eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Oncology

Meigs Syndrome: Differential Diagnoses & Workup

Author: Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Coauthor(s): Rajeshwari Chavda, MD, Consulting Staff, Emergency Care Group of Northwest; Ayesha Akhter, MD, Consulting Staff, Department of Internal Medicine, Columbia Tech Center, Vancouver Clinic; Mir Omar Ali, MD, Fellow, Department of Pulmonary Medicine, Lenox Hill Hospital, New York University; Lalit K Kanaparthi, MD, Fellow in Pulmonary Medicine, Lenox Hill Hospital
Contributor Information and Disclosures

Updated: Oct 9, 2008

Differential Diagnoses

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

Other Problems to Be Considered

Congestive heart failure

Workup

Laboratory Studies

Lab studies for patients with Meigs syndrome include the following:

  • CBC count: This study provides information about hemoglobin, hematocrit, and platelet levels. A low hemoglobin count requires further workup, including reticulocyte count, total iron-binding capacity, and iron and ferritin levels. Anemia in patients with Meigs syndrome is most likely due to iron deficiency. Anemia can be corrected emergently by blood transfusion in patients undergoing surgery for Meigs syndrome. Anemia can be treated with iron supplementation postoperatively.
  • Basic metabolic profile: Studies of sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, and glucose levels are included. These electrolytes are checked before the patient undergoes surgery. If necessary, corrections of these electrolytes are made.
  • Prothrombin time: Prothrombin time is checked before surgery. If elevated, it is a marker of coagulopathy. Elevated prothrombin time is corrected before surgery, either by administering vitamin K to the patient or by transfusing fresh frozen plasma.
  • Other than serum electrolytes and CBC count, the study of interest is the serum cancer antigen 125 (CA-125) test. Tumor marker serum levels of CA-125 can be elevated in Meigs syndrome, but the degree of elevation does not correlate with malignancy. In fact, a normal CA-125 level does not exclude the possibility of malignancy.8 The CA-125 level is not used as a screening test. The highest reported level of CA-125 after laparotomy is 1808 U/mL. This would be a false-positive result.
    • Physiologic sources of CA-125 are fetal coelomic epithelium and its derivatives, including the following:
      • Müllerian epithelium
      • Pleura
      • Pericardium
      • Peritoneum
    • Pathologic conditions related to an elevated CA-125 level include the following:
      • Pelvic inflammatory disease (PID)
      • Peritoneal damage or regeneration (eg, abdominal surgery)
      • Ovarian malignancy
      • Endometriosis
    • In 1992, Lin et al conducted a study to determine whether the ovarian fibroma was the source of serum CA-125 elevation. Using an immunohistochemical technique specific for the tumor marker, they localized CA-125 expression in the omentum and peritoneal surfaces rather than in the fibroma.9

Imaging Studies

  • Chest radiography confirms pleural effusion.
  • Abdominal and pelvic ultrasound confirms the ovarian mass and ascites.
  • CT scan of the abdomen and pelvis
    • CT scan confirms ascites and ovarian, uterine, fallopian tube, or broad ligament mass.
    • No signs of distant metastasis are observed.

Other Tests

  • Papanicolaou test findings are normal.

Procedures

  • Paracentesis: Ascitic fluid is mostly transudative. Findings are negative for malignant cells but can be positive for reactive mesothelial cells.
  • Thoracentesis: Pleural fluid is usually transudative. Findings can be exudative and negative for malignant cells.

Histologic Findings

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

  • Coelomic epithelial tumors: These tumors, which originate from the coelomic epithelium, constitute 80-85% of all ovarian tumors.
    • Serous cystadenoma and mucinous cystadenoma: 15-20% are malignant.
    • Endometrioid type and clear cell: 95-98% are malignant.
    • Brenner tumor: 2% are malignant.
  • Germ cell tumors: These tumors originate from the germ cell and constitute 10-15% of all ovarian tumors. All are malignant except mature teratomas and gonadoblastomas, which are always benign.
    • Mature teratoma
    • Immature teratoma
    • Dysgerminoma
    • Gonadoblastoma
    • Endodermal sinus
    • Embryonal carcinoma
    • Nongestational choriocarcinoma
  • Gonadal-stromal cell tumors constitute 3-5% of all tumors.
    • Granulosa cell
    • Fibroma: Fewer than 5% are malignant.
    • Thecoma: Fewer than 5% are malignant.
    • Sertoli-Leydig cell: Fewer than 5% are malignant.
    • Lipid cell type: 30% are malignant.
    • Gynandroblastoma: 100% are malignant.

More on Meigs Syndrome

Overview: Meigs Syndrome
Differential Diagnoses & Workup: Meigs Syndrome
Treatment & Medication: Meigs Syndrome
Follow-up: Meigs Syndrome
References
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References

  1. Meigs JV, Cass JW. Fibroma of the ovary with ascites and hydrothorax: with a report of seven cases. Am J Obstet Gynecol. 1937;33:249-267.

  2. Dunn JS Jr, Anderson CD, Method MW. Hydropic degenerating leiomyoma presenting as pseudo-Meigs syndrome with elevated CA 125. Obstet Gynecol. Oct 1998;92(4 Pt 2):648-9. [Medline].

  3. Schmitt R, Weichert W, Schneider W, Luft FC, Kettritz R. Pseudo-pseudo Meigs' syndrome. Lancet. Nov 5 2005;366(9497):1672. [Medline].

  4. Samanth KK, Black WC. Benign ovarian stromal tumors associated with free peritoneal fluid. Am J Obstet Gynecol. Jun 15 1970;107(4):538-45. [Medline].

  5. Loizzi V, Cormio G, Resta L, Fattizzi N, Vicino M, Selvaggi L. Pseudo-Meigs syndrome and elevated CA125 associated with struma ovarii. Gynecol Oncol. Apr 2005;97(1):282-4. [Medline].

  6. Zannoni GF, Gallotta V, Legge F, Tarquini E, Scambia G, Ferrandina G. Pseudo-Meigs' syndrome associated with malignant struma ovarii: a case report. Gynecol Oncol. Jul 2004;94(1):226-8. [Medline].

  7. Tjalma WA. Ascites, pleural effusion, and CA 125 elevation in an SLE patient, either a Tjalma syndrome or, due to the migrated Filshie clips, a pseudo-Meigs syndrome. Gynecol Oncol. Apr 2005;97(1):288-91. [Medline].

  8. Jones OW, Surwit EA. Meigs syndrome and elevated CA 125. Obstet Gynecol. Mar 1989;73(3 Pt 2):520-1. [Medline].

  9. Lin JY, Angel C, Sickel JZ. Meigs syndrome with elevated serum CA 125. Obstet Gynecol. Sep 1992;80(3 Pt 2):563-6. [Medline].

  10. Agaba EI, Ekwempu CC, Ugoya SO, Echejoh GO. Meigs' syndrome presenting as haemorrhagic pleural effusion. West Afr J Med. Jul-Sep 2007;26(3):253-5. [Medline].

  11. Aoshima M, Tanaka H, Takahashi M, Nakamura K, Makino I. Meigs' syndrome due to Brenner tumor mimicking lupus peritonitis in a patient with systemic lupus erythematosus. Am J Gastroenterol. Apr 1995;90(4):657-8. [Medline].

  12. Carson SA, Mazur MT. Atypical endometrioid cystadenofibroma with Meigs' syndrome: ultrastructure and S-phase fraction. Cancer. Feb 1 1982;49(3):472-9. [Medline].

  13. Cissé CT, Ngom PM, Sangare M, Ndong M, Moreau JC. [Ovarian fibroma associated with Demons-Meigs syndrome and elevated CA 125]. J Gynecol Obstet Biol Reprod (Paris). May 2004;33(3):251-4. [Medline].

  14. Lacson AG, Alrabeeah A, Gillis DA, Salisbury S, Grantmyre EB. Secondary massive ovarian edema with Meig's syndrome. Am J Clin Pathol. May 1989;91(5):597-603. [Medline].

  15. Mitrou S, Manek S, Kehoe S. Cystic struma ovarii presenting as pseudo-Meigs' syndrome with elevated CA125 levels. A case report and review of the literature. Int J Gynecol Cancer. Mar-Apr 2008;18(2):372-5. [Medline].

  16. Morán-Mendoza A, Alvarado-Luna G, Calderillo-Ruiz G, Serrano-Olvera A, López-Graniel CM, Gallardo-Rincón D. Elevated CA125 level associated with Meigs' syndrome: case report and review of the literature. Int J Gynecol Cancer. Jan-Feb 2006;16 Suppl 1:315-8. [Medline].

  17. Peparini N, Di Matteo FM, Silvestri A, Caronna R, Chirletti P. Abdominal hypertension in Meigs' syndrome. Eur J Surg Oncol. Sep 29 2007;[Medline].

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Further Reading

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Keywords

Meigs syndrome, Meigs-Salmon syndrome, pseudo-Meigs syndrome, pseudo-pseudo Meigs syndrome, fibromyoma, hydroperitoneum, hydrothorax, atypical Meigs, benign ovarian tumor, ovarian cancer, ascites, pleural effusion, ovarian fibromas, pelvic tumor, pelvic mass, thecoma, cystadenoma, granulosa cell tumor, teratomas, struma ovarii

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Contributor Information and Disclosures

Author

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Rajeshwari Chavda, MD, Consulting Staff, Emergency Care Group of Northwest
Disclosure: Nothing to disclose.

Ayesha Akhter, MD, Consulting Staff, Department of Internal Medicine, Columbia Tech Center, Vancouver Clinic
Disclosure: Nothing to disclose.

Mir Omar Ali, MD, Fellow, Department of Pulmonary Medicine, Lenox Hill Hospital, New York University
Mir Omar Ali, MD is a member of the following medical societies: American College of Physicians and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Lalit K Kanaparthi, MD, Fellow in Pulmonary Medicine, Lenox Hill Hospital
Lalit K Kanaparthi, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey B Garris, MD, Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine
Jeffrey B Garris, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Urological Association, Association of Professors of Gynecology and Obstetrics, Louisiana State Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Carl V Smith, MD, The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, University of Nebraska Medical Center
Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Arkansas Medical Society, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

 
 
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