A 29-year-old divorced Saudi woman presented with her parents at the gynaecology outpatients' clinic of Jazan General Hospital, Saudi Arabia, with a massive abdominal distension and discomfort. The patient has no living children from her previous marriage that lasted for 3 years. She was divorced one year back. Although the patient and her parents noticed gradual abdominal enlargement since 10 months back, they did not ask for a medical advice as they thought it was a pregnancy. As more than 9 months passed out without commencement of parturition, they consulted their general practitioner (GP) at the primary healthcare unit in their village. The GP suspected a huge abdominal tumour and referred the patient to Jazan General Hospital.
The patient had no previous medical diseases or surgical operations. Her menarche commenced at the age of 13 years with subsequent irregular cycles. She denied the use of any medications.
General examination revealed normal vital signs other than a slight tachypnea (Respiratory rate was 24/minute). Her body weight was 92 kg, her height was 162 cm and her abdominal circumference was 127 cm. Secondary sexual characters were evident. Previous exposure to burn during her childhood left old scars and depigmentation on her upper limbs. On abdominal examination, a huge ill-defined pelvi-abdominal mass was noticed, extended up to xiphisternum, with evident dermal striae. The abdomen was cystic tense on palpation without tenderness or shifting dullness (Figure 1).
Pelvic examination revealed normal sized non-pregnant firm uterus and fullness in the cul-de-sac and both adnexae. Transabdominal ultrasonography verified a massive multi-loculated cyst without solid components or surface papillary projections, extended up to the sub-hepatic area, with minimal free intraperitoneal fluid. The patient was asked to do some laboratory investigations including full blood picture, serum biochemistry, cervical cytology and cancer antigen (Ca-125). A plain chest X-ray on erect position was also done (Figure 2). Our patient was counseled and signed informed consent for surgical exploration. Under general anaesthesia, an initial midline subumbilical incision was done where a huge cystic mass was noticed arising from the left ovary. Later on, the incision was extended up, about 5 cm below xiphisternum, to deliver the cystic mass intact without exposed it to the risk of rupture intraperitoneally. The outer surface of the mass was smooth and intact all-around without external growths or adhesions. The uterus, right adnexa, and appendix were looking healthy. No ascites or enlarged para-aortic lymph nodes were discovered. Left salpingo-oophorectomy was performed as the whole ovary was involved in the mass and the left tube was abnormally dilated and adherent to the mass (Figure 3). The size of the tumour was 42 × 28 × 25 cm with 7,250 kg in weight. Microscopic examination revealed a cyst lined by a single layer of non-ciliated columnar epithelium without stromal invasion, the picture of which is compatible with mucinous cystadenoma (Figure 4). Postoperative recovery was uneventful and the patient was discharged on the 5th postoperative day to be followed-up every 3 months.