2007, Volume 23, Number 3, Page(s) 164-168
Mucinous cystadenoma in an ovarian remnant
Pınar UYAR GÖÇÜN
Gazi Üniversitesi Tıp Fakültesi Patoloji Anabilim Dalı, ANKARA
Keywords: Mucinous cystadenoma, ovarian remnant syndrome, pelvic mass
The ovarian remnant syndrome, a complication of bilateral salpingo-oophorectomy, has progressively received more attention in gynecological surgery literature, in recent years. The syndrome is manifested by pelvic pain, and a palpable or sonographic pelvic mass. In rare cases, patients may present with large masses. Cystic masses or carcinomas are reported to develop in some of the ovarian remnant syndromes after surgery.
We hereby present a 69-year-old white female, complaining of abdominal pain, an enlarging abdominal mass, pollakuria, and urinary incontinence with duration of 1 year, 25 years after bilateral salpingo-oopherectomy. Clinical and radiological evidence of a mesenteric cyst was discovered. The final pathological diagnosis was mucinous cystadenoma in an ovarian remnant. Curiously, this patient had no history of endometriosis, previous pelvic or abdominal surgery excl. hysterectomy, pelvic inflammatory disease, inflammatory bowel disease, dense pelvic adhesions, or difficulty encountered during the previous hysterectomy. This tumor is the largest among all other ovarian remnants published in the international literature.
Women with complaints of abdominal or pelvic mass and /or pain with a history of total abdominal hysterectomy- bilateral salpingo-oophorectomy must be searched carefully and it must be kept in mind that ovarian remnant syndrome can develop without predisposing potential risk factors.
Ovarian remnant syndrome (ORS) refers
to a condition occuring in women who have undergone
bilateral salpingo-oophorectomy, with or without hysterectomy, in which a remnant
ovarian tissue is left behind1
Ovarian remnant syndrome is not the same
entity as residual ovarian syndrome in which an
ovary intentionally left in place during gynecologic
surgery, eventually causes pelvic pain2.
An ovary can usually be removed without
difficulty. However when it is attached to other
pelvic organs, or the pelvic wall, some of the
cortex may adhere to peritoneal surfaces of these
structures3. Risk factors associated with incomplete
removal of an ovary and subsequent
development of ORS include a history of endometriosis,
pelvic inflammatory disease, previous
multiple abdominal or pelvic surgeries and pelvic
adhesive disease2,4. In addition, intraoperative
conditions (eg, intraoperative bleeding,
anatomical variation, or deviation from proper
surgical principles) may contribute to incomplete
removal of the ovaries1. Cortical tissue,
which has been separated from its major blood
supply, may undergo necrosis, cystic degeneration,
or neoplastic changes, or it may remain
functional, as Shemwell and Weed demonstrated
in their experiments with cats in 19705.
The condition in which the detached ovarian tissue
remains functional is called the ovarian remnant
syndrome3. Patients most frequently present
with chronic pelvic pain, pelvic pain associated
with a pelvic mass, or an asymptomatic
A 69-year-old woman, Gravida: 3, Para: 2,
and D&C: 1, comprised the study case. She had
a clinical history of total abdominal hysterectomy
and bilateral salpingo-oophorectomy
which was performed for leiomyoma uteri, 25
years earlier. She had menopausal symptoms
(vasomotor symptoms) for only two years after
total abdominal hysterectomy and bilateral
oophorectomy (TAH-BSO). After that period,
the symptoms subsided spontaneously, despite
the fact that she had not received hormone replacement therapy (HRT). She had no clinical
history of endometriosis, pelvic inflammatory
disease, previous pelvic and/or abdominal surgeries,
inflammatory bowel disease, or pelvic
adhesive disease. She presented to the gynecology
clinic in July 2003 with complaints of abdominal
pain, an enlarging abdominal mass,
pollakuria, and also urinary incontinence, which
had occurred in the previous year.
Laboratory findings: Normal blood biochemistry
and a slight degree of anemia (Hb:
11.3 mg/dl, Htc: 34.1%) was detected. Tumor
markers were not searched for.
Computerized tomography revealed a
28x35x20 cm, thin walled cystic mass between
the portal hilus and symphysis pubis which filled
the entire peritoneal cavity. This cystic mass
had resulted in compression of the abdominal
organs posteriorly. The urinary bladder was particularly
The pre-operative diagnosis was a mesenteric
Intraoperative findings: Status post-TAHBSO.
The pedunculated cystic mass originated
from the rectosigmoid junction, and was not attached
to visceral organs. The cyst contained 13
liters of yellow unclear fluid. A portion of the
fluid was sent to the pathology laboratory for intra-
operative cytological examination. Cytological
examination revealed macrophages filled
with mucinous material.
Macroscopical findings: A pedunculated,
oligolocular, smooth, and thin walled cyst measuring
35x25x20 cm. Its content was drained
during the surgery, and its residual content was
mucoid material (Figure 1).
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|Figure 1: Macroscopic appearance of a cystic mass. Thin walled,
unilocular cyst, 35 cm in its largest diameter.
Microscopical findings: Mucinous cystadenoma
with a single layer of mucinous epithelium.
In the epithelium no crowding, stratification,
hyperchromasia, or mitotic activity were seen
(Figure 2). Mucin lakes were seen in luminal
spaces. Focally ovarian stroma and corpus albicans
were seen (Figure 3). The final histological
diagnosis was a mucinous cystadenoma derived from an ovarian remnant tissue.
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|Figure 2: Single layer of columnar cells with abundant intracellular
mucin and small basilar nuclei. There is no stratification,
hyperchromasia, or mitotic activity (HE x40).
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|Figure 3: Ovarian tissue and corpus albicans, within wall of a
cyst. Single layer of columnar cells with small basilar nuclei
Ovarian remnant syndrome is a fairly uncommon
condition. However its incidence has
probably increased in the past four decades2
The pre-operative and operative diagnosis
of our case was mesenteric cyst. Primary tumors
and cysts of the mesentery are quite rare6. Reports
of mesenteric cysts originated from ovarian
tissue have been discussed under various titles.
Wharton reported that in 1875 and 1887, reports
had been published of women who continued
to menstruate after bilateral oopherectomy6. In 1903, Malcolm attributed this phenomenon
to incomplete removal of the ovaries. In
1953, a case of intestinal obstruction due to the
presence of a corpus luteal cyst within the mesentery
of the terminal ileum was reported. This
patient had undergone a bilateral oopherectomy6.
Hormonally active remnants manifest with
variable presentations, including pelvic and/or
flank pain, dyspareunia, hydronephrosis due to
ureteral compression, dysuria, bowel obstruction,
painful defecation, and a palpable, tender
The clinicopathological features of ovarian
remnants reported to date in the literature are
summarized in Table 1 7,9,10,11,12,13,14.
The largest series of ovarian remnants was reported
from Mayo Clinic by Magtibay MP, et al1. One hundred and eighty-six ORS patients
were evaluated. Their mean age was 37.6 years
(range, 20-73 years). The most common indications
for BSO were endometriosis (57%), an
ovarian mass (9%), PID (pelvic inflammatory
disease) (7%), or other pathological conditions
(28%) which were surgically managed during
hysterectomy. The mean numbers of laparotomies
and laparoscopies patients had undergone
before BSO were 1.4 (range, 0-8) and 0.77 (range
0-10), respectively. In previously mentioned
series 147 (79%) of the 186 patients, at least 1 abdominal surgery had been performed before
BSO. Histologically, remnant ovarian tissue was associated with corpus luteum in 78 (42%),
endometriosis in 54 (29%), follicular cyst in 12 (7%), simple cyst in 45 (24%), cystadenofibroma
in 3 (2%), serous cystadenoma in 2 (1%),
and cystadenoma in 1 (0.5%) case respectively.
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|Table 1: Clinicopathological features of ovarian remnants reported in the literature.
Symptoms commonly present within 5 years
after extirpative surgery7. Our patient began
to experience these symptoms 24 years after
extirpative surgery. The majority of women have
identifiable cystic structures on ultrasonography,
commonly measuring between 3 and 4
cm in their largest diameters (6). To date the largest
tumor reported in the literature was 26 cm
which was conclusively diagnosed as invasive
mucinous carcinoma7,8. Our patient’s tumor
was 35 cm in its largest diameter.
Most patients with ORS are generally young
and menopausal at the time of BSO. The
ovarian tissue remnants in these women often
remain functional and continue to secrete substantial
concentrations of hormones, including
estradiol. Therefore, a young woman with ORS
who is not immediately started on estrogen replacement
therapy (ERT) after a BSO, often lacks
the typical menopausal symptoms observed after
abrupt estrogen withdrawal. This clinical information
may provide the clinician with clues
to the diagnosis of ORS. In the recent series of
Mayo Clinic, 37% of patients have not showed
any symptoms of estrogen deprivation despite
no ERT1. Our patient had menopausal symptoms
for only two years after TAH-BSO and
those symptoms had resolved spontaneously,
without receiving ERT.
In our case, the mucinous cystadenoma
that developed from an ovarian remnant had the
largest dimensions among all the tumors developed
in ovarian remnant syndrome reported in
Tumors that have a preoperative diagnosis
of mesenteric cyst in women with a history of
TAH-BSO could be ovarian remnants. Therefore,
these cysts must be examined carefully in the pathology laboratory and proper sampling is necessary
to show residual ovarian tissue.
Women with complaints of an abdominal
or pelvic mass and/or pain with a history of
TAH-BSO, must be evaluated carefully and it
must be kept in mind that the ovarian remnant
syndrome can develop without predisposing potential
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Ovarian remnant syndrome. Am J Obstet Gynecol
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