A rare case of infection and spontaneous rupture in ovarian mucinous cystadenoma

Ovarian cysts exhibit variable clinical presentations depending on their size, type and resulting sequelae. Rupture of ovarian cysts is infrequent, and cyst infections are even rarer. Here, we report an unusual case involving a young, non-pregnant woman who presented acutely with features of peritonitis and sepsis and was found to have a complex adnexal mass. Following a rigorous diagnostic evaluation, which included an urgent exploratory laparotomy and salpingo-oophorectomy, common diagnoses including tubo-ovarian abscess, endometriotic cyst and pelvic tuberculosis were ruled out. Instead, she was diagnosed with an ovarian mucinous cystadenoma that had become infected, possibly due to pelvic inflammatory disease, leading to spontaneous rupture. Such a presentation has rarely been reported, especially in a non-pregnant setting. Therefore, we emphasise the importance of considering this rare complication as a potential differential diagnosis in similar clinical presentations and discuss the management implications, including the importance of adequately treating pelvic inflammatory disease.

A case report of huge pancreas mucinous cystic neoplasm during pregnancy: How doctors think

RATIONALE

Pancreas mucinous cystic neoplasm (PMCN) is uncommon, and its occurrence during pregnancy is rare. The management of PMCN during pregnancy, including diagnosis and surgical timing, is a great challenge.

PATIENT CONCERNS

A nontender epigastric mass of the upper abdomen was detected by palpation in a 35-year-old woman, gravida 2, para 1, during the 36th week of gestation. She was referred to our institution for further evaluation.

DIAGNOSES

Magnetic resonance imaging (MRI) showed a multilocular cystic mass in the body and tail of the pancreas (16.7/12.1/17.6 cm), well-circumscribed with a hyper signal on T2-weighted MRI images. The diagnosis of a pancreatic cyst, probable mucinous, was established.

INTERVENTIONS

The patient was informed of the possibilities of malignancy, rapid growth, and rupture of the tumor. After a laparotomy and cesarean section, a large cystic tumor was discovered adherent to the pancreas, spleen, mesocolon, and retroperitoneum. The spleen was preserved since there was no evidence of invasion. According to macroscopic examinations, the tumor measured 18 cm was filled with a dark yellow-brownish mucinous fluid and did not appear to communicate with the pancreatic ducts.

OUTCOMES

After six months of follow-up, there were no signs of recurrence in the patient.

LESSONS

PMCN may need to be surgically resected in cases characterized by malignancy risk during pregnancy. As female sex hormones may influence the behavior of PMCN during pregnancy, surgical timing should be determined based on the stage of pregnancy, malignancy status, and condition of the mother and fetus.

[Pseudoascitis by giant ovaric cyst]

The term pseudoascitis is used in patients who give the false impression of ascites, with abdominal distension but without peritoneal free fluid. The case of a 66-year-old woman, hypertensive and hypothyroid with occasional alcohol consumption, who consults due to progressive abdominal distension of 6 months of evolution and diffuse percussion dullness is presented, in whom a paracentesis is performed with the wrong endorsement of examination ultrasound that reports abundant intrabdominal free fluid (Fig. 1), later finding in the CT scan of the abdomen and pelvis an expansive process of cystic appearance of 295mm x 208mm x 250mm. Left anexectomy is programmed (Fig. 2) with pathological report of mucinous ovarian cystadenoma. The case report refers to the availability of the giant ovarian cyst within the differential diagnosis of ascites. If no symptoms or obvious signs of liver, kidney, heart or malignant disease are found and / or ultrasound does not reveal typical signs of intra-abdominal free fluid (fluid in the bottom of the Morrison or Douglas sac, presence of floating free intestinal handles), a CT scan and / or an RMI should be requested before performing paracentesis, which could have potentially serious consequences.

Postmenopausal woman with 24 kgs ovarian mucinous cystadenoma: a rare case report

A case of a 53-year-old postmenopausal woman presenting a giant ovarian cystic mucinous tumor weighing 24 kg is reported here. When she was seen first at our outpatient clinic, she had gross abdominal distension since 2 years, and she complained of unbearable aggressive pain. Her computed tomography (CT) scan was done which came suggestive of ovarian serous cystadenoma of large massive size 35 x 40 x 32 cm with moderate ascites. On exploratory laparotomy, a giant, totally cystic, vascularized and smooth mass attached to the right ovary was encountered. On the postoperative tenth day, she was discharged without any problem. Histopathology report of the right ovarian cystic mass came suggestive of multiloculated cyst with capsule intact with Borderline Mucinous tumor of right ovary weighing 24 kg. This is both one of the largest known examples in the literature and the largest ovarian cyst ever seen at our institution.

[Pancreatic mucinous cystadenoma with atypical clinical presentation]

We present a 33-year-old patient with atypical clinical course of pancreatic mucinous cystadenoma. The tumor had connection with pancreatic ductal system and led to bleeding into cystic cavity. This contributed to incorrect preoperative diagnosis of post-necrotic cyst. The final diagnosis of mucinous cystadenoma was established after histological examination. Distal pancreatectomy excluded incorrect treatment.

Intestinal-type mucinous ovarian carcinoma arising from a seromucinous precursor lesion

OBJECTIVE

Mucinous ovarian carcinoma is a tumor with gastrointestinal differentiation, which is not associated with endometrial-type (endometriotic or seromucinous) precursors. Here, we describe a peculiar case of mucinous ovarian tumor with intestinal differentiation arising in a seromucinous lesion, which may represent a distinct entity.

CASE PRESENTATION

A 58-year woman underwent surgery due to a 14.5-cm ovarian mass with lymph nodal, peritoneal, omental and colorectal involvement. Histological examination with ancillary immunohistochemical analysis has been performed. Histologically, the mass was a carcinoma with intestinal differentiation and expansile growth pattern, arising in a seromucinous cystadenoma with intestinal metaplasia. Both the carcinoma and the metaplasia showed loss of Müllerian markers (estrogen and progesterone receptors, PAX8) and positivity for intestinal-type markers (cytokeratin 20, CDX2).

CONCLUSIONS

Our case may represent the ovarian counterpart of endometrial gastrointestinal-type carcinoma, which is an aggressive entity developing from gastrointestinal metaplasia of the endometrial epithelium. Acknowledging the existence of such entity might be relevant in terms of diagnosis and patient management.

Pulmonary mucinous cystadenoma complicated with infection: A rare case report

RATIONALE

Mucinous cystadenoma is a benign tumor that is commonly found in the pancreas, ovaries, or appendix, but is rarely encountered in the lungs. Worldwide, only a few reported cases of these tumors originate in the lungs. Herein, we analyzed the imaging features of a case of pulmonary mucinous cystadenoma (PMCA). To the best of our knowledge, this is the first reported case of PMCA complicated by significant infection.

PATIENT CONCERNS

A 57-year-old man was admitted to our hospital with blood in sputum for more than 2 months. Serum laboratory examination showed significantly elevated leukocyte and tumor marker, carcinoembryonic antigen. Enhanced thoracic computed tomography and whole-body positron emission tomography/computed tomography showed a cystic-solid ill-defined mass in the right upper lung.

DIAGNOSIS

The tumor was considered malignant, both clinically and radiologically.

INTERVENTIONS

The patient underwent right upper lobe tumor resection and mediastinal lymph node dissection.

OUTCOMES

Postoperative specimen pathology was diagnosed as PMCA with infection. The patient was not administered any further treatment. The patient was alive without any recurrence or metastasis of the tumor after 2 years of follow-up.

LESSONS

Preoperative diagnosis of PMCA with atypical imaging and clinical manifestations is extremely difficult. This is the first reported case of PMCA complicated by a significant infection that was misdiagnosed preoperatively as a malignancy.

[Pancreatic cystic neoplasms: a clinical dilemma]

Pancreatic cystic neoplasms are increasingly detected in the general population. Although most of these lesions are benign, some are (pre)malignant and require follow-up or even surgical intervention. Three cases are presented and used to discuss the clinical implications of the renewed European Guideline on pancreatic cystic neoplasms in which relative and absolute indications for resection are proposed. In the first case, a pancreatic cystic lesion was found on abdominal ultrasound in a 77-year old female patient. After endoscopic ultrasound was performed, a serous cystic neoplasm was diagnosed without need for surveillance. In a 57-year old male, an abdominal MRI was performed to further assess an incidentally found pancreatic cystic lesion. Based on the MRI, a side-branch intraductal papillary mucinous neoplasm (SB-IPMN) was diagnosed and yearly surveillance was initiated. A 61-year old male underwent a laparoscopic distal pancreatectomy because of a mixed-type IPMN (MT-IPMN). The pathological results showed an IPMN with high-grade dysplasia.

[Mucinous cystadenoma of the ileocecal valve. Uncommon intestinal tumor in a oneyear-old boy. Case report]

Mucinous cystadenoma is usually found in the ovary, pancreas and appendix but its presentation in the intestine is extremely rare. In this case report we present an infant with partial intestinal occlusion due to a mucinous cystadenoma of the ileocecal valve. We performed an excision of the terminal ileum, ileocecal valve, cecum and appendix, followed by ileocolic anastomosis. The patient did well after the procedure and recovered uneventfully. To our knowledge, this is the first case report of this tumor in this location.

Mucinous Ovarian Tumors

Ovarian mucinous tumors range from benign cystadenomas to borderline tumors to frankly malignant adenocarcinomas, and may display either intestinal-type morphology or, less frequently, endocervical-type differentiation. The latter category has been the subject of recent controversy owing to its morphologic overlap with so-called "seromucinous" ovarian tumors, a group that shares more molecular features with endometrioid tumors than it does with either serous or mucinous ovarian neoplasias. Endocervical-type differentiation in ovarian mucinous tumors may also represent an endocervical metastasis. Distinction of primary ovarian mucinous tumors from gastrointestinal metastases can be difficult, as the morphology of intestinal-type ovarian mucinous primaries sometimes differs only subtly if at all from gastrointestinal metastases.

[Laparoscopic appendectomy for mucinous cystadenoma of the appendix]

Treatment of acute and chronic appendicitis is still an actual problem. There are some rare courses of the disease besides well-known complications of appendicitis. Mucocele is one of the rarest forms of chronic appendicitis. Mucocele is not accompanied by clinical symptoms and diagnosed accidentally in more than 25% of cases. The most serious complication of mucocele of the appendix is malignization observed in up to 36% of cases. Ultrasound, CT and colonoscopy are the most effective methods of perioperative diagnosis. Unclear symptoms, delayed diagnosis and surgical treatment increase the risk of complications (i.e. cystadenocarcinoma).

Surgical Treatment of a Mucinous Cystic Neoplasm in a Young Female Patient - A Case Report

The major challenge in the evaluation of pancreatic cystic neoplasms is identifying lesions with malignant potential or signs of malignancy. Overall, the risk of malignancy in incidentally detected pancreatic cysts is low. Pancreatic cystic neoplasms with malignant potential are: serous cystic tumors (SCTs), mucinous cystic neoplasms (MCNs), intraductal papillary mucinous neoplasms (IPMNs) and solid pseudopapillary neoplasms (SPNs). The risk for developing malignancy is very low for SCTs, moderate to high in MCNs, solid pseudopapillary tumors and some IPMNs (up to 70 percent for main-duct IPMNs). We present a thirty-five years old female patient, without risk factors for the occurrence of pancreatic cancer was diagnosed via clinical examination and crosssectional imaging of the abdomen with a 7 cm cystic lesion located in the pancreatic body and tail, in the context of gastric outlet obstruction and upper abdominal pain with no improvement following conservative treatment. A distal pancreatectomy was thus performed, with favorable postoperative outcome. The histopathology examination described a non-invasive mucinous cystic neoplasm with low grade dysplasia. Many pancreatic cysts can be followed with surveillance imaging, through an algorithm which combines CT scan, MRI or endoscopic ultrasound. The decision to recommend surgery should take into account factors such as the patient's age and general health, the malignant risk of the specific lesion, potential complications and the suspicion for malignancy.

Clinicopathological Features and Management of Appendiceal Mucoceles: A Systematic Review

Appendiceal mucoceles (AMs) are rare mucin-containing neoplasms with malignant potential. Lack of evidence-based data exists defining clinicopathological features for management. MEDLINE search between 1995 and 2015 was performed using search criteria "Appendix mucocele." Systematic review of patient-, pathologic-, and treatment-related characteristics was performed and data analyzed. Among 276 cases of non-perforated AMs, 163 (59%) patients were female, with variable and nonspecific presentation. Patients were treated with appendectomy (52.1%), right hemicolectomy (17.6%), partial cecectomy (17.2%), and ileocecetomy (13.1%). Pathologic evaluation revealed the following: cystadenoma/low-grade appendiceal mucinous neoplasm (54%), unspecified/benign (25%), retention cyst (14.1%), cystadenocarcinoma (4.2%), and mucosal hyperplasia (2.9%). All 11 (4.2%) patients with cystadenocarcinoma were female (P = 0.004), odds ratio for malignancy 1.07 times higher for women. Synchronous colonic malignancy was reported in three patients (27%) with cystadenocarcinoma (P = 0.007), odds ratio of 12.1. AMs have low risk for malignancy. Treatment should begin with appendectomy-only and subsequently guided by pathologic diagnosis.

Diagnosis, morphopathological profile and treatment of mucinous cystadenoma of the pancreas - a single center experience

AIM

Pancreatic mucinous cystadenoma (MCA) occurs almost exclusively in perimenopausal women and represents between 10% and 45% of cystic neoplasm of the pancreas, being considered a premalignant lesion.

MATERIALS AND METHODS

From 1983 to 2017, 31 patients underwent surgery for MCA of the pancreas in our Center. The median age was 47 years (range 17-81 years). All data were obtained retrospectively.

RESULTS

The female∕male gender ratio was 14.5∕1. Most of the patients (90.3%) were symptomatic. The most common clinical manifestation was non-specific abdominal pain (58.06%), followed by fatigue and vomiting. The median cyst size was 7 cm, with a range between 2 cm and 15 cm. There were 35 procedures in 31 patients (in four patients the resection was preceded by a drainage procedure). From the 28 resections, most of them (89.28%) were performed by an open approach; a minimal invasive approach was used in three patients (robotic - two; laparoscopic - one). Most of the resections (82.14%) were distal pancreatectomies. In all cases, the final diagnosis was based on histological examination that revealed columnar epithelium and ovarian-type stroma. Postoperative complications occurred in 10 (34.48%) patients. Postoperative mortality was 3.44% (one patient) by septic shock secondary to acute postoperative pancreatitis.

CONCLUSIONS

MCAs represent a rare pancreatic pathology with challenging diagnostic and therapeutic implications. Multi-detector computed tomography (MDCT) scan, endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI)∕magnetic resonance cholangiopancreatography (MRCP) are useful in the differential diagnosis with other pancreatic fluid collections and treatment. Oncological surgical resections are recommended. Histopathological examination establishes the final diagnosis. The most common postoperative complication is pancreatic fistula.

Urachal borderline mucinous cystadenoma: A rare case report and literature review

RATIONALE

Urachal borderline mucinous cystadenoma is very rare and has only 9 cases in the current literature with the biological behavior between adenoma and adenocarcinoma.

PATIENT CONCERNS

We reported a 41-year-old man with moderate lower abdominal pain, and the imaging examination found an irregular cystic lesion extending from umbilicus to the dome of urinary bladder with significant separations and calcifications.

DIAGNOSES

The diagnosis was confirmed according to the specific anatomical location and pathological examination which was proved as mucinous cystadenoma with low malignant potential.

INTERVENTIONS

The patient undertook radical excision and partial cystectomy.

OUTCOMES

His postoperative condition was good.

LESSONS

Urachal borderline mucinous cystadenoma can be located by image examination, which may also offer several diagnostic tips according to separation, calcification, and enhancement in computed tomography scan. When combined with pathological findings, qualitative diagnosis can be determined. Surgical resection should be chosen as an optimal treatment. Our present study reviewed the clinical and biological information of all previous cases which were diagnosed as urachal borderline mucinous cystadenoma and we supplemented more data for further study.

Benign, premalignant and malignant pancreatic cystic lesions: the pathology landscape

Pancreatic cystic lesions are being increasingly detected in last years. Pancreatic cysts can be classified grossly into pseudocysts and true cysts. In the true cysts group, it is important to distinguish mucinous from non-mucinous cysts because the former are considered being premalignant lesions. In this article the major types of pancreatic cysts are reviewed, with emphasis on the histopathological aspects. Molecular markers in the cyst fluid are being increasingly studied in recent years ; the clinical utility of such biomarkers should be addressed in future studies.

Appendiceal mucinous neoplasms: an uncertain nosological entity. Report of a case

INTRODUCTION

Appendiceal mucocele is a relatively rare condition characterized by progressive dilation of the appendix caused by intraluminal accumulation of mucoid substance. Its incidence is 0.07 - 0,63% of all appendectomies performed.

CASE REPORT

We report the case of a 70-year-old man who came to our observation with gravative pain in right lower abdominal region. A computed tomography abdominal scan revealed a cystic/tubular structure like an appendicular mass with wall enhancement but without calcifications suggestive of a mucocele. Into peritoneal cavity we found profuse mucinous material with a 1,5 cm size parietal nodule. We also identified a free perforation of the cecum with consensual spillage of gelatinous material mimicking a pseudomyxoma peritonei. We decided to perform a right hemicolectomy with excision of peritoneal lesion.

DISCUSSION

The controversy in the pathologic terminology can give rise to a clinical dilemma in terms of the management and follow-up plans. For mucosal hyperplasia and cystadenoma simple appendectomy is curative. Only in case of large base of implantation it may be necessary the resection of the ileum and caecum or right hemicolectomy. In case of mucinous cystoadenocarcinoma authors perform a right hemicolectomy.

CONCLUSION

Appendiceal mucinous neoplasms are different pathological entities. The correct surgical management depends on size and location of lesion. A preoperative diagnosis is obviously needed in order to perform the correct treatment. CT abdominal scan is the better diagnostic tool, but different authors show their inability to reach a preoperative diagnosis in the larger majority of cases.

Mucinous ductal ectasia of the biliary tree secondary to mucous metaplasia: A case report

Mucinous ductal ectasia is an uncommon disorder, characterized by ductal dilatation and filling with thick, viscid mucus, described in the pancreas. We report a case of mucinous ductal ectasia of the biliary tree. The cause of the mucus production was mucous metaplasia in the biliary epithelium. The patient was followed for 16 years, treated with serial saline flushings of the biliary tree whenever he became symptomatic.

Pre-operative Identification and Surgical Management of the Appendiceal Mucocele: A Case Report

An appendiceal mucocele (AM) is an uncommon differential in the patient being evaluated for acute appendicitis. Although often asymptomatic, AMs can clinically mimic acute appendicitis, and preoperative distinction between these processes facilitates optimal management. We report the case of a 60-year-old male with an AM presenting with nausea and periumbilical pain radiating to the right lower quadrant. Literature relevant to the diagnosis and treatment of AMs is reviewed, with emphasis on diagnosis through radiographic imaging and surgical management. Abdominal CT scan or ultrasound are useful in identifying AMs preoperatively. A decision to perform a right hemicolectomy should be influenced by the criteria reported by Gonzalez-Moreno. The safety of the laparoscopic resection relative to an open appendectomy is debated.

Sarcoma-Like Mural Nodule in a Borderline Mucinous Tumour of Ovary

A 37-year female presented with complaint of lower abdominal pain and amenorrhoea to the Military Hospital, Rawalpindi. Ultrasound of pelvis showed a right adnexal cystic lesion. On investigation, CA-125 was raised. Her MRI scan of pelvis revealed a right adnexal mass of fluid intensity measuring 15.2 x 12.9 x 9.2 cm. Right ovarian cystectomy was performed and the specimen was sent for histopathological examination. Grossly, the mass was cystic in appearance and measured 13.5 x 10 x 10 cm. On sectioning, it was unilocular and filled with turbid material. The cyst wall showed multiple papillary structures along with a nodule measuring 1.1 x 1 cm. Microscopically, the sections revealed borderline mucinous tumour with a sarcoma-like mural nodule composed of spindle shaped cells and epulis-like giant cells. Sarcoma-like mural nodules are rare nodules which are associated with mucinous tumours of the ovary. However, they have excellent prognosis and should not be interpreted as malignant.

Appendiceal mucocele - Case Report and Review of the Literature

Appendiceal mucocele (AM) was described for the first time by Rokitansky in 1842.1 Its incidence is 0.2 - 0.4% of all apendectomies performed, as it is observed predominantly in women with the ratio of 4/1 versus men and most frequently at the age of 50.2,3 We present to your attention a 64-year-old woman, who was referred to diagnostic further clarification after a preventive gynaecologic exam. Appendiceal mucocele with retrocecal location, enveloped by additional Jackson'™s membranes was determined intraoperatively. The formation has been dissected and appendectomy was performed without mucocele integrity being compromised. The permanent histological specimen revealed mucinous cystadenoma with clear resection lines, without any data on the appendiceal base being affected. The patient was discharged on the third day after surgery without any complications, and further follow-up was scheduled in 6 months.

Management of pancreatic cysts: a review of the current guidelines

The number of patients diagnosed with cystic pancreatic neoplasms (CPN) has increased significantly during the last decade due to the widespread use of cross-sectional imaging. These CPN consist of a heterogeneous group of neoplastic and non-neoplastic lesions with variable histopathological features, clinical presentation, and outcome. Until now we are not able to reliably identify all CPNs that require additional analysis, surgical resection or surveillance. Hence, physicians and surgeons are confronted with a difficult dilemma as they do not want to miss a diagnosis of pancreatic carcinoma, but this often leads to the risk of over- or misuse of diagnostic examinations with a risk of complications and increased health care costs. Currently, four expert consensus guidelines on cystic lesions of the pancreas are available. Unfortunately, recommendations vary considerably between these guidelines. The purpose of this review therefore was to compare the different guidelines and elaborate upon the topics where these guidelines disagree.

Mucocoele and mucinous tumours of the appendix: A review of the literature

INTRODUCTION

Mucocoele of the appendix is rarely encountered but consultant general surgical and trainees must be aware of it as a differential diagnosis, due to the nuances associated with its management. We aimed to provide a comprehensive review of the current literature concerning this rare surgical pathology.

METHODS

Search terms "appendi*", "tumour", "malignancy", "mucino*" and "cystadenoma" were used in combination to identify papers from PubMed. Abstracts and full text were manually reviewed to identify suitable papers.

RESULTS

Full search results included 311 articles. Review of titles and abstracts led to further full text review of 46 articles. Of these 30 were selected for inclusion based on relevance, adequate sample size and recent publication date.

DISCUSSION

Mucocoele of the appendix describes dilatation with associated luminal mucin and can result from benign and malignant processes. It contributes 0.2-0.7% of all appendiceal pathologies. The most common presenting symptoms are abdominal pain and a palpable mass in the right iliac fossa. Computed tomography of the abdomen and pelvis is key in facilitating diagnosis, although CEA and CA19-9 also have a role. The major complication of malignant causes of mucocoele is progression to pseudomyxoma peritonei. Treatment is surgical with or without chemotherapy depending on the underlying cause. Prognosis depends on aetiology.

CONCLUSION

Mucocoele of the appendix is a rare diagnosis. However, given the possibility of neoplastic peritoneal dissemination, it should be considered as a diagnosis, especially in older females with non-specific symptoms similar to appendicitis.

[Modern imaging of liver and pancreatic neoplasms]

Modern imaging modalities play an outstanding role in the detection, characterization, staging, therapy planning, treatment outcome evaluation and follow-up of patients with liver and pancreatic neoplasms. Diagnostic performance and accuracy of the available modalities are continuously improving therefore, it is necessary to overview from time to time the diagnostic protocols and algorithms.