Peritoneal tuberculosis mimicking advanced ovarian cancer: A retrospective review of 22 cases

doi:10.1016/j.ygyno.2006.04.010

Gynecologic Oncology

Volume 103, Issue 2, November 2006, Pages 565-569

https://doi.org/10.1016/j.ygyno.2006.04.010 Get rights and content

Abstract

Objective.

To evaluate the clinical, laboratory and diagnostic features in women with peritoneal tuberculosis that resembled advanced ovarian malignancy.

Methods.

A retrospective review of women with peritoneal tuberculosis who were managed at TCSB Ankara Etlik Maternity and Women's Health Teaching and Research Hospital from July 1992 to November 2004 was undertaken.

Results.

Among the 1826 women treated during the study period, 22 women with peritoneal tuberculosis (1.2%) were identified. The mean age was 36.9 years (range 21–68 years); the mean Ca125 level was 564.95 U/ml (3–2021 U/ml). All patients with peritoneal tuberculosis had ascites, 20 patients (90.91%) had elevated CA125 levels and 17 patients (77.27%) had detectable pelvic masses in the preoperative period. During preoperative diagnostic work-up, pulmonary tuberculosis was diagnosed and antituberculosis therapy had begun in two of 22 patients (9.09%). Among 20 patients, 11 (55%), 8 (40%) and 1 (5%) underwent exploratory laparotomy, diagnostic laparoscopy and laparoscopy converted to laparotomy due to dense pelvic adhesions, respectively. Since frozen section was not available during the surgery in 5 of 20, 3 patients (10%) underwent extended surgery. Frozen section was performed in 15 patients and revealed chronic granulomatous changes and final pathological examination confirmed the diagnosis.

Conclusion.

Our data indicate that the majority of the cases with peritoneal tuberculosis can be diagnosed intraoperatively through the use of frozen section in conjunction with clinical features. Ascites and high levels of Ca125 do not necessarily indicate that the clinical picture is malignant in reproductive women. Laparoscopic tissue biopsy may be a fundamental tool in the management of such cases to avoid extended surgery.

Introduction

Patients with ascites, abdominopelvic masses and elevated serum CA125 levels are considered to have ovarian or gastrointestinal system malignancy. Reports of peritoneal tuberculosis (peritoneal tbc) in the literature have been primarily limited to sporadic case studies which had been often misdiagnosed as carcinomatous peritonitis [1], [2]. Many series evaluated using current diagnostic tools for women with peritoneal tbc have yielded inconsistent results.

Although pulmonary tuberculosis is a common disease in developing countries, because of diagnostic difficulties, patients diagnosed peritoneal tbc are limited. Tuberculous peritonitis is a form of abdominal tuberculosis that predominantly involves the omentum, intestinal tract, liver, spleen or female genital tract in addition to parietal and visseral peritoneum [3]. Peritoneal tbc is currently defined to account for approximately 1–2% of all tuberculosis cases and, sometimes it is seen in association with pulmonary or disseminated form of the disease. The final diagnosis in such cases could only be achieved by tissue biopsies taken with laparoscopy or laparotomy.

In this paper, we present 22 cases of peritoneal tbc who were diagnosed at Gynecologic Oncology Clinic of TCSB Ankara Etlik Maternity and Women's Health Teaching and Research Hospital. The aim of this retrospective study is to identify characteristic feature of peritoneal tbc, which may be useful for differential diagnosis. The above data suggest that clinical features of such cases are not characteristic and that frozen section seems to be the sole tool both in confirming the diagnosis of tbc and in identifying occult disease that may be undiagnosed clinically. We noticed that tissue biopsies are necessary for the diagnosis of this apparently serious but curable infection which appears to be similar to an advanced stage ovarian carcinoma clinical presentation.

Section snippets

Methods

From July 1992 to November 2004, all patients who were suspected for ovarian cancer preoperatively and managed at Gynecologic Oncology Department of TCSB Ankara Etlik Maternity and Women's Health Teaching and Research Hospital were reviewed. During the study period, 22 women (1.2%) with peritoneal tuberculosis from a total of 1826 were submitted for this retrospective review (Table 1). Complete physical examination, medical and family history, complete blood count, routine biochemical tests, Ca

Results

The mean age of the patients was 36.9 years (range 21–68 years) (Table 2). The most common symptoms were abdominal swelling and pain (Table 3). The onset of the symptoms varied between 2 weeks and up to 1 year. None of the patients was receiving immune suppressive therapy and had family or past history for tbc. Ascites on ultrasonographic examination was shown to be present in all patients. A diagnosis of peritoneal tbc was ultimately established by surgery in 20 patients, although only 2 of 22

Discussion

The clinical features of symptomatic peritoneal tbc may resemble chronic pelvic inflammatory disease (PID) or any other pelvic disorders including ovarian cancer. Because many cases of peritoneal tbc are discovered incidentally and since majority of symptomless patients remain undiscovered, the precise incidence of peritoneal tbc in the developing countries cannot be determined. The present data have been collected from our selected population at gynecologic oncology unit and do not indicate

Conclusion

The rarity of peritoneal tbc in females contributes to a low index of suspicion and therefore a low incidence of accurate preoperative diagnosis. Routine physical, radiographic and laboratory examinations are not sensitive enough to determine the presence of peritoneal tbc or to differentiate those from advanced ovarian cancers. Ultrasonography and computed tomography have limited usefulness in evaluating peritoneal tbc because of diffuse nature and small implants associated with the disease.

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P.C. Hopewell

Overview of clinical tuberculosis

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Citation Excerpt :
The massive volume of ascites suggests that the blocking process is comprehensive. Peritoneal TB is one extrapulmonary which is rare and difficult to diagnose, accounting for 1% - 2% of all tuberculosis cases [2]. Tuberculosis is a major health problem in a developing country, WHO reported an estimated 9.4 million cases of TB globally in 2009, and most of the cases were from developing countries [5].
Peritoneal Tuberculosis is one of extrapulmonary tuberculosis that occurs in 1-2% of patients, its incidence is higher in developing countries. It is very difficult to diagnosed and can mimic advanced ovarian cases. Making an accurate diagnosis is vital, laparoscopy is a great modality for this purpose.
A 36 years-old woman got referred with abdominal distention and weight loss from an internist and digestive surgeon. The abdominal computed tomography said thickening of the stomach wall with ascites. Ultrasound concluded the uterus, ovary, and endometrium within normal. The CA 125 levels elevated to 1200 U/mL and the complete blood count was normal. We were making diagnosis of peritoneal tuberculosis, peritoneal carcinomatosis, and advanced ovarian cancer. We did the diagnostic laparoscopic and taking a biopsy sample, ascites with peritoneal carcinomatosis and omental cake were found, the peritoneal cavity was covered by miliary nodules. Histopathology results concluded peritoneal tuberculosis without malignancy signs. The patient was treated with tuberculosis drugs. The follow-up evaluations show significant clinical improvement.
When facing patients with massive ascites and elevated CA 125 without any ovary enlargement, a gynecologist should think that it may be a peritoneal TB case with peritoneal carcinomatosis and advance ovarian cancer possibility as differential diagnosis especially in developing countries. An exact diagnosis can be made using laparoscopy and histopathology examination.
Laparoscopy is the best modality to differentiate between peritoneal tuberculosis, peritoneal carcinomatosis, and advance ovarian cancer. The benefits are direct visualization and could take a biopsy for histology examination.
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We herein describe three such cases of incidental peritoneal TB detected during surgical exploration for other reasons.
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Diagnosis of tuberculous peritonitis with clinical, laboratory, and imaging findings is a difficult process. Tuberculous peritonitis accounts for 1%-2% of all cases of tuberculosis and occurs when abdominal or pelvic tuberculosis involves the peritoneum [1,2]. Tuberculous peritonitis and carcinomatosis peritonei have many common clinical, laboratory, and radiological findings [3,4].
The distinction between tuberculous peritonitis and peritoneal carcinomatosis is extremely difficult in patients with omental cake appearance on computed tomography and elevated CA-125 level. A 21-year-old female presented with abdominal distention, diarrhea, nausea, fever, weight loss, and night sweats. Serum CA-125 level was 563 U/L (normal range: <35 U/L) and other tumor markers were within normal range. Radiologic studies showed massive ascites, smooth minimal thickening and increased contrast enhancement of peritoneum, omental nodularities, hepatomegaly, and right pleural effusion. No underlying malignancy that could cause this condition was detected clinically and radiologically. Ultrasound-guided omental tru-cut biopsy was performed to exclude carcinomatosis peritonei. Histopathologic examination showed small-medium-sized granulomas with caseous necrosis. Molecular microbiology tests of biopsy specimens confirmed diagnosis of tuberculosis. In conclusion, tuberculous peritonitis should be in differential diagnosis of a patient with ascites, omental nodularities and elevated serum CA-125 levels.

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Peritoneal tuberculosis mimicking advanced ovarian cancer: A retrospective review of 22 cases

Abstract

Objective.

Methods.

Results.

Conclusion.

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Am. J. Obstet. Gynecol.

Am. J. Surg.

Gynecol. Oncol.

Gynecol. Oncol.

Dig. Liver. Dis.

Eur. J. Intern. Med.

Br. J. Obstet. Gynaecol.

Eur. J. Obstet. Gynecol. Reprod. Biol.

Tuberculous peritonitis-reports of 26 cases, detailing diagnostic and therapeutic problems

Eur. J. Gastroenterol. Hepatol.

Tuberculous peritonitis mimicking peritonitis carcinomatosis: a case report

Eur. J. Pediatr.

Overview of clinical tuberculosis