Dr.Rajshree D Katke*, Usha Kiran **, Mohit
Saraogi ***, Smita Sarode ****, Ravindra Thawal****
(* Medical Superintendant & Associate
Professor, ** Associate Professor, *** Assistant Professor, **** Post Graduate
Student. Department of Obstetrics & Gynecology, Cama & Albless
Hospital, JJ Group of Hospitals, Mumbai.
Abstract
We present to you the case report of a 42
year old woman with previous 3 caesarean sections (LSCS) who came to us with a
large pelvis mass corresponding to 32 weeks size. The patient was successfully
operated with a cystectomy followed by a total abdominal hysterectomy with
bilateral oophorectomy. The
histopathology report went on to indicate that she had a borderline type of
mucinous cystadenoma of the ovary which is a rare occurrence.
Introduction
Mucinous cystadenomas are benign
epithelial tumors of the ovary accounting for approximately 15% of all ovarian
tumors.[1] Mucinous
cystadenomas tend to arise from inclusions and invaginations of the celomic
epithelium of the ovary and persistence of mullerian cells, or from Wolffian
epithelium and teratomas.[2]
While mucinous cystadenomas themselves are not infrequent, majority of
them (80%) are benign while only 10% of them are borderline and another 10% are
malignant.[3] Operating on a giant mucinous cystadenoma can often
present as a surgical challenge due to its size as well as distortion of the
pelvic anatomy. On the other hand, any surgical intervention in a patient with
previous 3 lower segment caesarean sections (LSCS) can be a nightmare for any
gynecologist. In addition to bladder and bowel adhesions, there is a high
probability of iatrogenic trauma to the pelvic viscera intraoperatively leading
to possible life threatening complications. Hence performing a cystectomy
followed by hysterectomy in a patient of previous 3 LSCS with a giant mucinous
cystadenoma can be a particularly challenging affair often requiring a
multidisciplinary approach.
Case Report
A 42 year old woman, married since 27
years - P3L2 NND1 A1 with a history of previous 3 LSCS came to our Out Patient
Department (OPD) with complaints of distension of abdomen and abdominal
discomfort since the last one year. The patient gave history of weight gain of
6 kg over the last one year along with progressively increasing fatigue on
doing her daily activities. On direct questioning she gave a history of gastric
discomfort and dyspepsia which had aggravated over the last 3 months.
The patient also gave a history of a
gradual increase in abdominal girth, manifest as tightening of clothes . The
patient had consulted a private practitioner for the same and came to our OPD
with an ultrasonography (USG) of the abdomen and the pelvis which showed a large
cystic lesion arising from the pelvis, measuring 16x14x16 cm, with multiple
septae inside. On examination her general condition was fair, and her vital
parameters were stable. An abdominal examination revealed a 32 weeks sized tense,
cystic mass with restricted side to side mobility. The mass was smooth and non
tender. A speculum examination revealed a healthy cervix and vagina. On vaginal
examination the uterus could not be felt separate from the mass due to its
size. There was fullness in all the fornices and cervical mobility was
restricted. The patient was admitted and a CT scan of the abdomen and pelvis
was done for her. Her tumor markers ( CA 125, CEA, LDH and Beta HCG ) were sent
in addition to all the necessary routine investigations required for anesthesia
fitness for major surgery. Her tumor marker levelss were normal and the CT Scan
showed a well defined multiseptate cystic mass lesion arising from the right
adnexa, not separate from the ovary and extending into the abdominal cavity
(consistent with the USG). The impression was that of a benign right ovarian
cystic neoplasm.
Figure 1. CT scan of the abdomen and
pelvis.
A decision for exploratory laparotomy
with excision of the mass with frozen section was taken. A total abdominal
hysterectomy with bilateral salpingoophorectomy (TAH with BSO) was to be
performed based on the frozen section report. An oncosurgeon standby was
arranged for on the day of the surgery. An exploratory laparotomy was performed
under general anesthesia. A vertical midline incision was taken on the abdomen
over the scar of previous caesarean sections and extended 2 cm above the
umbilicus. A large cystic mass was seen in the abdominal cavity measuring
approximately 20x20x20 cm. Its outer wall was smooth and shiny with no evidence
of invasion of capsule. Peritoneal fluid was collected for cytology and the
mass was exteriorized. The mass could not be separated from the right ovary and
fallopian tube and it was clamped, cut and ligated by its pedicle.
Figure 2. The ovarian mass delivered
through the abdominal incision.
The mass measured 21x19.5x13 cm and
weighed 3.650 kg. It was multiloculated and filled with seromucinous fluid. No
solid areas or papillary excrescences suggestive of carcinomatous changes were
seen. It was sent for a frozen section. The report was a borderline mucinous
cystadenoma with an intestinal type of histology.
Figure 3. Dissection of the urinary
bladder from the front of the uterus.
The bladder was adherent to the anterior
uterine wall and was advanced up. It was gradually dissected sharply away from
the uterus lateral to medial till it could be pushed down significantly. During
dissection, a part of the uterine serosa had to be taken to prevent injury to
the bladder. Total hysterectomy and salpingo-oophorectomy of the other side
and partial omentectomy were done. The
postoperative course was uneventful and the patient was discharged on day 6 of
the surgery. The patient had a first follow up visit a week later when suture
removal was done. The wound was healthy and the patient was symptomatically
much better. The final histopathology report confirmed the diagnosis of frozen
section. The omental biopsy showed no malignancy. Peritoneal fluid showed no
malignant cells. A repeat follow up a month later showed the patient was very
comfortable. The patient has been asked to follow up 3 monthly for the first
year and then 6 monthly thereafter.
Discussion
Mucinous cystadenomas are rare benign
epithelial ovarian tumors which are commonly found in middle aged women and are
bilateral in 10 percent cases. These tumors are known to grow to massive sizes
with historical recordings of removal of a 137.4 kg tumor by O’hanlan in 1994.[2]
Our patient had a 21x19.5x13 cm mass that weighed 3.650 kg and could luckily be
removed intact despite her history of 3 caesarean sections in the past. Traditionally the epithelial lining of
mucinous cystadenomas can be one of 3 types – endocervical, intestinal or the
mullerian type. Our patient had a mucinous borderline tumor of the intestinal
type with only atypia. The patient fell into FIGO stage 1a for borderline
ovarian tumors.[4] The 5 year survival in such patients is usually
more than 99%.[5] The cytoplasm of epithelia of low malignant
potential mucinous tumours is more basophilic than the epithelium of mucinous
cystadenoma. They also show occasional evidence of inflammatory infilitrates.
In general in borderline tumors, the junction between the atypical epithelium
lining the papillary structures of the cyst wall of the tumor and the
underlying stroma is well defined (borderline tumors with atypia only – such as
in our patient). These tumors behave like benign tumors and are not usually
known to spread. However borderline tumors can occasionally present as
borderline with focal intraepithelial carcinoma which have been known to
metastasize occasionally.[5] The dissection of the adherent and
advanced bladder was an operative challenge with a high probability of injury
to the bladder. However the procedure went uneventfully. Borderline ovarian
tumors rarely metastasize, and when they do, they usually spread as
pseudomyxoma peritonei. Metastasis to the cervix in cases of borderline ovarian
tumors is extremely rare. As our patient had a borderline tumor with only
atypia a supracervical Hysterectomy could probably have been a reasonable
alternative for this patient in view of the bladder adhesions. This would not
have been possible if the tumor had been borderline with focal carcinoma.
However as there are no studies available on the 5 year survival rate in
patients with borderline mucinous cystadenomas having undergone a supracervical
hysterectomy – more studies are required
in this regard.
Conclusion
Managing a case of benign mucinous
cystadenoma can be a fairly straightforward procedure. However the line of
management is undefined and needs to be individualized in the case of
borderline tumors. Although a TAH with BSO with omentectomy with peritoneal
biopsies remains the procedure of choice in such cases (where the family is
complete), we may need to try alternative procedures (such as a supracervical
hysterectomy) in the case of preexisting complications).
References
1. Kemal RM, A massive ovarian Mucinous
Cystadenoma: A Case Report., Reproductive Biology and Endocrinology 2010, 8:24 Available
from: www.rbej.com/content/8/1/24.
2. de Lima SHM, dos Santos VM, Darós AC, Campos VP, Modesto FRD. A 57 year old Brazilian woman with a
Giant Mucinous Cystadenocarcinoma of the Ovary : A Case Report., Journal of
Medical Case Reports, 2014;8-82. Available from:
http://www.jmedicalcasereports.com/content/8/1/82
3.
Sebastian A, Thomas A, Regi A. Giant
Benign Mucinous Cystadenoma: A Case Report. Open Journal Of Obstetrics and
Gynaecology, 2012;2:220-222.
4.
Journal Article on the internet :
Patrono MG, Minig L, Diaz- Padilla I, Romero N, Moreno JFR, Donez JG.
Borderline Tumors of the ovary, current controversies regarding their diagnosis
and treatment. Ecancermedical science 2013;7:379. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869475/
5.
Lee, Kenneth R. M.D.; Scully, Robert
E. M.D.; Mucinous Tumors of the Ovary: A Clinicopathological Study of 196
Borderline tumors ( of intestinal type) and Carcinomas, Including an Evaluation
of 11 cases with ‘Pseudomyxoma Peritonei’; Am J Surg Pathol 2000;24
(11):1447-64.
Citation
Katke RD, Kiran U,
Saraogi M, Sarode S, Thawal R. Giant Borderline mucinous cystadenoma
with
previous 3 Caesareans. JPGO 2014 Volume 1 Number 9 Available
from: http://www.jpgo.org/2014/09/giant-borderline-mucinous-cystadenoma.html
http://www.jpgo.org/2014/09/giant-borderline-mucinous-cystadenoma.html
