Abstract / Summary
Polypoid endometriosis (PEM) is a rare form of endometriosis characterized by polyp-like lesions and atypical clinical and imaging features. Although PEM is generally benign, extensive abdominopelvic involvement and unusual manifestations may create substantial diagnostic challenges. Massive hemorrhagic ascites is exceptionally uncommon in PEM, and its clinical characteristics and management remain poorly described. A 41-year-old woman presented with progressive postmenstrual abdominal distension for four months, with marked worsening during the last week. She had a history of adenomyosis and surgically confirmed ovarian endometriosis. Imaging demonstrated mixed adnexal masses, massive ascites, and omental thickening, while serum CA125 and CA19-9 levels were elevated. Approximately 4000 mL of hemorrhagic ascites was drained by ultrasound-guided paracentesis, and cytologic examination showed no malignant cells. Laparoscopic exploration revealed extensive dense adhesions and multiple friable polyp-like lesions diffusely involving the abdominopelvic cavity, omentum, and mesentery. Intraoperative frozen-section examination revealed benign findings, and final histopathological examination confirmed PEM. Whole-exome sequencing identified a BMP4 p.H251Y missense variant. Postoperatively, the patient received 6 courses of GnRHa therapy followed by Dienogest, with no evidence of recurrence during 9 months of follow-up. This case highlights an exceptionally rare presentation of PEM characterized with massive hemorrhagic ascites and extensive abdominopelvic lesions, closely mimicking advanced gynecologic malignancy. Increased awareness of this unusual presentation, together with appropriate clinical assessment, may facilitate accurate diagnosis and help avoid unnecessarily radical surgery. Given the limited number of reported PEM cases, further studies are needed to clarify the pathogenesis and optimal postoperative management of this rare disease.