A 28-year-old Caucasian woman presented to our Emergency Unit with a short history of progressive shortness of breath and a swollen right arm. She had previously been in good health with no medical history of note but was just recovering from a severe upper respiratory tract infection, which had caused her to be unwell in bed for several days. Aside from the oral contraceptive pill she took no regular medication and had no family medical history of note. Initial investigations with a Doppler ultrasound of her right arm and axilla demonstrated a deep vein thrombosis in the right subclavian vein with extension into the proximal internal jugular vein. A computed tomography scan confirmed the presence of the right axillary vein thrombus and the pulmonary embolus and a large right pleural effusion as shown in Figure. Despite these findings, the patient was hemodynamically stable and after review by the vascular surgery team the decision was made to manage with anticoagulation rather than thrombolysis. The initial imaging also demonstrated enlarged lymph nodes, without the normal fatty hilum, in the mediastinum and right supraclavicular fossa. The imaging of the patient’s abdomen and pelvis demonstrated a mixed echogenicity 13.5cm left adnexal mass situated between the sacrum and the anterior abdominal wall shown in Figure. The tumor markers performed at presentation demonstrated normal values for both hCG and AFP whereas the CA-125 level was moderately elevated at 368U/mL (normal range 0 to 35). The initial management centered on the treatment of the pulmonary embolus with anticoagulation and the insertion of a prophylactic inferior vena cava filter. The differential diagnoses at this stage included: epithelial ovarian cancer, an ovarian germ cell tumor, an ovarian sex cord-stromal tumor or an atypical Meigs syndrome. After a week of anticoagulation treatment, a laparotomy was performed which demonstrated a large left ovarian mass with ascites but no other abnormal findings. The ovarian mass was removed along with a biopsy of the omentum and a fine needle aspirate of the supraclavicular lymph nodes was performed. Postoperatively the patient made an excellent recovery and was well enough to be discharged home 6 days later. On pathological examination the ovarian mass measured 14×8.5×6.5cm and weighed 470g. The outer surface was predominantly smooth with a focus of roughened area, suggesting a site of adhesion to adjacent structures. The cut surface was solid, tan in color and focally hemorrhagic. Histological examination, as shown in Figure, demonstrated a spindle cell tumor of variable cellularity with both hypercellular and hypocellular areas. The tumor cells were arranged in sheets and intersecting fascicles with the intervening stroma containing short collagen bundles and areas of necrosis and focal hemorrhage. The cells had oval to spindle nuclei with fine chromatin and inconspicuous nucleoli. No notable cytological atypia was seen. The mitotic activity was variable with most parts showing no mitotic figures while focally mitoses were seen with up to two mitotic figures per 10 high-power fields (HPF). On immunostaining the tumor cells expressed inhibin, calretenin (focally), progesterone receptor (weak expression in some cells) but were negative for estrogen receptor, CD34, HMB-45, S-100 protein, h-caldesmon, MNF116, epithelial membrane antigen, CAM 5.2 and cytokeratin 5/6. The morphology and immunoprofile were those of cellular fibroma. The omental tissue showed only mesothelial hyperplasia, and no tumor deposits and the ascitic fluid showed no malignant cells. The biopsy from the enlarged supraclavicular lymph nodes showed prominent interstitial reticulum cells, but no evidence of malignancy. The pathological findings, coupled with the rapid spontaneous resolution of the ascites, pleural effusion and lymphadenopathy postoperatively, confirmed the diagnosis of Meigs syndrome, combined with reactive lymphadenopathy. The patient was referred to the hematology team for investigation of any clotting tendency. Fortunately, the results of all investigations including Factor V, lupus and anti-cardiolipin screens were negative and routine anticoagulation was continued for 1 year and then discontinued. After 5 years of follow up the patient remains in good health and has recently had a successful pregnancy with a healthy baby girl delivered without complications.