Rajshree D. Katke
Department of Obstetrics & Gynaecology, Cama & Albless Hospital, Govt. Grant Medical College Mumbai, Maharashtra, India
Correspondence:
Dr. Rajshree D. Katke,
E-mail: drrajshrikatke@gmail.com
Received: 15 March 2014 Revised: 19 March 2014 Accepted: 23 March 2014
DOI: 10.5455/2320-1770.ijrcog20140636
ABSTRACT
Ovarian tumour is not a single entity, but a complex wide spectrum of neoplasms involving a variety of histological tissues. The most common are the epithelial tumours forming 80 % of all tumours. 80% are benign tumours, 10% borderline malignant and 8-10% malignant. Mucinous tumours represent about 8-10% of the epithelial tumours, they may reach enormous size filling the entire abdominal cavity.1 Here we would like to present a case of huge benign mucinous cystadenoma in a 50 year old female where the patient could not access medical care, and presented with huge tumour which lead to breathlessness and responded remarkably to surgical excision. The patient could go back to her normal life following the procedure.
Keywords: Huge benign mucinous cystadenoma, Mucinous cystadenoma
INTRODUCTION
Benign ovarian mucinous tumors are rare at the extremities of age, before puberty and after menopause. They are common between the third and the fifth decades. Mucinous cystadenomas may reach huge size as a matter of fact; many of the largest human tumours belong to this group. Grossly these tumours appear as rounded, ovoid or irregularly lobulated growths with a smooth outer surface of whitish or bluish white hue. The wall in many areas is so thin as to be translucent. Although adhesions to surrounding organs may be
present, they usually represent inflammatory adhesions and do not connote malignant extension. They are attached to the infundibulopelvic ligament by a relatively narrow pedicle that contains the markedly increased supply for the tumour. The content of the cyst is generally a clear viscid fluid, sometimes very thick at other times thin; a mixture of blood elements may give it a chocolate or brownish hue. This fluid is usually rather thin and flows freely at body temperature, but congeals and becomes gelatinous as it cools. The cut surface shows the cavity to be divided by septa into varying number of compartments or locules, these tumours have therefore often been spoken as a multilocular cyst. Microscopically, the distinctive feature of mucinous cysts is the characteristic single layer often undulating outline, of tall, pale-staining secretory epithelium, with nuclei placed at the basal poles of the cells, goblet cells are often seen, on occasion, even paneth and argentaffin cells are noted. Pseudomyxomaperitonii is often associated with mucinous cyst of ovary and mucocele of appendix and carcinoma of large bowel.
CASE REPORT
A 40 year female married since 30 years P1L1,
postmenopausal since 15 years presented on 30/11/13
with complaint of abdominal distension and pain since 6
months. Patient consulted at municipal hospital thane, but
symptoms were not relieved. On 25/09/13, CA 125 was
7.2 U/ml, CEA was 79 U (raised) and AFP - 3.3 U/ml.
On examination, her pulse rate was 82 beats/min, BP -
124/80 mmHg. She was mildly pale.
No lymphadenopathy on general examination. Breast
examination was normal findings. On per abdomen
examination - abdomen was markedly overdistended all
over. The skin was overstretched with prominent veins on
it. On palpation there is a very large palpable mass
arising from the pelvis extending to the epigastrium and
extended diffusely in both the flanks and all over the
abdomen. Consistency was cystic and at some places
firm. With large palpable lump with diffuse ill-defined
margins arising from pelvic region to epigastric region
with lower margins not palpable. Fluid Thrill was
positive. On 03/12/13, all haematological investigations
were normal; Pap smear done on 5/12/13 was suggestive
of atrophic smear with no evidence of malignancy. On
06/1 CT SCAN done on 09/12/13 was suggestive of
predominantly cystic large lesion 18.4 cm x 30 cm x 32
cm in abdominopelvic region with minimal thickened
septae, probably serous / mucinous cystadenocarcinoma.
Figure 1: Shows huge mucinous cystadenoma of the
ovary extending all over the abdomen.
Figure 2: The rectus sheath, muscle and peritoneum
adherent to the cyst wall and fused to become one layer.
Figure 3: Shows huge mucinous tumour of ovary
(20kg in total).
Figure 4: Left ovarian tumour weighing 3 kg.
Figure 5: Huge ovarian tumour of 20 kg.
ON 13/12 /13, exploratory laparotomy with tumour mass
excision with frozen section with total abdominal
hysterectomy with bilateral salpingo-oophorectomy done
under general and epidural anesthesia. Abdomen was
opened by taking midline incision. After opening the
rectus sheath the rectus muscle adherent to the posterior
rectus sheath with cautery the adhesions separated. After
that the thin out peritoneum completely fused with the
wall of the cyst all over and at some places the posterior
rectus sheath, peritoneum and cyst wall fused completely
and formed like one layer of the cyst wall. At some
places the peritoneum wall was very much thinned out
because of overstretching. There was no way to go to the
tumour so decompression of the tumor was done by
taking out the mucinous jelly like material of 10 liters
drained. After that we were able to go the peritoneal
cavity. There was a huge tumour extended to all over the
abdomen 60 cm x 40 cm x 35 cm. It is soft, cystic,
yellowish tumour spreading all over. Posteriorly it was
adherent to the colon the adhesions were separated with
fine dissection and cautery. There was another extension
of the tumour which is cystic mucinous tumour of size 25
cm x 30 cm x 28 cm from the left ovary adherent to the
left ureter and below to urinary bladder. Careful
dissection helped in separating tumour from the left
ureter and urinary bladder. The huge tumour separated all
the sides then delivered out and confirming the position
of the both the ureters keeping them away the pedicle
sealed and cut with cautery. Taken out the tumour
successfully. The total weight of the tumour measured as
20 kg. (Twenty kg) Haemostasis achieved by ligating the
vessels and ligating the pedicles. Total abdominal
hysterectomy with right sided salpingo-oophorectomy
with removal of huge ovarian tumour done. The
omentum was yellow jelly like. Surgeon explored the
bowel to see any other site of involvement of intestine.
Frozen section report came as Benign Mucinous
cystadenoma of the ovary, so pelvic lymph node
dissection was not done. Thorough wash was given.
Haemostasis achieved completely, after checking the
counts of instruments and sponges. Abdomen closed in
layers after keeping the drain in situ. Blood loss during
surgery was average. Her postoperative period was
uneventful. Stiches were taken out. Bilateral ureteric
stents removed and patient discharged. Patient came for
follow up; she was fine and resumed the work.
DISCUSSION Mucinous tumours of the ovary are usually evaluated
using ultrasound, computerized tomography scan, or
magnetic resonance imaging .These ovarian tumors may
be multi-septated, cystic masses with thin walls. They
may contain varying amounts of solid tissue which
consists of proliferating stromal tissue, papillae, or
malignant tumor cells. Tumour markers may also aid us
in telling us the origin of the tumour.3 Benign mucinous
cystadenomas comprise 80% of mucinous ovarian tumors
and 20% - 25% of benign ovarian tumours overall. The
peak incidence occurs be-tween 30 - 50 years of age.
Benign tumors are bilateral in 5% - 10% of cases.
Borderline mucinous cystadenomas make up about 10%
of mucinous ovarian neoplasm’s and are bilateral in 10%
of cases.
Figure 6: Computerized tomography imaging pictures
of the ovarian tumour.
In the modern era of medicine, such huge mucinous
ovarian tumours have become rare in the current medical
practice, as most of the cases are diagnosed early during
routine gynaecological examinations or incidental finding
on the ultrasound examination of the pelvis and abdomen.
Most of the patients who have large tumours they present
mainly with the pressure symptoms over the
genitourinary system leading to urinary complaints and
also pressure over respiratory system leads to respiratory
embarrassment. The role of imaging modalities like CT
scan and MRI gives better idea about the extension of the
tumour in the various quadrants of the abdomen and
consistency of the tumour. Management of ovarian cysts
depends on the patient’s age, the size of the cyst and its
histo-pathological nature. Conservative surgery as
ovarian cystectomy and salpingo-oophorectomy is
adequate for benign lesions.4 Frozen section is very
important to know the malignant variation of this tumour
and that helps in the management of the patient. As in the
huge tumours, the anatomical planes get distorted, so the
surgical expertise is required to prevent the
complications.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
REFERENCES
1. Wilfred Shaw, John Howkins, Gordon Lionel
Bourne. Disorders of the ovary and benign tumours.
In: Wilfred Shaw, John Howkins, Gordon Lionel
Bourne, eds. Shaw’s Textbook, 14th ed. London:
Churchill Livingstone; 2008: 334.
Howard W. Epithelial ovarian cancer. In: Jones,
Anne Colston Wentz, Lonnie S. Burnett, eds.
Novak’s Textbook of Gynaecology. 11th ed. UK:
Williams & Wilkins; 1988: 806-809.
3. Crum CP, Lester SC, Cotran RS. Pathology of
female genital system and breast. In: by Kumar V,
Abbas A, Fausto N, Mitchell R, eds. Robbins’ Basic
Pathology. 8th ed. USA: Elsevier Company; 2007:
Chapt. 19.
4. Alobaid AS. Mucinous cystadenoma of the ovary in
a 12-year-old girl. Saudi Med J. 2008;29(1):126-8.
For Full Article Link:
https://www.researchgate.net/publication/266208592
Department of Obstetrics & Gynaecology, Cama & Albless Hospital, Govt. Grant Medical College Mumbai, Maharashtra, India
Correspondence:
Dr. Rajshree D. Katke,
E-mail: drrajshrikatke@gmail.com
Received: 15 March 2014 Revised: 19 March 2014 Accepted: 23 March 2014
DOI: 10.5455/2320-1770.ijrcog20140636
ABSTRACT
Ovarian tumour is not a single entity, but a complex wide spectrum of neoplasms involving a variety of histological tissues. The most common are the epithelial tumours forming 80 % of all tumours. 80% are benign tumours, 10% borderline malignant and 8-10% malignant. Mucinous tumours represent about 8-10% of the epithelial tumours, they may reach enormous size filling the entire abdominal cavity.1 Here we would like to present a case of huge benign mucinous cystadenoma in a 50 year old female where the patient could not access medical care, and presented with huge tumour which lead to breathlessness and responded remarkably to surgical excision. The patient could go back to her normal life following the procedure.
Keywords: Huge benign mucinous cystadenoma, Mucinous cystadenoma
INTRODUCTION
Benign ovarian mucinous tumors are rare at the extremities of age, before puberty and after menopause. They are common between the third and the fifth decades. Mucinous cystadenomas may reach huge size as a matter of fact; many of the largest human tumours belong to this group. Grossly these tumours appear as rounded, ovoid or irregularly lobulated growths with a smooth outer surface of whitish or bluish white hue. The wall in many areas is so thin as to be translucent. Although adhesions to surrounding organs may be
present, they usually represent inflammatory adhesions and do not connote malignant extension. They are attached to the infundibulopelvic ligament by a relatively narrow pedicle that contains the markedly increased supply for the tumour. The content of the cyst is generally a clear viscid fluid, sometimes very thick at other times thin; a mixture of blood elements may give it a chocolate or brownish hue. This fluid is usually rather thin and flows freely at body temperature, but congeals and becomes gelatinous as it cools. The cut surface shows the cavity to be divided by septa into varying number of compartments or locules, these tumours have therefore often been spoken as a multilocular cyst. Microscopically, the distinctive feature of mucinous cysts is the characteristic single layer often undulating outline, of tall, pale-staining secretory epithelium, with nuclei placed at the basal poles of the cells, goblet cells are often seen, on occasion, even paneth and argentaffin cells are noted. Pseudomyxomaperitonii is often associated with mucinous cyst of ovary and mucocele of appendix and carcinoma of large bowel.
CASE REPORT
A 40 year female married since 30 years P1L1,
postmenopausal since 15 years presented on 30/11/13
with complaint of abdominal distension and pain since 6
months. Patient consulted at municipal hospital thane, but
symptoms were not relieved. On 25/09/13, CA 125 was
7.2 U/ml, CEA was 79 U (raised) and AFP - 3.3 U/ml.
On examination, her pulse rate was 82 beats/min, BP -
124/80 mmHg. She was mildly pale.
No lymphadenopathy on general examination. Breast
examination was normal findings. On per abdomen
examination - abdomen was markedly overdistended all
over. The skin was overstretched with prominent veins on
it. On palpation there is a very large palpable mass
arising from the pelvis extending to the epigastrium and
extended diffusely in both the flanks and all over the
abdomen. Consistency was cystic and at some places
firm. With large palpable lump with diffuse ill-defined
margins arising from pelvic region to epigastric region
with lower margins not palpable. Fluid Thrill was
positive. On 03/12/13, all haematological investigations
were normal; Pap smear done on 5/12/13 was suggestive
of atrophic smear with no evidence of malignancy. On
06/1 CT SCAN done on 09/12/13 was suggestive of
cm in abdominopelvic region with minimal thickened
septae, probably serous / mucinous cystadenocarcinoma.
ovary extending all over the abdomen.
adherent to the cyst wall and fused to become one layer.
Figure 3: Shows huge mucinous tumour of ovary
(20kg in total).
Figure 4: Left ovarian tumour weighing 3 kg.
ON 13/12 /13, exploratory laparotomy with tumour mass
excision with frozen section with total abdominal
hysterectomy with bilateral salpingo-oophorectomy done
under general and epidural anesthesia. Abdomen was
opened by taking midline incision. After opening the
rectus sheath the rectus muscle adherent to the posterior
rectus sheath with cautery the adhesions separated. After
that the thin out peritoneum completely fused with the
wall of the cyst all over and at some places the posterior
rectus sheath, peritoneum and cyst wall fused completely
and formed like one layer of the cyst wall. At some
places the peritoneum wall was very much thinned out
because of overstretching. There was no way to go to the
tumour so decompression of the tumor was done by
taking out the mucinous jelly like material of 10 liters
drained. After that we were able to go the peritoneal
cavity. There was a huge tumour extended to all over the
abdomen 60 cm x 40 cm x 35 cm. It is soft, cystic,
yellowish tumour spreading all over. Posteriorly it was
adherent to the colon the adhesions were separated with
fine dissection and cautery. There was another extension
of the tumour which is cystic mucinous tumour of size 25
cm x 30 cm x 28 cm from the left ovary adherent to the
left ureter and below to urinary bladder. Careful
dissection helped in separating tumour from the left
ureter and urinary bladder. The huge tumour separated all
the sides then delivered out and confirming the position
of the both the ureters keeping them away the pedicle
sealed and cut with cautery. Taken out the tumour
successfully. The total weight of the tumour measured as
20 kg. (Twenty kg) Haemostasis achieved by ligating the
vessels and ligating the pedicles. Total abdominal
hysterectomy with right sided salpingo-oophorectomy
with removal of huge ovarian tumour done. The
omentum was yellow jelly like. Surgeon explored the
bowel to see any other site of involvement of intestine.
Frozen section report came as Benign Mucinous
cystadenoma of the ovary, so pelvic lymph node
dissection was not done. Thorough wash was given.
Haemostasis achieved completely, after checking the
counts of instruments and sponges. Abdomen closed in
layers after keeping the drain in situ. Blood loss during
surgery was average. Her postoperative period was
uneventful. Stiches were taken out. Bilateral ureteric
stents removed and patient discharged. Patient came for
follow up; she was fine and resumed the work.
DISCUSSION Mucinous tumours of the ovary are usually evaluated
using ultrasound, computerized tomography scan, or
magnetic resonance imaging .These ovarian tumors may
be multi-septated, cystic masses with thin walls. They
may contain varying amounts of solid tissue which
consists of proliferating stromal tissue, papillae, or
malignant tumor cells. Tumour markers may also aid us
in telling us the origin of the tumour.3 Benign mucinous
cystadenomas comprise 80% of mucinous ovarian tumors
and 20% - 25% of benign ovarian tumours overall. The
peak incidence occurs be-tween 30 - 50 years of age.
Benign tumors are bilateral in 5% - 10% of cases.
Borderline mucinous cystadenomas make up about 10%
of mucinous ovarian neoplasm’s and are bilateral in 10%
of cases.
of the ovarian tumour.
In the modern era of medicine, such huge mucinous
ovarian tumours have become rare in the current medical
practice, as most of the cases are diagnosed early during
routine gynaecological examinations or incidental finding
on the ultrasound examination of the pelvis and abdomen.
Most of the patients who have large tumours they present
mainly with the pressure symptoms over the
genitourinary system leading to urinary complaints and
also pressure over respiratory system leads to respiratory
embarrassment. The role of imaging modalities like CT
scan and MRI gives better idea about the extension of the
tumour in the various quadrants of the abdomen and
consistency of the tumour. Management of ovarian cysts
depends on the patient’s age, the size of the cyst and its
histo-pathological nature. Conservative surgery as
ovarian cystectomy and salpingo-oophorectomy is
adequate for benign lesions.4 Frozen section is very
important to know the malignant variation of this tumour
and that helps in the management of the patient. As in the
huge tumours, the anatomical planes get distorted, so the
surgical expertise is required to prevent the
complications.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
REFERENCES
1. Wilfred Shaw, John Howkins, Gordon Lionel
Bourne. Disorders of the ovary and benign tumours.
In: Wilfred Shaw, John Howkins, Gordon Lionel
Bourne, eds. Shaw’s Textbook, 14th ed. London:
Churchill Livingstone; 2008: 334.
Howard W. Epithelial ovarian cancer. In: Jones,
Anne Colston Wentz, Lonnie S. Burnett, eds.
Novak’s Textbook of Gynaecology. 11th ed. UK:
Williams & Wilkins; 1988: 806-809.
3. Crum CP, Lester SC, Cotran RS. Pathology of
female genital system and breast. In: by Kumar V,
Abbas A, Fausto N, Mitchell R, eds. Robbins’ Basic
Pathology. 8th ed. USA: Elsevier Company; 2007:
Chapt. 19.
4. Alobaid AS. Mucinous cystadenoma of the ovary in
a 12-year-old girl. Saudi Med J. 2008;29(1):126-8.
For Full Article Link:
https://www.researchgate.net/publication/266208592
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