More V*, Warke H**,
Mayadeo NM***, ***. Satia MN
(* Assistant Professor, ** Associate Professor, *** Professor. Department of Obstetrics and Gynecology, Seth GS
& KEM Hospital, ) Mumbai, India
Mucinous cystadenoma accounts for 8-10% of all the epithelial ovarian tumors. Large benign ovarian tumors are rare due to general awareness and improved diagnostic technology. We report a case of a 30 year old woman who presented with a large ovarian cyst. Exploratory laparotomy with total abdominal hysterectomy and bilateral salphinogoophorectomy was performed. Final histopathology report was suggestive of bilateral mucinous cystadenoma of the ovary.
Mucinous cystadenoma is a benign ovarian tumor. It arises from the surface epithelium of the ovary. Mucinous cystadenoma accounts for 8-10% of all the epithelial ovarian tumors. Eighty percent of the mucinous tumors are benign and only ten percent of them are bilateral. They are commonly seen in the reproductive age. They may attain enormous size filling the entire abdomen and may cause pressure symptoms. Prognosis is good after surgical debulking.
A 30 year old woman, married for 14 years but separated from husband for 12 years, came to the gynecology outpatient department with complaints of abdominal distension for 8 months and decreased appetite and breathlessness for 2 months. Ulltrasonography from a private hospital was suggestive of a large complex cystic mass of 20x16x19cm with mild free fluid in the abdomen with gross hydronephrosis and hydroureter. There was no significant medical and surgical illness. On examination her general condition was fair and vital parameters were stable. She was poorly built and nourished with body weight of 51 kg. Systemic examination revealed no abnormality. On abdominal examination there was a cystic mass filling the entire abdominal cavity extending up to the xiphisternum. There was another separate cystic mass or lobulation of the same cyst in right hypochondriac and subcoastal region extending laterally and posteriorly for around 15 cm. Computerized tomography of abdomen and pelvis showed two different cystic multiloculated masses occupying the entire abdominal cavity, gross hydronephrosis and hydroureter, with no evidence of ascites. Tumor markers including serum LDH, Ca 125, AFP, CEA, beta hCG were normal. Ca 19-9 was 1234.75 u/ml, which was markedly raised. Complete hemogram, blood sugars, liver function tests, renal function tests, urinalysis, chest radiograph and electrocardiogram were within normal limits. Preoperative ureteric stenting was done. Exploratory laparotomy was performed under epidural and spinal anesthesia. Abdomen was opened with a midline vertical incision which was extended10-12 cm above the umbilicus. Mild ascites was present. Peritoneal fluid was sent for cytology. Intraoperatively bilateral large ovarian cysts were noted, both well capsulated without any surface invasion. Left ovarian cyst measured 28x12x10 cm and right ovarian cyst measured 23x8x10 cm. Bilateral salphingoophorectomy was done and the specimen sent for frozen section. The left ovarian cyst weighed 10 kg and the right ovarian cyst weighed 7 kg. Frozen section report was inconclusive for malignancy. In view of bilateral large ovarian masses with ascites total abdominal hysterectomy and omentectomy were done. Liver, spleen and bowels were normal. Post operative course was uneventful. Final histopathology report was suggestive of a benign mucinous cystadenoma. Cytology of peritoneal fluid was negative for malignant cells. The ureteric stents were removed postoperatively. Postoperatively the patient weighed 33 kg.
Figure 1: Black arrow shows right ovarian cyst, yellow arrow shows left ovarian cyst and green arrow shows uterus.
Ovarian tumors are divided into four major categories: epithelial tumors, germ cell tumors, sex-cord-stromal tumors and metastatic tumors. Mucinous cystadenomas are epithelial tumors which are cystic and have loculi lined with mucin secreting epithelium. Mucinous cystadenomas represent 8-10% of all epithelial ovarian tumors and 15% of all ovarian tumors.[1,2] The tumors are bilateral in only 10% of cases which was the case in our patient. They are further divided into benign, borderline and malignant and have a tendency to attain huge sizes filling the entire abdominal cavity. In our case, both cysts were huge, left sided ovarian cyst measuring 28x12x10 cm weighing 10 kg and right sided ovarian cyst measuring 23x8x10 cm weighing 7 kg. On gross appearance, they are characterized by cysts of variable sizes without surface invasion. They are more common in reproductive age group. Patients present with gradually increasing mass in the abdomen and dull aching pain. When the tumor is big enough to fill the entire abdomen, then it may lead to cardiorespiratory embarrassment or gastrointestinal symptoms. Ultrasonography, computerized tomography and magnetic resonance imaging help in evaluation of these tumors. Management of the ovarian cysts depends on the patient’s age, the size of the cyst and histopathology. In benign lesions, ovarian cystectomy or salphingooophorectomy is adequate. But in our case both the cysts were huge destroying the entire ovarian tissue with presence of ascites and malignancy could not be ruled out on frozen section. Hence total abdominal hysterectomy with bilateral salphingo-oophorectomy with omentectomy was performed. Postoperatively the patient was counseled regarding occurrence of menopausal symptoms and the need of hormone replacement therapy.
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