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.