Meigs Syndrome. At the end of the presentation, students should be able to understand Meigs syndrome, it's pathophysiology, epidemiology, and common presentation. Students should also be able to come up with likely differential diagnoses and suggest a relevant workup and treatment options. Meigs syndrome is defined by the triad of ascites, pleural effusion, and a benign ovarian fibroma. 1% of patients with ovarian fibromas present with Meigs syndrome. Pseudo-Meigs syndrome is the triad of ascites, pleural effusion, and any benign ovarian apart from a fibroma.
An example includes mature teratoma. The pathophysiology behind the ascites and pleural effusion is currently not known. Meigs suggested that inflammation of the peritoneal surfaces by a hard solid ovarian tumor could stimulate the production of peritoneal fluid. Other proposed mechanisms causing the ascites include pressure on surrounding lymphatic vessels, hormonal stimulation, and release of mediators from the tumor leading to increased capillary permeability. The pleural effusion is thought to be secondary to the passage of ascitic fluid to the pleural space through the diaphragm or diaphragmatic lymph vessels.
The incidence of Meigs syndrome increases at 30 years of age and progressively peaks at 70 years of age. Patients with Meigs syndrome usually presents with vague chief complaints such as abdominal distention, fatigue, weight loss, menstrual irregularity, shortness of breath, and a nonproductive cough. Women with Meigs syndrome may have a family history of ovarian cancer. Differential diagnoses to Meigs syndrome includes Pseudo-Meigs syndrome and malignant ovarian tumors, pseudomyxoma peritonei-- a peritoneal tumor associated with mucinous ademonas of the appendix, gastrointestinal tract, and ovaries also similarly present with an abdominal mass associated with the ascites and pleural effusion. Any form of severe liver disease, such as hepatocellular carcinoma can cause hypoalbuminemia leading to ascites and pleural effusion. Thyrotoxicosis can sometimes present with chylous ascites, where patients have ascitic fluid with high triglyceride content, and pleural effusion secondary to cardiac failure. The workup for Meigs syndrome is similar to the workup for ovarian cancer. For blood investigations, a full blood count, urea electrolyte panel and PT/PTT are ordered to assess the patient's fitness for surgery.
Blood levels of the tumor marker CA 125 should also be ordered, as this marker may be elevated in Meigs syndrome. Imaging investigations include a chest x-ray to assess the extent of pleural effusion, cardiac function for surgery, and to look for the presence of any lung metastases. A pelvic ultrasound should be done to image the ovarian mass to identify features of malignancy. The CT scan confirms the extent of disease to assist in the planning of surgical intervention. An esophagogastroduodenoscopy and colonoscopy rules out any tumor which has originated from or has spread to the upper or lower gastrointestinal tract. Paracentesis and thoracocentesis can be done to assess the cytology of the ascitic and pleural fluid. Treatment includes symptomatic treatment and surgery with frozen section. Symptomatic relief of the pleural effusion and ascites is done via thoracocentesis and paracentesis.
Surgery with frozen section is done to distinguish between benign and malignant ovarian tumors. If frozen section shows a benign tumor, unilateral salphingo-oophorectomy is done for young women. A total hysterectomy with bilateral salphingo-oophorectomy is done for women who have completed their families. If frozen section shows a malignant tumor, surgical staging and total hysterectomy with bilateral salphingo-oophorectomy together with peritoneal cytology, lymph node dissection, and omenectomy is done. In Meigs syndrome, the ascites and pleural effusion resolve with tumor resection.
In summary, Meigs syndrome as a triad of an ovarian fibroma, ascites, and pleural effusion. It presents similarly to advanced stage ovarian cancer. Meigs syndrome remains as a differential diagnosis until it is ruled out by histopathology. It has a good prognosis after surgical resection.
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