A Postmenopausal Woman with Giant Ovarian Serous Cyst Adenoma

Abstract

Giant (>10 cm) ovarian cyst is a rare finding. In the literature, a few cases of giant ovarian cysts have been mentioned sporadically, especially in elderly patients. We report a 57-year-old postmenopausal woman with a giant left ovarian cyst measuring 43 × 15 × 9 cm. She was referred to us from the local health center in view of palpable pelvic mass for six-month period. Considering the age and menopausal state, we performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy with excision of the giant left ovarian cyst intact and successfully without any significant complication. On histopathological examination, the cyst was confirmed as benign serous cystadenoma of the ovary. During the management of these high-risk cases of multidisciplinary approach, intraoperative and postoperative strict vigilance is necessary to avoid unwanted complications.

Case

A 57-year-old, para 04 postmenopausal woman was referred to our hospital from the local health center with a palpable pelvic mass for the last six months. She had been menopausal for the 7 years with the last childbirth occurring 17 years ago. She is a known case of hypothyroidism and on Tab. Thyroxin 50 microgram once daily. No significant surgical history was obtained.

On presentation, she was asymptomatic and had no complaints of anorexia, nausea vomiting, weight loss, or any postmenopausal bleeding. Her bowel and bladder habit was normal.

On general examination, she was found to be average built and weighing 62 kg. Abdominal examination revealed a pelvic mass extending beyond the umbilicus, corresponding to 26-week gravid uterus. The mass was mobile, firm, and nontender on palpation. On vaginal examination, cervix was found normal and fornixes were obliterated due to presence of the mass.

Laboratory tests were unremarkable except that the TFT value-TSH was 35.5 mIU/Li and free T4 was 6.9 pico mol/Li. Tumor markers were within normal limit, and CA 125 revealed 12 U/ml. Cervical PAP smear showed no evidence of dyskaryotic or malignant cells.

Radiological ultrasound revealed normal sized and shaped uterus with endometrial thickness 7 mm. A large left adnexal cyst was seen which was bilocular, thin smooth walled with clear anechoic contents measuring around 17.5 × 17.3 × 9.5 cm.

We did not conduct computerized tomography (CT) scans or magnetic resonance imaging (MRI) as the ultrasound scan findings were highly suggestive of a benign cyst, that is, a unilateral cyst with no solid areas or irregular surface and no ascites.

The calculated RMI (risk of malignancy index) was 1 × 3 × 12 = 36. Total score was USG score × menopausal score × Ca₁₂₅ (U/Ml). USG score was as follows: 0, no risk factor; 1, one risk factor; 3, 2–5 risk factors. High-risk factors in USG were multilocular cysts, solid areas, bilateral lesions, ascites, and evidence of metastasis. Menopausal status was as follows: 1, premenopausal; 3, postmenopausal. Score < 200 indicates low risk (risk of ovarian malignancy is 0.15 times). Score > 200 indicates high risk (risk of ovarian malignancy is 42 times) [3].

We planned for TAH with BSO considering her age and menopausal status. After normalization of thyroid hormones value, we performed TAH with BSO.

The abdomen was opened by a low transverse incision. Intraoperative around 40 × 15 cm sized left ovarian cyst (Figure 1) was seen; no healthy ovarian tissue was seen separately. The left tube was adherent and stretched over the cyst (Figure 2). Right tube, ovary, and the uterus were found healthy (Figure 3). There were no intraoperative complications and delay in total operative procedure. The blood loss was minimal.

On histopathology examination, the cyst was bilocular with smooth thin walled measuring 43 × 15 × 9 cm and lined by a single layer of bland flattened epithelial cells with occasional cuboidal epithelial cells. The cyst was filled with clear serous fluid. No malignant cells or nuclear atypia were observed. The histopathology was suggestive of benign serous cystadenoma of the ovary.

Her postoperative period was unremarkable. Oral feeding and ambulation were started 12 hours after the surgery. She was discharged on the fourth postoperative day in good condition.

Discussion

Large/giant ovarian cysts are benign in most of the cases and histopathologically these cysts are either serous or mucinous [4].

Serous tumors secrete serous fluids and are originated by invagination of the surface epithelium of ovary. Serous tumors are commonly benign (70%); 5–10% have borderline malignant potential, and 20–25% are malignant. Only 10% cases of all serous tumors are bilateral [3].

Serous cystadenomas are multilocular. In some instances, they include papillary projections. Giant ovarian serous cyst adenoma is a rare finding. In the literature, a few cases of giant ovarian cysts have been mentioned sporadically and especially in elderly postmenopausal women [2, 3].

Our presented case was a 57-year-old postmenopausal para 4 woman who experienced a palpable pelvic mass for six-month period without any other associated symptoms. We performed the total abdominal hysterectomy and bilateral salpingo-oophorectomy with the removal of an intact giant left ovarian serous cyst adenoma measuring 43 × 15 × 9 cm successfully.