A case of an ovarian tumour pre-operatively thought to be malignant, which was per-operatively diagnosed as benign and later confirmed as a mucinous cystadenoma. Ob-Gyn Department, BIRDEM-2 General Hospital, Shegunbagicha, Dhaka, Bangladesh

1. Mucinous cystadenoma
A case presentation
Dr. Shadman Abdal Joarder
Intern doctor
Obstetrics & Gynaecology Unit 4
BIRDEM-2 General Hospital

2. Particulars of the patient
Name: Ms. X
Age: 26 years
Occupation: student
Address: Khilgaon, Dhaka
Date of admission: 6/4/19

3. Chief complaints
1. Heaviness in lower abdomen for 2 months
2. Right sided lower abdominal pain for 2 days

4. History of present illness
According to the patient’s statement, she was
reasonably well 2 months back. Then she noticed a
feeling of heaviness in her lower abdomen, which
was progressively increasing.
 She also complained of lower abdominal pain, which
was localized to the right side, sudden, mild, dull pain
with no radiation, without any exacerbating factor.

5. For these reasons, she was advised MRI of abdomen
which showed “Huge complex (2000 mL) right
ovarian cyst occupying abdomino-pelvic cavity,
without any adhesion with surrounding structures or
any ascites”.
She is non-diabetic, normotensive and non-
asthmatic.

6. Menstrual history Obstetric history
Menarche at: 13 years
MP: 5-6 days
MC: 30-40 days
Menstrual flow: Scanty
Dysmenorrhea: Absent
LMP: 1st April 2019
She is unmarried

7. Past history
Past surgical: No abdominal surgery
Past medical: Nothing significant
Personal history
Nothing significant
Family history
Father is hypertensive; Mother is diabetic
Socio-economic history
Middle class

8. General examination
Height: 149 cm
Weight: 61 kg
BMI: 27.4
Nutrition: Average
Anemia: Absent
Jaundice: Absent
Cyanosis: Absent
Edema: Absent
Dehydration: Absent
Clubbing: Absent
Leukonychia: Absent
Koilonychia: Absent
Neck veins: Not engorged
Lymph nodes: Not palpable
Thyroid: Not enlarged
Skin: Normal
Vitals:
Temperature: 98.6 ℉
Pulse: 80/min
Respiratory rate: 16 breaths/min
Blood pressure: 130/90 mmHg

9. Systemic examination
On examination of Cardiovascular, Respiratory and
Nervous system, no abnormalities were found.

10. Abdominal examination
Inspection: Abdomen was enlarged. Umbilicus
inverted.
Palpation: A mass was found which was situated in
the midline, size around 6X6 cm, firm in consistency,
mobile in all direction.
Percussion: Dull in center; Flanks were tympanic.

11. Per vaginal and Per speculum examination
Not done as she is unmarried

12. Salient features
Ms. X, a 27 year old non-diabetic, normotensive, non-asthmatic
student, got admitted with the complaints of feeling of
heaviness in her abdomen for 2 months which was
progressively increasing.
She also complained of right sided lower abdominal pain for 2
days which was dull, sudden, mild with no radiation and no
exacerbating factor.
On General examination, no abnormalities were detected.
Systemic examination also revealed no abnormalities.

13. Provisional diagnosis
Right ovarian cyst

14. Investigations
Test Results Normal range for adult
female
Hb% 12.3 g/dL 11.5-15.5 g/dL
ESR 27 0-20mm in 1st hour
RBC Count 4.28X10^6 µL 3.8-4.8 X10^6 µL
WBC Count 6.66X10^3 µL 4.00-11.00X10^3 µL
Platelet Count 287X10^3 µL 150-450X10^3 µL
Neutrophils 63.9% 40-75%
Lymphocytes 28.2% 20-40%
Monocytes 5.1% 2-10%
Eosinophils 2.6% 1-6%
Basophils 0.2% <01%
CBC on 20/3/2019

15. Test Results
Quantity Sufficient
Colour Straw
Appearance Clear
Sediment Nil
Sp. Gravity Not done
pH, Albumin, Sugar Nil
Pus cell 1-2/HPF
Epithelial cell 3-4/HPF
RBC 3-5/HPF
Casts and Crystals Nil
Urine R/E on 1/4/2019

16. Date Investigation Results Normal range for
adult female
28/3/2019 Serum CA-125 8.7 U/L Up to 35
Serum TSH 5.34 0.34-5.60 µIU/L
Serum FT4 0.87 0.60-1.45 ng/dL
Serum creatinine 0.8 0.5-1.1 mg/dL

17. Date Investigation Results
20/3/2019 Blood Group O Positive
HBsAg Negative
VDRL Non-reactive

18. Date Investigation Results
22/3/2019 USG of Whole abdomen Slightly bulky uterus. Big semi-solid
mass with thick internal septations in
pelvic cavity, more on right, attached
to right ovary (ovarian cyst).
30/3/2019 MRI of Lower Abdomen Huge complex (2000 mL) right
ovarian cyst (20X15X12 cm)
occupying abdomino-pelvic cavity
(suggestive of malignant ovarian
tumour) without adhesion to
surrounding structures or any ascites.

19. Fig: USG of Whole abdomen

20. Treatment
Surgical:
Laparotomy followed by right-sided salpingo-oophorectomy

21. OT Note (7/4/2019)
With all aseptic precaution under G/A, abdomen was
opened by low midline incision. There was a large thick-
walled ovarian cyst extending upto xiphisternum.
The tumour was free and mobile in all directions and looked
benign. After taking precaution not to contaminate the
peritoneal cavity, a stab incision was given and the content
was sucked out which was mucinous (1600 mL).

22. OT Note (Continued)
A specimen was sent for frozen section and report showed no
evidence of malignancy. So, right sided salpingo-
oophorectomy was done.
Omentum was free and healthy looking.
Uterus contained a small fibroid on the anterior wall near
fundus.
Left fallopian tube and ovary were healthy-looking.
There was no ascites.
Abdomen was closed in layers after ensuring all points of
hemostasis and after counting all mops and instruments.

23. Fig: Suction after stab incision

24. Fig: Removal of the tumour

25. Fig: Examination of other ovary and omentum

26. Fig: Collection after suction –
1600 mL of blood stained
fluid

27. Fig: Processing for Frozen Section

28. Fig: Cross-section showing multiple loci and septa

29. Post-operative order
Please keep the patient NPO till further order
Inf. 5% DA (1L) + 5% DNS (1L) IV @ 25 drps/min
Inj. Ceftriaxone 1gm IV stat and OD
Inj. Metronidazole 500mg IV stat and TDS
Inj. Esomeprazole 40mg IV stat and BD
Inj. Ondansetron 8mg IV stat and TDS
Inj. Pethidine IM stat and 8 hourly after checking BP
Supp. Diclofenac Na 1 stick P/R stat and BD
Monitor vitals routinely
Maintain I/O chart
Continue catheterization for 24 hours

30.  Frozen Section on 7/4/2019
Impression: No malignant cells seen
 Histopathology report on 10/4/2019
Gross: Specimen received fresh for Frozen section consists of 20X18X9
cystic ovary. On opening the cyst wall shows multiple loci filled with slimy
material. Embedded two blocks for Frozen section and later on four blocks
for paraffin embedded section.
Microscopic: Section shows ovarian tissue. It reveals a multilocular cyst.
The wall is composed of fibrocollagenous tissue. The loculi are lined by
single layer of mucin containing columnae epithelial cells. The wall exhibits
congested blood vessels. No malignancy is seen.
Diagnosis: Right ovarian cyst- Mucinous cystadenoma

31. Test Results
Quantity Sufficient
Colour Straw
Appearance Clear
Sediment Nil
Sp. Gravity Not done
pH, Albumin, Sugar Nil
Pus cell 1-2/HPF
Epithelial cell 3-4/HPF
RBC Nil
Casts and Crystals NIl
Urine R/E on 9/4/2019
Hb% on 9/4/2019 11.0 g/dL

32. Discussion on
Mucinous Cystadenoma

33. Mucinous cystadenoma
These account for up to 20% of all ovarian tumours.
In approximately 10% of cases the tumour is bilateral.
They may attain a very large size and may be multilocular.
The growing point of the cyst is marked by a mass of small
locules and some of the large locules may result from a
breakdown of partitions.
The outer wall varies in thickness and is white, grey or silvery -
blue in colour.
Adhesions to adjacent tissues are not present unless there have
been degenerative changes in the wall.

34. Fig: WHO classification of Ovarian tumour

35. Fig: Classification of Mucinous tumours

36. The cysts are lined by tall columnar cells and these
secrete a mucus material—a glycoprotein with a high
content of neutral polysaccharides.
The appearance of the epithelium is remarkably like that
of the glands of the cervix or of the intestine.
The fluid content is thick in consistency and glairy, and is
colourless, yellow, green or brown depending on the
presence of blood pigments derived from previous
intracystic haemorrhages.

37. Take Home Message
Even though the mucinous cysadenoma is a benign
tumour, it can lead to a rare complication when it
ruptures and spills into the peritoneum, known as
Pseudomyxoma peritonei.
When this happens, the epithelial cells of the tumour
spread as a film over the visceral and parietal peritoneum
and from these sites they secrete semisolid mucin into
the abdominal cavity and this causes distension, aching,
pain and vomiting.
So it is advisable to diagnose mucinous cyst adenoma
carefully and treat surgically as soon as possible.

38. Thank you