare presentations. Here, we present a case report of a 26-year-old nulliparous woman with 36 weeks gravid uterus size advanced stage yolk sac tumour of one ovary with fever as main clinical presentation and overt hypothyroidism. We did staging laparotomy with total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy with multiple peritoneal biopsies. Postoperatively, we had started adjuvant chemotherapy. Since yolk sac tumours are highly aggressive tumours as they rapidly increase in size, their early diagnosis and appropriate surgical management is required particularly in young women where fertility sparing surgery is possible in early stage with good prognosis.

Trousseau’s syndrome associated with an ovarian borderline tumour

A 71-year-old woman was admitted to our hospital because of sudden onset of weakness on the left side of her body. Her medical history was unremarkable, and on physical examination, hemiparesis and hyperreflexia on the left side were found. MRI of the brain showed multiple areas of restricted diffusion in both parietal lobes and in the cerebellum, consistent with embolic shower. Magnetic resonance angiography showed no abnormal findings. A contrast-enhanced CT scan revealed multiple pulmonary emboli. Abdominal MRI showed a 135 mm left ovarian tumour composed of a solid and a cystic component with liquid level formation. After a total hysterectomy and bilateral adnexectomy, the histopathology confirmed a seromucinous borderline tumour. Therefore, the patient was diagnosed with Trousseau’s syndrome associated with an ovarian seromucinous borderline tumour. To our knowledge, this is the first report mentioning a borderline ovarian tumour detected as Trousseau’s syndrome.

Brenner’s tumour of the ovary

Brenner’s tumour of the ovary is a rare diagnosis that is usually incidental in either clinical finding or laparotomy. Pathologically, it can be classified as being an uncommon surface epithelial tumour. Originally known as a transitional cell tumour due to its histological similarity to the urothelium, Brenner is usually an unilateral and benign tumour. The site of incidence is predominantly the ovary and can very rarely occur in other locations including the testis. The following is a case of Brenner’s tumour of the ovary in a postmenopausal woman after surgical treatment, the features of which will be discussed briefly.

Hyperandrogenism due to ovarian Leydig cell tumour presenting with polycythaemia

A postmenopausal woman in her 60s was referred due to an elevated haemoglobin value found during her annual check-up. On physical examination, characteristic features of hyperandrogenism were observed which were not earlier mentioned. Laboratory investigations revealed polycythaemia accompanied by a normal erythropoietin and a negative analysis for JAK2-V617F mutation. A disproportionally and markedly elevated testosterone in combination with normal levels of adrenal androgens raised the suspicion of an ovarian source. CT scan showed nodular hyperdense lesions in both ovaries. A bilateral oophorectomy was performed and histological evaluation unfolded a Leydig cell ovarian tumour. Testosterone levels and haematological parameters normalised after surgery. Polycythaemia secondary to hyperandrogenism in postmenopausal women is an extremely rare condition and patients should be carefully analysed for the presence of androgen-secreting neoplasms. Diagnosis of the underlying pathology requires careful history, physical examination and comprehensive investigation. Treatment for this condition is surgery and resolves polycythaemia.

Primary malignant melanoma of the vagina

Primary malignant melanoma of the vagina is a rare gynaecological neoplasm with an aggressive course of disease. Although not many cases have been reported in the literature, its manifestations appear to be fairly consistent. The challenge comes in knowing how to approach this cancer clinically, since information about its staging and treatment is limited. In this report, we present a case of an 84-year-old postmenopausal woman in whom a suspicious vaginal lesion was discovered incidentally during a procedure. Wide local excision was carried out at a later date and histopathology confirmed a malignant melanoma of the vagina contained locally with no radiological finding of distant metastases. No additional treatment was given, and three monthly follow-ups were arranged for this patient. We review the literature and briefly discuss the epidemiology, treatment approaches, prognostic factors and expected outcomes of this rare disease.

Metastatic follicular carcinoma arising from struma ovarii

Struma ovarii (SO) is an uncommon monodermal teratoma predominantly composed of mature thyroid tissue. Approximately 5% of SO are malignant; however, metastases are rare. A single female in her 40s, with a medical history of Graves’ disease and bilateral cystectomy 10 years prior for right endometriotic cyst and left SO, presented with an enlarging abdominal mass for 4 months. Ultrasound pelvis showed a 13.8 cm left adnexal heterogeneous solid-cystic mass with internal septations and vascularity. She underwent open left salpingo-oophorectomy and resection of fibrous nodules from the right infundibulo-pelvic ligament and fallopian tube. Histology showed highly differentiated metastatic follicular carcinoma. She subsequently underwent total thyroidectomy, total hysterectomy, right salpingo-oophorectomy, tumour debulking and omentectomy followed by radioactive iodine treatment. Four-year follow-up did not show tumour recurrence or metastases. Due to its rarity, there are no well-established guidelines for the management and follow-up of metastatic follicular carcinoma arising from SO.

Olaparib-induced cutaneous side effects in a patient with recurrent ovarian cancer

Over the past decade, the treatment of ovarian cancer has been revolutionised by poly(ADP-ribose polymerase (PARP)) inhibitors. Based on the results from clinical trials, olaparib, a PARP inhibitor, is indicated for use in the first-line treatment for patients with BRCA gene mutations, and as a maintenance treatment in platinum‐sensitive relapsed ovarian cancer after a complete or partial response to platinum‐based chemotherapy. Although PARP inhibitors have been shown to be well tolerated, adverse side effects can affect the quality of life of patients and lead to the discontinuation of therapy. Here, we report a case of dermatosis of the left dorsal hand as a rare adverse side effect of olaparib. Dermatological adverse side effects may become the crux of a clinical problem that requires the cooperation of professionals in many fields.

Mature thyroid teratoma in a newborn

Diffuse large B-cell lymphoma of the vagina in pregnancy

A 28-year-old primigravida was evaluated for complaints of difficulty urinating and pelvic pain of 6-weeks duration. She denied fever, night sweats, weight loss or fatigue. Pelvic ultrasonography revealed a single fetal pole with cardiac activity and a 7 cm mass in the anterior vagina which encased the urethra. The diagnosis of diffuse large B-cell lymphoma germinal centre type was made on analysis of biopsied pelvic mass. Whole body MRI revealed the disease was limited to the vagina. The patient received six cycles of Rituximab-cyclophosphamide, doxorubicin, vincristine and prednisone with significant improvement in her symptoms. Serial ultrasounds over the subsequent months showed appropriate development of the fetus. Whole body MRI after treatment showed decreased size and decreased signal of the primary pelvic mass compatible with favourable treatment response. Challenges in the management of this rare presentation of lymphoma are discussed.

Invasive cervical adenocarcinoma arising from extension of recurrent vulval Paget’s disease

An 83-year-old woman with a long-standing history of both invasive and vulval extramammary Paget’s disease (EMPD) was referred to a tertiary gynaecological oncology service for suspicion of contiguous extension to the vagina and cervix. Vaginal biopsies confirmed EMPD; however, a loop excision of the cervix demonstrated invasive adenocarcinoma arising from Paget’s disease. The patient subsequently underwent laparoscopic radical hysterectomy, bilateral salpingo-oophorectomy and radical upper vaginectomy, confirming FIGO stage 1B1 cervical adenocarcinoma. She was recommended but declined to have adjuvant pelvic external beam radiotherapy. To our knowledge this is the second case of invasive cervical adenocarcinoma arising from vulval Paget’s disease in the literature.

Quadruple synchronous primary cancers in a single patient

Patients diagnosed with quadruple synchronous primary cancers are extremely rare and we present here, to the best of our knowledge, the first case report of this combination of primary cancers. A 70-year-old woman was diagnosed with cervical adenocarcinoma, melanoma on the right leg, invasive ductal cell carcinoma metastasis in the left axilla with no primary breast tumour detected and multiple basal cell carcinomas on the limbs, all within 2 months. The management was conducted in collaboration with six medical specialties. The cancers were surgically managed, with further adjuvant chemotherapy and ongoing hormone therapy for her breast cancer. Four years after the diagnosis, no signs of recurrence or further metastases from any of the cancers are present.

Dermatomyositis presenting as heart failure revealed a concealed cervical malignancy: an infrequent clinical nexus

Dermatomyositis (DM) belongs to the spectrum of inflammatory myopathies which are a heterogeneous group of acquired disorders in which dysregulated immune system is thought to play a major pathologic role. Patients with DM generally present with characteristic skin manifestations with or without muscle weakness and pain. Although subclinical myocardial involvement in DM is well reported in literature, heart failure (HF) as its principal manifestation is extremely rare. Recognition of DM, a known paraneoplastic syndrome, should prompt clinicians to search for underlying malignancy. While gynaecological malignancies are common in association with DM, cervical cancer has rarely been heard of as an aetiology of paraneoplastic DM. We are reporting a case of DM in a postmenopausal woman presenting with advanced decompensated congestive HF with hidden squamous cell carcinoma of cervix.

Cellular angiofibroma of labia minora in pregnancy

Cellular angiofibroma (CAF) is benign mesenchymal tumour primarily affecting vulvovaginal region in women. Often they are asymptomatic with small size, but rarely these tumours may grow significantly necessitating differentiation from aggressive malignant growth. This is a case report of primigravida mother who was in her early 30s, who present to our setting in near-term gestation with approximately 10 cm pedunculated mass arising from labia minora. Following a caesarean section and surgical excision, histopathology confirmed the diagnosis of CAF. This case highlights the importance of recognising this entity in pregnant patients to ensure appropriate surgical management and a favourable prognosis. CONCLUSION: This is a rare case recorded involving the labia minora in a pregnant patient, which has grown to such an extent making patient symptomatic making her to walk with difficulty.

Extramammary breast cancer of the vulva

A woman in her 70s was seen in the gynaecology outpatient clinic with a swelling on the right side of the vulva. Surgical excision of the lesion revealed unexpectedly an extensive ductal carcinoma in situ with a focus of a grade 2 invasive ductal carcinoma arising in extramammary breast tissue of the vulva. Postoperative staging studies showed normal breasts, with no evidence of disease elsewhere. The patient underwent a wider excision of the right vulva and sentinel node biopsy of the right inguinal region, which revealed no further disease. The patient is currently taking adjuvant hormonal therapy and has remained disease free at 2-year follow-up. This case underscores the importance of considering rare presentations of vulvar malignancies and the necessity for a multidisciplinary approach in managing such cases.

Vulval superficial myofibroblastoma with lymphocytic and eosinophilic infiltrate

We present the case of a vulval superficial myofibroblastoma with a lymphocytic and eosinophilic rim in a woman in her late 20s. The tumour presented in pregnancy as a cystic lesion with pain and increasing size. While the histopathology of superficial myofibroblastomas has been well defined in the literature, to our knowledge, there has been no documentation of the presence of an inflammatory infiltrate of lymphocytes and eosinophils surrounding and within the tumour. This may potentially act as a diagnostic or prognostic reference.

Giant aggressive angiomyxoma of the vulva in two women

Aggressive angiomyxoma (AA) of the vulva is a rare, benign, slow-growing tumour that arises from the myxoid cells of the connective tissue. It has a low tendency to metastasise, but a high chance of multiple local recurrences. Here, we report two cases of AA of the vulva. In both these cases, women in the reproductive age group presented with the condition of a large, fleshy, pedunculated mass on the labia majora. The mass was surgically resected and sent for histopathology, which confirmed the diagnosis. AA should be kept as one of the differential diagnoses for a vulvovaginal mass. Its correct diagnosis, optimal treatment and long-term follow-up are necessary for appropriate management of such patients.

Diagnosis and management of primary vulvar adenocarcinoma of mammary gland type: report of two distinct cases

Adenocarcinoma of mammary gland type (AMGT) of the vulva is extremely rare and its aetiopathogenesis is not fully understood. Low incidence is partly responsible for the lack of guidelines for patient management. Here, two cases of postmenopausal patients diagnosed with AMGT with different therapeutical approaches are reported. Histopathological patterns are considered essential for diagnosis. The triple-negative immunohistochemical (IHC) profile of one of the cases represented a diagnostic challenge. Interestingly, it presented an immunophenotypical profile similar to triple-negative breast cancers, supporting the molecular similarities between vulvar AMGT and breast carcinomas. Surgical procedures include radical vulvectomy or radical local excision. Lymphatic involvement may be assessed by sentinel lymph node biopsy or lymphadenectomy. Adjuvant treatment was dependent on the IHC profile and disease staging. Although both cases had similar features on clinical examination, pathological and molecular characteristics and treatment approach were distinct. That illustrates the diagnostic and therapeutical challenge of this rare entity.

Vulval squamous cell carcinoma arising from hidradenitis suppurrativa

A 47- year-old woman developed a rapidly enlarging vulvar mass. Although the clinical appearance suggested malignancy, its lack of atypia and invasion on initial superficial biopsy delayed the pathological diagnosis. It was not until a large incisional biopsy was performed that showed the diagnosis of verrucous squamous cell carcinoma (VSCC) involving pre-existing sinuses of hidradenitis suppurativa (HS). VSCC arising in HS is very rare and often leads to death in published cases. This case demonstrates the challenge in pathological diagnosis of this condition which impacted time to treatment.

Bartholin gland carcinoma in a young female: a rare disease in an unusual age group

Primary Bartholin gland carcinoma (BGC) is an extremely rare disease. It typically presents in elderly women. It can be confused with Bartholin gland cyst, which is a benign condition leading to a delay in diagnosis and treatment. We are presenting a case report of BGC in a 35-year-old woman, which has created a diagnostic as well as therapeutic dilemma.

Metastatic malignant struma ovarii to the pituitary presenting as a sellar mass and responding to total thyroidectomy with adjuvant radioactive iodine therapy

Malignant struma ovarii (MSO) is a rare ovarian teratoma composed primarily of thyroid tissue. Common sites of metastasis include peritoneum, bone, liver, lung, gastrointestinal tract and omentum. We present a woman in her 50s with a history of remote oophorectomy presenting with hypopituitarism and a 2.7 cm sellar mass. Trans-sphenoidal surgery for presumed pituitary macroadenoma achieved near total resection and resultant pathology surprisingly showed ectopic thyroid tissue. The patient acquired her ovarian pathology report from Southeast Asia which showed struma ovarii of the left ovary. The pituitary mass was thus determined to be a metastatic lesion from MSO. She underwent total thyroidectomy and radioactive iodine ablation therapy with good initial response and no regrowth of the tissue or emergence of distant metastases after 5 years of annual follow-up. To our knowledge, this is the first reported case of MSO to the pituitary.

Imaging findings of granulosa cell tumour of right ovary with rupture and torsion presenting as acute abdomen

Aversion of surgical exploration in patients with complex ovarian cysts secondary to overt hypothyroidism: A series of three cases

Long-standing, overt hypothyroidism-induced bilateral multiloculated ovarian cysts represent an infrequent occurrence. Our first case, presented with bilateral complex ovarian masses, exhibited overt hypothyroidism symptoms, including lethargy, weight gain and subfertility, prompting consideration for surgical intervention. Similarly, in the second case, a girl aged 11 years with stunting, delayed bone age and academic challenges was referred for surgical exploration due to bilateral complex ovarian masses. Both cases revealed elevated thyroid-stimulating hormone levels during preoperative workup. Commencing levothyroxine replacement therapy resulted in complete regression of ovarian cysts and substantial symptom improvement within an 8-week timeframe. The third case, a previously diagnosed patient with Hashimoto’s thyroiditis, benefited from the lessons gleaned in managing the initial cases, responding well to levothyroxine therapy, thereby averting the necessity for surgery in all three instances. These cases underscore the significance of considering thyroid function in the evaluation of ovarian masses and highlight the efficacy of levothyroxine replacement therapy in resolving both hypothyroidism and associated ovarian cysts, thereby obviating the need for surgical intervention.

Thoracic Gorham-Stout disease masquerading as an ovarian malignancy: a differential diagnosis in non-malignant causes of raised Ca-125 and overview of this rare pathology

Gorham-Stout disease (GSD) is thought to be due to uncontrolled proliferation of vascular and lymphatic structures within bone tissue causing destruction and osteolysis of bone. We present a patient in her mid-40s who reported chronic shoulder pain, a pleural effusion and irregular periods. Investigations showed osteolysis of her ribs, pleural effusions, an ovarian mass and a raised carbohydrate antigen 125 (Ca-125). She was subsequently diagnosed with GSD, and referred to gynaecology-oncology in consideration of potential ovarian malignancy. GSD is a diagnosis of exclusion that requires a high degree of clinical suspicion, as well as multiple investigations to achieve diagnosis. Clinicians rely on a small number of case reports to provide guidance for this. Therefore, this report provides an overview of a rare pathology, considers the differentials of a raised Ca-125 and describes how a pleural effusion, which links them both, alarmed us regarding an incidental finding of an ovarian cyst.

Recurrent pyometra coupled with xanthogranulomatous endometritis mimicking pyelonephritis and malignancy: unravelling clinical complexities

Histiocytic or xanthogranulomatous endometritis (XGE) is an extremely rare benign histopathological entity with only a few cases reported in literature to date. It is characterised by the replacement of endometrial tissue with sheets of foamy histiocytes, giant cells, lymphocytes and plasma cells; calcification and necrosis. It involves chronic inflammation and may be associated with endometrial hyperplasia, endometrial carcinoma and atrophy, causing cervical stenosis and recurrent pyometra, especially in postmenopausal women. We report a case of senile recurrent pyometra masquerading as pyelonephritis clinically and endometrial malignancy radiologically, confirmed later on histology as XGE. Due to deceptive manifestation and rarity of this clinical condition, it is very important for a gynaecologist, radiologist and histopathologist to have a clear understanding of this entity.

Managing concurrent endometrial stromal sarcoma during pregnancy

The co-occurrence of endometrial stromal sarcoma and pregnancy is a rarely documented occurrence, leading to a scarcity of comprehensive research and treatment guidelines in the current literature. This case is centred around a low-grade stromal sarcoma in a woman at 15 weeks of gestation. Initially presenting with left iliac fossa pain and elevated inflammatory markers, the diagnosis was suspected to be pyelonephritis, which prompted the initiation of intravenous antibiotics. Persistent symptoms prompted an MRI at 19 weeks’ gestation, which revealed a mass expanding into the left internal iliac and left common iliac veins, as well as compression and invasion of the left distal ureter and associated obstructive uropathy to the level of the mass. This case highlights the diagnostic challenges and multidisciplinary management of the patient as well as the justification for supporting her wishes to continue with the pregnancy.

Primary ovarian diffuse large B-cell lymphoma

Primary ovarian lymphoma is a rare malignancy, representing <1% of ovarian neoplasms and a small subset of extranodal lymphomas, with diffuse large B-cell lymphoma (DLBCL) being the most frequent subtype. Diagnosis is often delayed because symptoms overlap with more common gynaecological or infectious conditions. We report a woman in her 20s presenting with hoarseness, exertional dyspnoea and low-grade fever. Imaging showed mediastinal lymphadenopathy, and repeated biopsies revealed necrotising granulomatous inflammation without malignancy. Persistent symptoms prompted fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT, which detected a hypermetabolic right adnexal mass; MRI suggested a high-grade neoplasm, and tumour markers were normal. Laparoscopic biopsy confirmed high-grade DLBCL (stage IV, germinal-centre B-cell subtype) with a high Ki-67 index. We report a woman in her 20s presenting with hoarseness, exertional dyspnoea and low-grade fever. Imaging showed mediastinal lymphadenopathy, and repeated biopsies revealed necrotising granulomatous inflammation without malignancy. Persistent symptoms prompted FDG PET-CT, which detected a hypermetabolic right adnexal mass; MRI suggested a high-grade neoplasm, and tumour markers were normal. Laparoscopic biopsy confirmed high-grade DLBCL (stage IV, germinal-centre B-cell subtype) with a high Ki-67 index.

A ruptured ovarian cystadenofibroma presenting with life-threatening sepsis and an incidental synchronous endometrial stromal sarcoma

A woman in her 60s presented with a rare complication of an ovarian cyst which many clinicians may not consider at first presentation. She was admitted with life-threatening staphylococcus aureus sepsis. She presented shocked with a collapse following a 2-day history of diarrhoea, vomiting and pain in the right iliac fossa. She was taken to theatre where a ruptured, widely infarcted left ovarian serous cystadenofibroma was discovered with over 2 litres of purulent fluid exuding from the cyst into the abdomen. She had a left cyst removal, hysterectomy and bilateral salpingo-oophorectomy performed. Histological analysis and molecular gene testing of an incidentally discovered uterine neoplasm revealed an undifferentiated uterine sarcoma. She successfully recovered as an inpatient and was discharged under the care of an oncology team for ongoing management.

Pembrolizumab as adjuvant therapy in a patient with Lynch syndrome with synchronous mixed clear cell carcinoma of ovarian origin and endometroid endometrial carcinoma

A 48-year-old woman was diagnosed with synchronous mixed clear cell carcinoma of ovarian origin and endometroid endometrial carcinoma after presenting with intermenstrual bleeding for 2 years prior. Shortly after diagnosis she became progressively unwell requiring intensive care unit admission with respiratory failure, pleural effusions and pulmonary emboli. Following a total abdominal hysterectomy, bilateral salpingo-oophorectomy, laparotomy and emergency percutaneous thrombectomy, she remained critically unwell and was deemed not safe for chemotherapy. Given a high index of suspicion for Lynch syndrome, the patient was treated with adjuvant pembrolizumab and achieved a complete response. Lynch syndrome was subsequently confirmed through germline genetic testing. The patient made an excellent recovery and remains disease-free at 23 months.

Endometriosis of para-aortic node masquerading a malignancy: a rare occurrence

Endometriosis is a benign estrogen-dependent disorder affecting women in their reproductive age group. Endometriosis means ‘abnormal growth of endometrial glands’ outside the uterus. Multiple theories on aetiopathogenesis of endometriosis have been postulated, Halban’s theory on ‘Benign Metastasis’ which proposed the presence of endometriotic cells in lymphatic vessels and lymph nodes provides the basis of this case report. Here, we report a case of 26-year-old nulliparous woman who presented with grossly elevated CA 125 with endometriosis in her para-aortic nodes mimicking as ovarian cancer.

Robot-assisted laparoscopic hysterectomy for endometrial cancer in a patient with Herlyn-Werner-Wunderlich syndrome

Herlyn-Werner-Wunderlich syndrome, a rare Mullerian duct anomaly, includes a triad of uterine didelphys, obstructed haemivagina and ipsilateral renal agenesis. A 58-year-old woman with Herlyn-Werner-Wunderlich syndrome, reported of recurrent genital bleeding for 9 years, was finally diagnosed with endometrial cancer. She had a history of vaginal septum resection and nephrectomy of atrophic right kidney. MRI demonstrated uterine didelphys, a tumour filling the left uterus and a cyst on the right lateral side of the uterus. Robot-assisted hysterectomy, including bilateral salpingo-oophorectomy and pelvic lymphadenectomy, was performed. As the cyst communicated with the right cervix, but not with the urinary tract, a Gartner duct cyst was diagnosed. Uncertain diagnosis and delay of treatment in endometrial cancer may occur in patients with Herlyn-Werner-Wunderlich syndrome. We should preoperatively fully evaluate the anatomy of the uterus and surrounding tissues and plan surgical procedures, especially in patients with urogenital malformations.