CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 2 (2011) 100–102
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
Ovarian hydatid cyst: A case report L. Cattorini ∗ , S. Trastulli, D. Milani, R. Cirocchi, G. Giovannelli, N. Avenia, F. Sciannameo Department of General Surgical, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
a r t i c l e
i n f o
Article history: Received 26 October 2010 Received in revised form 26 November 2010 Accepted 1 December 2010 Available online 24 March 2011 Keywords: Cyst Hydatid Ovarian Treatment
a b s t r a c t Discovering an hydatid cyst in pelvic region, especially as primary localization, is a rare event; as a matter of fact according to data provided by literature the incidence is between 0.2 and 2.25%. The ovarian involvement is often secondary to a cyst’s dissemination localized in a different site. When possible the optimal treatment is represented by radical laparotomic cystectomy. We report a case of an old woman affected by this pathology that we have treated with a cyst’s marsupialization after a draining and irrigation of cyst cavity with hypertonic saline solutions. © 2011 Surgical Associates Ltd. Elsevier Ltd. All rights reserved.
1. Introduction The echinococcus granulosus has been described as the most frequent cause of the hydatid cysts. This infection is very frequent in some regions of the world such in the Mediterranean area, East Europe, South America, Middle East, East Africa and Australia.1 In Italy it is still endemic with an incidence of approximately 4 cases/100,000/year.2 They most frequently occur in the liver (63%) followed by the lungs (25%), muscles (5%) and bones (5%). They can also be found uncommonly in the kidney, brain and spleen.1 It is rare to diagnose an hydatid cyst in the pelvis, especially as a primary localization.3 The incidence being given as 0.2–2.25%.4 In 80% of cases reported with a cyst in this location, the ovary is the most common affected organ followed by the uterus.5,6 Cases of primary ovarian hydatid cysts are reported, but more commonly ovarian involvement is secondary to a cyst’s dissemination from another site.7–15
and a multiloculated cyst (68 mm × 62 mm) situated in the pouch of Douglas. So the patient underwent to surgery. During surgical intervention hypogastric hernial sac was opened and, after a prolonged viscerolysis, a senile atrophic uterus with calcific fibroma of fundus was exposed. The Pouch of Douglas was obliterated by uterus-vaginal adhesions and, after their lysis, a large cyst as seen on the CT scan was found between the posterior vaginal wall and the anterior wall of the rectum in continuity with the right ovary. An hysterectomy was performed followed by drainage of what appeared to be an echinococcal cyst containing daughter cysts. A large swab soaked in hypertonic solution was introduced following which marsupialization was carried out as it proved impossible to perform a radical cystectomy due to the dense adherence between cyst and the vagina.15 The patient made an uncomplicated postoperative recovery and was discharged from hospital on the 11th postoperative day. 3. Discussion
2. Case report A 76 years old woman was admitted as emergency with a diagnose of pelvic mass. She had previously undergone an operation for sub-hepatic hydatid cyst about 20 years earlier. Clinical examination revealed her to be in pain with a distended abdomen in part to a large hypogastric incisional hernia. There was tenderness on deep palpation. Laboratory results showed all routine blood tests and tumour markers to be within the normal range. Anti-echinococcus antibodies (IHA) screen was negative. Abdominal CT scan showed a hepatic hydatid cyst in segment 4 of the liver (45 mm × 41 mm)
∗ Corresponding author. E-mail address:
[email protected] (L. Cattorini).
The cyst of echinococcus was a rare finding in pelvic sites. In our case the ovarian hydatid cyst is most probably a secondary one, due to a spontaneously or iatrogenic rupture of the hepatic cyst removed 20 years earlier. Pelvic echinococcosis symptomatology is non-specific and can include abdominal tumefactions, abdominal pain, menstruation irregularities, infertility and urinary disturbances.10 Ovarian echinococcosis can simulate either polycystic disease or malignancy.11,12 The difficulties that occur in making a correct diagnosis is due to the non-specific clinical symptomatology, associated with atypical ultrasonographic and radiological images which merely show a solid ovarian masse.12 A high grade of suspicion or a preoperative diagnosis of echinococcus cyst makes it possible to avoid an intraoperative iatrogenic rupture, and when available, to administer previously an albendazole-based
2210-2612/$ – see front matter © 2011 Surgical Associates Ltd. Elsevier Ltd. All rights reserved. doi:10.1016/j.ijscr.2010.12.005
CASE REPORT – OPEN ACCESS L. Cattorini et al. / International Journal of Surgery Case Reports 2 (2011) 100–102
Fig. 1. Daughter cysts and contingent calcifications of the cyst’s wall.
101
Fig. 3. Daughter cysts and contingent calcifications of the cyst’s wall.
4. Conclusions therapy in order to reduce the risk of dissemination that can lead to recurrences.13 In our case ultra-sound (US) and CT scan associated with a positive clinical history of a previous hepatic echinococcal cyst raised the diagnosis of hydatid disease, allowing us to implement all the procedures that could avoid the onset of secondary disease. The US scan, especially if performed trans-vaginally, is an important imaging examination that allows to recognize the cystic aspect of the lesion, showing the characteristic fluctuating membranes of the multilocular cyst. CT scan confirms the diagnosis revealing daughter cysts and contingent calcifications of the cyst’s wall (Figs. 1–3). The treatment of choice in ovarian hydatid cysts is surgery which could be either radical or conservative. Care must be taken to reduce the risk of possible cyst’s rupture. Ovarian cystectomy, when possible, represents the goldstandard treatment. Cases of hydatid cysts aspirated using saline agents are reported. In our case it was not possible to execute a radical cystectomy due to dense adhesions between the cyst and vaginal wall, so cyst marsupialization after drainage and irrigation of its cavity with hypertonic saline solution was performed.
In conclusion an ovarian hydatid cyst is a rare finding.1 To diagnose this pathology one must have a high grade of suspicion and anamnestic data as it is important to differentiate between benign or malignant neoplasms and polycystic ovaries. Transvaginal ultrasonography and abdominal CT are the best methods of imaging available to avoid an intraoperative break. When possible the optimal treatment is radical laparotomic cystectomy. In some cases this approach is not possible in the need to preserve surrounding structures. In these circumstances a partial cystectomy or marsupliazation taking all the necessary precautions not to spill daughter cysts together with anti-helminthic therapy to reduce the chance of recurrence are alternative acceptable approaches.15 Conflict of interest statement None. Funding None. Ethical approval Authors have obtained written and signed consent to publish the case report from the patient and declare that the privacy of patient it is not exposed. References
Fig. 2. Daughter cysts and contingent calcifications of the cyst’s wall.
1. Aksu MF, Budak E, Ince U, Aksu C. Hydatid cyst of the ovary. Arch Gynecol Obstet 1997;261(1):51–3. 2. Montinaro L, Sisinni AG, Sartorelli P. L’echinococcosi: un’endemia persistente. G Ital Med Lav Erg 2004;26(3):202–7. 3. Bas¸arano˘glu M, Sonsuz A, Perek A, Perek S, Akin P. Primary pelvic hydatid cyst. J Clin Gastroenterol 1998;26(March (2)):157–8. 4. Tampakoudis P, Assimakopoulos E, Zafrakas M, Tzevelekis P, Kostopoulou E, Bontis J. Pelvic echinococcus mimicking multicystic ovary. Ultrasound Obstet Gynecol 2003;22(August (2)):196–8. 5. Diaz-Recasens J, Garcia-Enguidanos A, Munoz I, Sainz de la Cuesta R. Ultrasonographic appearance of an echinococcus ovarian cyst. Obstet Gynecol 1998;91:841–2. 6. Baba L, Chaieb H, Keskes J. Profil epidemiologique d l’hydatidose pelvienne. J Gynecol Obstet Reprod (Paris) 1991;20:657–60. 7. Uchikova E, Pehlivanov B, Uchikov A, Shipkov C, Poriazova E. A primary ovarian hydatid cyst. Aust N Z J Obstet Gynaecol 2009;49(August (4)): 441–2.
CASE REPORT – OPEN ACCESS 102
L. Cattorini et al. / International Journal of Surgery Case Reports 2 (2011) 100–102
8. Konar K, Ghosh S, Konar S, Bhattacharya S, Sarkar S. Bilateral ovarian hydatid disease – an unusual case. Indian J Pathol Microbiol 2001;44(October (4)): 495–6. 9. Adewunmi OA, Basilingappa HM. Primary ovarian hydatid disease in the Kingdom of Saudi Arabia. Saudi Med J 2004;25(November (11)): 1697–700. 10. Dede S, Dede H, Caliskan E, Demir B. Recurrent pelvic hydatid cyst obstructing labor, with a concomitant hepatic primary. A case report. J Reprod Med 2002;47(February (2)):164–6. 11. Pekindil G, Tenekeci N. Solid-appearing pelvic hydatic cyst: transabdominal and transvaginal sonographic diagnosis. Ultrasound Obstet Gynecol 1997;9(April (4)):289–91.
12. Aysun A, Petek BK, Mehmet AY, Omer Yalcin. Huge solitary primary pelvic hydatid cyst presenting as an ovarian malignancy: case report. J Turkish–German Gynecol Assoc 2009;10:181–3. 13. Arif SH, Shams-Ul-Bari, Wani NA, Zargar SA, Wani MA, Tabassum R, et al. Albendazole as an adjuvant to the standard surgical management of hydatid cyst liver. Int J Surg 2008;6(December (6)):448–51 [Epub 2008 August 16]. 14. Hamamci EO, Besim H, Korkmaz A. Unusual locations of hydatid disease and surgical approach. ANZ J Surg 2004;74:356–60. 15. Zia S, Enam A, Salahuddin I, Khan A. Role of irrigation with hypertonic saline for a recurrent skull base hydatid cyst: case report and review of the literature. Ear Nose Throat J 2010;89(September (9)):E22–6.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
