Adnexal Mass with Ascites and High Cancer Antigen -125 in a Young Female: Not Always Malignancy!

Sir,

The close similarities in presentation between abdominopelvic tuberculosis (TB) and ovarian carcinoma, with severe limitations of diagnostic tools, create a diagnostic dilemma to differentiate them. One of the contributive diagnostic tests in ovarian malignancy is cancer antigen (CA)-125, which is elevated in more than 90% of women with epithelial ovarian cancer in advanced stage and 50% in Stage 1. The sensitivity and specificity of CA-125 in ovarian cancer has been reported to be 64%–90% and 94%–98%, respectively.[1] CA-125 has a sensitivity and specificity of about 80%–90% and 95% for TB, respectively.[2]

A 12-year-old girl presented with complaints of loss of appetite, weight loss, abdominal pain, and distension for 4 weeks. Her built was poor (31 kg) and she had generalized abdominal distension with gross ascites. Ultrasound abdomen and contrast-enhanced computed tomography abdomen showed a multiloculated complex cyst 6 cm × 9 cm in the left adnexa with gross ascites [Figure 1]. Investigations revealed anemia (hemoglobin, 7.4 g/dl) and CA-125 of 862.1 U/ml (n < 35); lactate dehydrogenase, beta-human chorionic gonadotropin, alpha-fetoprotein, and CA19-9 were normal. Ascitic fluid analysis revealed few mesothelial cells with lymphocytes, coagulum present, and no malignant cells; GeneXpert Mycobacterium tuberculosis was negative. Acid-fast bacilli staining of ascitic fluid was negative. Chest X-ray was also normal. Mantoux test was negative. The patient received bacillus Calmette–Guerin vaccination in infancy. The screening of the family members for TB suggested negative results.

Figure 1

Contrast-enhanced computed tomography abdomen showing gross ascites

She was referred to our institute for chemotherapy. Discussion was done in institutional tumor board meeting, and a consensus was reached to do a diagnostic laparoscopy with tissue and fluid biopsy. Diagnostic laparoscopy revealed 2.5 L of straw-colored ascites with multiple septations and tubercles in the peritoneal cavity [Figure 2]. The peritoneum was studded with tubercles. The left ovary had a firm mass of about 2 cm × 3 cm. Adhesiolysis with sampling of the ascitic fluid and biopsy of the tubercles and septations were done. Histopathology of tubercles revealed necrotizing granulomatous reaction suggestive of TB. Ascitic fluid adenosine deaminase was 150.6 IU/L (n < 24). The patient was started on antitubercular drugs and is doing well on follow-up of 6 months.

Figure 2

Diagnostic laparoscopy view showing multiple flimsy and dense adhesions, tubercles and ascites in peritoneal cavity

A large number of literature has been reported about the misdiagnosis of abdominopelvic TB as ovarian cancer in adult age group due to their similarities in clinical presentation and investigations, including imagings and CA-125 levels. This misdiagnosis has led to certain pitfalls such as chemotherapy being given for months, radical surgery consisting of total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentum resection, and involved organ removal.[3] This has been a radical management, with probability of depriving females from being fertile. There is very few literature on abdominal TB misdiagnosed as ovarian cancer in pediatric age group.[4] Studies have suggested that diagnostic laparoscopy with histopathology can lead to a diagnosis of TB of the abdomen in more than 97% of patients.[5]

Due to lack of definitive diagnostic modalities to differentiate abdominopelvic TB and advanced ovarian malignancy in clinical presentation, in cases where there is raised CA-125 level in adolescent and reproductive age group, differential diagnosis of TB should always be prioritized, especially in endemic zones. Laparoscopy has a great role in diagnosis and definitive management.

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Conflicts of interest

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