Letters to the Editor

Abstract

11 November 2009 Dear Editor, BENIGN OVARIAN TUMOUR PRESENTING AS HUGE ABDOMINAL MASS The annual incidence of ovarian neoplasms in the paediatric and adolescent population is estimated to be 2.6 cases per 100 000, with germ cell tumours being the most common ones.1 We presented a girl with a huge abdominal mass without any discomfort or pain. In this paper, we emphasised the diagnosis of serous cystadenoma in children who present with asymptomatic abdominal mass. A 12-year-old pre-menarchal girl presented with a history of increasing abdominal distension, without discomfort, pain or any other urinary and gastrointestinal symptoms (Fig. 1a). The patient's weight was 60 kg, and height was 163 cm. No pain or abdominal masses were noted upon examination. The other physical and systemic examinations were unremarkable. The first ultrasonographic examination of the abdomen was performed by a paediatrician in an effort to reveal the cause of frequent micturition, and a cyst of the left ovary was an incidental finding. Pelvic ultrasonographic examination revealed a large cystic mass (56 cm) arising from the left ovary, reaching to the level of the xiphoid. Magnetic resonance imaging showed a huge mass arising from the left ovary with no signs of organ invasion (Fig. 1b,c). Laboratory results including endocrinological tests (follicle-stimulating hormone (FSH)-immunochemiluminometric assays (ICMA) 25.08 mIU/mL, LH-ICMA 5.06 mIU/mL, oestradiol 58 pg/mL), as well as thyroid-stimulating hormone [TSH] and T4, were normal for the age and pubertal stage of the patient. The ovarian tumour marker values (alfa feto protein [AFP], beta human chorionic gonadotropin [βHCG], carcinoembryonic antigen [CEA], cancer antigen-125 [CA125] and lactate dehydrogenase [LDH]) were also normal. The cyst was surgically removed with preservation of normal ovarian tissue, and histopathology revealed a serous cystadenoma. The huge cyst was unilocular, with a thin wall and clear content. Both of the ovaries were visible by pelvic magnetic resonance imaging, and their volumes were found within normal limits (Fig. 1d). The patient was followed up regularly, and there was no evidence of recurrence 30 months after surgery. (a) The patient with minimal abdominal distension at admission. (b,c) Magnetic resonance imaging demonstrated an enormous mass occupying almost the entire abdomen. (d) Cyst was surgically removed, with preservation of normal ovarian tissue. Although there are numerous classes of epithelial ovarian cancer in adults, the histological subtypes of epithelial ovarian tumours in children include only serous and mucinous tumours.2 Benign serous cystadenomas are rare benign neoplasms in the paediatric age group.3 Although this tumour is rare, this diagnosis should be considered in 11–15-year-old girls presenting with a huge abdominal mass. Malignant transformation is possible in 5–10% of cases, in particular, the adenomatose shapes that can induce transformation into adenocarcinoma.4 However, serous cyst tumour of the ovary in our patient occurred prior to menarche, and these tumours tend to present with abdominal distension. The FSH levels were measured by new ICMA. The normal ranges were calculated by age and Tanner stage (premenopausal: 5–30 IU/L). The patient was a pre-menarchal pubertal girl at Tanner stage 4. She exhibited an elevated basal FSH level; however, the menses had not started, and the mid-follicular oestradiol levels were normal. FSH serum levels were high during spontaneous puberty and slowly normalised thereafter in our patient. The differential diagnosis of ovarian masses in pre-menarchal girls includes cysts, torsion with subsequent oedema, benign or malignant ovarian neoplasm, and, rarely, involvement of the ovary by lymphoma, leukaemia, or metastatic disease.5 Ovarian causes of cysts in adolescents include follicular and corpus luteum cysts, haemorrhagic functional cysts, endometriomas, or benign and malignant neoplasms. Disorders of the fallopian tube such as hydrosalpinx, pyosalpinx, paratubal cyst or ectopic pregnancy can mimic an ovarian cyst. Peritoneal cysts or peri-appendiceal abscesses are occasionally mistaken as adnexal pathology.6 Patients with a serous cyst might present late, and this may lead to renal insufficiency secondary to urinary outflow obstruction. A mass may also be totally asymptomatic and revealed by ultrasonography incidentally. Benign cystadenomas are the most common cysts and are effectively treated by unilateral cystectomy.7 Conservative surgery is adequate for benign lesions and early-stage ovarian tumours of borderline malignancy. Early detection of adnexal masses and surgical techniques makes it possible to remove the tumour and preserve the underlying ovary and subsequent fertility. Surgical treatment of our case was successful, and the patient adjusted well to her post-operative body image.