|LETTER TO THE EDITOR
|Year : 2011 | Volume
| Issue : 1 | Page : 29-31
A case of unusually large giant retroperitoneal cyst
Manoranjan Kar1, Jugal K Kar2, Saswati Maiti3
1 Department of Surgery, Medical College, Kolkata, India
2 Department of Medicine, Midnapur Medical College, Kolkata, West Bengal, India
3 Department of Gynecology and Obstetrics, Burwan Medical College, Burdwan, India
|Date of Web Publication||24-Aug-2011|
Flat -3B, 64/1/34A, K. B. Sarani, Kolkata, West Bengal - 700 037
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kar M, Kar JK, Maiti S. A case of unusually large giant retroperitoneal cyst. Ann Nigerian Med 2011;5:29-31
Retroperitoneal cysts are uncommon, with an estimated incidence of 1/5750 to 1/250,000. As the retroperitoneum is a large potential space, these cysts can grow to considerable size before becoming symptomatic. Retroperitoneal location of cystic lymphangiomas in adult patients is rare. Their clinical presentation is not specific. The authors report a case of unusually large giant retroperitoneal cyst with a literature review.
A 43 year female patient presented with sensation of fullness of lower abdomen for duration of two years. She also complained of feeling of stretching of abdomen particularly during squatting position and mild low-back pain. There was no history of fever, loss of appetite and gross weight loss. There was mild to moderate degree of dysmenorrhoea. There was no dyspareunia. She was married and having two children with normal vaginal delivery. Last childbirth was 17 years back. Bowel habit was normal. There was increased frequency of micturition without any burning sensation. On examination, general condition was average, mild pallor was present, neck glands were not enlarged, no dependant pitting edema, pulse rate was 78 per minute, respiratory rate was 16 per minute and temperature was normal. Abdominal examination revealed fullness of almost whole of the abdomen with doughy consistency, no definite lump, no shifting dullness and no fluid thrill. Per vaginal examination revealed anteverted uterus and fullness of right fornix with cystic feeling. Per rectal examination revealed cystic fullness of pouch of Doglus with no definite lumpy feelings or ballotability.
On investigation, routine haemogram -Hemoglobin level 10.4 gm%, total leukocytes count 6800 per dl, lymphocyte count - 22%, erythrocyte sedimentation rate-34 mm/hr. Urine- pus cell 1-2 per hpf and no growth on culture of urine. Chest radiograph was normal. Ultrasonography examination of abdomen - impression of a Sonologist was huge ovarian cyst or encysted ascites. Blood level of cancer antigen 125 was normal. Patient was from lower socioeconomic status and from a remote rural area. They could not afford further investigation.
On explanation about diagnosis, per-operative complication, operative outcome, prognosis, -- patient and her responsible guardians consented for exploratory laparotomy, which was done in peripheral rural surgical setup with two units of blood in hand, through a lower midline incision.
A huge multiloculated cystic mass with clear content was found retroperitonealy from pelvis behind the right broad ligament upwards upto inferior surface of liver. Uterus and both tubes-ovaries were normal in size. The mass was displacing uterus anteriorly and to the left, caecum- terminal ileum above and to the left. Right sided round ligament made a groove over the swelling [Figure 1]. The mass was multiloculated containing clear fluid [Figure 2]. Blunt dissection was done. The mass was dissected from all structures easily from every aspect except near the uterus. Complete excision of the mass with total hysterectomy with bilateral salpingo-ophorectomy was done [Figure 3]. Ureters were lying behind the mass. Dimension of the mass was 38 cm ΄ 31 cm ΄ 18 cm. Weight was thirteen and half kilogram. Histopathological examination report was cystic lesion with flattened epithelium without any malignant changes. Ultrastructural and immunohistochemical examination was not available in this rural set-up. Post-operative period was uneventful [Figure 4]. On follow-up after three years there was no recurrence.
|Figure 1: Peroperative photograph showing part of the lesion behind broad ligament and grooved by the right round ligament|
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Retroperitoneal cysts (RPCs) are rare with an estimated incidence of 1/5750 to 1/250,000.  Approximately one third of patients with retroperitoneal cyst are asymptomatic and the cyst is found incidentally. ,,,,, As the retroperitoneum is a large potential space, these cyst can grow to a considerable size before becoming symptomatic.  Based on origin and histological differentiation,  RPCs are classified into (a) Urogenital; (b) Mesocolic; (c) Lymphatic cyst;(d) Dermoid cyst; (e) Traumatic; (f) Parasitic. Only those cysts that lie in the retroperitoneum without connection with any adult anatomical structure, except by areolar tissue, are included in this group of cysts. The urogenital cysts arise from the vestiges of the embryonic urogenital apparatus and can be classified into pronephric, mesonephric, metanephric, and mullerian. When these cysts are exposed and seen in situ, they appear bluish thin-walled cysts and rather flabby with no visible vessels in their walls, and when removed, they are translucent and lose their bluish tinge. They have no pedicle and no connections apart from the areolar tissues with the surrounding structures. When opened, they have a smooth, glistening lining membrane; are single, not multilocular; and contain a clear serous fluid. The wall is thin and lined by a low columnar epithelium, or cubical and rarely flattened.
The lymphatic cysts are subdivided into those formed in the lymphatics returning from the intestine and are known as chylous cysts, and those arising in the lymphatic field behind the peritoneum and are not connected with the intestine. They are unilocular or multilocular cysts containing clear or milky fluid and lined with a single layer of flattened endothelium. ,, Our reported case was of a multiloculated cyst with clear content and lined by flattened endothelium resembling cystic haemangioma. Mesocolic cysts are found only in the area between ascending and descending colon and below the transverse mesocolon, anterior to the spermatic or ovarian vessels, and are composed of a fibrous wall lined by a delicate flattened epithelium. Cysts arising in cell inclusions such as dermoid cysts are found frequently in the retroperitoneum, and have thick walls and usually filled with sebaceous material and hair.
There are no pathognomonic signs or symptoms for RPCs, and in approximately one third of patients, the cyst is found incidentally. ,,,,, Two thirds of patients present with an abdominal mass or chronic abdominal symptoms. Other symptoms include back pain, referred pain to the lower limbs, oedema of the lower limbs, weight loss or fever. More commonly, only a soft tissue mass with displacement of the bowel is seen.
Computed tomography (CT) is ideal for assessing RPCs ,, because it provides discrete sectional images of the organs and retoperitoneal compartments. Mullerian cyst, for example, manifests as a unilocular or multilocular thin-walled cyst containing clear fluid, and clinical history may help differentiate it from other retroperitoneal masses as it is more common in obese patients with menstrual irregularities. Cystic lymphangioma typically appears as a large, thin-walled, multiseptate cystic mass. Its attenuation values vary from that of fluid to that of fat. An elongated shape and a crossing from one retroperitoneal compartment to an adjacent one are characteristic of the mass, and calcification of the wall is rare. Magnetic resonance imaging (MRI) is also useful for preoperative localization and differentiation of retroperitoneal cyst. ,
Symptomatic cysts should be enucleated or excised, while preserving the surrounding vital structures. At times, the cyst can be marsupialized or drained if surgical enucleation is difficult or the cyst is infected. However, draining the cyst usually results in recurrence. ,,,,,
The relevant clinical pictures are included for educational value of this rare case.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]