Diagnosis and resection of a giant ovarian cyst presenting in a young patient with contralateral back pain and lower limb deep vein thrombosis

Abstract

We present a case of a giant ovarian cyst in a 20-year-old woman who presented atypically at our Emergency Department with left-sided back pain followed by acute left leg swelling. Blood tests showed significantly raised C-Reactive Protein and D-Dimer. CT-Abdomen-Pelvis demonstrated a large mass in the region of the right ovary with suspicious heterogeneous filling defects in the left external iliac vein, confirmed as a left-sided deep-vein thrombosis on ultrasound Doppler. MRI revealed the lesion to be cystic and the deep venous thrombosis was treated with twice-daily Clexane. Prior to removal of the cyst, an Inferior Vena Cava Filter was placed to reduce thromboembolic risk. The cyst was resected without complication and the postoperative period was uneventful. This case occurred while face-to-face services were limited by COVID-19 and illustrates the need for robust systemic measures to safeguard patients against the emergency sequelae of insidious gynaecological pathology.

Background

Ovarian cysts are typically benign tumours that up to 1 in 10 women require surgery for—but with greater awareness and testing in primary care, surveillance is better than ever before.¹ During the 2020 COVID-19 pandemic, however, access to primary care services has been limited, with many general practitioners carrying out phone consults. This has its limitations—specifically lack of physical examination to rule out differential diagnoses. This is further complicated by the fact that, with improved surveillance, giant ovarian cysts with a dimension larger than 10 cm on first presentation have become very rare. While such giant cysts have been known to impact other organ systems, these authors are not aware of a giant cyst causing symptoms contralateral to the side where it arose. This case also illustrates the impact of the pandemic’s logistical limitations on patient well-being.

Case presentation

This 20-year old gravida 0 para 0 woman with no previous comorbidities or operations presented overnight with acute left-leg swelling. It had started 3 hours prior to her attendance following 5 days of atraumatic left-sided back pain. She thought this had come from sleeping poorly. Following a virtual consultation, her GP recommended back physiotherapy and over-the-counter analgesia. This was ineffectual and on noticing the leg swelling, she attended our Emergency Department.

The patient was alert, orientated and denied fever, lethargy or night sweats. She was passing urine and stool normally with no menstrual irregularities. During the first COVID-19 lockdown, she had eaten more and had gained an unquantifiable amount of weight. This was not of great concern to her. She was 163 cm tall and weighed 94.5 kg, which amounted to a BMI of 35.6. Finally, she was taking Microgynon as a contraceptive as she was sexually active and living with her partner.

The patient had unremarkable baseline observations. She was independently ambulant but noticed an indistinct ache when weight-bearing on the left leg. That leg was a subtle purple in colouration, was visibly more swollen and on palpation, the skin felt tighter compared with the right and had pitting oedema from thigh to foot.

On examination of her abdomen, there was a large but painless mass with a well-defined upper and lateral border in the right-iliac fossa which she had not previously noticed. On raising of the left leg, she was also unable to raise it beyond 45° due to developing back pain; the right leg could be raised to 90°. There was also tenderness in the soft tissue lateral to the spine on the left.

Though the patient was initially not aware of this, collateral history following her diagnosis revealed an extensive family history of ovarian cysts, adenomyosis and endometriosis.

Investigations

Basic full blood count, renal function and liver function tests were within normal limits. More specialised CEA, CA-125 and AFP were also within normal ranges and the patient tested negative for B-HCG.

However, in view of the deranged bloods (see table 1), the abdominal mass and the swollen leg, a Contrast CT Abdomen-Pelvis (figure 1A–C) was performed to confirm the mass’s size and the location of any blockage. This revealed a 28×16 x 19 cm multicystic mass most likely arising from the right adnexa, with left iliac vein expansion, heterogeneous filling defects and fat stranding consistent with deep venous thrombosis (DVT).

Table 1.

Deranged bloods

Test	Value	Unit	Reference range
C-Reactive Protein	127	Mg/L	<5
D-Dimer	1181	ng/mL	<243
CA19-19	37	kU/mL	<33

Figure 1.

(A) Contrast-enhanced CT Abdomen-Pelvis coronal section showing 28×16×19 cm multicystic mass in right lower quadrants. (B) Contrast-enhanced CT Abdomen-Pelvis Sagittal and Axial sections showing IVC compression. (C) Contrast-enhanced CT Abdomen-Pelvis Axial section showing left sided venous engorgement and heterogeneous filling defects suspicious for DVT. DVT, deep venous thrombosis.

On referral to Gynaecology, the patient received an ultrasound Doppler to characterise the DVT, as well as a pelvic MRI to characterise her mass. Ultrasound demonstrated DVT extending past the saphenofemoral junction in the left limb and on T2 weighting, fluid content of the cyst was elucidated on MRI (figure 2A and B; figure 3A and B).

Figure 2.

(A) Ultrasound in relation to the left saphenofemoral junction showing extension of DVT. (B) Ultrasound Doppler showing diminution of flow secondary to the DVT through the saphenofemoral vein. DVT, deep venous thrombosis.

Figure 3.

(A) Coronal and sagittal sections of contrast-enhanced MRI pelvis in T2 view—showing fluid content and multiloculation of the cyst. (B) Axial T1 view showing impairment of contrast flow visible within left iliac vein compared with the right.

Differential diagnosis

Our primary aim with the differentials and investigation was to rule out malignancy and determine the specific location of the venous blockage.

The most likely diagnosis on initial examination was an ovarian cyst, due to her age and its location. Further differential diagnoses were focused on the back pain and what could cause congestion of the venous system. As such, the DVT could be considered either incidental or secondary; our differentials could also be split into gynaecological and non-gynaecological (see table 2).

Table 2.

Differential diagnoses

Gynaecological	Non-gynaecological
Benign ovarian cysts and tumours (including dermoid cysts/cystadenoma)	Discitis
Ovarian carcinoma	Psoas abscess
Endometriosis with metastasis of uterine tissue	Herniated lumbar disc
	Incidental Lumbago

Treatment

The initial DVT was treated in A&E with high dose low-molecular weight heparin (Clexane) adjusted to her weight. Following her gynaecology multidisciplinary team discussion, she was arranged for surgery 5 weeks from the diagnosis date and was commenced on oramorph pain relief and twice-daily Clexane to reduce the impact of the diagnosed DVT. Five days before her surgery, she underwent insertion of an inferior vena caval filter to prevent thrombus dissemination. Surgery was successfully conducted via laparotomy on 18 August 2020. The cyst reached to the xiphisternum, but the Fallopian tubes, uterus and left ovary were preserved. Using Oschsner gallbladder trocar, the cyst’s fluid contents were removed and the sac was subsequently resected. As intraoperative frozen section (see figure 4) revealed it to be a mucinous cystadenoma, lymph nodes and the omentum remained preserved. Estimated blood loss was 200 mL.

Figure 4.

(A) Low power view of section showing ovary containing a cyst lined by single-layered epithelium. (B) High power of cyst lining—columnar ‘endocervical’ type mucinous epithelium. Single-layered with mild tufting at most. No excessive proliferation or stromal invasion present.

Outcome and follow-up

Postoperative recovery was unremarkable. The patient was fit for discharge the day after her operation. She was to cease Microgynon due to the increased risk of coagulopathy and take Enoxaparin twice daily for 6 months to prevent complications secondary to the DVT. She was also encouraged to take pain relief, rest and to not undertake heavy activities till at least 6 weeks postop.

Follow-up would be through Gynaecology clinics and she will soon undergo caval filter removal under interventional radiology. She has been assured of her preserved fertility due to the non-pathological appearance of her left ovary and unimpacted Fallopian tubes.

Discussion

Though there are many forms of ovarian cyst, benign mucinous cystadenomas make up the bulk of the existing literature surrounding giant cysts. However, such giants remain extremely rare. Rarer still are cases wherein the cyst is associated with caval thrombosis or lower limb DVT.^2–4 It is notable however that within the literature, those giant cysts associated with lower limb DVTs occurred ipsilaterally to them. Our case demonstrated the opposite. Indeed, it is the first case these authors are aware of where a giant cyst has been associated with and likely caused a contralateral DVT.

While the average age of presentation for giant cysts is around 50, they may occur at any time between the second and ninth decades of life; our patient was fresh from adolescence.^5–7 The possibility of giant cysts occurring at the extremes of age ranges means they should not be discounted as differentials for abdominal masses. Diagnosis of the cyst is made histologically postexcision, as aspiration is considered to significantly raise the risk of cyst recurrence.^{8 9} 80% of mucinous cystadenomas are benign, with 10% borderline and 10% being malignant.¹⁰

Ovarian cysts below 70 mm do not generally require laparotomy, which is the gold standard for treatment.¹ Though giant cysts have successfully been removed laparoscopically, there is no high-grade evidence supporting this; the laparoscopic approach also reduces the surgeon’s ability to examine other organs should malignancy be suspected.^{1 11} In any case, should they enlarge further, the risk of gynaecological complications such as torsion and cyst rupture increases, as does the risk of compressing other organ systems; rupture may also be responsible for malignant transformation.¹² Reassuringly, even if the cyst is considered ‘giant’, fertility is not compromised with unilateral ovary removal.¹³

Commentary has to be made surrounding virtual consultations in both primary and secondary cares. COVID-19 prompted rapid restructuring of the healthcare system and that can come at a cost to insidiously developing conditions like giant ovarian cysts. It is very unusual that ovarian cysts would present with an acute symptom such as a DVT; indeed, this female only presented because of this secondary complaint. With patients having more limited access to physical examinations and waiting times having increased for outpatient appointments and elective procedures, the importance of thorough history taking and clearly communicated care plans has rarely been more paramount. Moreover, national guidance has been in place since at least March 2020 specifying the exceptional circumstances within which physical examination may be considered.¹⁴ Speaking broadly, Gynaecology units have typically been able to cope through restructuring clinics and increasing use of telecommunications, which is both cost-effective and acceptable for patients. Nonetheless, cases such as this demand robust communications down to primary care level, especially with regard to the need for physical examination, so that they are not missed in future.¹⁵

Patient’s perspective.

After experiencing what I thought was simple back pain, it was a horrible shock being initially diagnosed with the cyst. It was definitely a bit overwhelming and confusing having to suddenly undergo all these tests and treatments to figure out exactly what it was. I did not know this beforehand, but my Aunt and Nan had had similar problems to me a long time ago; my mum only really told me this after I was diagnosed. I have not really spoken to them about it though. I have kept things between my Mum and my brother, who was an A&E nurse working a shift the night I was diagnosed and encouraged me to come in in the first place after my leg started swelling up.

It is been quite rough, especially when it comes to the (clexane) injections, which add more pain to what I was feeling with the leg and my back, but now I am 3 weeks postop, I am feeling a lot more positive. There is a bit of residual pain around where they operated, but I am taking things slowly but surely. The multidisciplinary team have been very clear in their explanations—I know I am not to go back to work until about Mid October, and in that time even if I feel I am able to do things like drive, I should err on the side of caution so I do not break my stitches. Fertility wise, they have also given me the all clear, which is very encouraging as I do want to have children. All in all, even though this was all happening in a pandemic, I am just really grateful to the A&E and Gynae teams for moving things along so quickly for me. The main thing I have wanted out of this whole situation is as fast a return to normality as possible. I feel that I have been lucky enough to essentially get that through my management plan.

Learning points.

• Giant Ovarian Cysts can present through impacting other organ systems before gynaecological symptoms present.

• The masses can compress the venous system and can result in lower limb deep vein thrombosis, both ipsilaterally and contralaterally depending on location.

• Given the limitations of the virtual consultation, patients with suspicious atraumatic back pain should be thoroughly questioned in primary care settings with exceptions being made to facilitate examination if the history is in any way suggestive of gynaecological pathology.

• Gold standard of treatment is laparotomy, but the case must be discussed with a multidisciplinary team before proceeding to surgery