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.
The patient is a 25-year-old woman, gravida 0, who was referred to the gynecology oncology division at Chonnam National University Hospital with lower abdominal pain and abdominal mass. Her gynecologic history was unremarkable. Physical examination was notable for abdominal mass that was near at xiphoid process. Pelvic ultrasound revealed about more than 20 cm cystic mass. Magnetic resonance imaging of the pelvis revealed about 23×21×9 cm sized serous borderline cystic tumor in the right ovary and 2.2 cm corpus luteum of the left ovary. There was no remarkable findings in the uterus and no abnormal pelvic lymphadenopathy. The tumor marker profile was as follows: CA-125 38.2 U/mL (0-35). Another tumor markers and the result of hematological analyses were within their normal ranges.\nExploration of the abdominopelvic cavity revealed about 23 cm sized brownish fluid contained cyst located within the right fallopian tube. Its surface was clear and on cut section, it had multiple papillary growing in inner surface (). The left ovary had about 1 cm sized whitish nodule. A right salpingectomy, left ovary wedge biopsy, appendectomy and cytology were performed. A frozen section of the right fallopian tube revealed a serous borderline tumor. And a frozen section of the left ovary revealed a fibroma. Exploration of the right ovary and left tube was unremarkable, and, in view of patient's age and desire for future fertility, no further surgical procedure was undertaken. Histologically, right tubal mass was serous borderline tumor and appendix uninvolved by tumor cells and cytology of peritoneal washing fluid was negative for malignant cells. Tumor had cystic change and papillary nodules. On microscopic examination the papillae were covered by serous type of epithelium (), displaying stratification and budding with focal nuclear atypia (). There was no invasion of the supportive stroma of the papillae or into the fallopian tube wall. Micropapillary pattern of the tumor was absent and there was no papillary tubal hyperplasia in the fallopian tube. In general, the histology of the tumor was similar to that of an ovarian borderline serous tumor. Pathologic diagnosis was serous borderline tumor of the right fallopian tube. Close follow-up was recommended and currently, the patient's postoperative recovery was uneventful.