Key Words

Mucinous cyst,ovary,epithelial tumors.

Introduction

The mucinous cyst is a benign tumor of the ovary containing a mucoid fluid from which the adjective (mucinous). Mucinous cysts of the ovary are often seen in women aged 20 to 50 years, with an average age of 42 years [2]. They account for about 20% to 25% of all benign ovarian tumors and 75% to 85% of all ovarian mucinous tumors; this frequency is identical to that of serous cysts of the ovary (20 to 25% of benign tumors of the ovary). Mucinous cysts are rarely bilateral (5% of cases, or 2 to 3% for some authors).

Observation

This is a 70-year-old patient, multiparous, menopausal for 25 years, consulted for abdominal distension. The abdominal examination finds an abdominopelvic mass extending up to the level of the two hypochondria at the top. The gynecologic examination find a polyp delivered by the cervix. A thoraco-abdominopelvic CT scan , showed an heterogeneous abdominal-pelvic cyst with a thick septa measuring 25/17 cm. This mass comes into contact with the uterus and pushes the digestive structures upwards. the tumor markers was performed and returned with a high CA19-9 level. a laparotomy was performed and showed an abdominal-pelvic mass of 30 cm / 30 cm. it is a well-limited mass, thickened wall at the expense of the left ovary occupying the entire abdomen with the presence of ascites fluid. Left adnexectomy was performed after detachment of the mass of the peritoneal cavity. The exploration of the peritoneal cavity was unremarkable. Samples were taken: peritoneum, right appendix, epiploon and the ascites fluid. The follow-up was simple for the patient with a clear improvement of the general condition. . The pathological report has returned in favor of a huge cystic mucinous mass weighing 5kg (Figure 1). Its inner wall is lined with gelatinous membranes with the presence of multiparystic septate whose opening finds a viscous liquid.

Figure 1

1

Comment

Mucinous cysts sit in the ovary in about half of the cases, but they can develop in the mesovarium (mesovarium) or the broad ligament. The volume of mucinous cysts is variable, but in fact, it is the ovarian cysts that can reach the largest sizes (maximum of 50 cm). Their volume varies from a few cubic centimeters to several tens of liters (94 liters in a case published by Tuffier) ​​[1]. They are typically bumpy because multilocular (realizing a honeycomb appearance), often with locules separated by partitions less than 3 mm thick; Usually, there are one or a few major locusts, then multiple small secondary locules. Mucinous cysts are sometimes unilocular.Their outer surface is opaque, white and rarely translucent. Their content is liquid, citrine, but sometimes red or chocolate if there is an intra-cystic haemorrhage. It is a fluid with a mucous-like appearance, sometimes very thick, gelatinous, but in some cases it can be fluid like the usual contents of serous cystadenomas. In this fluid we can find many elements figured in variable proportion: large epithelial cells, leucocytes, red blood cells; then organic chemicals such as cholesterol and various lipids, saccharides, urea and in particular paralbumin (considered by Waldeyer as characteristic in mucinous cysts). The bilaterality of the mucinous cyst may suggest the malignancy or the borderline characteristic (at the borderline of the malignancy) of the tumor [2]. The wall of the mucinous cyst is composed of two layers: a fibrous outer layer, with a conjunctivo-elastic tissue and traversed by blood vessels that can reach large diameter (veins 1 to 2 cm in diameter), then a network of lymphatic vessels anastomosing to those of the broad ligament. an inner epithelial layer: according to the type of this epithelium, we can distinguish three types of benign mucinous cysts: The epithelium lining the cystic cavity is usually unistratified, consisting of cylindrical cells with homogeneous and clear cytoplasm, with a small nucleus, uniform and aligned in contact with the basal membrane, and especially of the endocervical type (mucinous cystadenoma of the endocervical variety: cells predominant endocervical type). In the rare enteroid variety of mucinous cysts (mucinous cystadenoma with predominant intestinal type cells), mucinous, endocervical lining of the cyst, argentaffin cells, neuroendocrine cells, and goblet cells of Paneth are pseudostratified nuclei and abundant and hypersecretory cytoplasm [3].Mucinous cysts of the enteroid variety can associate with other tumors and pathologies: a Brenner tumor; an appendicular mucocele; a benign cystic teratoma (in 5% of cases, this form was formerly called “dermomucoid cyst – Lebert, 1852”); endometriosis; a tumor with Leydig and Sertoli cells; primary ovarian sarcoma; one or more solid nodules of the cystic wall that may be adenofibromas, carcinomas or pseudosarcoma. There is also a mixed variety of mucinous cysts: endocystic endocystic epithelium of endocervical and enteric type. Of the mucinous tumors of the ovary: 85% are benign; 5% are borderline tumors (borderline malignancy) with good prognosis; 10% are malignant tumors (mucinous cystadenocarcinoma). Etiology : The etiology of mucinous cysts is unknown, but it has occasionally been described that these cysts may be associated with other ovarian tumors, probably because of their common origin: teratomas, ganulosa tumor, Brenner tumor, carcinoid tumor of the ovary; then metastases of tumors from the appendix to the ovary may take the form of mucinous cystadenoma. The frequency of mucinous cysts in the ovary is increased in women with Peutz-Jeghers syndrome. Management of benign mucinous cysts of the ovary: Total cystectomy or oophorectomy (depending on the context) is curative for mucinous cysts of the ovary [4].

Conclusion

Most epithelial tumors of the cystic ovary have a benign and malignant side, but also a borderline at the edge of the malignancy or borderline which makes the whole difficulty of the management. To improve this management, close collaboration between the surgeon and the pathologist is essential to define the indications and the limits of the extemporaneous examination and for a good transmission of the operative specimen.