Acta Chir Belg, 2008, 108, 354-355
A Mucinous Cystadenoma in the Mesentery of the Right Hemicolon
S. Zwaveling, A. J. den Outer, S. A. da Costa
Department of Surgery, Rijnland Hospital, Leiderdorp, The Netherlands.
Key words. Mucinous cystadenoma mesocolon.
Abstract. Cysts of the mesentery, retroperitoneum and omentum are rare. We present a patient with a mucinous cystadenoma in the mesentery of the right hemicolon. The exact aetiology of these cysts at the aforementioned sites is still
unclear. Adenocarcinomas can arise in mucinous cystadenomas. Therefore, in our opinion, to prevent spillage the right
approach is to primarily perform a laparatomy instead of attempting to remove these lesions laparoscopically, even if
clinical and radiological signs of malignancy are absent.
Case report
Discussion
An 18 year old otherwise healthy female was seen at our
outpatient clinic. She presented with progressive abdominal swelling on the right side which she had initially
noticed a few weeks earlier. Although the swelling was
painless it hindered her in her movements, particularly
when bowing. No nausea, vomiting or problems concerning menstruation, urination and defecation were
noted. The further history was unremarkable.
On examination a mild swelling was visible on the
right side of the abdomen at the level of the kidneys. A
large, tender, elastic mass could be palpated. No other
abnormalities were found. Laboratory investigations
were normal. An additional ultrasound and CT scan
revealed a 15 cm intra-abdominal cystic mass located on
the right side, tightly adjacent to the right kidney but not
connected to it (Fig. 1a). There were no signs of malignancy and no further diagnostic imaging was considered
necessary.
A median explorative laparotomy showed a large cyst
in the mesentery of the right hemicolon (Fig. 1b). No
connections with retro- or intraperitoneal structures were
detected and no aberrancies in other organs were noticeable. The cyst was carefully dissected until a small root
at the base of the mesentery could be coagulated. The
wound was closed lege artis and two days after surgery
the patient was discharged. Since then she has not
encountered any surgery related problems and the wound
has healed well.
Pathological examination revealed a benign mucinous
cystadenoma, which had been removed unimpaired from
the mesentery of the right hemicolon.
Primary omental, mesenteric and retroperitoneal cysts
are relatively rare tumours which, according to their
origin, are classified as developmental, neoplastic, traumatic or infectious (1). Their accumulative incidence is
estimated to be in the range of 1 in 105,000 hospitalised
patients (2). Although known to occur in the mesentery
of the left hemicolon (3) and the transverse mesocolon (4) the appearance of a mucinous cystadenoma in
the mesentery of the right hemicolon has, to our knowledge, not been described before in English literature. A
number of theories concerning the development of these
cysts has been proposed. The hypothesis was postulated
that, due to the resemblance to ovarian tumours, cyst formation in ectopic ovarian tissue or supernummary
ovaries may lay the foundation of this condition (2, 5-7).
This is, however, opposed by the fact that associated
ovarian tissue is uncommonly reported (5-8). Moreover,
recently reports were published describing male patients,
thus further diminishing the likelihood that an ovarian
origin is involved (9, 10). Alternatively, outgrowth of
mucinous epthelium over other components of a primary
teratoma may be considered (6, 7, 9). Despite these and
other postulations the exact aetiology is still unclear (57, 9). Presently, the most widely accepted hypothesis
comprises the inclusion of celomic epithelial cells which
eventually evolve into mucinous tumours as a result of
metaplastic changes (6, 7, 9).
Mucinous cystadenocarcinomas can arise in cystadenomas (1). Since the distinction with a potentially fatal
malignancy cannot always be made in advance, either
clinically or radiologically, laparoscopic attempts for
A Cystadenoma in the Right Mesocolon
355
a
b
Fig. 1
a : A transverse CT scan clearly depicting an intra-abdominal cyst on the right side ; b : Removal of the intact cyst following explorative laparotomy.
removal of seemingly benign mucinous cystadenomas
should in our opinion not be undertaken. To avoid
spillage, we suggest performing an explorative laparotomy with intact excision of the cyst as shown in this
report. Indeed, several other authors seem to underscore
this approach (4, 8).
When after the initial operation a cyst is established to
be malign, the extent of the successive surgery is still a
matter of debate. Some authors are very aggressive while
others advocate a more conservative treatment (7). If a
malignant cyst ruptures during the procedure patients
may benefit from adjuvant chemotherapy and radiotherapy, but this is still controversial as well (4, 7, 9). There
is consensus, however, that patients should be followed
up. Notably, “borderline malignant” lesions are also able
to metastasise and patients have to be monitored regularly after surgery (3). In contrast, benign lesions carry a
good prognosis and patients can be excluded from follow
up.
Conclusion
We present a patient with a benign mucinous cystadenoma of the right mesocolon. Even if such lesions seem
benign, complete removal must be pursued by means of
laparotomy rather than via laparoscopy to prevent
spillage in case an adenocarcinoma is present.
References
1. MCEVOY A. W., CAHILL C. J., JAMESON C. Mucinous cystadenoma
of the sigmoid mesocolon : a previously unreported abdominal
tumor. Eur J Surg Oncol, 1997, 23 : 88-90.
2. VANEK V. W., PHILIPS A. K. Retroperitoneal, mesenteric and omental cysts. Arch Surg, 1984, 119 : 838-42.
3. TALWAR A., BELL N. J., NICHOLAS D. Mucinous Cystadenoma of
Colonic Mesentery : Report of a Case. Dis Colon Rectum, 2004,
47 : 1412-14.
4. LINDEN P. A., ASHLEY S. W. Mucinous cystadenocarcinoma of the
mesentery. Surgery, 2000, 127 : 707-8.
5. KEHAGIAS D. T., KARVOUNIS E. E., FOTOPOULOS A. et al. Retroperitoneal mucinous cystadenoma. Eur J Obstet Gynaecol Reprod
Biol, 1999, 82 : 213-5.
6. TANGJITGAMOL S., MANUSIRIVITHAYA S., SHEANAKUL C. et al.
Retroperitoneal mucinous cystadenocarcinoma : a case report and
review of literature. Int J Gynecol Cancer, 2002, 12 : 403-8.
7. DE LEÓN D. C., PÉREZ MONTIEL D., CHANONA VILCHIS J. et al.
Primary retroperitoneal mucinous cystadenocarcinoma : report of
two cases. World J Surg Oncol, 2007, 5 : 5.
8. COTTRILL H. M., ROBERTS W. S. Primary retroperitoneal mucinous
borderline tumor : A case report. Gynecol Oncol, 2007, 106 : 6267.
9. TJALMA W. A. A., VANEERDEWEG W. Primary retroperitoneal mucinous cystadenocarcinomas are a distinct entity. Int J Gynecol
Cancer, 2008, 18 : 184-8.
10. THAMBOO T. P., SIM R., TAN S. Y. et al. Primary retroperitoneal
mucinous cystadenocarcinoma in a male patient. J Clin Pathol,
2006, 59 : 655-7.
S. Zwaveling, M.D., Ph.D.
PO Box 85090
3508 AB Utrecht, The Netherlands
E-mail : s.zwaveling@umcutrecht.nl