Borderline endometrioid tumor arising in a paratubal cyst: a case report

BACKGROUND: Paratubal cysts, generally known as hydatid cysts of Morgagni, are small round cysts attached by a pedicle to the fimbriated end of the tube. The following represents the first reported case of an endometrioid tumor of low malignant potential arising in a paratubal cyst. CASE REPORT: A 45-year-old nulliparous female was referred with a complex right adnexal mass on pelvic sonogram. She underwent laparoscopic bilateral ovarian cystectomy and partial right salpingectomy (for a 3-cm torsed paratubal cyst). All frozen-section diagnoses were benign; however, final pathology revealed a borderline tumor of low malignant potential of endometrioid type in the right paratubal cyst. The patient underwent extensive counseling regarding management options and decided to have a laparoscopic right salpingo-oophorectomy. Final pathologic analysis revealed no evidence of persistent borderline tumor. CONCLUSION: Paratubal cysts are very difficult to diagnose with sonography; therefore, their management should be approached as any other adnexal mass. Laparoscopic surgery is an option in the management of adnexal masses; however, rupture or puncture of masses should be avoided when possible to prevent potential tumor dissemination in the event of a malignancy.     

Paratubal Borderline Malignancy: A Case of a 17-Year-Old Adolescent Female Treated with Laparo-Endoscopic Single-Site Surgery and a Review of the Literature

BackgroundAlthough paratubal cysts are common, borderline paratubal cysts are extremely rare. We describe the case of a large borderline paratubal cyst in a 17-year-old adolescent female treated with laparo-endoscopic single-site surgery (LESS), and review the literature.CaseA 17-year-old female was referred due to a large right adnexal cyst on pelvic sonogram. A CT scan showed a 19-cm cystic lesion with enhancing papillary projection along the wall. Laparo-endoscopic single-site surgery confirmed a large cystic mass that originated from the right salpinx. Right salpingectomy and right ovarian wedge resection were performed, and intraoperative frozen section analysis was conducted. The result of the frozen section analysis and final pathologic review indicated that the cyst was a serous papillary-type borderline tumor in a paratubal cyst.Summary and ConclusionTo the best of our knowledge, this is the first case report of a BPC treated with LESS. We suggest that minimally invasive, fertility-preserving surgery should be considered as a standard treatment of borderline paratubal cysts if patients desire future fertility.     

Recurrent Ovarian Torsion due to Paratubal Cysts in an Adolescent Female

BackgroundThough paratubal and paraovarian cysts are rare in adolescent females, the influence of post-menarchal hormonal stimulation on these tubal derivates can produce large and clinically significant adnexal pathology. Ovarian torsion secondary to paratubal cysts is rare due to the cyst’s location and ipsilateral recurrence is uncommon.CaseWe report a case of an 11-year-old female with a large right paratubal cyst causing ovarian torsion on two separate occasions within one year and our approach to surgical management.ConclusionExcision of a paratubal or paraovarian cyst that causes ovarian torsion is necessary to decrease the risk of cyst recurrence and ovarian torsion in the future. Timely diagnosis and treatment of ovarian torsion enables preservation of ovarian function and patient fertility.     

Unilateral Ovarian Dermoid Cyst Accompanied by an Ipsilateral Paratubal Cyst in a Girl with Proteus Syndrome Discovered by Laparoscopic Surgery

BackgroundProteus syndrome is a rare hamartomatous disorder characterized by the overgrowth of multiple tissues in a mosaic pattern. Tumors of genitourinary tract in Proteus syndrome are uncommon.CaseWe here report a 5-year-old girl with Proteus syndrome who developed a cystic mass in the pelvic cavity. The cyst was discovered by ultrasonographic examination and finally proved to be a unilateral ovarian dermoid cyst accompanied by an ipsilateral paratubal cyst by laparoscopic surgery.Summary and ConclusionProteus syndrome accompanied by an ovarian cyst is rare in girls. The possibilities of underlying ovarian cyst required for surgical intervention should be considered in Proteus syndrome.     

Modified Arias-Stella reaction in paratubal epithelium

The Arias-Stella reaction (hyperplastic changes of the endometrial epithelium associated with cellular atypia) may be seen in uterine or extra-uterine pregnancies. I found a modified Arias-Stella reaction in paratubal epithelial cells. The fallopian tube studied was removed because of ruptured ectopic pregnancy. Although this phenomenon has not been previously reported, it is not really remarkable because of the embryological similarity of paratubal and endometrial epithelium.     

Rare case of a paratubal cystadenoma with bilateral hydrosalpinges in an infertile woman

ObjectiveSerous tumors can occur on the surface of the ovaries and—rarely—as primary tumors on the peritoneal surface. However, the origin of extraovarian serous tumors is unknown. An unusual case of a serous tumor is presented here.Case reportA 34-year-old nulligravid woman presented for evaluation of her primary infertility, with acute abdominal pain. At laparoscopy, a paratubal cyst, independent of the ovaries, was found to be associated with bilateral hydrosalpinges. The final pathology diagnosis was of a benign paratubal serous cystadenoma.ConclusionWe present an unusual case of a paratubal serous cystadenoma with bilateral hydrosalpinges in an infertile woman, which was resected laparoscopically..     

Ovarian hilus cell heterotopia.

A systematic pathologic study was done of the paratubal and parametrial tissues, submitted along with distal tubal segments excised for sterilization and with uteri (with or without attached adnexa) removed for common gynecologic conditions. Heterotopic ovarian hilus cell rests were noted in 12 cases, giving an overall incidence of 0.52% (12/2299). These cell rests, confined exclusively to the endosalpinx and perisalpinx, were easily differentiated from pregnancy-related decidual nodules, Walthard rests, foci of paratubal endometriosis, and ectopic adrenal rests.     

Paratubal borderline tumor diagnosed in the adolescent period: a case report and review of the literature

Background

Borderline paratubal cysts are rare entities. These tumors are identified as epithelial proliferation without stromal invasion.

Case

A 19-year-old virgin patient was admitted to our clinic with abdominal pain and nausea. The sonographic evaluation showed a left adnexal mass 89 × 80 mm in diameter with solid tissue projections. Doppler examination revealed no significant blood supply. At surgery, a torsed left paratubal cyst 10 cm in diameter and normal bilateral ovaries were encountered. Cystectomy was performed and of frozen section revealed a borderline Fallopian tube neoplasm. Final pathology review was reported as a serous borderline paratubal tumor.

Conclusion

The evaluation of the structure of cyst by ultrasound and the performance of intraoperative frozen section analysis are two important issues to diagnose the nature of a cyst. Fertility-sparing surgery is the main point of management.     

A Case of Paratubal Serous Borderline Tumor Driven by a Somatic BRAF Mutation in an Adolescent Patient

BackgroundWe describe a rare paratubal serous borderline tumor occurring in an adolescent and provide insight into its molecular underpinnings.CaseA 14-year-old girl presented with irregular menstrual cycles and a large right pelvic mass. Computed tomography imaging revealed a cystic neoplasm arising from the right ovary with peripheral calcification. During laparotomy, a cystic tumor located at the right parametrium independent of the fallopian tube was identified. The ovary was intact and the tumor was successfully removed. Intraoperative diagnosis using the frozen section technique and subsequent pathology revealed a paratubal serous borderline tumor. Molecular analyses revealed a chromosomally stable tumor genome and a pathogenic somatic mutation (c.1799 T > A, p.Val600Glu) in the B-Raf proto-oncogene, serine/threonine kinase (BRAF) gene.Summary and ConclusionThis case shows that the BRAF p.Val600Glu mutation likely acts as an oncogenic driver in this rare neoplasm.     

Paratubal Cyst Recurrence in Children and Adolescents

Study ObjectiveTo examine the association between patient characteristics and risk for recurrence risk of paratubal cysts (PTC) in children and adolescents.DesignRetrospective chart review at a single institution.SettingSingle academic children's hospital.ParticipantsPediatric patients presenting to Texas Children's Hospital between July 2007 and March 2019. Patients were identified for the study by reviewing pathology reports and were included if they met inclusion criteria of a pathologic diagnosis of a paratubal or paraovarian cyst removed during any surgical procedure between July 2007 and March 2019.InterventionsSubjects with pathologic diagnoses of a paratubal cyst during the study period underwent chart review for the following data points: age at presentation, ethnicity, pathologic recurrence of paratubal cysts, pubertal status, body mass index (BMI), diagnosis of polycystic ovary syndrome (PCOS), size of cyst, laterality of cysts, and number of cysts.Main Outcome Measure(s)Recurrence, Pathology types.ResultsOf the 627 patients that met inclusion criteria, the incidence of recurrence was 11.3%. Group 1 included those with recurrence of PTC (N = 70). Group 2 was identified as those without recurrence of PTC (N = 557). There were no differences related to age, BMI, ethnicity, history of PCOS, cyst size, laterality or number of cysts present. PTC NOS and serous PTC occurred most frequently. Of the unique cases involving recurrence, 70.1% recurred on the ipsilateral side. There were no cases of paratubal cyst malignancies in this cohort. The range of pathology diagnoses included pathologies that may occur in ovarian cysts. This is particularly interesting, given the known origins of ovarian cancer from fallopian tube transformations. Rare pathology diagnoses likely did not occur with frequency to determine definitive risks of recurrence in these cases.ConclusionsThere appears to be a baseline recurrence risk for PTC, for which patients can be counseled. Recurrence does not appear to be associated with any particular pathology type, cyst size, number of cysts, BMI, PCOS, or puberty stage. Recurrence, should it occur, appears to occur more commonly on the ipsilateral side.     

Un rôle de la chirurgie robot-assistée pour préserver la fertilité féminine ? Réflexion à propos d’une première exérèse de kyste paratubaire par cœliochirurgie robot-assistée « Da Vinci S » chez une jeune fille

In the field of adnexal surgeries in children, robotic surgery seems to make easier the realization of minimal invasive surgery. It could lead to a decrease of post-surgical adherences and therefore preserve the fertility of young patients. We report the first paratubal cystectomy performed using robotic assistance on a child in order to preserve her future fertility and discuss advantages and disadvantages of this technology.     

Controversies in the management of endometriomas in patients undergoing assisted reproduction

Introduction

Paraovarian or paratubal cysts (PTCs) constitute about 10?% of adnexial masses. Although they are not uncommon; they rarely cause symptoms and are usually incidentally found. Actual incidence is not known. The symptoms occur when they grow excessively, or in case of hemorrhage, rupture or torsion.

Methods

Here, literature review reporting the incidence, presentation and complications of PTCs is performed. Uncommon presentations of PTCs in three different cases, a giant PTC, torsion of PTC and borderline paratubal tumor, are also reported and discussed.

Results

Ultrasonography, CT or MRI may be performed in preoperative evaluation; but none of these imaging techniques have specific criteria for diagnosis. So, in most cases misdiagnosis as an ovarian mass remains to be a problem.

Conclusion

Paratubal cysts can become extremely big before causing symptoms. Torsion is another urgent issue regarding PTCs, necessiating urgent surgery for preservation of the ovary and the tube. Although malignancy is rare, borderline paratubal tumors have been reported in the literature.     

Extrauterine lesions of intermediate trophoblast.

Lesions of intermediate trophoblast arising in the uterus include exaggerated placental site, placental site nodule, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor. Only 12 examples of extrauterine lesions of intermediate trophoblast (ELIT) have been previously reported; 7 new cases are described herein. Six lesions were located in the fallopian tube or paratubal region and one in the ovary. The patients were 25 to 47 (average 36) years of age. The lesions ranged from 0.6 to 4 cm in diameter; four were cystic. The four placental site nodules (three tubal, one paratubal) were composed of small, sharply circumscribed nodules of intermediate trophoblast with no mitotic activity. The three PSTTs (two tubal, one ovarian) exhibited irregular stromal infiltration by intermediate trophoblast, mitotic activity, and necrosis. Chronic salpingitis was seen in the six tubal/paratubal cases, and endometriosis was seen in four cases. Immunoreactivity for human placental lactogen, human chorionic gonadotropin, and cytokeratin in two cases was consistent with an origin from intermediate trophoblast. ELITs presumably arise from previous ectopic pregnancies, a history of which was present in two of these patients. Follow-up, available on two of the three patients with PSTT, was uneventful at 6 and 12 years, but study of additional cases is necessary to reliably determine the behavior of extrauterine PSTTs.     

Giant Paratubal Serous Cystadenoma in an Adolescent Female: Case Report and Literature Review

BackgroundParaovarian/paratubal cysts constitute 5-20% of all adnexal lesions and typically originate from the paramesonephric or Müllerian duct. The primary epithelial tumors arising from paraovarian cysts account for 25% of the cases, but giant cystadenomas of paraovarian origin are extremely uncommon during childhood and adolescence with very few cases reported in the literature.CaseWe present the case of a 15-year-old female that presented with a bulky mass in the abdomen and pelvis. An initial clinical and radiological examination indicated an ovarian cyst measuring ∼25 × 20 cm. However, explorative laparotomy revealed a giant paratubal cyst that was successfully treated with complete excision using fertility-sparing surgery. Histopathological examination was consistent with a serous cystadenoma. The postoperative course was uneventful and the girl was discharged on the seventh postoperative day. At the follow-up of 6 months, the patient was doing well.     

Parafallopian tube transitional cell carcinoma

BACKGROUND: Transitional cell carcinoma (TCC) has recently been acknowledged as a distinct histologic pattern of the uncommon primary fallopian tube carcinoma. However, rare cases of TCC that are closely associated to the extraluminal portion of the tube remain widely unrecognized. CASE: We present a left adnexal high-grade TCC in a 56-year-old postmenopausal woman with an elevated serum CA-125 level. The tumor was attached by a small stalk to the serosal surface of the left fallopian tube and was completely separate from the uninvolved uterus and ipsilateral ovary. Histologic examination of the tubal lumen epithelium revealed neither atypia nor involvement by the neoplasm. Immunohistochemistry showed the tumor cells to be positive for pankeratin, calretinin, progesterone and estrogen receptors, and cytokeratin 7, and negative for cytokeratin 20, consistent with a Mullerian derivation. CONCLUSION: Our case represents the fourth reported instance of a primary paratubal TCC. Perhaps, this entity falls under a previously unrecognized category of carcinomas that collectively may arise from Walthard's rest, paratubal cyst, or directly from the tubal serosa.     

Uteroovarian ligament torsion of the due to a paratubal cyst

Paratubal cysts rarely undergo torsion. When they do, typically they involve the infundibulopelvic ligament and affect the ovary and fallopian tube. We present a case and discussion of torsion of the uteroovarian ligament secondary to a large paratubal cyst with preservation of the ovary and fallopian tube.     

Tubal torsion during pregnancy--case report

Tubal torsion is a very rare event, especially in pregnancy. We present a case of a patient of 20 weeks gestation that was admitted to our clinic with acute abdomen. Radiological and biochemical investigations did not reveal the cause of abdominal pain which resulted in laparatomic exploration. During the operation, the paratubal cystic mass, previously explored by ultrasonographic examination, and the left fallopian tube were found twisted among themselves. Salpingectomy was performed due to the necrotic appearance of the fallopian tube.     

Laparoscopic excision of adnexal masses

STUDY OBJECTIVE: The purpose of the present study was to evaluate a prospective series of consecutive patients with adnexal masses selected with strict preoperative clinical and ultrasonographic criteria. DESIGN: Prospective series of consecutive patients (Canadian Task Force classification II-2). SETTING: Tertiary care university hospitals. PATIENTS: Six hundred and eighty-three consecutive patients under 40 years of age with ultrasonographic evidence of an adnexal cystic mass without thick septa, internal wall papillation, or solid components, except for sonographic pattern suggestive of dermoid. INTERVENTIONS: Operative laparoscopy and follow-up. MEASUREMENTS AND MAIN RESULTS: After initial diagnostic laparoscopy in 13 patients with stage 4 endometriosis and extensive bowel adhesions, in 2 patients with large-volume dermoids, and in 1 patient with suspect ovarian and peritoneal implants, the procedure was converted to laparotomy. Therefore, 667 patients were completely managed by laparoscopy. There were 1069 cysts excised. Histologic diagnosis was endometrioma in 57% of the excised cysts, serous cyst in 13%, dermoid in 12%, paratubal in 8%, mucinous cysts in 5.3%, functional cyst in 2.8%, other benign histotypes in 1.1%, and ovarian malignancies (seven borderline tumors and one endometrioma with a microfocus of G1 endometrioid carcinoma) in 0.7% of the cysts and 1.2% of the patients. These last patients are alive with no evidence of disease after a mean follow-up of 62 months. CONCLUSIONS: In the present series, with accurate preoperative and intraoperative selection, the rate of unexpected borderline or focally invasive malignancies was 1.2% of the patients, and the laparoscopic management of these adnexal masses did not adversely impact on prognosis.     

Pregnancy-preserving Laparoendoscopic Single-site Surgery for Gynecologic Disease: A Case Series

Study ObjectiveThe study objective was to assess the feasibility of laparoendoscopic single-site surgery (LESS) for the management of nonobstetric, gynecologic disease processes in pregnant patients.DesignA retrospective case series of 13 pregnant women aged 21 to 42 years who underwent LESS for various gynecologic pathology. If able to be contacted, the patients were followed up until the delivery of the fetus.SettingThe surgeries were performed in a single institution between January 2015 and June 2019.PatientsThe patients were selected if a laparoscopic intervention was indicated.InterventionsThe cases included 6 ovarian cystectomies and 2 salpingo-oophorectomies for adnexal masses; 1 myomectomy for a degenerated myoma; 1 salpingectomy for a heterotopic pregnancy; 2 cerclage placements for recurrent pregnancy loss and cervical insufficiency; and 1 paratubal cystectomy. The patients underwent LESS through a 2.5-cm umbilical incision. The masses were exteriorized using a laparoscopic specimen retrieval bag, with the exception of 2 large adnexal masses, which were aspirated at the incision site, exteriorized after content drainage, and cystectomies performed extracorporeally. The fascial incision was repaired with a permanent suture.Measurements and Main ResultsVarious data were collected from patients, including age, surgical and obstetric history, gestational age at surgery, and ultrasonic imaging results. The outcomes measured were operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring before and after surgery, pathologic findings, conversions, intraoperative complications, and pregnancy outcomes.Eight cases were performed in the first trimester, 4 in the second trimester, and 1 in the third trimester, with the surgeries lasting between 45 minutes and 298 minutes. The blood loss ranged from 5 mL to 300 mL, and postoperative symptoms of mild pelvic or abdominal pain were reported. There were 2 conversions to traditional multiport laparoscopic surgery for the 2 cerclage cases, and there were no open surgery conversions or intraoperative complications. The fetal heart rate ranged between 130 beats per minute and 167 beats per minute postoperatively. Of the 9 patients who were able to be contacted for follow-up, all had successful deliveries. One patient was healthy at 31 weeks and 5 days without complication at the time of her last follow-up.ConclusionLESS may be performed by experienced surgeons on gravid patients in any trimester for adnexal masses, myomas, heterotopic pregnancy, and cervical incompetence. Future multiple-center studies may provide further evidence that LESS is a feasible and safe option for gynecologic surgery during pregnancy.     

Cirugía laparoscópica ginecológica en coneja utilizada como modelo animal quirúrgico experimental

A laparoscopic surgery teaching program is ready to begin at the Gynecology Department of the Lozano Blesa University Hospital. This program has been approved by the Ethics Committee for Animal Research of the Zaragoza University and will use rats, female rabbits and sows. This project aims to follow a «a step by step» process, with progressive surgery complexity from the rat and rabbit models to more difficult surgery in sows. The present article describes how to perform total hysterectomy with double annexectomy using vaginal extraction of uterus, tubes and ovaries in the female rabbit through the laparoscopic approach.