Keywords : endometerioma, ovarian neoplasm, ovarian cyst, CA-125
Ovarian endometeriotic cysts, though common, rarely assume massi ve s izes . We report a case of huge endometerioma mimicking an ovarian neoplasm.
Case: A 44-y ear old married woman, PIL I was admitt ed in Ap ril 2001 with a 2 month history of he aviness and pain in lower abdomen associated with frequent micturition, malaise, anorexia, obstipation, and d ysp ar eunia. She had undergone cesarian section fo r fetal di stress 13 years ago and since then had adop ted contraception. Her menstrual history was normal. General physical and systemi c examination was unremarkable. Abdominal examination revealed a su p rapubic firm mass corresponding to 20 weeks of gravid uterus, with irregular contours and restricted mobility. There was no guarding, rigidity or rebound tenderness. Speculum examination showed a healthy ce r vi x without bleeding or discharge. On vaginal ex amin a tion, the same mass was felt bimanually through anterior fornix, separate from th e uterus. Her baseline investi gations, including che st skiag ram were all normal. CA-125 levels were mildly (80.4 u / ml) raised . Ultrasonography outlined a large well defined 20x17x18 cm size pelvicoabdominal cyst ic lesion, with multiple thick septas, irregular loculations and minimal wall thickening. The cyst displaced the normal size uterus to left. Left ovary was 3.5 x 2.6 cm in size . Computerized tomography scan confirmed a large multilocular, septate, pelvicoabdominal midline cystic mass with a wall of non-uniform thickness. Maximum diameter was 20 ems. Possibility of right ovarian cystic neoplasm was stro ng. There were no other significant findings.
Cystoscopy rev ea led mild cystitis only. With a pro visional diagnosis of right ovarian neoplasm, a staging laparotomy was performed. Since there was no free fluid, peritoneal washings were sent for cellblock analysis and further exploration of abdomen was done in a systematic manner. Liv er, gall bladder, kidneys and sp leen were found to be normal. No abnormal lymph node was seen. A mass, mor e cys tic than solid, me asuring 22x15 ems was see n arising from the pelvi s, occupying th e whole right lower abdom en. The right ovary could not be identified from this mass which was adherent to the uterus. Left ovary was normal in size with a small cyst havin g clear fluid. Sigmoid colon was badly adherent to the mass and to the posterior surface of the uterus . The whole appearance was more suggestive of endometerioma than ovari an neoplasm. Cyst was fir st decompressed to facilit ate dissection . Almos t 700 cc of th ick hemorrh a gic fluid ex p resse d was also se n t for cytology. As peritoneal washings were negative for malignancy, dissection of the mass was sta rted . All the septa which enclos ed hemorrhagic fluid were broken and the cyst completely exci sed car efully and gradually. Patient r ec eived four units of b loo d transfusion. Post-operative period was unev entful. Histopathology of excised cy st reveal ed benign endometriotic cyst with endometriosis in the wall. No malignant cells were seen. Post-surgery CA125 levels reduced to 43.7 u / ml. Subsequently patientwas put on danazol, 600- 800mg / day for 6months.She is on regular follow up and is symptom free.
Endometriosis affects four out of every 1000 women of 15-64 years being hospitalized annually with intermenstrual bleeding, dysmenorrhoea, pelvic pain or infertility'. Rarely they present as cystic masses. Current literature describes three different mechanisms by which endometriotic cysts originate. Cortical invagination cyst arises when surface ovarian endometriotic deposits adhere to another structure (such as broad ligament, uterus etc.) blocking the egress of menstrual fluid produced cyclically, which then collects and causes the ovarian cortex to be invagianated. Surface inclusion cysts in related endometriotic cysts develop when endometriotic tissue colonizes pre-existing inclusion cysts. Physiological cyst related endometriotic cysts occur when endometriosis gains access to a follicle such as at the time of ovulation-. Whatever the mechanism, the cyst can theoretically attain a huge size. The complex pathology of ovarian endometerioma makes preoperative exclusion of malignancy almost impossible especially when CA125 is also raised", more so, since polypoid endometerium, old blood clots, fibrosis, dense adhesions, both inside and outside, and hemorrhagic dysfunctional cysts, add to the multilocular structure. Laparotomy is justified when malignancy cannot be excluded. This case in particular highlights our faith in old-fashioned laparotomy, which enables a detailed evaluation of the area and complete cystectomy especially when malignancy is a strong possibility. This further reports the attainment of huge sizes by endometriotic cyst, a rarity these days, which can mimic malignancy.
