|Year : 2019 | Volume
| Issue : 2 | Page : 114-117
A rare and interesting presentation of ruptured ovarian cystic tumor posing a diagnostic dilemma
S Ashitha1, Shrivalli Nandikoor1, Aruna R Patil1, Sruthi Jacob1, Abhilasha Narayan2
1 Department of Radiology, Apollo Hospitals, Bengaluru, Karnataka, India
2 Department of Oncogynecology, Apollo Hospitals, Bengaluru, Karnataka, India
|Date of Submission||26-Dec-2018|
|Date of Acceptance||29-Apr-2019|
|Date of Web Publication||19-Jun-2019|
Department of Radiology, Apollo Hospitals, 154/11, Opp IIM, Bannerghatta Road, Bengaluru - 560 076, Karnataka
Source of Support: None, Conflict of Interest: None
An ovarian cyst is the most common gynecological presentation. Majority are benign, with only a few being malignant. Epithelial ovarian tumors account for majority of ovarian neoplasm which usually present with vague symptoms of abdominal pain or asymptomatic and are detected incidentally. Spontaneous rupture of cystic tumors is an unusual presentation. We report here a case of ruptured serous borderline tumor in a young female.
Keywords: Ovary, rupture, tumor
|How to cite this article:|
Ashitha S, Nandikoor S, Patil AR, Jacob S, Narayan A. A rare and interesting presentation of ruptured ovarian cystic tumor posing a diagnostic dilemma. Apollo Med 2019;16:114-7
|How to cite this URL:|
Ashitha S, Nandikoor S, Patil AR, Jacob S, Narayan A. A rare and interesting presentation of ruptured ovarian cystic tumor posing a diagnostic dilemma. Apollo Med [serial online] 2019 [cited 2019 Aug 18];16:114-7. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/114/260695
| Introduction|| |
Epithelial ovarian tumors that include mucinous and serous subtypes constitute majority of ovarian neoplasms. Ovarian tumors usually present as nonspecific abdominal pain and mass per abdomen but sometimes may undergo complications such as rupture or torsion and present with acute abdomen. Hemorrhage and torsion are common complications, but spontaneous rupture is very unusual in the absence of predisposing factors such as pregnancy and anticoagulation therapy. Imaging plays an important role in identifying the complications. We document the ultrasound (USG) and magnetic resonance imaging (MRI) findings of a case of rupture of ovarian serous cystadenocarcinoma.
| Case Report|| |
A 31-year-old nulligravida presented with a history of abdominal discomfort for 14 days. There was no other history of associated symptoms such as nausea, vomiting, anorexia, or weight loss. She had no personal or family history of carcinoma breast or gynecological malignancy. She had no history of contact with tuberculosis patients. Her last menstrual period was 16 days prior, and there was no history of abnormal vaginal bleeding or discharge. On general physical examination, the patient was afebrile, vitals were stable, there was no axillary or cervical lymphadenopathy, breasts were normal, thyroid was not enlarged, per abdomen was soft, and per speculum cervix and vagina grossly appeared normal.
She was evaluated with an abdominal ultrasound which revealed mildly bulky left ovary with small follicles. A large torturous thick-walled tubular structure with collapsed lumen measuring ~95 mm × 92 mm × 38 mm was noted in the pelvis. The bulk of the lesion was seen at the right adnexa, which seemed to be continuous posteriorly into the pouch of Douglas (POD) to the left adnexa. Color Doppler study showed moderate vascularity at the wall. The right ovary could not be visualized. Moderate free fluid with mobile internal echoes was noted in the lower abdomen [Figure 1].
|Figure 1: Axial and longitudinal sonogram images of the right adnexa showing a thick-walled tubular structure with collapsed lumen (arrow), moderate peripheral vascularity, and free fluid in the pelvis (star). UB: Urinary bladder, U: Uterus|
Click here to view
For further characterization, MRI pelvis without contrast was done which revealed an irregular thick-walled T1 hypointense and T2/Short Tau Inversion Recovery hyperintense cystic lesion in the right adnexa extending to the POD with possible breech in left anterolateral aspect. The right ovary could not be separately identified [Figure 2] and [Figure 3].
|Figure 2: Axial and sagittal T2-weighted image showing complex right adnexal lesion extending to the pouch of Douglas and left adnexa with possible breech in left anterolateral aspect (star)|
Click here to view
|Figure 3: Short tau inversion recovery coronal image showing irregular right adnexal complex cystic lesion (star)|
Click here to view
Further laboratory tests also showed an elevated serum CA 125 level of 33,100 U/ml.
A provisional diagnosis of a ruptured ovarian cyst with collapsed walls was made.
The patient underwent laparoscopic right salpingo-oophorectomy, staging laparotomy, bilateral pelvic lymph node dissection, and infracolic omentectomy.
Peroperatively, there was ascitic fluid and ruptured and collapsed right adnexal cyst with cyst contents within the peritoneal cavity [Figure 4] and [Figure 5].
|Figure 4: Laparoscopic image showing free fluid in the pelvis (plus), cyst (star), and the left ovary (arrow)|
Click here to view
Pathological evaluation of lesion confirmed borderline papillary serous adenocarcinoma [Figure 6], [Figure 7], [Figure 8].
|Figure 6: Gross image showing the cyst wall of variable thickness. The inner surface shows extensive papillary excrescences|
Click here to view
|Figure 7: Microscopic image showing broad papillae showing hierarchical branching with broad fibrovascular core. No breach in the basement membrane seen with no invasion into the stroma|
Click here to view
|Figure 8: Microscopic image showing papillae lined by single layered to multilayered tumor cells which are columnar with vesicular nuclei and moderate amount of cytoplasm|
Click here to view
The patient was discharged without postoperative complications on the 4th postoperative day.
| Discussion|| |
Epithelial ovarian tumors represent majority of all ovarian tumors (65%–75%) and range from benign to borderline, to highly malignant tumors. The prevalence increases with age and peak in fifth to sixth decades of life. Serous ovarian cystadenoma with or without papillary projections is the most common type of epithelial ovarian tumors. About 10%–20% of primary ovarian epithelial tumors are intermediate in their histologic appearance between the innocuous cystadenoma and the highly aggressive cystadenocarcinoma. Stromal invasion is the only histologic feature that consistently distinguishes carcinomas from the borderline tumors. Borderline ovarian tumors most commonly affect women of reproductive age group. The mean age of presentation is ~20 years earlier than ovarian carcinomas. The patient may be asymptomatic or present with vague abdominal symptoms such as abdominal pain and distension and bloating. Clinically, gastrointestinal and genitourinary pathologies mimic ovarian pathologies.
Serous borderline ovarian tumor may behave in an aggressive fashion with associated peritoneal implants and regional lymphadenopathy. However, peritoneal lesions are classified as implants instead of metastasis since extra-ovarian spread of disease has a good prognosis. Lymph node involvement has no prognostic value about sites of recurrence and progression to carcinoma.,
Ovarian tumor can complicate due to rupture or torsion. Rupture can be due to torsion with infarction, direct trauma, infection of the contents, malignant change, and internal pressure from the rapid growth of the cyst. Ovarian cyst rupture releases cyst contents, which may cause peritoneal irritation resulting in abdominal pain. Differential diagnosis of such pain in a premenopausal woman includes hemorrhage or rupture of an ovarian cyst, ovarian torsion, endometriosis, pelvic inflammatory disease, and neoplasm or nongynecological conditions such as appendicitis or renal calculi.
Ultrasound is the initial imaging modality in a patient presenting with pelvic pain. Computed tomography (CT) and MRI are useful as a problem solving tool for doubtful lesions on ultrasound.
Imaging appearance of a ruptured cyst depends on time since rupture and cyst contents. Distorted shape of cyst, heterogeneous fluid in the pelvis, discontinuity of the cyst capsule, mesenteric stranding, and perihepatic fatty deposits are the features which can be appreciated on USG/CT or MRI.
Irregular thick collapsed wall of a ruptured cyst can mimic hydrosalpinx, pyosalpinx, tubo-ovarian mass, lymphocele, and peritoneal inclusion cyst.
Ruptured cystic ovarian tumor content results in intraperitoneal malignant cell dissemination modifying staging and prognosis of the patient.
Cross-sectional imaging (both MRI and multidetector CT) plays a major role in diagnosis, management, and surveillance of patients with borderline ovarian tumors. Imaging and characterization of ovarian mass are of importance in the preoperative evaluation of an ovarian neoplasm so that carcinoma of the ovary could be anticipated before surgery and accordingly adequate surgery could be planned. Post operatively, for long term follow up, ultrasound and tumor markers (CA125 and CA19-9) examination are useful.
| Conclusion|| |
The radiological appearance of right adnexal lesion in our case such as distorted shape, discontinuity of the capsule and heterogeneous fluid in the pelvis appreciated on USG and MRI were complementary to each other, thereby establishing the diagnosis of possible rupture.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hart WR. Ovarian epithelial tumors of borderline malignancy (carcinomas of low malignant potential). Hum Pathol 1977;8:541-9.
Lalwani N, Shanbhogue AK, Vikram R, Nagar A, Jagirdar J, Prasad SR. Current update on borderline ovarian neoplasms. AJR Am J Roentgenol 2010;194:330-6.
Fadare O. Recent developments on the significance and pathogenesis of lymph node involvement in ovarian serous tumors of low malignant potential (borderline tumors). Int J Gynecol Cancer 2009;19:103-8.
Seidman JD, Kurman RJ. Ovarian serous borderline tumors: A critical review of the literature with emphasis on prognostic indicators. Hum Pathol 2000;31:539-57.
Salvadori PS, Bomfim LN, von Atzingen AC, D'Ippolito G. Spontaneous rupture of ovarian cystadenocarcinoma: Pre- and post-rupture computed tomography evaluation. Radiol Bras 2015;48:330-2.
Herrmann UJ Jr., Locher GW, Goldhirsch A. Sonographic patterns of ovarian tumors: Prediction of malignancy. Obstet Gynecol 1987;69:777-81.
Kajiyama A, Edo H, Takeya C, Kubushiro K, Oharaseki T, Gomi T. Spontaneously ruptured paraovarian tumor of borderline malignancy with extremely elevated serum carbohydrate antigen 125 (CA125) levels: A comparison of the imaging and pathological features. Am J Case Rep 2017;18:919-25.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]