{"paper_id":"7d9873b7-345a-4397-98f4-7d109aee5189","body_text":"IJMSDH, (2025)                                                                                                                                                           PageNo.108-114 \nwww.ijmsdh.org   \n \n  \nIJMSDH 108 \n \n \n \n \n \n \n \nGiant Paraovarial Cystadenoma in An Adolescent: Case Report and Literature \nReview \n \n      Fedoruc A. \nNational Scientific-Practical Center of Pediatric Surgery <Natalia Gheorghiu=, Moldova \n \n      Babuci S. \nNational Scientific-Practical Center of Pediatric Surgery <Natalia Gheorghiu=, Moldova \n \n      Gladun S. \nNational Scientific-Practical Center of Pediatric Surgery <Natalia Gheorghiu=, Moldova  \nState University of Medicine and Pharmacy \"Nicolae Testemitanu\" \n \n      Ambros I. \nNational Scientific-Practical Center of Pediatric Surgery <Natalia Gheorghiu=, Moldova \nState University of Medicine and Pharmacy \"Nicolae Testemitanu\" \n \n     Petrovici V. \nNational Scientific-Practical Center of Pediatric Surgery <Natalia Gheorghiu=, Moldova \nState University of Medicine and Pharmacy \"Nicolae Testemitanu\" \n \n \n \nReceived: 19 September 2025, accepted: 30 September 2025, Published Date: 22 October 2025 \n \n \nIntroduction. Paraovarian cysts are adnexal formations \nin the mesosalpinx within the broad ligament. They are \nthought to arise from remnants of the paramesonephric \n(Müllerian) ducts in approximately 30% of cases, the \nmesonephric (Wolffian) ducts in about 2% of cases, or \nfrom mesothelial tissue in nearly 68% of cases. [1, 8]. \nThese cystic formations can occur in women of all ages, \nwith the peak incidence in the third and fourth decades \nof life [25]. The reported incidence of paraovarian cysts \nin children and adolescents is approximately 4 –7.3%. \n[23, 25, 34].  \nThe average size of paraovarian cysts is approximately \n7.5 cm, with 95% measuring less than 2.0 cm in diameter. \nThere is no consensus on the definition of a giant cyst [7, \n19]. Only 12.96% of these cysts exceed 15 cm, which \nsome authors consider as giant [8, 28], while others \npropose a diameter of 20.0 cm as a more appropriate \nthreshold [36]. In adolescents, the size of giant cysts \nreported in the literature has ranged from 17 to 40 cm, \nmaking the differential diagnosis challenging. Potential \ndifferentials include benign or malignant ovarian tumors, \ntubal formations, tubo-ovarian abscesses, and non-\ngynecological abdominal cystic lesions [92]. Few cases of \ngiant paraovarian cysts in the pediatric population have \nbeen published, all managed with different surgical \napproaches [26]. In this context, we present a case of an \nadolescent girl with a giant paraovarian cyst, which \nposed diagnostic challenges on imaging. \nCase presentation.  Patient A., a 16-year-old girl, \npresented to the hospital with complaints of \nintermittent abdominal pain that began 5 days prior, \naccompanied by abdominal distension. On physical \nexamination, a large, tender, and moderately mobile \nInternational Journal of Medical Science and Dental \nHealth (ISSN: 2454-4191) \nVolume 11, Issue 10, October 2025 \nDoi: https://doi.org/10.55640/ijmsdh-11-10-12 \n \nOpen Access \n \n\n\nIJMSDH, (2025)                                                                                                                                                           PageNo.108-114 \nwww.ijmsdh.org   \n \n  \nIJMSDH 109 \n \nmass was palpated in the lower abdomen, extending into \nthe mesogastric region. \nThe patient’s medical history revealed no history of \nsexual intercourse, no use of hormonal medications, and \nno prior surgical interventions. \nInitial investigations included abdominal \nultrasonography, laboratory tests, and magnetic \nresonance imaging (MRI). Ultrasonography revealed an \nintra-abdominal cystic formation of unknown etiology, \nmeasuring approximately 13 × 10 cm. Results of \ncomplete blood count, biochemical analyses, and \nurinalysis were within normal reference ranges. Serum \ntumor marker testing showed normal α-fetoprotein \nlevels at 6.20 ng/mL (reference range 0 –20 ng/mL), \nwhereas hCG was elevated at 16.22 mIU/mL (reference \nrange 0–10 mIU/mL). \nMRI revealed a unilocular cystic formation with \nhomogeneous fluid content similar to cerebrospinal \nfluid, without septations, located in the anterior pelvic \ncompartment and extending into the abdominal cavity \nup to the L3 level. The cyst was elongated in the \ntransverse plane, well-defined, and measured 18 cm \n(vertical) × 6.6 cm (anteroposterior) × 20 cm (transverse). \nThe lesion caused a marked mass effect on the uterine \nadnexa, uterus, bladder, and intestinal loops, without \nevidence of intramural nodules, fat, or calcified \ncomponents (Fig. 1).\n \n \nFig. 1. Patient A. aged 17. Preoperative MRI: cystic, single-chamber, purely fluid formation  with signs of pronounced \nmass effect on uterine adnexa, uterus, bladder, bowel loops (explanation in text). \n \nConsidering the large size of the cystic formation and the \nuncertain nature of the tumor (benign or malignant), an \ninferior midline laparotomy was performed instead of \nlaparoscopy. The choice of an open abdominal approach \nwas also supported by the imaging findings, with a \nmesenteric cyst included in the differential diagnosis. \nUpon opening the abdominal cavity, a large cystic \nformation was identified, attached medially to the \nampulla of the fallopian tube. The cyst was punctured, \nreleasing approximately 1.5 liters of yellowish serous \nfluid. After exteriorization, the lesion was confirmed to \nbe paraovarian on the right side, without adhesions to \nadjacent organs. The right ovary was intact, while the left \novary showed polycystic changes. The cyst was removed \nen bloc within its own capsule (Fig. 2). Subsequently, the \nbroad ligament on the right side was reconstructed and \nperitonized. The procedure concluded with restoration \nof normal anatomical planes. \n\n\nIJMSDH, (2025)                                                                                                                                                           PageNo.108-114 \nwww.ijmsdh.org   \n \n  \nIJMSDH 110 \n \n \nFig. 2. Intraoperative aspects of mobilization of the cystic formation (A, B). C - macroscopic aspect of the removed cyst. \nThe postoperative course was uneventful, and the \npatient was discharged in satisfactory condition on the \nseventh postoperative day. At one-month follow-up, she \nreported no complaints, and the surgical wound had \ncompletely healed. \nMacroscopic examination of the specimen revealed a \nflaccid cystic formation with a <pear= shape and a pearly \nsurface, featuring non-transparent areas with prominent \nvascular markings. On dissection, the cyst contained \ntransparent serous fluid. The internal surface was \npearlescent like the external surface, mostly opaque, \noccasionally semi-transparent, with prominent vascular \nmarkings. A circular fold of firm, elastic consistency \nextended across the entire internal surface, \ncorresponding to the boundary between the \ndisproportionate volumes of the cyst (Fig. 3). \n \nFig. 3. Macroscopic aspects of the removed paratubal cyst: A - pear-shaped cystic formation, externally pearly, flaccid \nappearance after partial removal of serous fluid; B - dissected cyst: transparent ser ous content in the cavity, at the \nboundary between the cyst volumes a fold (black arrow); C - fold on the intern al surface of the cyst having the same \nthickness as the cyst wall\nHistological examination revealed a fibrillar connective \nwall containing spindle-shaped cellular elements of mild \nto moderate density. The internal surface was frequently \nlined by a cuboidal or columnar pseudo-stratified, \nsometimes multi-layered ciliated epithelium. In some \nareas, Hobnail cells (cells with clear cytoplasm), \ncharacteristic of tubular epithelium, were observed (Fig. \n4A, B). The fold region exhibited a structure similar to the \ncyst wall, with an epithelial lining analogous to that \nfound in other areas of the cyst, showing a pseudo- or \nmulti-layered pattern. Adjacent to the fold, a small \nplateau with stromal-epithelial papillary structures \nexhibiting minimal proliferation was noted (Fig. 4C, D).\n\n\nIJMSDH, (2025)                                                                                                                                                           PageNo.108-114 \nwww.ijmsdh.org   \n \n  \nIJMSDH 111 \n \n \nFig.4. Histopathological aspects of the cyst wall. A - mixed pseudo-stratified (a) and cuboi dal (b) surface epithelium. \nColour. HE, 200x; B - epithelium with features of tubular origin with the presence of Hobnaila cells (arrow). Color.  HE, \n200x; D - small papillary structure of the fold in the apical area and an adj acent small plateau of papillary stromal-\nepithelial papillary structures. Color. HE, 200x; D - small waist plateau with fibro-epithelial structures lined with ciliated \npseudostratified columnar epithelium. Color. HE, 200x; \n \nOf note, no mitotic activity, dysplasia, or atypia of the \ncystic epithelium was observed. Portions of the fallopian \ntube showed stasis congestion, stromal edema, and, in \nsome areas, lymphocytic infiltration and sclerotic \nchanges. Taken together, these histological findings \nconfirm the diagnosis of a benign paraovarian cyst, \nrepresented by a focal micropapillary serous \ncystadenoma. \nDiscussions. A paratubal or paraovarian cyst is a fetal-\norigin lesion, first described as a distinct pathological \nentity by Kariminejad M.H. and Scully R.E. in 1973 [16]. \nThe terms <paratubal= and <paraovarian= are used \naccording to the proximity of the cyst to the fallopian \ntube or ovary, respectively. [35]. \nAccording to some authors, only six cases of giant \nparaovarian cysts, ranging in size from 17 to 20 cm in \nadolescent girls, were reported by 2019, and \nlaparoscopic surgery was performed in only one of these \ncases [18]. \nParaovarian cysts are predominantly asymptomatic, \nwhich is why only 30 –44% are identified preoperatively \n[12], and in 15.7% of cases they are discovered \nincidentally during diagnostic laparoscopy [6]. During the \ncourse of the condition, patients may experience lower \nabdominal heaviness, mild pain, or urinary symptoms, \nwhich in some cases may be accompanied by fever [15]. \nOccasionally, clinical complications may arise due to \nprogressive enlargement of the cystic formation, \nincluding hemorrhage, torsion, cyst rupture with \nhemoperitoneum, torsion of the tumor or ipsilateral \nfallopian tube, or malignant transformation [17, 24, 33, \n34].  \nParatubal cysts may be simple or of neoplastic origin \n[14]. Simple paraovarian cysts arise from embryonic \n\n\nIJMSDH, (2025)                                                                                                                                                           PageNo.108-114 \nwww.ijmsdh.org   \n \n  \nIJMSDH 112 \n \nremnants of the urogenital system (mesonephric and \nparamesonephric ducts) or from invagination of the \nserosa of the fallopian tubes, forming mesothelial cysts. \nNeoplastic paraovarian cysts develop either from \nneoplastic transformation of a simple paraovarian cyst or \nfrom the adjacent ovary [10]. The majority of paratubal \ncysts are benign, with malignancy reported in \napproximately 2 –2.9% of cases; the main secondary \nneoplasms are cystadenocarcinoma and papillary \ncarcinoma [31, 37]. However, some studies have \nreported a higher incidence of neoplastic paraovarian \ncysts, around 25%, usually diagnosed in adults [22, 29]. \nHistological examinations have also revealed, in addition \nto simple paraovarian cysts, cases of cystadenofibroma, \ncystadenoma, adenomatoid tumors of mesothelial \norigin, and borderline papillary serous tumors [14, 27]. \nCases of borderline tumors arising in paratubal cysts in \nadolescent girls have been reported [20]. For differential \ndiagnostic purposes with epithelial tumors, it is \nrecommended to assess tumor markers such as cancer \nantigens (CA-125, CA 15-3, CA 19-9), inhibin B, beta-\nhuman chorionic gonadotropin ( β-HCG), \ncarcinoembryonic antigen (CEA), lactate dehydrogenase \n(LDH), alpha-fetoprotein (AFP), estradiol, and others [3, \n21]. According to some studies, these markers are \nelevated in only 54% of malignant adnexal neoplasms \nand in about 6.5% of benign lesions [30]. \nPreoperative differential diagnosis between ovarian and \nparatubal cysts remains challenging, as pathognomonic \nimaging features specific to paraovarian cysts are \nincompletely described [35]. According to some studies, \na definitive preoperative diagnosis of a paratubal cyst by \nultrasound is achieved in only 25–44% of cases, whereas \ncolor Doppler ultrasound demonstrates a specificity of \n99% but a sensitivity of only 14% [17, 25]. Some authors \nconsider ultrasonography and magnetic resonance \nimaging (MRI) to be more useful than computed \ntomography (CT) [1]. According to a consensus \nstatement, regardless of patient age, cysts larger than 7 \ncm warrant further evaluation with MRI [14]. \nThe differential diagnosis of paraovarian cysts includes \nintestinal duplication, internal hernias, intestinal \nlymphangioma, and peritoneal inclusion cysts [32]. \nThere is no consensus regarding the surgical \nmanagement of paraovarian cysts [36]. No specific \ncriteria have been established for choosing between \nlaparoscopy and laparotomy; surgical techniques are \nadapted according to cyst size, risk of intraoperative \nrupture, patient age, concomitant pathologies, and other \nfactors [3, 4, 11, 38]. Treatment options for paratubal \ncysts include cystectomy, cystectomy with \nsalpingectomy, or, in complicated cases, adnexectomy \n[2, 3, 5, 13]. Aspiration of the cystic fluid must be \nperformed with great precision to avoid intraperitoneal \nspillage, which could result in tumor seeding in the \nperitoneal cavity in cases of malignant cystic lesions [11]. \nThus, this clinical case report highlights the rarity of a \nlarge benign paratubal serous cystadenoma diagnosed in \nadolescent girls, as well as the challenges associated with \npreoperative diagnosis. In the present case, laparotomy \nwas preferred over laparoscopy due to the large size of \nthe cyst and the risk of intraperitoneal dissemination of \nits contents. The presence of papilliform tissue on the \ninner surface of the cyst should be carefully considered, \nas some neoplasms, including borderline tumors, \ncystadenocarcinoma, and papillary carcinoma, may arise \nfrom this tissue. \nReferences \n1. Almehmeed E., Alshaibani A., Alhamad H., Abualsel \nA. Giant paratubal cyst mimicking mesenteric cyst. \nHindawi Case Rep. Surg. 2022. Art. 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