Non-Tender Huge Abdominal Mass in an Adolescent: Bilateral paraovarian cysts

Paraovarian cysts constitute about 10% of all adnexal masses in females and occur most commonly in the third and fourth decades of life. These cysts are benign and usually uncommon in adolescence. Such cysts pose a diagnostic challenge while distinguishing them from ovarian cysts clinically and during radiological investigations. We report a rare case of a 13-year-old female patient with bilateral paraovarian cysts, including a giant cyst in right mesosalpinx presenting to Sohar hospital, Oman in 2018. The definitive origin of the huge mass on the right side of abdominal cavity could not be established in the current case despite contrast enhanced computerized tomography. It was only on laparoscopic exploration that this mass was identified as a giant paraovarian cyst. Both the giant cyst and a smaller paraovarian cyst on the left side were enucleated with minimally invasive surgery while preserving the fertility of the patient. Only one other similar case of bilateral paraovarian cysts in an adolescent, including a giant cyst managed with laparoscopy, has been documented previously.

An incidental diagnosis of a giant paraovarian cyst in a female teenager: A case report

RATIONALE

Paraovarian cysts (PCs) are cystic tumors that can be encountered between the ovarian hilum and the ovarian fimbria located within the mesosalpinx and broad ligament, being usually diagnosed within the 3rd and 4th decade of life.

PATIENT CONCERNS

We report the case of a 15-year-old female admitted in our clinic for consciousness loss, who was incidentally diagnosed with a giant pelvic cystic at ultrasound.

DIAGNOSES

The magnetic resonance image showed a cystic mass of 170/140/85 mm, suggesting an origin from the left ovary, reaching the subhepatic area.

INTERVENTIONS AND OUTCOMES

The surgical intervention revealed 3 PCs, a giant one and 2 smaller ones within the large ligament. The cysts were removed by laparoscopic approach, and the histologic examination did not reveal any signs of neoplasia.

LESSONS

In addition to their rarity, giant PCs can be an incidental diagnosis in patients presenting unrelated symptoms resulting in increased difficulties related to the diagnosis. Moreover, the imagistic tools might not establish precisely the origin of these cysts, and therefore, the final diagnosis and treatment approach could be determined sometimes only during the surgical intervention.

Parovarian tumors of borderline malignancy

The incidence of a parovarian tumor is 10-20% of all uterine adnexal masses, however, it is benign in most cases, and a borderline or malignant tumor is extremely rare. The classification of disease stage and treatment is still controversial owing to its scarcity. We have managed one mucinous and two serous cystadenomas of borderline malignancy originating from paraovarian cysts in our institute over ten year. We report and discuss the cases herein.

Paratubal cyst: a case report

Paratubal cyst can undergo torsion that can make it difficult to diagnose since tubal cysts mimic ovarian cysts. Most reported cases of paratubal cysts have occurred in pediatric patients, and this type of cyst rarely causes symptoms of lower abdominal pain mimicking appendicitis. We present the case of a 28-year-old female who was taking Carbergoline for hyperprolactinoma associated with a pituitary adenoma who came to the ER at Henry Ford Hospital in Detroit experiencing severe abdominal pain. Her pain was not accompanied by nausea, vomiting or other gastrointestinal symptoms. A transvaginal ultrasound revealed a normal uterus with the right ovary containing a cyst measuring 3 cm. x 2 cm. She was released on analgesics and seen at the clinic at Henry Ford Hospital three days later. She was still experiencing pain and was given antibiotics and Darvocet. When the pain had not subsided 48 hours later, a decision was made to perform diagnostic laparoscopy. Surgery was performed 10 days later and a paratubal cyst was removed that was twisted twice on its pedicle. This case illustrates the fact that torsion of paratubal cyst should be included in the differential diagnosis of adnexal pain.

Parovarian cystadenoma: sonographic features associated with magnetic resonance and histopathologic findings

Differentiation between malignant and benign parovarian tumors is necessary before any surgery is planned, because the postoperative spread of ovarian cancers is well documented. Both malignant and benign parovarian tumors may contain intracystic projections, so their presence is not a differentiating factor. We describe the cases of 2 patients with parovarian cystadenomas that were evaluated using sonography, MRI, and histopathology in an attempt to begin to identify the sonographic characteristics of such lesions and correlate them with MRI and histopathologic findings. In both cases, sonography revealed a cystic mass that contained multiple small intracystic mural nodules, most of which were associated with the "Chinese hat" artifact. MRI findings confirmed the presence of the cystic masses and the nodules. Histopathologic findings confirmed the diagnosis of serous cystadenoma arising in a parovarian cyst; the intracystic nodules consisted of fibrotic tissue covered with a single layer of epithelium. Thus, the results of all 3 evaluations correlated well. This characteristic sonographic appearance may be useful in making an accurate preoperative diagnosis of parovarian cystadenomas.

Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings

INTRODUCTION

Uterine adnexal torsion is a rare and potentially lethal condition that may arise most unexpectedly in women of any age. It may be partial or complete, the later often resulting in necrosis, gangrene and peritonitis if untreated. The purpose of the study was to determine the spectrum of the histologic and gray-scale sonographic pictures in a series of surgically proven cases of uterine adnexal torsion.

METHODS

The study population for the pathologic analysis of twisted uterine adnexa included 92 patients with surgical confirmation of torsion of the uterine adnexa; all the patients were treated radically. All the pathology records were reviewed retrospectively over a 10-year period (from 1992 to 2002) by the coding of ovarian, fallopian tube or adnexal torsion. The gray-scale sonographic findings were analysed in 20 patients who underwent sonographic examination before surgery and adnexal torsion was confirmed at surgery.

RESULTS

Neoplasms constituted 46% (42/92) and cysts formed 48% (44/92) of all the twisted uterine adnexa. Normal-sized twisted adnexa were found in five patients (5%) while in one patient simultaneous torsion of both normal fallopian tubes was found (1%). The prevalence of the twisted neoplasms was 16 mature teratomas, nine serous cystadenomas, five mucinous cystadenomas, three serous borderline carcinomas, two fibroma/thecomas, two mucinous borderline carcinomas, two malignant granulosal-stromal cell tumours, one malignant dysgerminoma, one immature teratoma and one clear cell adenocarcinoma. The twisted cysts were 18 serous cysts, 11 paraovarian cysts, nine corpus luteum cysts, three hydrosalpinges, one mucinous cyst and one endometrioma. In one case the torsion of the right ovary was due to hyperstimulation of the ovaries with gonadotropin therapy for IVF treatment. Gray-scale sonographic examination demonstrated cystic lesions in 80% (16/20), solid masses in 5% (1/20) and normal adnexa in 15%; cul-de-sac fluid was present in 55% (11/20). Laparotomy revealed reactive cul-de-sac fluid in ten of these cases (50%) and haemoperitoneum in one (5%).

CONCLUSION

Adnexal torsion is most commonly associated with benign processes (89%) and usually occurs in patients under 50 years old (80%). The spectrum of sonographic findings varies due to the adnexal pathology, the degree and the duration of adnexal torsion.

A voluminous twisted paraovarian cyst in a 74-year-old patient: case report and review of the literature

Although paraovarian cysts rarely cause symptoms, they may be complicated due to massive size, torsion or internal haemorrhage from rupture. Moreover, benign or malignant neoplasms may occasionally develop in paraovarian cysts. The risks from voluminous ovarian or paraovarian cysts are due to severe cardiovascular, pulmonary, and circulatory problems including surgical and postoperative complications. We present a case of a 74-year-old patient who suffered from a twisted voluminous right paraovarian cyst. Her preoperative respiratory function required attention. The patient was treated surgically with good results and she showed notable improvement of her respiratory function, postoperatively. The maximum diameter of the mass was 26 cm and its total weight was 5,100 g. In addition, a simple cyst was found in the left ovary with a maximum diameter of 9.5 cm and total weight of 300 g. In conclusion, paraovarian cysts, even in elderly patients, can reach large sizes requiring awareness of the problems that these large masses may cause.

Value of ultrasound-guided fine-needle aspiration in the management of ovarian and paraovarian cysts

This study was designed to assess if cytology was accurate for an appropriate diagnosis of ovarian and paraovarian cysts, and if the ultrasound-cytology-estradiol (UCE) triad was sufficient to discriminate functional vs. nonfunctional cysts, the latter requiring surgical resection. One hundred twenty-two ultrasound-diagnosed adnexal cysts were punctured and surgically removed, and then subjected to cytologic and histologic examinations; 90 of these fluids were assayed for estradiol. Histologically, 30 cysts were functional and 92 were nonfunctional. A correct discrimination between functional and nonfunctional origin was obtained in 54.9% of cases with cytology, in 94.4% with estradiol assay, in 50.8% with ultrasonography, and in 97.8% with these three examinations combined (UCE triad). Among the 34 patients with no criteria of neoplastic origin (age >40, ultrasonographic findings), the UCE triad diagnosed six functional cysts. Therefore, 17.6% (6/34) of these young women could have avoided unnecessary surgery. Diagn. Cytopathol. 2000;22:70-80.

Paraovarian cystadenomas and cystadenofibromas: sonographic characteristics in 14 cases

PURPOSE

To describe the sonographic features of paraovarian cystadenomas.

MATERIALS AND METHODS

We searched the computerized pathology and radiology databases for cases of histopathologically proved paraovarian cystadenomas from January 1993 through December 1996 in which preoperative sonography had also been performed. Fourteen paraovarian cystadenomas or cystadenofibromas were identified in 14 patients aged 20-57 years. Sonographic and pathologic findings were correlated.

RESULTS

Three of the masses appeared as simple cysts sonographically. Of the remaining 11 masses, nine had solid nodular areas within the cyst; three had septations; and four had a thick wall, an irregular wall, or both at sonography. At sonography, four masses were thought to arise outside the ovary, four were erroneously thought to arise in the ovary, and the location was uncertain in six.

CONCLUSION

Paraovarian cystadenomas are cystic masses that usually contain one or more small solid nodules and occasionally contain septations.

Sonographic diagnosis of paraovarian cysts: value of detecting a separate ipsilateral ovary

OBJECTIVE

The purpose of this study was to determine the frequency with which sonographic detection of a normal separate ipsilateral ovary enables the diagnosis of paraovarian cysts.

MATERIALS AND METHODS

We reviewed the initial sonographic reports, sonograms, and medical records of 42 patients with surgically proved paraovarian cysts. All sonograms were obtained with a 3.5-MHz transabdominal probe. The location, size, shape, wall thickness, internal echoes of the cyst, and visualization or nonvisualization of the ipsilateral ovaries were recorded during sonographic examination.

RESULTS

Forty-six paraovarian cysts were identified in 42 patients. One patient had bilateral cysts, and one had multiple (four) unilateral cysts. A teratoma in one patient and an ovarian cyst in another coexisted with a paraovarian cyst in the same adnexa. With the exception of these two, 31 (76%) of 41 ovaries abutted by cysts were detected. All detectable ovaries were normal. With one exception, all cysts were thin walled and unilocular, and 43 of 46 were anechoic. During surgery, two patients were found to have cyst torsion, two were found to have papillary serous cystadenoma, and one was found to have both.

CONCLUSION

Unlike the findings of previous reports, our results indicate that most patients with paraovarian cysts have a separate, normal ipsilateral ovary that can be detected easily by means of transabdominal sonography, thus aiding in distinguishing paraovarian from true ovarian cysts.

Torsion of parovarian cyst--report of two cases

A parovarian cyst oxiginates from the tissue of the broad ligament, predominantly from mesothelium covering the peritoneum but also from paramesonephric and mesonephric remnants. Clinically, torsion of a parovarian cyst is uncommon, and it is difficult to distinguish it from torsion of other adnexal masses, an ovarian accident, appendicitis, etc. Recently, we experienced two cases of torsion of parovarian cysts. In one case, it was associated with 32 weeks' intrauterine gestation. In this case, pelvic sonography during the first and second trimester showed no cystic lesions. In the other case, a lower abdominal pain continued about two weeks. A sonogram revealed a very small cyst like a follicle. These twisted parovarian cysts were removed at laparotomy. The clinical and pathological features of the torsion of parovarian cysts are briefly discussed and the literature is reviewed.