A 27-year-old, nulliparous (0-0-0-0), married woman was referred to our institution with a huge pelvic mass and left flank pain. She had no history of surgical or medical disease. Transvaginal ultrasonography revealed a 16 cm right adnexal cyst with intramural nodules and thickened cyst wall (). Abdomino-pelvic computed tomography (CT) scan showed a 16 cm cystic mass with enhancing solid intramural nodules in the pelvic cavity (). The CT scan showed no evidence of ascites, peritoneal seeding, omental cake, or pelvic or para-aortic lymph node involvement. It looked like an epithelial ovarian cancer because the CT scan showed delayed enhancement. Her serum cancer antigen 125 (CA-125) concentration was 19.3 U/mL (reference value, <35 U/mL), and the results of other preoperative work-up tests were unremarkable.\nWe performed an exploratory laparotomy through a low midline abdominal incision, which revealed a 16 cm right paratubal cyst completely differentiated from the right ovary and fallopian tube. Paratubal cystectomy was performed without rupture of the cyst. Frozen section analysis of the specimen showed that it was a paratubal serous borderline tumor. Exploration of the entire peritoneal cavity showed no evidence of intraperitoneal tumor spread. Her fallopian tubes, ovaries and uterus were not involved. Washing cytology and multiple peritoneal biopsies were taken. Because the patient and her husband had a strong desire to preserve fertility, her uterus and both adnexae were preserved.\nGrossly, the tumor had a homogeneous, purplish white inner surface and multiple papillary projections up to 2.1 cm in greatest dimension (). The external surface of the tumor was homogeneously purplish white and smooth, with multifocal hemorrhage. However, there was no evidence of surface involvement. The final pathology results were identical to the frozen biopsy results indicating that the mass was a paratubal serous borderline tumor (). The results of the peritoneal washing cytology and multiple biopsies were negative.\nHer postoperative course was uneventful and she was discharged 5 days after surgery. Regular check-ups at the outpatient clinic include serum CA-125 measurements, transvaginal ultrasonography, and/or abdomino-pelvic CT. She delivered a healthy baby at term 13 months after surgery. Twenty months after surgery, she is doing well, without evidence of disease.
An obese 31-year-old nulliparous woman was admitted to the general emergency service with back pain that had started one week earlier and gradually become constant and increased in intensity. She was also vomiting but denied fever, dysuria, constipation, diarrhoea or anorexia. She had never been pregnant and had had amenorrhea for the past 7 years, due to polycystic ovary syndrome. Her body mass index was 39 kg/m2 (height 168 cm; weight 110 kg); she was taking no medication and had no other surgical or medical history to disclose.\nDuring her physical exam, her vital signs were normal and abdominal examination revealed only tenderness in right quadrants, without guarding or rebound. Blood tests were performed and revealed a high white blood cell count (16,700 per mm3, 72% neutrophils), normal renal function and were negative for C-reactive protein. Urine analysis and pregnancy test were also negative.\nBecause her pain worsened, despite the administration of analgesic drugs, the patient underwent an abdominal and pelvic computed tomography (CT) scan, which showed a huge central abdominal-pelvic cyst arising from the right adnexa (). The cyst measured 25 cm × 20 cm × 14 cm and there was an adjacent enlarged oedematous ovary, highly suggestive of torsion. The left ovary, uterus and the appendix were normal and no free fluid in the abdomen and pelvis was observed.\nShe was then referred to the gynaecology department. Her gynaecologic exam was apparently normal but limited due to obesity. A pelvic ultrasound revealed a 20 cm × 20 cm thin-walled mass of the right adnexa, not clearly separate from it. Doppler examination showed that the right ovary was visible and had a polycystic ovarian morphology and apparent presence of vascular flow. The left ovary had the same polycystic pattern.\nHer pain became acutely worse, which reinforced the hypothesis of adnexal torsion. Based on these findings and the increased pain, we decided to perform exploratory laparotomy. Intraoperatively, a giant (~25 cm) cystic median mass of apparent right adnexal origin was seen, occupying the entire pelvis up to the diaphragm. The cyst wall was intact, adhesion-free and swollen. Necrotic ovarian tissue was identified within the mass, but no cleavage planes were identified. The pedicle, which included the infundibulopelvic and utero-ovarian ligaments, was twisted twice around its stalk (). The left adnexa and the uterus looked normal.\nThe patient underwent resection of the mass without rupture. Frozen-section analysis was not available since the surgery was performed during the night. The final pathology report noted a paratubal serous papillary cystadenoma, an ovary with polycystic morphology and a normal fallopian tube. All fragments had congestion, oedema and haemorrhage, consistent with obstruction of the arteriovenous flow (torsion). The postoperative course was uneventful.