Author
Information
Chawla T*. Fernandes
G**, Parulekar SV***
(* First Year Resident, *** Professor and Head, department of
Gynecology and Obstetrics; * Associate Professor, Department of Pathology, Seth
GS Medical College & KEM Hospital, Mumbai ,
India
Abstract
Peritoneal inclusion cysts are not very
common. They may be found incidentally. They are usually reactive, but may be
developmental in some cases. We present an unusual case that developed in
response to tubal sterilization operation using silastic bands.
Introduction
Peritoneal inclusion cysts are not very
common. They are usually found in the reproductive age women. They are usually
reactive, but may be developmental in some cases. The most common causes of
reactive development of the cysts include pelvic surgery, infection, or
endometriosis. We present an unusual case that developed in response to tubal
sterilization operation using silastic bands.
Case Report
A 41 year old female, married for 26 years, para 3 living 3 abortion 1,
with tubal ligation done 15 years back presented with complaints of menorrhagia
for 6 months with soakage of 6 pads per day. It was also associated with
passage of clots and dysmenorrhea. She had history of pelvic inflammatory
disease 1 year back for which she was prescribed a course of doxycycline and
metronidazole. There was no history of any bowel or bladder related symptoms, no complaints of
weight loss, and no other medical or surgical risk factors. Her general and
systemic examination findings were within normal limits. The abdomen was soft.
There was a mini-laparotomy tubal ligation scar above the pubis. A speculum
examination showed Nabothian follicles on the cervix and healthy vagina. On per
vaginal examination, the uterus was approximately 6-8 weeks size, mid-posed,
the fornices free and non tender. Her
biochemical preoperative investigations, chest radiography and
electrocardiogram were normal. Her hemoglobin was 10 g/dL. Abdominopelvic
ultrasonography revealed 2 fundal leiomyomas of approximately 3 cm X 4 cm and 2
cm X 3 cm on the anterior and posterior uterine wall respectively. A vaginal
hysterectomy was performed under spinal anesthesia. Three unilocular,
translucent cysts measuring 1 cm X 0.5 cm, 0.5 cm X 0.5 cm, and 0.5 cm X 0.5 cm,
containing clear fluid were present on the lateral wall of uterus on the
isthmic portion of fallopian tube, very close to the silastic band applied to
the tube for tubal sterilization. The postoperative period being uneventful.
The comprehensive histopathological examination of the specimen revealed the
cysts to be peritoneal inclusion cysts.
Figure 1. Simple
hysterectomy specimen showing three unilocular, translucent cysts (yellow
arrows) on the serosa of the left fallopian tube close to the cornu. The
silastic band is seen nearby (black arrow).
Figure 2. Cut
surface of the cyst showing a smooth inner wall (white arrow). A leiomyoma is
also seen (black arrow).
Figure 3.
Microphotograph showing a cyst within the serosa. Smooth muscle bundles of the
myometrium are seen to the right. (H&E x 50)
Figure 4.
Microphotograph showing a tiny microscopic cyst in the vicinity of the larger
cyst. (H&E x 50)
Figure 5.
Microphotograph showing cyst wall lined by a single layer of hobnail shaped cells
resembling mesothelial cells. (H&E x 1000)
Figure 6. Microphotograph showing cyst wall
lined focally by multilayered cuboidal cells with bland nuclear features.
(H&E x 1000)
Discussion
Peritoneal
inclusion cysts usually occur in women in the reproductive age group. Most of
them are reactive in origin.[1,2] Some of those located in the
mesentery of the small intestine, mesocolon, retroperitoneum, spleen or kidney
may be developmental.[3] They arise by invagination of the serosa. They
may be incidental findings at laparotomy. They are usually small, single or
multiple, unilocular, thin-walled, translucent cysts. They may be attached or
lie free in the peritoneal cavity. They usually lie beneath the serosal
surface. They have a smooth lining of a single layer of flattened, benign
looking mesothelial cells. Their contents vary from watery and yellow to
gelatinous.[4] Multilocular cystic masses may be very large, measuring
up to 20 cm in diameter. They are usually attached to the pelvic organs. They
usually cause lower abdominal pain and/or palpable mass. They may mistaken for
a cystic ovarian tumor. Their septa and walls may contain abundant fibrous
tissue. Their contents may be like those of the unilocular cysts, or they may
be bloody. They are usually lined by a single layer of flat to cuboidal cells, though
occasionally it may be of hobnail-shaped mesothelial cells showing bland
nuclear features.[5] Some reactive atypia may be found. Other
occasional features include small papillae, cribriform pattern, squamous
metaplasia, intra- and extracellular hyaline bodies, adenomatoid tumor-like
patterns, an infiltrative appearance.[6]
About 5% cases have a history of a prior abdominal operation, pelvic
inflammatory disease, or endometriosis. This supports the reactive theory of genesis of these cysts. The case
presented here had these cysts very close to tubal sterilization with silastic
band on one fallopian tube. Silastic is inert chemically and does not elicit
any tissue reaction. That explains the rare occurrence of this condition in
association with tubal sterilization with silastic bands. It was unusual that
she had such cysts on only one fallopian tube, though silastic bands had been
applied to both the tubes. She had pelvic inflammatory disease in the past too.
But we feel it was unlikely to be the cause, because it had been a single
episode of acute infection, which had been controlled with antibiotics. A
chronic infection is more likely to cause development of such cysts. Another
factor favoring the sterilization procedure over the pelvic infection as the
cause of these cysts in this patient was the location of the cysts only on the
fallopian tube, which was otherwise healthy in appearance. Pelvic infection
would have caused development of the cysts on other pelvic structures too, and
the tubes would have shown effects of the past infection. Though a malignant
behavior is not seen in multilocular cysts, about 5% of them the recur one or
more times, after months to many years. These could be development of new cysts
as a result of the irritation caused by the operation for excision of the
previous cysts.
References
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McFadden DE
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Urbańczyk K, Skotniczny K, Kuciński J, Friediger J. Mesothelial
inclusion cysts (so-called benign cystic mesothelioma)--a clinicopathological
analysis of six cases. Pol J Pathol. 2005;56(2):81-7.
3.
Arber DA, Strickler JG, Weiss LM. Splenic mesothelial cysts mimicking
lymphangiomas. Am J Surg Pathol 1997;21:334-338.
4.
Clement PB, Young RH. The Peritoneum. In Sternberg's Diagnostic
Surgical Pathology. Ed. Mills SE. 5th Edition Lippincott Williams &
Wilkins. 2010. pp. 2392-2418.pp 2396-7.
5.
Ross MJ, Welch WR, Scully RE. Multilocular peritoneal inclusion cysts
(so-called cystic mesotheliomas). Cancer 1989;64:1336-1346.
6.
Lamovec J, Sinkovec J. Multilocular peritoneal inclusion cyst
(multicystic mesothelioma) with hyaline globules. Histopathology
1996;28:466-469.
Citation
Chawla T, Fernandes G, Parulekar SV. Peritoneal Inclusion Cysts.
JPGO 2014. Volume 1 Number 12. Available from: http://www.jpgo.org/2014/12/peritoneal-inclusion-cysts.html