Extraovarian primary seromucinous cystadenoma masquerading as mesenteric cyst
- Kishor R J ,
- Bhuvaneshwari Harikrishnan ,
- Naveen Alexander and
- Veena Bheeman
- General Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
- Correspondence to Dr Naveen Alexander; naveenalexander@yahoo.co.in
Abstract
We report an interesting case of extraovarian, primary seromucinous cystadenoma, which presented as a mesenteric cyst. A 31-year-old woman came with complaints of lower abdominal pain for 2 years, which is intermittent and aggravated during the menstrual cycle. On examination, her vitals were within normal limits; per abdominal examination revealed 7×7 cm mass in the right lumbar and right hypochondrium with well-defined margins. A Contrast-enhanced whole abdomen done showed a thin-walled of cyst of size 7×8×9 cm in the right lumbar region abutting and replacing the mesenteric border of ascending colon suggesting of mesenteric cyst. Patient underwent laparoscopic excision of mesenteric cyst. Histopathology revealed seromucinous cystadenoma without ovarian stroma.
Background
Seromucinous cystadenoma of the ovary is a new class of ovarian neoplasm introduced by WHO in 2014.1 These tumours exhibit both serous and mucinous features. These cases are frequently associated with endometriosis and involve both ovaries. Here, we present a rare case of primary seromucinous cystadenoma of extra ovarian origin, which presented as abdominal cyst. Surgical excision, either laparoscopic or open approach, remains mainstay treatment for such cases.
Case presentation
The patient was a 31-year-old woman with no known comorbidities presented with intermittent, dull aching lower abdominal pain for 2 years, which was insidious in onset, gradually progressive and aggravated during menstrual cycle. There was no abnormal vaginal discharge or change in bowel habits. She had undergone previous two lower segment caesarean sections. She had a history of cyclical pain during menstruation at Caesarean section scar site for which she had undergone scar excision and diagnosed to have scar endometriosis.
On examination, her vital signs were within normal limits. On abdominal examination, right lumbar region tenderness presents, lower C section scar presents, a firm mass of size 7×7 cm in the right lumbar and right hypochondrium with well-defined borders was palpable, mass immobile. No free fluid was noted. Per vaginal and per rectal examinations were normal.
Investigations
Routine blood investigations were within normal limits. Contrast-enhanced CT of whole abdomen showed a thin-walled, nonenhancing cyst of size 6.7×7.5×9.3 cm, volume 233 cc in the right lumbar region abutting and displacing the ascending colon anteriorly and superiorly (figure 1A,B). Ovaries and fallopian tube were found to be normal and separate from the cyst, and two foci of scar endometriosis were seen. No pathologically enlarged abdominal, para-aortic or inguinal lymph nodes were noted. An imaging diagnosis of mesenteric cyst was made.
(A) CT axial section showing thin-walled cyst in the right lumbar region. (B) CT sagittal section showing cyst abutting and replacing the ascending colon.
Treatment
Patient was taken up for laparoscopic excision of mesenteric cyst. A 5 mm camera port was made in palmer’s point, and a cyst of size 10×10 cm was noted replacing the medial border of ascending colon (figure 2A,B). Uterus was found adherent to the anterior abdominal wall with omental adhesions to the anterior abdominal wall and fundus of the uterus. Ovaries and fallopian tube were found to be normal. A 10 mm and a 5 mm working port were made in the left lumbar region and suprapubic region, and cyst was skeletonised from the surrounding structure. Cyst excised in toto. Specimen was sent for histopathological examination. On gross examination, the inner surface of the cyst wall was smooth with grey-white surface with no solid or papillary areas. Microscopic section of cyst showed cyst wall lined by cuboidal epithelium and focally by mucinous epithelium suggesting seromucinous cystadenoma (figure 3). No ovarian stroma was noted, and, hence, this is classified as extraovarian origin.
(A) Intraoperative image showing cyst in the right lumbar region. (B) Intraoperative image showing skeletonised cyst.
Histopathological image showing cyst wall lined by cuboidal and mucinous epithelium without ovarian stroma.
Outcome and follow-up
The patient was doing well after surgery and is on regular follow-up. Patient had a spontaneous conception 1 year following surgery. Ultrasound done showed a left adnexal mass of size 1.8×2.2 cm close to and separate from ovaries and yolk sac was seen. Cardiac activity present with haemoperitoneum in pelvis, suggesting ruptured ectopic pregnancy for which she underwent laparoscopic left salpingectomy.
Discussion
The commonly occurring ovarian neoplasms are epithelial tumours that arise from the surface epithelium and adjacent stroma. In 2014, WHO classification of tumours of female reproductive organ introduced a new class of ovarian neoplasms called ‘seromucinous tumours’.1 2 Fox and Lange initially used the term seromucinous tumour in 1976.3 These tumours exhibit both serous and mucinous features and are composed of serous cells, endocervical type of mucinous epithelium, endometroid cells, squamous cells and undifferentiated cells.4 These tumours usually involve both ovaries and are usually associated with endometriosis.5 These tumours are seen in women of late reproductive age, and they usually present with nonspecific abdominal pain and discomfort.6 Seromucinous cystadenoma of the ovary accounts for about 1% of ovarian benign epithelial neoplasm.7 Primary benign seromucinous cystadenoma of abdomen is rare, and to our knowledge, no cases have been reported in the literature. This case is classified as extraovarian origin because of the absence of ovarian stroma on histology. Though the exact pathogenesis behind this tumour is not fully understood, it is postulated that the Mullerian or paramesonephric duct remnants deposited when the ovary descended during embryogenesis gives rise to these tumours.8 These tumours may be benign, borderline or invasive depending on the cytological features, presence or absence of invasion.9 The mainstay treatment for abdominal cyst is surgical removal. Aspiration of the cyst is not recommended. These cysts should be treated with the suspicion of malignancy and care should be taken not to rupture cyst intraperitoneally as it may lead to tumour spillage causing tumour seeding and development of pseudomyxoma peritonei.
Learning points
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We are presenting a rare case of extra ovarian seromucinous cystadenoma mimicking mesenteric cyst.
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Though intra-abdominal cysts are usually benign, a suspicion of malignancy should always be in mind as tumour spillage may worsen the prognosis.
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Despite in advantages of imaging studies, definitive diagnosis of cystadenomas is by histopathological examination.
Footnotes
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Contributors NA—chief surgeon, final approval. KJ—assisting the case, drafting the work. BH—assisting the case, draft revision. VB—assisting the case, draft revision.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.
References
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