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.
A 34-year old multigravida was found to have right adnexal mass on her routine gynecologic examination. Her previous medical history was uneventfull and Pap smear was normal. Transvaginal ultrasonography identified a cystic mass adjacent to the right ovary. Serum CA 125 was 5.1 U/ml (reference range: < 35 U/ml). At laparoscopy a dilated fallopian tube with bluish discoloration was found. The contralateral fallopian tube, ovaries and uterus were unremarkable. Exploration of the abdomino-pelvic cavity revealed smooth and shiny peritoneal surphace. Obtained peritoneal and pelvic washing were negative. Fine needle aspiration of dilated part of the fallopian tube revealed a 4 ml of bloody content. Cytological findings were consistent with hematosalpinx. Right salpingectomy was performed without using endoscopic bag. The patient was followed up by means of ultrasonography and serum CA 125 for 4.6 years. During this period she had no evidence of the disease.\nGrossly, a 7.0 cm long fallopian tube was irregularly dilated up to 4.4 cm in diameter at the ampulary region. The fimbriae were intact. The serosal surphace was smooth. Sections of the dilated part of the fallopian tube revealed a cystic tumor with focally yellow to tan, soft papillary excrescences protruding into the lumen (Fig. ) and foci of intracystic hemorrhage. On microscopic examination the papillae were covered by serous type of epithelium, displaying stratification and budding with focal nuclear atypia (Fig. ). Three types of cells were recognised; ciliated cells, hob-nail cells and mesothelium-like cells. Small foci of tumor tissue necroses and hemorrhage were noted. There was no invasion of the supportive stroma of the papillae or into the fallopian tube wall. Focus of endosalpingiosis within the adjacent mesosalpinx was found. DNA analysis determined by flow cytometry paraffin technique revealed DNA diploid tumor with low S-phase fraction of 6.5 %.