Giant forms of abdominopelvic tumors have become. Management of Giant Ovarian Cysts: A Review of 5 Case Reports

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1 JOURNAL OF GYNECOLOGIC SURGERY Volume 32, Number 3, 2016 ª Mary Ann Liebert, Inc. DOI: /gyn Management of Giant Ovarian Cysts: A Review of 5 Case Reports Balla Diop, MD, 1,2 Mamadou Mansour Niang, MD, 1 Pape Abdoulaye Ba, MD, 3 Pape Souleymane Toure, MD, 1 Abdou Sy, MD, 1 Youhanidou Wane, MD, 1 and Serigne Mamadou Sarre, MD 1 Abstract Background: Articles on giant ovarian cysts have become less common in medical literature. These cysts mimic ascites, presenting with abdominal distension and shifting dullness. They are predominantly serous and mucinous cystadenomas. Rare cases of low-grade of malignant tumors and adenocarcinomatous ovarian cysts have been reported. Materials and Methods: This was a retrospective descriptive study of 5 cases recruited between 2009 and The selected patients had large ovarian cysts extending to the epigastric region. Solid, mixed, or predominantly solid ovarian cysts were excluded from the study. Results: The mean age of the patients was 28, with extremes of ages 22 and 39. Ascites was detected clinically with transabdominal fluid thrills in all cases. Cysts were unilocular in 4 cases and multilocular in 1 case. Oophorectomy and salpingectomy were performed without preoperative drainage. Histology testing showed serous cystadenoma in 4 cases and mucinous low-grade adenocarcinoma in 1 case. The average follow-up time was 54 months. No recurrences were observed. Conclusions: Imaging (ultrasound, computed tomography, and/or magnetic resonance imaging) is paramount for planning management of giant ovarian cysts as imaging facilitates the distinction between ascites and pseudoascites as well as the identification of any suspicious features of malignancy (multiple partitions, and endo- or exocystic vegetations). Complete excision without opening the cyst is the procedure of choice. ( J GYNECOL SURG 32:162) Introduction Giant forms of abdominopelvic tumors have become less commonly written about in in medical literature. Improved health of populations and increasingly early management of patients in the early stages of the condition have contributed to this reduction in frequency. However, in Africa it is not uncommon to encounter extra-large forms of ovarian cysts that are insidious in onset and often present without alarming symptoms. The majority of cases occur in young sexually active patients. These cysts are predominantly benign epithelial tumors in 70% of the cases and are commonly serous or mucinous cystadenomas. 1 Rare cases of low-grade malignancy and adenocarcinoma ovarian cysts have reported. Several questions have arisen regarding the histologic nature, optimal management, and role and associated risks of preoperative and/or intraoperative drainage. This article presents 5 case reports of patients treated for giant cysts of the ovary and discusses their pathogenesis, clinical presentation, and management. Materials and Methods This was a retrospective descriptive study of 5 cases from the Department of Surgery at Ouakam Military Hospital, in Dakar, Senegal, between January 2009 and December Patients with large ovarian cysts extending to the epigastric region were selected. Solid, mixed, or predominantly solid ovarian cysts were excluded from the study. Patient assessment included clinical examination, and abdominopelvic ultrasound and computed tomography (CT) scans. Laboratory tests performed were CA-125 and/or ß human chorionic gonadotropin. Cardiovascular and respiratory anesthetic risk assessments were performed preoperatively. Open surgery (annexectomy) with removal of the cysts was the adopted approach in all the cases. Results The 5 patients were in their early reproductive years, with a mean age of 28 (extremes of 22 and 39 years, 1 Department of Surgery, Military Hospital of Ouakam, Dakar, Senegal. 2 UFR Santé, University of Thies, Thies, Senegal. 3 Department of General Surgery, Regional Hospital Center of Thies, Thies, Senegal. 162

2 GIANT OVARIAN CYSTS 163 Table 1. Clinical and Laboratory Data Patient # Age (in years) Symptoms Abdominal CT scan CA-125 ß-hCG 1 25 Heaviness; increase in abdominal girth & Unilocular cyst; cm a 65 discomfort when walking 2 27 Abdominal distension; constipation & Multilocular cyst; cm b reduced walking distance 3 29 Abdominal distension & heaviness Unilocular cyst; cm c 4 39 Abdominal distension & heaviness Unilocular cyst cm d Abdominal distension; heaviness; dyspnea & discomfort when walking e Unilocular cyst, cm f 6 See Figs: a 1; b 2 (A&B); c 3; d 4A; e 5A; & f 5B. CT, computed tomography; hcg, human chorionic gonadotropin. FIG. 1. area. Giant ovarian unilocular cyst reaching epigastric respectively). Two patients were nulliparous, while the other 3 were multiparous. Increased abdominal girth accompanied by a sensation of heaviness in the lower abdomen associated with weight gain was present in all cases. Amenorrhea was present in 3 patients. Constipation was noted in 4 cases. Abdominal examination suggested ascites or pseudoascites with abdominal distension and shifting dullness in all cases. A transabdominal fluid thrill was noted without a palpable mass (both liver and spleen were impalpable in each case). The clinical and laboratory data for all of the patients aresummarizedintable1andillustratedinfigures1,2,3, 4A, 5A,B. Patient #1 presented with progressive abdominal distension, constipation, and 3 months of amenorrhea. Ultrasound and abdominal CT scans showed a giant, unilocular, thinwalled ovarian cyst without vegetations (Fig. 1). In the month preceding this patient s operation, she noticed a sudden decline in abdominal girth accompanied by polyuria. Her abdominal distension was noted to be less prominent at a review the day prior to surgery, and laparotomy FIG. 2. (A&B) Ovarian multilocular cyst with several partitions.

3 164 DIOP ET AL. Table 2. Intraoperative Data, Procedures, and Histology Types Patient # Intraoperative exploration Procedure Histology 1 Reabsorption of the cyst; large ovary with a puttylike appearance & thin film of ascites 2 Multilocular cyst; thick-walled; minimal ascites 3 Unilocular cyst; thick-walled & with Annexectomy Annexectomy with removal of cyst Annexectomy with removal of cyst Ovarian follicular cyst Mucinous cystadenocarcinoma with low-grade malignancy Serous cystadenoma venous maze 4 Unilocular cyst; regular thin walls. a Annexectomy with removal of cyst Serous cystadenoma 5 Unilocular cyst; thin walls; rupture Annexectomy with removal of cyst Serous cystadenoma a See Figure 4B. consequently showed a regressed cyst. An enlarged right ovary was noted, with an opaque appearance and a thin film of ascites. Patient #2 presented with a giant multilocular cyst with minimal ascites. The walls and partitions of the cyst were thick without vegetations (Fig. 2). Table 2 summarizes intraoperative findings, procedures performed, and histopathology results for all 5 patients. An operative illustration is shown in figure 4B. Paracentesis or preoperative drainage was not approved by the whole team and was therefore not performed. The postoperative period was uneventful in all patients. Patients were monitored every 3 months. The average followup time was 54 months. No recurrences were observed. Discussion Ovarian cysts are benign in 70% of cases and can be fluidfilled, solid, or mixed. The main subtypes are mucinous, serous, endometrioid, and teratoma. 1 3 Ovarian cysts may be borderline in 5% 10% of cases and malignant in 20% 25% of cases, largely depending on the age of the patient. 1 These cysts are much more common in young patients of childbearing age as noted in the current series and are rare before puberty or after menopause. Voluminous forms are predominantly serous cystadenomas (75% of cases) and mucinous cysts (25% of cases), FIG. 3. Voluminous abdominal unilocular cyst reaching the epigastric area. FIG. 4. Abdominopelvic unilocular cyst, driving back loops. (A) Scanned image. (B) Actual cyst.

4 GIANT OVARIAN CYSTS 165 FIG. 5. Abdominal distension (A) caused by a unilocular monstrous cyst (B). sometimes appearing up to impressive dimensions. 4,5 Mucinous cystadenomas are benign in 75% of cases, borderline in 10% of cases, and malignant (cystadenocarcinoma) in 15% of cases. This spectrum presents a management dilemma whether to perform intraoperative laparoscopiccontrolled drainage or laparotomy. 6 Giant ovarian cysts, however, are defined differently in the literature. Definitions for giant cysts range from cysts >10 cm seen on imaging studies 7,8 to cysts that extend above the umbilicus noted on inspection and abdominal palpation. 9,10 These definitions, however, do not include the clinical presentation caused by certain extra-large cysts occupying much of the abdominal cavity up to the diaphragm, as was noted in most of the current patients. These giant ovarian cysts are associated with uncomfortable abdominal distension, heaviness, weight gain, difficulty with walking, discomfort when recumbent, dyspnea or orthopnea, and tachycardia. 11,12 Giant cysts, as reported in the literature, might compress the inferior vena cava causing lower- limb edema, compression of the diaphragm with risks of atelectasis, pulmonary edema, and more seriously, abdominal compartment syndrome. 1,11,13 In 1905 Spohn reported a 328 pound ovarian tumor. 14 Since then, Abe et al. identified 22 cases of ovarian tumors reported in the literature measuring between 47 kg and 134 kg. 11 The cysts were benign in 72.7% of cases and borderline or malignant in 27.2% of cases. 11,15 In a literature review, Einenkel et al. found an overall malignancy rate of 37% in giant ovarian cysts. 12 The differential diagnosis can be difficult to establish in the presence of abundant ascites. Abdominal distension, shifting fluid dullness, and transabdominal fluid thrill were positive findings in all 5 of the current patients, suggesting significant ascites. This demonstrates the difficulty in differentiating ascites from pseudoascites clinically, as many conditions such as extreme bladder distension, duodenal diverticula, hydronephrosis, mesenteric cysts, cystic echinoccosis, pancreatic pseudocysts, and ovarian cysts may mimic ascites. 16,17 Paracentesis in these settings carries increased peritoneal risks and complications. 18,19 Imaging studies (ultrasound, CT scanning, and/or magnetic resonance imaging [MRI]), therefore, are important for establishing the diagnosis and, in addition, may reveal additional findings, such as the presence of a displaced bowel, fluid levels, or a pseudocyst with clear borders (sometimes with endocystic partitions and vegetations). Preoperative drainage remains controversial. Advantages include reduction of the cyst size, thereby making it easier to manipulate during the operation and extraction, with minimal sacrifice of the parietal wall, and symptomatic relief (reducing intra-abdominal pressure). Similarly, this drainage improves respiratory and cardiovascular function and might prevent pulmonary edema. 1,20 Thus, drainage remains relevant for some symptomatic giant cysts. However, it must be performed gradually, with the aim of avoiding long drainage tubes that carry risks of infection, peritonitis, and sudden massive bleeding. 11 The major drawback of drainage however, is the potential dissemination into the peritoneal cavity of a peritoneal carcinoma or gelatinous disease of the peritoneum caused by rupture of a mucinous cyst. 12 Several studies have shown a 10% 26% rate of cyst rupture in cases of laparotomy and 22% 100% for a laparoscopic incision. 3 The lack of quality data on the risk of peritoneal contamination has led some researchers to discourage preoperative drainage. 12 A low-grade mucinous cyst/adenocarcinoma with minimal ascites was noted in the current series. In this case (patient #2), there was no recurrence after 5½ years of follow-up. Other complications are associated with drainage, such as hypovolemic shock, massive hemorrhage, peritonitis, pulmonary edema, pneumonia or atelectasis. 11

5 166 DIOP ET AL. Intraoperative laparoscopic-controlled drainage remains as an alternative to laparotomy. It reduces leakage and allows easier removal of the mass. 3,7 Conclusions Extra-large forms of ovarian cysts while now rare are a challenge for practitioners. Imaging (ultrasound, CT, and/ or MRI) enables the exclusion of ascites, analysis of the cystic wall, and detection of partitions and endo- or exocystic vegetations, which are suspicious features of malignancy. While complete excision without opening the cyst is the procedure of choice, there are minimal data showing the poor outcome of giant cysts that were complicated by rupture or that were drained pre- or intraoperatively. Acknowledgments The authors thank Roslyn Mackenzie, MD, for helpful criticism, advice, and assistance with revising and translating the manuscript for this article. Author Disclosure Statement The authors report no conflicts of interest. References 1. Mülayim B, Gürakan H, Dagli V, Mülayim S, Aydin O, Akkaya H. Unaware of a giant serous cyst adenoma: A case report. Arch Gynecol Obstet 2006;273: Koonings PP, Campbell K, Mishell DR Jr, Grimes DA. Relative frequency of primary ovarian neoplasms: A 10-year review. Obstet Gynecol 1989;74: Vlahos NF, Iavazzo C, Marcopoulos MC, et al. Laparoscopic management of large ovarian cysts. Surg Innov 2012;19: Sri Paran T, Mortell A, Devaney D, Pinter A, Puri P. Mucinous cystadenoma of the ovary in perimenarchal girls. Pediatr Surg Int 2006;22: Kazem Moslemi M, Yazdani Z. A huge ovarian cyst in a middle-aged Iranian female. Case Rep Oncol 2010;3: Rodriguez IM, Prat J. Mucinous tumors of the ovary: A clinicopathologic analysis of 75 borderline tumors (of intestinal type) and carcinomas. Am J Surg Pathol 2002;26: Eltabbakh GH, Charboneau AM, Eltabbakh NG. Laparoscopic surgery for large benign ovarian cysts. Gynecol Oncol 2008;108: Ou CS, Liu YH, Zabriskie V, Rowbotham R. Alternate methods for laparoscopic management of adnexal masses greater than 10 cm in diameter. J Laparoendosc Adv Surg Tech A 2001;11: Salem HA. Laparoscopic excision of large ovarian cysts. J Obstet Gynaecol Res 2002;28: Sagiv R, Golan A, Glezerman M. Laparoscopic management of extremely large ovarian cysts. Obstet Gynecol 2005;105: Abe T, Iwaoki Y, Tanji H, Kodama S, Shigeta N, Sumimoto K. Resection of a giant ovarian mucinous cystadenoma with intraoperative drainage. J Gynecol Surg 2012;28: Einenkel J, Alexander H, Schotte D, Stumpp P, Horn LC. Giant ovarian cysts: Is a pre- and intraoperative drainage an advisable procedure? Int J Gynecol Cancer 2006;16: Chao A, Chao A, Yen YS, Huang CH. Abdominal compartment syndrome secondary to ovarian mucinous cystadenoma. Obstet Gynecol 2004;104(5[pt2]): Spohn AE. Multicystic ovarian tumour weighing 328 lb. Tex State J Med ;1: Fobe D, Vandervurst T, Vanhoutte L. Giant ovarian cystadenoma weighing 59 kg. Gynecol Surg 2011;8: Kaya M, Sakarya MH. Pseudoascites: Report of three cases. Turk J Gastroenterol 2009;20: Fiedorek SC, Casteel HB, Reddy G, Graham DY. The etiology and clinical significance of pseudoascites. J Gen Intern Med 1991;6: Hackethal A, Brueggmann D, Turovets M, Bassaly B, Stein A, Gerber EL, Muenstedt K. Removal of enormous bilateral mucinous cystadenomas of the ovaries with abdominal plastic reconstruction. Arch Gynecol Obstet 2009;279: Gyves-Ray, Hernandez RJ, Hillemeier AC. Pseudoascites: Unusual presentation of omental cyst. Pediatr Radiol 1990; 20: Koshiba H, Kitawaki J, Fujita H, Honjo H, Okumura J. Giant ovarian tumor removed after preoperative drainage, with abdominoplasty: A case report. J Reprod Med 2003; 48:652. Address correspondence to: Balla Diop, MD Department of Surgery Military Hospital of Ouakam BP Dakar Senegal dballa33@yahoo.fr