Objective
To report a higher than estimated recurrence rate of benign mucinous cystadenomas after complete resection of the first one, and to assess potential risk factors for recurrence after complete surgical excision.
Study Design
We retrospectively reviewed all cases of women who underwent either laparoscopic or laparotomic removal of benign mucinous adnexal cysts by either adnexectomy or cystectomy in our institution between 1996 and 2006.
Results
Included were the data of 42 women who fulfilled study entry criteria. Three of them (7.1%) underwent a second operation because of a recurrence of the lesion. A significantly higher rate of women who had cyst recurrence had undergone cystectomy as opposed to adnexectomy ( P < .05). Intraoperative rupture of cysts during cystectomy was also significantly associated with cyst recurrence ( P < .03).
Conclusion
Mucinous cystadenoma recurrence is apparently not as rare as reported in the literature. Intraoperative cyst rupture and cystectomy instead of adnexectomy emerged as being two risk factors for recurrence.
Mucinous tumors are the second most common type of epithelial tumors, comprising 8-10% of ovarian tumors. Almost all of them are cystadenomas, which are divided into benign, borderline, and malignant types. Although they may reach massive dimensions, their size alone is not a sign of malignancy, because up to 80% of all mucinous tumors are benign. Ovarian mucinous cystadenomas are characteristically unilateral, with only 5% presenting bilaterally, and the peak incidence occurs among women who are between the ages of 30 and 50 years. Benign mucinous tumors typically have a lobulated, smooth surface, are multilocular, and contain mucoid material within the cystic loculations.
Laparoscopy has become the standard of care in the management of ovarian cysts, owing to the lower morbidity rate, improved postoperative recovery and reduced cost. Conservative procedures, such as ovarian cystectomy, may be preferred by younger patients who desire to preserve their fertility to enable retention of functioning ovarian tissue. Because laparoscopy has been shown to be feasible with adnexal masses >10 cm, it is considered as a viable option when approaching both simple and complex masses, whether large or small.
One concern associated with both laparoscopy and cystectomy in the treatment of adnexal mass is inadvertent intraoperative cyst rupture, which may cause spillage and dissemination of its content. Previous studies have assessed the rate of cyst rupture during laparoscopy as ranging between 6-27%. The risk of rupture was found to be related to the patient’s age, prior hysterectomy, and concomitant hysterectomy. Spillage rates of laparoscopic adnexectomy procedures were found to be less than those of laparoscopic cystectomy procedures. In particular, intraoperative rupture and spillage of mucinous tumors into the abdomen was associated with an increased risk for pseudomyxoma peritonei.
Earlier studies had estimated that recurrence of mucinous cystadenoma after optimal excision is very rare. In fact, only 5 such cases have been reported to date. In our search for long-term outcomes of inadvertent intraoperative mucinous cystadenoma rupture among our patients, we also came across several cases of mucinous cystadenoma recurrence after complete excision of the first one. This led us to question the true incidence of recurrence and to try to identify possible risk factors associated with recurrence.
Materials and Methods
We conducted a computerized search of our database for cases of women who underwent either laparoscopic or laparotomic removal of mucinous adnexal cysts by either adnexectomy or cystectomy in our institution between 1996 and 2006. Cases in which pathologic examination revealed foci of borderline mucinous tumor were excluded, as were those in which pathologic examination revealed a combination of mucinous cystadenoma and another histologic type of ovarian tumor. The patients’ demographics, operative findings, surgical procedure, and pathologic diagnoses were retrospectively retrieved from their medical records. Approval to conduct this study was obtained from the Institutional Review Board.
Laparoscopy was conducted using pneumoperitoneum, and first trocar placement in the umbilicus was the first choice of entry in most cases. Palmer’s point or a supraumbilical position was chosen for the patients who had undergone previous laparotomies and in cases in which large adnexal cysts were anticipated. Two additional trocars (5 or 10 mm) were inserted in the lower abdomen. Laparotomy was conducted using a Pfannenstiel incision. All specimens were sent for pathologic evaluation and diagnosis. All the laparoscopic procedures were carried out by 1 of 2 surgeons who were endoscopic gynecologic specialists, and the laparotomic procedures were performed by 1 of 2 other experienced gynecologic surgeons.
Statistical analysis
Correlations between cyst spillage and various selected parameters (patient’s age, ovarian cyst size, pregnancy, torsion of the adnexa, concomitant adnexal and uterine surgery, pelvic adhesions, and endometriotic foci) were examined by using the Fisher’s exact test, the 2-way analysis of variance test and the Student t test. Calculations were performed with the use of SPSS software (version 11; SPSS, Chicago, IL). Significance was set at P < .05.
Results
A total of 2357 women underwent either laparoscopic or laparotomic removal of adnexal cysts in our institution between 1996 and 2006. Forty-eight women were operated because of mucinous cystadenoma, of whom 42 women fulfilled inclusion criteria and comprised the study cohort. The mean cyst size was 9.2 ± 4.7 cm and the patients’ mean age at surgery was 40.2 ± 15.8 years (range, 17–78 years). Laparoscopy was the approach used in 37 of the women (88%), and the other 5 (12%) underwent laparotomy. Six women of the laparoscopy group underwent concomitant surgery (including cholecystectomy, subtotal laparoscopic hysterectomy, tubal ligation, and hysteroscopy), whereas 1 woman of the laparotomy group underwent concomitant cesarean section. Two patients (2/42; 4.7%) were pregnant (15 and 37 weeks of gestation) at the time of surgery. The distribution of cyst location was on the left side in 20 patients (47.6%), right side in 19 patients (45.2%), and bilateral in 3 patients (7.1%). The primary indication of surgical intervention was either an asymptomatic sonographic finding (38 women, 90.5%) or abdominal pain (4 women, 9.5%). Two women in the laparotomy group also had torsion of the adnexa. Mild-to-moderate pelvic adhesions were found in 12 (28.6%) cases, severe adhesions in 2 (4.8%) and endometriotic foci in 2 (4.8%).
Three women (7.1%) underwent the second operation because of a recurrence of a mucinous cyst. Of special interest is that all 3 women had undergone laparoscopic cystectomy in which cyst rupture had occurred. Also noteworthy are the findings that all 3 recurrences were located on the same ovary that contained the first excised lesion and that all 3 recurrences were diagnosed within the first year after the initial surgery. Finally, the pathologic examination revealed endocervical-type cells alone in each of these 3 cases.
The clinical and surgical characteristics of the women who had cyst recurrence vs those who had no recurrence are presented in Table 1 . There was a significantly higher rate of intraoperative cyst rupture in the cases of cyst recurrence compared with those with no recurrence ( P = .01). Furthermore, a significantly higher rate of women who had cyst recurrence underwent cystectomy rather than adnexectomy ( P < .05). Although the mean age of the women with cyst recurrence was significantly higher than those with no cyst recurrence ( P < .05), this difference disappeared when controlled for procedure type (explained by the greater proportion of younger patients undergoing cystectomy rather than adnexectomy). There were no significant differences between the recurrence and the no recurrence groups in terms of the distribution rate of cyst location, surgical approach, adnexal torsion, pelvic adhesions, presence of endometriotic foci, previous abdominal surgery, ongoing pregnancy, and mean cyst diameter ( Table 1 ).
| Characteristic | Recurrence (n = 3) | No recurrence (n = 39) | P value |
|---|---|---|---|
| Cyst rupture, n (%) | 3 (100) | 7 (17.9) | .01 |
| Surgical procedure, n (%) | |||
| Cystectomy | 3 (100) | 11 (28.2) | < .05 |
| Adnexectomy | 0 | 28 (71.8) | |
| Age, y (mean ± SD) | 21.7 ± 4.5 | 41.6 ± 15.4 | < .05 |
| Cyst diameter, cm (mean ± SD) | 6.3 ± 3.5 | 9.4 ± 4.8 | NS |
| Cyst location, n (%) | |||
| Right | 3 (100) | 16 (41) | NS |
| Left | 0 | 20 (51.2) | NS |
| Bilateral | 0 | 3 (7.7) | NS |
| Intraabdominal adhesions, n (%) | |||
| None | 3 (100) | 25 (64.1) | NS |
| Mild-moderate | 0 | 12 (30.8) | NS |
| Severe | 0 | 2 (5.1) | NS |
| Surgical approach, n (%) | |||
| Laparoscopy | 3 (100) | 34 (87.2) | NS |
| Laparotomy | 0 | 5 (12.8) | NS |
| Adnexal torsion, n (%) | 0 | 2 (5.1) | NS |
| Previous abdominal surgery, n (%) | 0 | 14 (35.8) | NS |
| Endometriosis, n (%) | 0 | 2 (5.1) | NS |
| Pregnancy, n (%) | 0 | 2 (5.1) | NS |
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