|Year : 2015 | Volume
| Issue : 4 | Page : 1030
Brenner's tumor associated with ovarian mucinous cystadenoma reaching a huge size in postmenopausal woman
Ahmed Mohamed Abbas1, Mariam Taher Amin2
1 Lecturer, Woman's Health Center, Assiut, Egypt
2 House Officer, Assiut University, Assiut, Egypt
|Date of Web Publication||15-Feb-2016|
Mariam Taher Amin
Assiut University Hospitals, Assiut University, Assiut - 71526
Source of Support: None, Conflict of Interest: None
A case of a 70-year-old Egyptian postmenopausal woman presenting a Brenner's tumor associated with mucinous cystadenoma weighing 20.7 kg is reported here. Patient was admitted in our hospital with abdominal pain of one-month duration. On abdominal ultrasound, a huge heterogeneous mass was found to encompass the whole abdomen. At laparotomy, a giant, right heterogeneous mass was encountered and removed intact by right salpingo-oophorectomy. On the seventh postoperative day, she was discharged without any problem. Her pathology report disclosed a 52 x 41 x 36 cm, partially solid, partially cystic mass diagnosed as benign Brenner's tumor with mucinous cystadenoma weighing 20.7 kg. This is the largest ovarian mass that is ever reported in our hospital and one of the largest among the reported cases in the literature.
Keywords: Brenner′s tumor, giant ovarian mass, mucinous cystadenoma
|How to cite this article:|
Abbas AM, Amin MT. Brenner's tumor associated with ovarian mucinous cystadenoma reaching a huge size in postmenopausal woman. J Can Res Ther 2015;11:1030
| > Introduction|| |
Ovarian tumors are classified according to its origin into three main groups: Epithelial, stromal and germ cell tumors. The most common type is that of epithelial origin.  Ultrasonographic scanning allows early diagnosis of ovarian masses, but in few cases they can attain huge size while remain asymptomatic.  However, these huge ovarian masses still endanger patients' life due to certain complications faced preoperatively as severe cardiovascular, pulmonary, and circulatory problems result from diaphragmatic elevation and aortocaval compression.  Also, intraoperative complications can occur due to technical difficulties of surgery, risk of massive hemorrhage, and possibility of rupture and spillage of contents. 
We reported this case of huge Brenner's tumor because of its rarity in our locality, besides it is one of the largest masses reported in the literature.
| > Case report|| |
In May 2014, a 70-year-old woman was admitted to Assiut Women's Health Hospital with vague abdominal pain of one-month duration. Abdominal pain had started one month ago with gradual onset, progressive course, diffuse and not associated with any gastrointestinal symptoms. She was Para 7 + 0, postmenopausal for 20 years. Apart from being hypertensive on treatment, her medical history was uneventful. She had no previous history of operations.
On general examination, she was average body built, weighed 76 kg. Her vital signs were normal. There was no pallor, jaundice, edema or lymphadenopathy. Cardiac and chest examinations were unremarkable. Abdomen was grossly distended by a pelvi-abdominal mass corresponding to the size of a 36 weeks pregnant uterus by palpation. This mass was irregular; cystic on some areas and solid on the others, not tender and had limited mobility. Liver, spleen and kidneys were difficult to be palpated. There was moderate ascites and intestinal sounds were audible. Vaginal examination was unremarkable.
During the ultrasound examination, a huge mass filling the whole abdomen was observed. The mass could not be measured and was separated from a normal-sized uterus. It was multilocular with thick septa, ill-defined borders, turbid contents and multiple solid areas [Figure 1]. A moderate free intraperitoneal collection was observed. The abdominopelvic MRI showed a large heterogeneous mass encompass the whole abdomen. Laboratory investigations, including hemoglobin level, prothrombin concentration, and renal and liver function tests were all within normal range. Tumor marker CA.125 was elevated (92 ng/ml). Chest X-ray was normal.
|Figure 1: Abdominal ultrasound, showing multilocular mass with thick septae and turbid content|
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The patient was counseled for the possibility of hysterectomy, and an informed written consent for abdominal exploration was obtained. Abdominal exploration was done under general anesthesia through a right paramedian incision while the patient was installed in a supine position. There was a huge tense heterogeneous mass originating from the right ovary not adherent to the surrounding viscera. Marked ascites was present. The mass removed intact, with ipsilateral Fallopian tube stretched and adhered to its surface, by right salpingo-oophorectomy. Then, total hysterectomy with left salpingo-oophorectomy was performed due to the high possibility of malignancy in this age. The removed mass measured 52 × 41 × 36 cm and weighted 20.7 kg [Figure 2].
|Figure 2: Huge right ovarian mass weighted 20.7 kg has been removed intact|
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Histopathological examination revealed the presence of cystic areas lined by a single layer of mucinous epithelium and solid areas consisting of fibrovascular tissues with well-defined nests of urothelial epithelium with nuclear grooving. No cellular atypia was observed. This picture was diagnostic of benign Brenner's tumor associated with mucinous cystadenoma [Figure 3]. Uterus and the other ovary were normal.
|Figure 3: Light microscopy examination showing cystic areas lined by a single layer of mucinous epithelium and solid areas consist of fibrovascular tissue with well-defined nests of urothelial epithelium with nuclear grooving|
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Postoperative follow-up was uneventful and the patient was discharged on the seventh postoperative day.
| > Discussion|| |
Giant ovarian masses are extremely rare. A majority of them are benign as malignancy is rarely to be asymptomatic before attaining a huge size. 
Brenner's tumor is a rare epithelial tumor, which represents about 1-2% of all ovarian tumors and mostly in postmenopausal women.  Grossly, it is a solid tumor with grayish cut surface surrounded by a thick fibrous capsule and may contain some areas of cystic degeneration. Microscopically, it is composed of transitional cell epithelium enclosed in a fibrous stroma. It is benign, but in about 3-5%, it may be borderline or malignant.
These tumors have also been reported to occur in extra-ovarian sites like the myometrium.  They are usually about 2 cm in diameter, asymptomatic and can be discovered accidentally during abdominal exploration for any other diseases. 
Although it is commonly small, it may reach a huge size if it is malignant or associated with other benign ovarian tumors such as mucinous cystadenoma. 
In our case, Brenner's tumor was associated with mucinous cystadenoma. As reported, such finding is present in about 10% of Brenner's tumors.  Our patient was too late in seeking medical advice, because of that, she remained asymptomatic for a long time until the abdominal pain started and became progressive so the mass reached such huge size.
Delay in seeking medical care is common in our locality due to poverty, illiteracy, living in discrete rural areas with difficult transportation and family problems. Globally, ovarian masses rarely reach huge sizes due to improvement of medical care and imaging modalities. In spite of that, many cases were reported with huge-sized ovarian mucinous cystadenoma. ,
The swelling can be unnoticed because of extreme obesity in some patients or inattention in patients who present at a later stage with such giant masses. These huge neglected masses can mimic other medical conditions on clinical examination, such as pregnancy, massive ascites and colonic volvulus. 
Surgical management is the usual way to manage these patients. Although it is difficult to remove such huge masses intact and many complications may result from their rupture such as bleeding, peritonitis and dissemination of malignancy, we succeeded to remove the mass from our case intact without intraoperative or postoperative complications.
The usual management of Brenner's tumors in postmenopausal women is abdominal hysterectomy with bilateral salpingo-oophorectomy. This was done for our patient because of her menopausal state and the possibility of malignancy. Prognosis is usually excellent for those patients after surgery.
In conclusion, this case proves that huge asymptomatic Brenner's tumors still occur in patients. Proper histological examination of the surgically removed specimens is essential to confirm the diagnosis. No ovarian mass of such weight has been ever reported in our hospital before, and it is one of the largest ovarian masses reported in the literature in Egypt.
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[Figure 1], [Figure 2], [Figure 3]