A 33-year-old Caucasian, nulligravida patient initially presented with pleural effusion, ascites, and a left adnexal mass in August 2007. Her CA-125 level was 230 U/ml but clinically, she was asymptomatic. The patient underwent a diagnostic laparoscopy, which revealed several, diffuse peritoneal nodules. Initially, a presumptive diagnosis of small, bilateral hydrosalpinges was made. The ovaries were diffusely embedded within the disease process. Approximately 70 ml of straw-colored fluid was identified in the pelvis and left upper quadrant. The ascites was aspirated and submitted for cytologic examination. Moreover, sections of the right lower quadrant abdominal wall were biopsied to rule out malignancy (fig. 1).
The differential diagnosis included tuberculosis, sarcoidosis or an unusual infection. Final pathologic evaluation revealed sarcoidosis. The patient was referred to pulmonary medicine and started on corticosteroid therapy, whereupon her condition improved dramatically.
During the patient's follow-up examination in May 2009, a 9-cm pelvic mass was detected (fig. 2), although she remained asymptomatic. Her CA-125 was 128 U/ml. A diagnostic laparoscopy was performed to determine if the cystic structure could be removed laparoscopically, particularly since recurrent sarcoidosis was the presumed etiology.
A variety of options were explained preoperatively, but the family's preference was conservative (i.e., fertility retention) management. However, due to the magnitude of disease, the prospect of a hysterectomy was also comprehensively discussed.
The mass was cystic, containing a light brown-colored fluid. Culture and sensitivity testing was obtained. Consequently, a hysterectomy with bilateral salpingo-oophorectomy was again considered, but after an intraoperative discussion was held with the patient's family, we continued with conservative management. The mass was excised with the exception of an approximately 3.5 cm x 3.5 cm plaque, which could not be removed without excising the ovaries.
Frozen section revealed endometriosis, granulomatous inflammation and focal necrosis, with no evidence of malignancy (fig. 3). The findings were consistent with sarcoidosis. Currently, the patient is doing well with 5 months of follow-up and is followed by the departments of gynecologic oncology and pulmonary medicine.