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The Gulf Journal of Oncology is published with the financial supportfrom the Kuwait Foundation for the Advancement of Sciences
Table of Contents
Original ArticlesSpectrum of Breast Diseases: Histopathological and Immunohistochemical Study from North India...................................................06Sumyra Khurshid Qadri, Pranjali Sejwal, Rashmi Priyadarshni, Milan Jaiswal, Ruchi Khandewal, Manisha Khanna, Tanu Agarwal, Hema Pant, Ratana Saxena
Concurrent Paclitaxel and Radiotherapy for Node Positive Breast Cancer ..............................................................................................14Asmaa Ali Hassan, Noha Yehia Ibrahim, Mohamed Abdel Rahman Kassem, Abdel Aziz Mostafa Toeama
Cancer Control Priorities and Challenges in Saudi Arabia: A Preliminary Projection of Cancer Burden ................................................22Maha T. Alattas
A Novel Approach to Obtain Follow-up Data on the Vital Status of Registered Cancer Patients: The Kuwait Cancer Registry Experience....................................................................................................................................................31Eiman Alawadhi, Ahmed Al-Awadi, Amani Elbasmi, Michel P. Coleman, Claudia Allemani
Cancer survival trends in Kuwait, 2000-2013: A population-based study .............................................................................................39Eiman Alawadhi, Ahmed Al-Awadi, Amani Elbasmi, Michel P. Coleman, Claudia Allemani
Triple Negative Breast Cancer: 10-Year Survival Update of The Applied Treatment Strategy in Kuwait ...............................................53Salah Fayaz, Gerges A. Demian, Mustafa El-Sherify, Heba Eissa, Mary Aziz, Sadeq Abuzallouf
Early Calcium Supplementation After Total Thyroidectomy Can Prevent Symptomatic Hypocalcemia - Findings from a Retrospective Study .....................................................................................................................................................60Manu Santhosh, Sajith Babu Thavarool, Sandeep Vijay, Adharsh Anand, Guru Charan Sahu,v Satheeshan Balasubramaniam
Association between nodal metastasis and histopathological factors in postoperative gingivo-buccal complex squamous cell carcinoma: A Retrospective Study .....................................................................................................................66Sweta Soni, Tej Prakash Soni, Nidhi Patni
Review ArticlesImpact of HPV on the Pathobiology of Cancers .........................................................................................................................................72Ritesh Kumar, Pranay Tanwar, Angel Rajan Singh, Showket Hussain, G.K. Rath
Cancer Immunotherapy: An Updated Overview of Current Strategies and Therapeutic Agents .............................................................76Osama Abu-Shawer, Tariq Bushnaq, Mohammad Abu-Shawer
Case ReportsExtremely Giant Ovarian Mucinous Cystadenoma ....................................................................................................................................83Abdulaziz Alobaid, Heba Elamir, Mohammed Abuzaid, Ahmed Abu-Zaid
Hemorrhagic Brain Metastasis as the Initial Manifestation of Esophageal Adenocarcinoma ................................................................87Hussein Algahtani, Bader Shirah, Yehya Seddeq, Hatim Al-Maghraby
Conference Highlights/Scientific Contributions• News Notes............................................................................................................................................................................................91
• Advertisements .....................................................................................................................................................................................94
• ScientificeventsintheGCCandtheArabWorldfor2019 ..................................................................................................................95
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Corresponding Author: Ahmed Abu-Zaid, MD, PhD (candidate); College of Graduate Health Sciences,
University of Tennessee Health Science Center, Memphis, Tennessee 38163,
United States of America; Tel.: +1 901-283-4596; Fax: +1 901-448-7360;
Email address: [email protected]; ORCID ID: http://orcid.org/0000-0003-2286-2181
IntroductionOvarian mucinous cystadenomas are cystic neoplasms
lined by mucin-producing epithelial cells. They roughly account for 15-20% of all ovarian neoplasms. They are approximately 80% benign, 10% borderline and 10% malignant (1, 2). They are frequently asymptomatic at early stages; however, pressure-related symptoms may occur when the cysts reach massive dimensions (3). The average diameter of ovarian mucinous cystadenomas ranges from 15 to 30 cm (4). Ovarian cysts with more than 10 cm in diameter are most often referred to as “giant” ovarian cysts (5). Herein, we report the case of a giant benign ovarian mucinous cystadenoma which measured 73 x 51 x 42 cm and weighed 108 kg. To the best of our knowledge, we report the largest ovarian cyst in Saudi Arabia, and one of the largest (probably the third) in the English medical literature.
Case PresentationA 53-year-old postmenopausal woman presented
with a huge pelvi-abdominal distention that started ten months ago and was progressively increasing in size. It
Abstract
Ovarian mucinous cystadenomas are cystic neoplasms lined by mucin-producing epithelial cells. They are mostly benign (80%) and frequently asymptomatic at early stages. The average diameter of ovarian mucinous cystadenomas ranges from 15 to 30 cm. Herein, we report the case of a giant benign ovarian mucinous cystadenoma in a 53-year-old postmenopausal woman. The patient presented with a very huge pelvi-abdominal distention that started ten months ago and was progressively increasing in size. It was associated with on-off abdominal pain, nausea and urinary retention. The case was discussed with a multidisciplinary team. Subsequently, the patient was consented for exploratory laparotomy. The origin of the mass was identified to be the right ovary, and right salpingo-oophorectomy was done. The resected mass measured 73x51x42 cm and weighed 108 kg. The left
ovary had a multilocular mass of 15 cm in diameter, and left salpingo-oophorectomy was successively performed. There was no ascites. Histopathological examination confirmed the diagnosis of bilateral benign mucinous cystadenoma. At a postoperative 9-month follow-up in the outpatient clinic, the patient showed up in good condition without evidence of recurrence. To the best of our knowledge, we report the largest benign ovarian cyst in Saudi Arabia, and one of the largest (probably the third) in the English medical literature. It is technically feasible to manage an extremely large-sized benign mass with satisfactorily perioperative outcomes. This should be done through a multidisciplinary approach that demands an orchestrated collaboration between different specialists to yield an optimized perioperative care.
Keywords: Ovary; mucinous cystadenoma; giant ovarian cyst; case report
Case Report
An Extremely Giant Ovarian Mucinous CystadenomaAbdulaziz Alobaid1, Heba Elamir1, Mohammed Abuzaid1, Ahmed Abu-Zaid2,3
1 Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Saudi Arabia 2 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
3 College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, United States
was associated with on-off abdominal pain, nausea and urinary retention. Systemic review was remarkable for severe decreased appetite, cachexia and immobilization with bedsores. Past medical and surgical history were unremarkable. Social history was notable for low socio-economic status and living in a rural area.
On physical examination, vital signs were remarkable for tachypnea. Upon admission, the body weight was 172 kg. On general examination, the patient looked ill, lethargic, cachectic and lying on her right side with a huge
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Giant Ovarian Mucinous Cystadenoma, Abdulaziz Alobaid, et. al.
abdominal distention (Figure 1 and Figure 2). Abdominal examination was remarkable for a cystic, diffuse, tense and palpable mass with scattered foci of pressure ulcers. The abdominal circumference was 181 cm. On per-vaginal examination, vulva, vagina and cervix were normal.
Laboratory tests were remarkable for elevated CA-125 level (298 U/mL). Abdominal-pelvic ultrasound revealed a huge multi-loculated cyst occupying the whole abdomen with multiple thick septi (12 mm) and fine internal echoes. There was minimal free intraperitoneal fluid.
The case was discussed with a multidisciplinary team. Subsequently, the patient was consented for exploratory laparotomy. The patient remained on her right side throughout the entire procedure as it was difficult to mobilize the mass. Away from the pressure ulcers foci, a midline incision of about 35 cm in the healthy skin was performed (Figure 3). The mass was resected (73x51x42 cm) and 84 liters of mixed serous-mucinous fluid were drained from it through multiple holes (Figure 4). A frozen section biopsy was consistent with benign mucinous cystadenoma. The origin of the mass was identified to be the right ovary, and right salpingo-oophorectomy was done. The left ovary had a multilocular mass of 15 cm in diameter, and left salpingo-oophorectomy was successively performed. There was no ascites; abdominal organs and omentum were normal (Figure 5). Finally, the midline incision was closed (Figure 6). The estimated blood loss was 1100 ml and the surgery went uncomplicated. Histopathological examination confirmed the diagnosis of bilateral benign mucinous cystadenoma.
Postoperatively, the patient was transferred intubated to the intensive care unit. In the first few days post-operation, there was about 6-8 liters/day of serous fluids draining from the abdominal cavity. Patient was extubated 8 days post-operation.
At discharge, the patient’s pressure ulcers improved with granulation tissue. The poor muscle power improved with physiotherapy. Nutritional assessment was done on a daily basis as she was given high-caloric and high-protein diet. Home care was arranged.
The patient was discharged home in good condition at 14 days post-operation. The pre-operative patient body weight was 172 kg, and the postoperative weight was 64 kg. Thus, it is believed that the tumor weighed about 108 kg. At a postoperative 9-month follow-up in the outpatient clinic, the patient showed up in good condition without evidence of recurrence.
Figure 1. Side view of the huge pelvi-abdominal mass with pressure ulcers foci and dilated veins
Figure 3. A midline incision of about 35 cm in the healthy skin away from the pressure ulcers foci
Figure 2. Frontal view of the huge pelvi-abdominal mass with pressure ulcers foci and dilated veins
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30 cm in diameter, they are most frequently 80% benign. Bilaterality is uncommon and observed in about 5-10% of the cases (1, 2).
Most patients with ovarian cysts are asymptomatic (3, 6). However, space-occupying and compression-related symptoms may take place when the cysts attain large dimensions. Such symptoms may include: non-specific abdominal pain, early satiety, nausea, vomiting, constipation and urinary retention (3, 6). Our patient developed some of these symptoms in addition to severe bedsores that are secondary to prolonged immobilization. Low socio-economic status, lack of nearby healthcare facilities as well as cultural-related fears of surgery and malignancy are substantial contributors to late presentation and diagnosis of ovarian cysts (3). Furthermore, some patients present to clinical attention only when cysts grow enormously, symptoms become greatly intolerable, or mobilization comes to be severely limited. The most common complications of benign ovarian cysts comprise: hemorrhage, torsion and rupture (2). A serious consequence of ruptured ovarian mucinous cystadenoma is the development of pseudomyxoma peritonei — a condition characterized by mucinous deposits on the peritoneum.
Our patient had very a large pelvi-abdominal distention. The differential diagnosis is broad and may include: ascites, accentuated obesity, pelvic endometriosis, abdominal cysts, hydronephrotic kidneys and a wide range of neoplasms of various origins (endometrial, gastrointestinal tract, retroperitoneal and others) (7). Ascites appear to be a common finding in patients with ovarian cysts (7, 8), however, our patient had minimal free intraperitoneal fluid on ultrasound.
A large-sized ovarian cyst does not automatically denote malignancy. In fact, malignant ovarian cysts account for roughly 10% of all ovarian cysts (8). Tumor markers such as alpha fetoprotein (αFP), beta human chorionic gonadotropin (β-HCG), cancer antigen 125 (CA-125) and carcinoembryonic antigen (CEA) may be clinically beneficial in early diagnosis, management and follow-up of patients with malignant ovarian cysts (9). However, conflictingly, several studies reported elevated levels of these tumor markers even in patients with benign cystic ovarian neoplasms. Relevant to our case, the CA-125 level was significantly elevated in our patient despite the benign pathology. Histopathological/ immunohistochemical findings of the ovarian cysts provide the definitive diagnosis of malignant ovarian cysts (8).
Our patient had a giant benign ovarian mucinous cystadenoma which measured 73 x 51 x 42 cm and weighed 108 kg. Reports of giant ovarian cysts include those documented by Spohn of 148.6 kg (10), and O’Hanlan
Figure 4. The resected pelvi-abdominal mass measured 73 x 51 x 42 cm and was multi-loculated with a smooth surface
Figure 5. The pelvi-abdominal cavity post bilateral salpingo-oophorectomy
Figure 6. Intraoperative closure of the midline incision
Discussion and ConclusionOur patient had bilateral benign ovarian mucinous
cystadenoma. Generally, the vast majority of diagnosed ovarian cysts are benign(2). Ovarian mucinous cystadenomas account for around 15-20% of all ovarian neoplasms. Despite they can grow to large sizes exceeding
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Giant Ovarian Mucinous Cystadenoma, Abdulaziz Alobaid, et. al.
of 137 kg (11). To the best of our knowledge, we report the largest ovarian cyst in Saudi Arabia, and one of the largest ovarian cysts (probably the third) in the English medical literature.
Conservative surgery, such as ovarian cystectomy and/or salpingo-oophorectomy, is largely satisfactory for management of benign lesions (3,12). However, management of giant ovarian cysts can sometimes prove to be very challenging. Satisfactory management requires concentrated pre-, intra- and post-operative care. In our case, a multidisciplinary team was assembled, consisting of healthcare specialists from gynecologic oncology, anesthesia, plastic surgery, intensive care unit, cardiology, infectious diseases, psychology, nursing, physiotherapy, wound care and dietary care.
In conclusion, we report the largest benign ovarian tumor in Saudi Arabia, and one of the largest in the English medical literature. Also, we report that it is technically feasible to manage an extremely large-sized benign mass with satisfactorily perioperative outcomes.
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