The patient, a 41-year-old woman with a non-relevant past medical history, concluded her fourth pregnancy by cesarean delivery owing to macrosomic product (July 2013). Tubal ligation was performed on postoperative day one by the Kroener fimbriectomy method, which coursed uneventfully and without any remarkable findings. The specimens obtained were sent for routine histopathological assessment, and the patient was discharged after full recovery. To date she is healthy and without any complaints.\nBoth distal tubes and fimbriae were identified; the large tube was bulky with a nodular appearance (3.5×2×1.3 cm) (). Transverse sections taken from this dilated duct revealed an overfilled lumen with a caramel-like substance surrounding an ill-defined peripheral spot, which, when seen under a magnifying glass, showed a fractal pattern similar to a snowflake (). Histologically, this hazy frame was sketched by a slender stalk with progressively branching papillae lined by columnar non-ciliated cells with plump eosinophilic cytoplasm showing focal pseudostratification and budding (, ). The nuclei of these cells were centrally located, enlarged, and rounded or oval. The nuclei displayed a variable appearance, either dense and hyperchromatic, or vesicular with a prominent nucleolus, and sometimes having coarse chromatin, membrane foldings, pseudoinclusions or grooves. Mitotic activity was not identified.\nDespite the presence of luminal extracellular mucin, several subnuclear mucin-filled vacuoles were also identified, occasionally expanding into cyst-like structures (). Periodic acid– Schiff and Alcian blue stains highlighted the extracellular and intracellular mucin, while the intracytoplasmic vacuoles were stained with Mayer’s mucicarmine (–).\nImmunoperoxidase stains demonstrated an intensely positive reaction for cytokeratin cocktail (CK AE1/AE3) in the membrane and cytoplasm () of cells, as well as for epithelial membrane antigen (EMA) with weak cytoplasmic expression and luminal border reinforcement (). Detection of progesterone receptors (PR) was markedly positive in 95% of cells, while estrogen receptors (ER) and androgen receptors were moderately and weakly positive in 70% and 10% of cells, respectively (–). The proliferation index labeled with Ki-67 was rated in approximately 3% of cells (). Surprisingly, cyclin D1 staining was observed in nearly 90% of cells (). No reaction was detected toward a variety of factors, including carcinoembryonic antigen (CEA), human chorionic gonadotropin, human epidermal growth factor receptor 2 (HER2/Neu), or B-cell lymphoma 2 protein (Bcl-2).\nAccordingly, the proliferation was diagnosed as a metaplastic papillary tumor of the Fallopian tube, with a note to the clinician about the benign behavior of the alteration.
A 31-year-old woman presented with abdominal distention and discomfort worsening over the past 6 months. Concurrently, she had development overactive bladder symptoms, bloating, and dyspepsia. Her medical history was pertinent for epilepsy controlled with antiepileptic medications. Urine analysis was negative for any signs of infection, and her pregnancy test was negative. Abdominal examination was positive for a firm and distended abdomen, uniformly enlarged from the xiphoid bone to the pubic symphysis. No tenderness was reported on palpation; however, pressure was endorsed. A bedside abdominal ultrasound was performed that revealed an abdomen fully distended with fluid, initially suspected to be ascites. Computed tomography in 2.5 mm helical slices with both IV and oral contrast suggested the presence of an encapsulated cystic mass containing clear fluid (6 Hounsfield units). Dimensions reported were 36 cm in long axis, 28 cm in transverse diameter, and 15 cm in anteroposterior diameter, corresponding to 7 liters in volume, suggestive of a right ovarian cystadenoma (Figures and ). No capsular irregularities were seen or intracystic vegetations identified. Concurrently noted was right renal pelvicalyceal dilatation resulting from compression due to the proximity of the right ureter with the renal pelvis measuring 2 cm in anteroposterior diameter. No abdominal ascites or other abdominopelvic abnormalities noted. Tumor markers were in the normal ranges (CA125: 12.13 U/ml, CEA:1.51 ng/ml, and AFP: 1.46 IU/ml). While understanding her risks, the patient stressed the avoidance of excision of ovarian or fallopian tissue due to fertility concerns and preferred that the cyst be removed in a cosmetic manner including avoidance of larger laparotomy incisions.\nThe patient underwent resection of the mass. The procedure was begun by drainage of the cyst in order to identify the stalk and excise all cyst walls. A 3 cm supraumbilical incision was performed with careful dissection until reaching the peritoneal cavity. An Alexis O™ wound protector/retractor Applied Medical was introduced through the small incision permitting better visualization of the cyst (). Three hemostats were used to hold the cyst wall in place, followed by meticulous introduction of an 11 mm trocar into the cyst cavity under direct vision. This was followed by insertion of a 5 mm suction tube through the trocar to aspirate the fluid contents while avoiding spillage of fluid into the peritoneal cavity. Eight liters of serous fluid were aspirated. Following fluid evacuation, the cyst wall had collapsed. The trocar site in the cyst wall was sutured shut in a purse-string manner followed by a second closure layer. Then, the cyst was released off the hemostats, and the laparoscopic gel cap was fitted onto the Alexis retractor to convert the abdominal incision into a laparoscopic port site. This was used to insufflate the abdomen with CO2. Thereafter, 2 additional 5 mm trocars on each side of the midline were introduced.\nThe cyst borders were identified (). Using the bipolar forceps and scissors, it was completely dissected off the fallopian tube. Both the fallopian tube and ovarian tissues were noted to be intact. The cyst was removed through the supraumbilical incision and sent to pathology. The trocars were removed and all incisions approximated as per protocol. The patient was discharged soon thereafter from the observation unit.