(47) Giant Mucinous Cystadenoma in a Young Transgender Man: Case Report

Background: Mucinous cystadenomas are among the most common ovarian neoplasms in child and adolescent patients, but giant ovarian cysts measuring >15cm remain rare. To date, no cases have been reported among transmasculine patients on hormone replacement therapy with testosterone. This case aims to provide insight on the preoperative and intra-operative considerations in this patient population.

Case: This 19-year-old transgender patient presented for gender-affirming mastectomy but was referred preoperatively to the emergency department for evaluation of new, rapid-onset abdominal distention. Imaging showed a 17 x 26 x 36cm septated, cystic pelvic mass suspected to be of ovarian origin. Serum tumor markers were normal, and a benign pelvic mass was suspected. Gender affirming hysterectomy and bilateral salpingo-oophorectomy were discussed pre-operatively, and the patient ultimately decided to preserve future fertility yet was amenable to staging for oncologic benefit in the event a malignancy was identified.

Exploratory laparotomy was initiated with a 4cm midline vertical incision and the cystic mass was encountered upon peritoneal entry. A controlled drainage was attempted via needle aspiration following the application of skin glue, wound protector and retention suture (Figure 1). Given concern for minimal spillage of cyst contents intra-operatively, as well as difficulty accessing the multiple loculations within the large mass, the incision was ultimately extended to 10cm and the mass was decompressed via suction to a volume of 7850mL.

The cyst was externalized (Figure 2) and found to originate from the left ovary, while the right adnexa were normal in appearance. A unilateral salpingo-oophorectomy was performed, and pathology was suspected to be benign on frozen section. The final pathology confirmed benign mucinous cystadenoma with associated mural granulation tissue and an endometriotic cyst. Cytologic analysis of peritoneal washings was negative for malignancy.

Comments: Large cystic ovarian tumors with loculated morphology require special surgical considerations. While minimally invasive approaches are generally preferred, we advise a modest approach to drainage unless imaging is unequivocal. We recommend shared preoperative decision-making that addresses the risk of borderline and malignant pathology, as well as the transgender patient’s goals for gender affirmation and future fertility. For patients undergoing surgery that will delay other gender-affirming care, it is imperative to provide clear communication about how surgical management may affect time to care.