Case Presentation
An 18 year old female patient was brought to the clinic with complain of heaviness in abdomen and abdominal pain. On per abdominal examination some cystic nonmobile mass was palpable up to 6cm above the umbilical level. Vital were in normal range. On ultrasonographic examination cystic mass of 17 x 10 x 8 cm was found. Right ovary was not seen separately. Another 7 x 6 cm cystic swelling was found arising from left ovary. Serum CEA and CA 125 was done & found to be 1.29 and 14.9 respectively, which is within normal limits. After preoperative fitness patient was taken to the operation theatre. Pfannenstiel incision was given considering patient’s age and cosmetic factors. With good anesthetic support and muscle relaxation exteriorization of cystic mass was possible. Mass was arising from the right side ovarian tissue and right fallopian tube was stretched out over the mass like a very thin strip. With skillful surgical technique the tube was gently separated from the mass and the cystic mass of about 19 x 15 x10 cm was taken (Figure-1). Right side ovary and tubes were preserved. The right fallopian tube was stretched to about 18-20 cm long. Serosa of tube was sutured with vicryl 4-0 in such a way that the tubal opening was bear right ovary and towards the ovary. Skillful and sterile salpingopexy to the ovarian tissue was done. On left side 8 x 7 cm cystic mass was separated and tube and ovary was preserved, closure done and post operative period was uneventful. Both cystic masses were sent for histopathological examination which turned out to be bilateral benign papillary serous tumors. Postoperative follow up after 1 week was done and stitches removed. Patient resumed the routine activity.
Discussion: The most common clinical presentations of ovarian cysts are abdominal pain, nausea and vomiting, and a history of previous episodes of similar pain and low grade fever [4, 5]. In pubertal girls, the differential diagnosis with functional cysts can involve some delay. A functional cyst is mainly a unilocular and anechoic cyst with thin borders. Second differential diagnoses of ovarian cysts are omental cysts. Omental cysts occur in all age groups, but most often they present in children and young adults. Other diagnoses may be mesenteric cysts, cysts arising from retroperitoneal structures like pancreatic pseudo cysts, urinary retention, bladder diverticulum, hydronephrosis, cystic lymphangiomas, choledochal cysts, splenic cysts, multicystic dysplastic kidney, gastrointestinal duplication cysts and large uterine tumors [7]. Malignant transformation is not well known but clonal origin of benign CA, borderline tumors and low-grade epithelial carcinomas is suspected as differential [3]. Management of ovarian cysts depends on the patient’s age, the size and structure of the cyst and menopausal status. Surgical management of cysts is by laparotomic or laparoscopic cyst excision or cystectomy with oophorectomy. In addition, the contralateral ovary should be examined and where it looks suspicious, a frozen section will assist in deciding whether to remove it or not [2, 6]. Some authors have emphasized that intact cyst removal, with gradual rolling of the mass off the inferior vena cava, is the optimal technique. On the contrary, Hunter et al. have reported that gradual decompression prevents rupture of the cyst capsule and greater dissemination [8]. The potential complication of repeated paracentesis is the intraperitoneal spillage of cyst components. This could result in tumor seeding of the peritoneal cavity or paracentesis tract if the cyst is malignant. Other complications associated with repeated paracentesis include infection, bleeding, and an increase in the number and density of peritoneal adhesions, making eventual cyst removal even more difficult [9]. In the cases of emergency surgery that do not allow waiting for results of tumor markers, decision of choice, laparoscopy versus laparotomy, can be based on size and structure of the enlarged ovary [1,9]. Low malignant recurrences have been reported more than ten years after initial surgery in the adult patient population, so it may be safe to assume that those diagnosed in adolescence should be observed into adulthood. Although adherence to long-term follow-up can be difficult, as evidenced by patient who was lost to follow-up since years, this should not alter the decision to perform a conservative surgical procedure in an attempt to preserve a patient’s fertility [10]. A gynecologist should go for Histopathological evaluation and blood biochemistry must be done in case of family history of any ovarian cancer. Germ cell tumors are the most important causes for giant ovarian masses in children, but epithelial tumors must not be forgotten in the differential diagnosis.