A Giant Paraovarian Cyst in a single woman in her third decade: A case report

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Hisham Hussein Imam^*

Citation: Hisham Hussein Imam, ”A Giant Paraovarian Cyst in a single woman in her third decade: A case report, vol 3, no. 1, 2020, pp. 1-3.

Copyright Hisham Hussein Imam . This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract:

Description:

INTRODUCTION

Paraovarian  cysts  (PCs)  are  cystic  tumors  that  can  be  encountered  between  the  ovarian  hilum  and  the  ovarian  fimbria located within the mesosalpinx and broad ligament, being usually diagnosed within the 3rd and 4th decade of life [1].These lesions are usually benign, accounting for 5% to 20% of all adnexal tumors, and they may originate from the Müllerian (paramesonephric) or Wollfian (mesonephric) ducts, or mesothelium [2]. Sixty eight per cent of the PCs originate from  the  mesothelium  that  covers  the  peritoneum,  being lined with flattened epithelium. Nevertheless, 30% of them originate from the paramesonephric remnants, being lined with secretory, ciliated columnar, or cuboidal epithelium, while the remaining 2% originate from the mesonephric remnants, and are characterized by cuboidal or flattened epithelium.[3,4]

Paraovarian  cysts  (PCs)  are  usually  diagnosed  during the 3rd or 4th decade of life, and up to 80% of them are asymptomatic being diagnosed incidentally during a random abdominal ultrasound. However, in certain cases these patients can present with abdominal pain, nausea, or vomiting due to cystic complications, such as perforation, bleeding, excessive growth,  torsion,  and  malignant  transformation.[5,6]  The prevalence of neoplastic PCs is usually very low.[7]Diagnosis  of  both  ovarian  and  Paraovarian  Cysts  are usually  done  using  Ultrasonography  (US),  Computerized Topography (CT) and/or Magnetic Resonant Imaging (MRI) [1].

Ultrasonography (US) may show a cystic mass within the pelvis, usually an anechoic unilocular mass, but it may not  show  accurately  the  origin  of  this  lesions.  Moreover, it  was  reported  that  most  often  PCs  are  misdiagnosed  as ovarian cysts (OCs), or other types of cystic pelvic masses, such  as  lymphoceles  or  peritoneal  inclusion  cysts.[8]. Moreover, Ultrasonography (US) is both examiner and patient dependent being more difficult in obese patients [9]. On the contrary, computed tomography (CT) or Magnetic Resonant Imaging (MRI) proved to be more useful in differentiating these 2 entities by showing a clear delimitation between the normal affected-side ovary and the unilocular cystic lesion [10]. Despite all these facts, the preoperative differentiation between PCs and OCs remains very difficult to be established and most often the precise diagnosis is established during the surgery [1].

Case Summary

A twenty nine years old single patient. She has long standing abdominal  discomfort,  dyspepsia,  urinary  frequency  and presented with pelvi-abdominal mass. She has regular menses with no marked dysmenorrhea or any intermenstrual bleeding. Her past medical and surgical history is irrelevant. She is not smoking and do not drink alcohol. Her abdominal examination revealed a giant pelvi-abdominal mass cystic in consistency, not tense or tender and reaching up to the xiphisternum.

Examination

Her general examination is unremarkable with normal pulse, temperature, blood pressure and respiratory rate. Examination of the other systems reveal unremarkable findings. The patient body weight is 70.3 KG.

Investigations

Blood group O positive, Hemoglobin 13.9 gm/dl, serum creatinine 0.82 gm/dl and RBS 110 mg/dl. CT of abdomen and pelvis revealed a large pelvi-abdominal cystic lesion seen extending  from  the  pelvic  region  till  the  epigastric  region upwards. It measures 36 X 30X 27 cm in its widest dimensions (Fig. 1,2,3) . It shows clear fluid density. It shows mass effect upon the related abdominal organs and the bowel loops in the form of displacement of bowel loops and pancreas. The cyst is clearly separated from the other abdominal organs. No loco-reginal enlarged lymph nodes. Clear Lung bases. Normal size and homogenous parenchymal attenuation of the Liver. Normal CT appearance of the gallbladder, pancreas, adrenals, spleen, both kidneys, aorta and IVC. Normal uterus with no lesions or masses. No free ascites. Impression: Large pelvi-abdominal cystic mass lesion mostly of ovarian origin, for further assessment.

Operative Remarks

Under general anesthesia and after abdominal preparation, the  abdomen  was  opened  in  layers  by  a  midline  incision starting  below  the  umbilicus  and  extending  up  around  the umbilicus reaching to just below the xiphisternum to be able

to deliver the giant mass. There was no remarkable adhesions between  the  mas  and  surrounding  structures.  Examination of the mass revealed that it was arising from the right broad ligament with the right ovary looks normal in shape and size. The right fallopian tube was seen to be over stretched and present on the outer surface of the mass and looked unhealthy. The leaves of the broad ligament peeled off from the surface of the Paraovarian cyst. The Giant cyst removed from the abdomen.    The  redundant  broad  ligament  tissues  together with the overstretched right Fallopian tube was excised to avoid possible right tubal ectopic pregnancy in the future.  The mass measures 35 X 26 X 18 cm and weighs 12160 gm (Fig.4, 5). The abdomen was closed on layers and subcuticular sutures to the skin. The mass was sent to the laboratory for histopathological examination which revealed the presence of a huge benign Paraovarian and benign paratubal cysts. The postoperative period of the patient was uneventful and she was discharged home in the third postoperative day.

Discussion

Paraovarian cysts (PCs) constitute a homogeneous group of  cystic  masses  originating  from  the  mesosalpinx  or  the broad ligament, located in the proximity of the ovary and the Fallopian tube [11]. The histologic variants of PCs include mesonephric, mesothelial, and paramesonephric origins. [1, 2] The most frequent reported type was paramesonephric variant [12]. In our case, the giant PC was also located within the broad ligament and the histologic examination revealed no signs of neoplasia. The microscopic examination revealed the cyst to be lined by a single layer of columnar ciliated (tubal-like) epithelium, thin layer of smooth muscle and underling congested fibrovascular tissue. Usually these PCs grow slowly, and they are discovered incidentally during the third or fourth decade of life, being rare during childhood or adolescence [6].

The preoperative differentiation between OCs and PCs is very difficult to be certainly established despite proper imagistic assessments. The clinical presentation of OCs and PCs are almost the same and the importance of differentiation is only theoretical because the management is also almost the same. This current case was diagnosed by CT as being ovarian in origin but without defining from which ovary it arises. Any trial to aspirate the cyst to decrease its size to minimize the size of the abdominal incision is not advisable to avoid spillage of the cysts contents which cannot be defined preoperatively [1].

Kazem Moslemi M and Yazdani Z, 2010 reported a Huge Ovarian Cyst in a Middle-Aged Iranian Female with an almost similar weight ( 12 KG) to our current patient, however, the mass was ovarian and in an older woman [13].  Kassidi F, et al. 2017, reported a successful Management of a Giant Ovarian Cyst in a 32-year old Moroccan woman [14]. Albers C E, Ranjit E, Sapra A, et al, 2020, reported bilateral multicystic ovarian masses in a 58 years old woman and advised that (Clinician Beware, Giant Ovarian Cysts are Elusive and Rare) [15]

References

1.Mărginean CO, Mărginean C, MeliÅ£ LE, Săsăran VÅž, PoruÅ£iu M, Mărginean CD. An  incidental  diagnosis  of  a  giant  paraovarian  cyst  in  a  female teenager:  A  case  report.  Medicine  (Baltimore).  2018;97(48):e13406. doi:10.1097/MD.0000000000013406

2.Savelli L, Ghi T, De Iaco P, et al. Paraovarian/paratubal cysts: comparison of  transvaginal  sonographic  and  pathological  findings  to  establish diagnostic criteria. Ultrasound Obstet Gynecol 2006;28:330–4. [PubMed] [Google Scholar].

3.Vlahakis-Miliaras E, Miliaras D, Koutsoumis G, et al. Paratubal cysts in young females as an incidental finding in laparotomies performed for right lower quadrant abdominal pain. Pediatr Surg Int 1998;13:141–2. [PubMed] [Google Scholar].

4.Stenbäck F, Kauppila A. Development and classification of parovarian cysts.  An  ultrastructural  study.  Gynecol  Obstet  Invest  1981;12:1–0. [PubMed] [Google Scholar].

5.Betancor L, Eduvigis C, Vázquez Rueda F, et al. Quiste paratubárico en la infancia. Manejo laparoscópico. Prog Obstet Ginecol 2011;54:376–8. [Google Scholar].

6.Abad  P,  Obradors  J,  Ortuño  P,  et  al.  Torsion  of  paraovarian  cyst  in pediatrics  [in  Spanish].  Cir  Pediatr  2005;18:46–8.  [PubMed]  [Google Scholar].

7.Smorgick  N,  Herman  A,  Schneider  D,  et  al.  Paraovarian  cysts  of neoplastic  origin  are  underreported.  JSLS  2009;13:22–6.  [PMC  free article] [PubMed] [Google Scholar].

8.Kajiyama A, Edo H, Takeya C, et al. Spontaneously ruptured paraovarian tumor  of  borderline  malignancy  with  extremely  elevated  serum carbohydrate antigen 125 (CA125) levels: a comparison of the imaging and pathological features. Am J Case Rep 2017;18:919–25. [PMC free article] [PubMed] [Google Scholar].

9.Mărginean CO, Mărginean C, Voidăzan S, et al. Correlations between leptin  gene  polymorphisms  223A/G,  1019G/A,  492G/C,  976C/A,  and anthropometrical and biochemical parameters in children with obesity: a prospective case-control study in a Romanian population-The Nutrichild Study. Medicine (Baltimore) 2016;95:e3115. [PMC free article] [PubMed] [Google Scholar].

10.Kiseli  M,  Caglar  GS,  Cengiz  SD,  et  al.  Clinical  diagnosis  and complications of paratubal cysts: review of the literature and report of uncommon  presentations.  Arch  Gynecol  Obstet  2012;285:1563–9. [PubMed] [Google Scholar].

11.Savelli L, Ghi T, De Iaco P, Ceccaroni M, Venturoli S, Cacciatore B. Paraovarian/paratubal cysts: comparison of transvaginal sonographic and pathological findings to establish diagnostic criteria. Ultrasound Obstet Gynecol. 2006;28(3):330-334. doi:10.1002/uog.2829

12.Samaha M, Woodruff JD. Paratubal cysts: frequency, histogenesis, and associated clinical features. Obstet Gynecol 1985;65:691–4. [PubMed] [Google Scholar]

13.Kazem Moslemi M, Yazdani Z. A Huge Ovarian Cyst in a Middle-Aged Iranian  Female.  Case  Rep  Oncol.  2010;3(2):165-170.  Published  2010 May 7. doi:10.1159/000314525.

14.Kassidi  F,  Moukit  M,  Ait  El  Fadel  F,  El  Hassani  ME,  Guelzim  K, Babahabib A, et al. Successful Management of a Giant Ovarian Cyst: A Case Report. Austin Gynecol Case Rep. 2017; 2(1): 1012.

15.Albers  C  E,  Ranjit  E,  Sapra  A,  et  al.  (January  23,  2020)  Clinician Beware, Giant Ovarian Cysts are Elusive and Rare. Cureus 12(1): e6753. doi:10.7759/cureus.6753