Author
Information
Atre R*, Gupta AS**.
(*
Fourth
Year
Resident, ** Professor. Department of Obstetrics & Gynecology,
Seth G.S.Medical College & KEM Hospital, Mumbai,
India.)
Abstract
Anatomical
aberration in the development of organs leads to their development at
an abnormal anatomical site.
Such
aberrations are seen in various organs resulting in development of
accessory breasts,
accessory
pancreas,
accessory
spleen,
accessory
ovaries and so on. All these are rare entities,
Accessory
ovary being extremely rare.
Accessory
ovary may either develop at the time of embryogenesis due to
separation during migration or it may develop in a normal adult ovary
due to trauma caused by an inflammatory process or during
surgery.[1,2]
Our
patient is a case of bilateral ovarian cysts who at the time of
exploratory laparotomy was incidentally found to have an accessory
ovary like tissue near the normal left ovary but separate from it.
Introduction
Accessory
ovary is defined as a part of ovarian tissue situated close to but
connected
(at
least by the vascularity) to the normal ovary. It is a rare condition
with incidence of 1:29,000-700,000 in indoor patients.
Anomalies
of other organs can coexist with an accessory ovary.
In
the genital system defects seen are accessory Fallopian tubes,
uterus
didelphys,
septate
uterus,
and unicornuate
uterus.
Urinary
system anomalies seen are bladder diverticulum,
agenesis
of unilateral kidney,
ureter,
accessory
suprarenal gland.
Gastrointestinal
system may show presence of a lobulated liver or accessory
pancreas.[3]
Incidence
of such an association is 36%. Accessory ovaries are usually detected
incidentally at laparotomies done for other pathologies as they
themselves are most often asymptomatic.[4]
Case
Report
A
24 year old nulligravida, married since one year,
came
to the gynecology outpatient department with complaints of pain in
lower abdomen and an ultrasononography report suggestive of bilateral
ovarian cysts.
She
had regular menses which lasted for 4-5 days each cycle and came
every 28-30 days with moderate flow without any associated
dysmenorrhea. On examination,
general
and systemic examination was within normal limits.
On
abdominal examination,
a
16week size mass was palpable in the left iliac fossa,
cystic
in consistency,
mobile,
and non
tender.
On
vaginal examination,
a
16-18wk size mass was palpable,
well
differentiated from the uterus,
non
tender,
and mobile.
Patient
was admitted for evaluation.
A
repeat pelvic ultrasound was suggestive of a large cystic lesion
measuring 6.0 cm * 5.5
cm
in the right adnexa with a fat containing component measuring 4
cm
* 3.5
cm
within the cyst with calcification.
There was
no evidence of torsion.
All
these features suggested
a dermoid cyst arising from the right ovary.
Another
large clear cyst measuring 11
cm
* 9.9
cm
was noted in the pelvis adjacent to the above cyst.
Left
ovary was normal.
Right
ovary was not identified.
A
computed tomography examination of the pelvis confirmed the presence
of a right ovarian dermoid cyst and a left ovarian cyst.
An
exploratory laparotomy with left ovarian cystectomy and
right
ovarian dermoid enucleation
with bilateral ovarian reconstruction was done under spinal plus
epidural anesthesia.
Intraoperative
findings revealed a 10
cm
* 11
cm
*
12
cm
paraoophoron cyst in the left adnexa which was seen anterior to the
uterus as shown in Fig 1.
Uterus
was normal in size and left Fallopian tube was stretched over the
cyst.
Left
ovary was normal.
Right
ovary, with a right ovarian dermoid cyst of about 4
cm
*
5
cm
*
5
cm
was also noted which was seen posterior to the uterus.
A
small 2
cm
*
1
cm
*
1
cm
ovarian like tissue was seen in the left ovary at the junction of the
fimbriae and the left paraoophoron cyst.
It
was seen separately from the normal left ovarian tissue suggestive of
an accessory ovary as shown in
the
figure 1.
Figure
1: Laparotomy Findings: Left Paraoophoron Cyst (P), accessory ovary
(Blue arrow), Stretche Fallopian Tube (T) right sided Dermoid cyst
(D) and the uterus (U and the yellow arrow).
A
biopsy was taken from this ovarian like tissue and sent for
histopathological examination which revealed mature ovarian
parenchyma with stroma thus confirming the finding of an accessory
ovary.
Post
operative period was uneventful.
Discussion
Accessory
ovary,
as
defined above was first described by Grobe in 1864.
Development
of an accessory ovary during embryogenesis as a result of separation
during migration was explained.
Lachman
and Berman had an alternative point of view and said accessory
ovaries are actually implants caused by trauma and are not of
embryological origin.[2]
Tumors
arising in an accessory ovary are extremely rare but reports of
various tumors
like cystadenoma
(serous
or mucinous),
dermoid
cyst,
Brenner
tumor,
steroid
cell tumor are available.
This
suggests that the various types of tumours seen in an accessory ovary
are similar to those seen in a normal ovary.[5]
In
our case,
accessory
ovary was an incidental finding and was detected
due
to the symptomatic
bilateral
ovarian cysts.
We did not find any abnormalities in the Fallopian tubes,
uterus.
The
accessory ovary did not appear to be associated with any other
anomalies in other systems.
In
summary,
accessory
ovary is a rare under
reported
condition which should be looked for at exploratory laparotomies and
if noticed we should be vigilant about any other anomalies associated
with it.
This
condition is associated with a high risk of pelvic and renal
anomalies and should lead to further evaluation in order to advise
patients about future reproductive function and management of
congenital anomalies.
These accessory ovary can be a source for the development of
neoplasm. The clinicians should document their presence for future
reference.
References
- Lim MC, Park SJ, Kim SW, Lee BY, Lim JW, Lee JH, et al.Two dermoid cysts developing in an accessory ovary and an eutopic ovary.J Korean Med Sci. 2004 Jun;19(3):474-6.
- Lachman MF, Berman MM. The ectopic ovary. A case report and review of the literature. Arch Pathol Lab Med. 1991 ;115(3):233-5.
- Sharatz SM, Treviño TA, Rodriguez L, and West JH. Giant serous cystadenoma arising from an accessory ovary in a morbidly obese 11-year-old girl: a case report. J Med Case Reports. 2008; 2: 7.
- Vendeland LL, Shehadeh L.Incidental finding of an accessory ovary in a 16-year-old at laparoscopy. A case report. J Reprod Med. 2000;45(5):435-8.
- Kim AR, Sung WJ, Kim MJ. A Fibroma with Cystic Change Developing in an Accessory Ovary- A Brief Case Report - The Korean Journal of Pathology 2011; 45: 319-321.
Atre
R, Gupta AS. Accessory
Ovary: An Incidental Finding. JPGO 2015. Volume 2 Number 9. Available
from: http://www.jpgo.org/2015/09/accessory-ovary-incidental-finding.html