Author Information
Rane V*, Samant PY**, Honavar P***.
(* Second Year Resident, ** Additional Professor, *** Assistant Professor, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India.)
Abstract
A 45 years old, perimenopausal, multiparous, diabetic woman presented with chronic pelvic pain. Her imaging studies were suggestive of left ovarian cyst but on exploration we found a large left hydrosalpinx with normal ovaries. Left hydrosalpinx excision with right salpingectomy with bilateral oophorectomy was performed. Here, we discuss this unusual case of an atypical hydrosalpinx mimicking an ovarian cyst.
Introduction
An ovarian cyst is a common finding on pelvic examination and ultrasonography (USG), of which 70 % are benign cysts, 24 % are functional and 6 % are malignant.[1] We frequently rely on USG features to confirm the diagnosis with regards to the risk of pelvic malignancy on the basis of characteristics like size, laterality, complex appearance with solid component (with Doppler flow present in solid areas), mural nodules and ascites. Rarely, ultrasonically diagnosed complex ovarian cyst may turn out to be large hydrosalpinx as in our case. Misdiagnosis may be due to the tube’s large dimensions, very thin walls, septations and spherical appearance. Loculated ascites may also look like an ovarian cystic mass on USG. Hydrosalpinx due to distal tube occlusion may be secondary to pelvic inflammatory disease, endometriosis, fimbrial serosal obstruction following an adjacent inflammation like appendicitis and previous surgery (either tubal, pelvic or abdominal) or tubal ligation near fimbrial end.
Case Report
A 45 years old multiparous woman presented with gradual onset of dull aching pain in left iliac fossa for the last six months. She had history of severe pain with vomiting one month before presentation which was treated conservatively. Abdominopelvic ultrasound in private clinic showed a cystic adnexal mass for which she was sent to our institute. She had no complaints of burning micturition or vaginal discharge, fever, anorexia or weight loss suggestive of any genitourinary or systemic infection. She had no other urinary or bowel complaints due to pressure of pelvic mass. She had no complaints of pedal edema, chest pain, paroxysmal nocturnal dyspnea, palpitations, syncope or seizures. She had previous three cesarean sections, with tubal ligation done at the time of last section 18 years ago. She had irregular menses with amenorrhea for 3 months before presentation to our outpatient department. Urinary pregnancy test was negative and she had been given progesterone for 5 days for withdrawal bleeding. On physical examination, she was afebrile. Pulse was normal and blood pressure was raised (140/90 mm Hg). Her BMI was 27 kg/m2. Chest auscultation revealed normal heart sounds with ejection systolic murmur, respiratory system was clear.
On per abdominal examination, patient had both midline vertical scar and Pfannensteil scar with a 24 weeks size mass felt in lower abdomen more on right side arising from pelvis. Patient had mild tenderness in left iliac fossa and suprapubic region. Per speculum examination showed healthy cervix and vagina. On per vaginal examination, uterus was retroverted, soft, firm, mobile, normal in size. Mass was not well appreciated due to obesity. Both fornices were free and non-tender.
Her investigations revealed raised blood sugars, raised HbA1c (7.17). She was started on metformin and sitagliptin by endocrinologist. Her cholesterol levels were normal. Her hemogram, liver and renal function tests were normal. She was seronegative for syphilis, hepatitis B, C and HIV. Tumor markers AFP, CEA, Beta HCG, CA 125 were normal, LDH was elevated (624 IU/liter). Repeat LDH was 503 IU/liter. 2D echocardiogram showed atrial septal defect with large ostium secundum and left to right shunt. Pap smear showed inflammatory cells.
USG was suggestive of a thin walled, avascular, multiloculated, anechoic lesion measuring 11.2 x 9.9 x 8 cm in left ovary most likely complex ovarian cyst. Right ovary was normal, and no adnexal mass was seen. Computerized tomography scan (CT scan) showed thin walled multiloculated cystic lesion in pelvis measuring 9.6 x 8.4 x 10.2 cm representing ovarian cyst probably from left ovary. There was no ascites or lymph node enlargement. Chest radiograph showed patchy opacities in left mid zone suggestive of infective etiology; bilateral costophrenic angles were clear.
Patient was counseled for total abdominal hysterectomy with bilateral salpingo-oophorectomy SOS omentectomy and peritoneal fluid cytology. Exploratory laparotomy was done after taking cardiology, endocrinology and chest medicine references for fitness for surgery.
Intraoperatively, peritoneal fluid was sent for cytology. Uterus was normal in size. Urinary bladder was found to be densely adherent to the anterior uterine wall. Left hydrosalpinx of about 7 x 8 cm adhered to the omentum was noted (figure 1).
Figure 1. Left hydrosalpinx.
Left ovary was normal with 3 x 2.5 cm simple cyst. Right ovary and fallopian tube looked normal. Hysterectomy could not be done due to dense adhesions between bladder and anterior uterine wall. Left hydrosalpinx with left ovary was excised with right salpingo-oophorectomy after informing the patient and relatives about anticipated difficulty in hysterectomy and risk of bladder injury. Postoperatively, patient was given deep venous thrombosis prophylaxis with strict monitoring of blood sugars.
Cytology of peritoneal fluid revealed degenerative changes with many erythrocytes and a few monolayered sheets of degenerated mesothelial cells. No malignant cells were seen. Histopathology report was suggestive of normal ovarian stroma, corpus albicans and follicular cyst identified. Fallopian tube section showed features of hydrosalpinx.
Discussion
Chronic pelvic pain is a common problem seen in gynecologic outpatient department. Gynecological causes of chronic pelvic pain can be endometriosis, inflammatory or post-operative adhesions, ovarian cysts, tubo-ovarian mass, adenomyosis, myoma or pelvic congestion. Of these, ovarian cysts and large hydrosalpinx may be difficult to differentiate both clinically and on imaging studies. Hydrosalpinx after pelvic inflammatory disease is often a sequela of chlamydial infection which affects fallopian tube epithelial transporters and ion channels particularly cystic fibrosis transmembrane conductance regulator. This results in increased epithelial secretion, decreased fluid absorption, hence accumulation of fluid.[2] Ultrasound is useful for adnexal pathology but requires high index of suspicion to rule out various similar appearing causes of pelvic pain.
Simple cysts appear unilocular with lack of cyst wall papillae, but hemorrhagic cysts have echogenic content which may be homogenous or heterogenous. A resolving blood clot may show fibrin strands (cobweb/ reticular/ lace like pattern) mimicking septations. Dermoid cysts are easy to identify due to hyperechoic bone, teeth, hair in hypoechoic cyst. Para ovarian cyst can be correctly diagnosed when ovary is seen separately from the cyst. Endometrioma shows uni- or multiloculated homogenous echoes and ground glass appearance.[3] Malignancy may be detected by Doppler study. A typical hydrosalpinx appears as a tubular retort shaped cystic mass with incomplete septation or indentations along its walls (cogwheel/ waist sign), mural nodules may give it a “beads on string” appearance.[4] In our case, it appeared large with spherical shape and hence was mistaken as ovarian cyst. Hydrosalpinx with menstrual cycle dependent changes due to fallopian tube endometriosis has been reported.[5] Hydrosalpinx can also mimic ovarian malignancy as both present as adnexal mass. Transabdominal sonography may be non-discriminative. Elevated tumor marker levels like CA125, CEA or LDH should clinch the diagnosis.[6] In some cases of hydrosalpinx, the tumor markers also may be raised.[7] CA 125 may be high in tuberculosis. In our case, LDH was high. We planned total abdominal hysterectomy with bilateral salpingo-oophorectomy for ovarian neoplasia. On laparotomy, it was large left hydrosalpinx which was excised along with right fallopian tube and both ovaries, uterus being densely adherent to bladder could not be removed. Risk reducing salpingo-oophorectomy without hysterectomy is a known modality of treatment in cases of BRCA carriers.[8]
Conclusion
It is important to remember that hydrosalpinges can have an atypical appearance due to significantly large size along with rise in tumor markers mimicking a malignant ovarian cyst.
References
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Rane V, Samant PY, Honavar P. Large Hydrosalpinx Mimicking An Ovarian Cyst. JPGO 2017. Volume 4 No.7. Available from: http://www.jpgo.org/2017/07/large-hydrosalpinx-mimicking-ovarian.html