Large Solitary Luteinized Follicle Cyst of Pregnancy and Puerperium: a Rare Post-partum Clinical Presentation

Abstract

Abstract Introduction/Objective In literature, all large solitary luteinized follicular cysts of pregnancy and puerperium (LSLFCPP) recognized were removed before or during delivery. This would be the first case in literature describing the clinical behavior of the LSLFCPP in the post-partum period. Methods We herein report a rare case of 21-year-old G2P2 female who underwent a full-term uneventful spontaneous vaginal delivery (39w0d, APGARS 9,9) without removal of the undiagnosed LSLFCPP, which nearly doubled in size post-partum. Her past medical history was significant for treated syphilis and normal Pap Test of the cervix. Three months after delivery, the patient presented with LSLFCPP exhibiting mass effect (retroverted uterus, mild right-sided obstructive uropathy, compressed bladder and intermittent pain). The antepartum ultrasound showed 14 cm pelvic mass that had grown to 30 cm on CT scan, in largest dimension. Beta-hCG levels returned to pre- pregnancy levels. Treponema pallidum antibody, FTA-ABS and RPR were reactive. Alpha-fetoprotein, inhibin B, CA- 125, CEA, and CA 19-9 screen were unremarkable. The patient underwent exploratory laparotomy cyst removal with right salpingo-oophorectomy. Results Grossly, the tumor weighed 22 lbs with a diameter of 28 cm; excrescences were not noted. Intraoperative consultation revealed a unilocular benign cyst. Histologically, the cyst was not only lined by luteinized cells but nests of luteinized cells infiltrated the fibrous wall. These cells were positive for Inhibin A and calretinin. A rare mitotic figure was noted. A diagnosis of LSLFCPP was rendered. Conclusion High levels of gonadotropin in pregnancy are implicated in the pathogenesis of LSLFCPP; however, in our case, the cyst doubled in size three months after delivery with undetectable beta-hCG levels. This indicates that the pathogenesis of this cyst relies on more than beta-hCG stimulation. LSLFCPP is important to recognize because it can mimic a malignant proliferation on frozen section and can potentially compromise fetal viability with mass effect.