Meigs Syndrome

INTRODUCTION @

Background: Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. The ovarian tumor in Meigs syndrome is a fibroma.

In 1934, Salmon described the association of pleural effusion with benign pelvic tumors. In 1936, Meigs and Cass described 7 cases of ovarian fibromas associated with ascites and pleural effusion. In 1954, Meigs proposed limiting true Meigs syndrome to benign and solid ovarian tumors accompanied by ascites and pleural effusion, with the condition that removal of the tumor cures the patient without recurrence. Histologically, the benign ovarian tumor might be a fibroma, thecoma, cystadenoma, or granulosa cell tumor.

Pseudo-Meigs syndrome consists of pleural effusion, ascites, and benign tumors of the ovary other than fibromas. These benign tumors include mature teratomas, struma-ovarii, leiomyoma of ovary, and benign tumors of the fallopian tube or uterus.

Atypical Meigs: Two case reports have been made of atypical Meigs characterized by a benign pelvic mass with right-sided pleural effusion but without ascites. As in Meigs syndrome, pleural effusion resolves after removal of pelvic mass.

@

Pathophysiology:
@

Etiology of ascitic fluid: The pathophysiology of ascites in Meigs syndrome is speculative. Meigs suggested that irritation of the peritoneal surfaces by a hard, solid ovarian tumor could stimulate the production of peritoneal fluid. Samanth and Black studied ovarian tumors accompanied by ascites and found that only tumors larger than 10 cm in diameter with myxoid component to the stroma are associated with ascites. These authors believe that their observations favored secretion of fluid from the tumor as the source of the ascites.

Other proposed mechanisms are direct pressure on surrounding lymphatics or vessels, hormonal stimulation, and tumor torsion. Development of ascites may be due to release of mediators (eg, activated complements, histamines, fibrin degradation products) from the tumor, leading to increased capillary permeability.

Origin of pleural effusion: The etiology of pleural effusion is unclear. Efskind and Terada theorize that ascitic fluid is transferred via transdiaphragmatic lymphatic channels. The size of the pleural effusion is largely independent of the amount of ascites.

Study by Efskind: Efskind injected ink into the lower abdomen of a woman with Meigs syndrome and found that, within half an hour, the ink particles had accumulated in the lymphatics of the pleural surface. Blockage of these lymphatics prevented accumulation of pleural fluid and caused an increase in ascitic fluid.

Study by Terada: In 1992, Terada et al injected labeled albumin into the peritoneum and found that within 3 hours the maximum concentration was detected in the right pleura.

Nature of the ascitic and pleural fluid: Ascitic fluid and pleural fluid in Meigs syndrome can be either transudate or exudate. Meigs performed electrophoresis on several cases and determined that pleural and ascitic fluids were similar in nature. Tumor size, rather than the specific histologic type, is thought to be the important factor in the formation of ascites and accompanying pleural effusion.

@

Frequency:
@

Mortality/Morbidity: Meigs syndrome, being a benign condition, has a very good prognosis if properly managed, though it mimics a malignant condition. Life expectancy after surgical removal of the tumor is the same as in the general population.

Age: Incidence of ovarian tumor begins to increase in the third decade and increases progressively to peak in the seventh decade. Case reports have been made of Meigs syndrome in prepubertal girls with benign teratomas and cystadenomas.

CLINICAL @

History: Patients may have a family history of ovarian cancer. The chief complaints are vague and generally present over a period of time.

Physical: Positive signs include the following:

DIFFERENTIALS @

Cirrhosis
Colon Cancer, Adenocarcinoma
Hypoalbuminemia
Lung Cancer, Non-Small Cell
Lung Cancer, Oat Cell (Small Cell)
Nephrotic Syndrome
Ovarian Cancer
Pleural Effusion
Tuberculosis


Other Problems to be Considered:

Congestive heart failure

WORKUP @

Lab Studies:
@

Imaging Studies:
@

Procedures:
@

Histologic Findings: Ovarian tumors are divided into the following histologic subgroups, and Meigs syndrome can be seen with any of the benign tumors.

TREATMENT @

Medical Care:

Surgical Care:

Consultations: Gynecologic-surgical consult for surgical management of the case

Activity: Activity as tolerated

FOLLOW-UP @

Further Inpatient Care:

Further Outpatient Care:
@

Prognosis:
@

MISCELLANEOUS @

Medical/Legal Pitfalls:
@

BIBLIOGRAPHY @