Chen et al. BMC Pediatrics(2024) 24:525
https://doi.org/10.1186/s12887-024-05001-9

BMC Pediatrics

CASE REPORTOpen Access

Tubal mesosalpinx cysts combinedwith adnexal torsion in adolescents: a reportof two cases and review of the literature
Junzhuo Chen1, Changjun Li2, He Zhang3, Dongqi Li2 and Wei Wang1*
Abstract
Background Tubal mesosalpinx cysts are paratubal cysts, that account for approximately 10% of adnexal masses,
and the presence of these cysts combined with adnexal torsion is a rare acute abdominal condition, with few cases
reported in the literature. We reported two cases of adolescent tubal mesosalpinx cysts combined with adnexal
torsion and reviewed the literature to help improve the diagnosis of the disease.
Case reports The first patient was an 11-year-old girl with left lower abdominal pain for 5 days and fever with nausea
and vomiting for 3 days, who was found to have a cystic pelvic mass on preoperative imaging and was diagnosed
intraoperatively and postoperatively on pathology as having a left tubal mesosalpinx cyst combined with adnexal
torsion. The second patient was a 13-year-old girl with right lower abdominal pain for 16 h and a palpable mass in thelower and middle abdomen on examination, which was hard and tender to palpate. Preoperative imaging revealeda large cystic mass in the right adnexal region, and intraoperative and postoperative pathology revealed a right tubal
mesosalpinx cyst combined with adnexal torsion.
Conclusions Tubal mesosalpinx cysts combined with adnexal torsion are rare causes of acute lower abdominal pain.
Early diagnosis and timely surgery are necessary to ensure ovarian and tubal function. Accurate preoperative imaging
diagnosis is challenging, and MRI is a beneficial supplement to ultrasound and CT examinations, providing moreobjective imaging information and reducing the incidence of adverse outcomes.
Keywords Tubal mesosalpinx cysts, Paratubal cysts, Adnexal torsion, Adolescent*Correspondence:
Wei Wang
mtcz_2009@mail.ccmu.edu.cn
1
Department of Radiology, Beijing Youan Hospital, Capital Medical
University, No. 8 Xitoutiao, Youanmen Street, Fengtai District,
Beijing 100069, China
2
Department of Radiology, Linzhou People’s Hospital, Linzhou, China
3
Department of Gynecology, Henan Provincial People’s Hospital,
Zhengzhou, China

Background
Tubal mesosalpinx cysts are paratubal cysts, that mostly
occur in women of childbearing age and are rare in children and adolescent women [1]. It may lead to acutecomplications, such as rare adnexal torsion, which ismore difficult to diagnose preoperatively. Adnexal torsion is the twisting of the adnexa around the infundibulopelvic ligament and the ovarian ligament. It is one of
the gynecological acute abdominal conditions [2, 3].
Adnexal torsion carries certain risks to future fertility,
so early diagnosis and immediate intervention are necessary to ensure ovarian and tubal function in young© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation
or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://
creativecommons.org/licenses/by-nc-nd/4.0/.

Chen et al. BMC Pediatrics(2024) 24:525

female patients with adnexal torsion. However, due tothe lack of specificity of its clinical manifestations, preoperative diagnosis of this disease is extremely difficultand it is often misdiagnosed, leading to delayed treatment [4]. We reported two cases of adolescent girls who
were diagnosed with tubal mesosalpinx cysts combinedwith adnexal torsion and reviewed the literature to help
improve the diagnosis of the disease.

Case reports
Case 1

An 11-year-old girl was admitted to the hospital with“left lower abdominal pain for 5 days and fever with nausea and vomiting for 3 days”. On physical examination,
the abdomen appeared flat, the abdominal wall was soft,and there was tenderness and rebound pain in the left
lower abdomen. Laboratory examination revealed a leukocyte count of 1.8 × 104/L with no other abnormalities.
The adolescent had her menarche half a month ago andexperienced no menstrual pain.
Ultrasound revealed a cystic echo approximately
6.88cmx5.03 cm in the left adnexal region, with clear
borders and regular morphology, and an enlarged andtwisted ovary in front of the lesion on the same side,which is closely related to the cystic lesion, and the “ovarian crescent sign” [5] can be seen. CDFI showed no bloodflow signal(Fig. 1a). CT revealed a cystic lesion on the left
side of the pelvis, measuring approximately 6.80 cm x
5.07 cm with a CT value of roughly 10 HU (Fig. 1b and c).
On MRI, the lesion displayed a low signal on T1WI anda high signal on T2WI. The boundary between the lesion
and the left ovary was unclear. The left ovary exhibitedswollen morphology and uneven density. The uterus
showed external compressive changes and had a clear
boundary with the cystic lesion (Fig. 1d).
Surgery: Laparoscopic surgery was performed undergeneral anesthesia. Intraoperatively, two trocars areplaced lateral to the left rectus abdomins muscles, 2 cm
above and 2 cm medial to the anterior superior iliac
spine, respectively. Then, another trocar was placed at
the right reverse McBurney’s point. It was found that theleft adnexa was significantly enlarged with purplish-blueischemic changes, and a cyst with a diameter of approximately 8 cm was observed in the left tubal tract area.
The left fallopian tube and ovary twisted 2 turns along
the infundibulopelvic ligament (Fig. 2a and b). We repositioned the left adnexa, restored its blood supply. The
ovary and the cyst were completely separated, and thecyst was completely stripped.
Postoperative pathological microscopic findings: The
specimen exhibited cystic wall-like tissue without clear
overlying epithelium and significant hemorrhage within
the wall, consistent with a cyst (Fig. 2c).

Page 2 of 7

Case 2

A 13-year-old girl was admitted to the hospital with acomplaint of “16 hours of pain in the lower right abdomen.” On physical examination, there was tenderness andrebound pain in the lower right abdomen, along with thedetection of a mass measuring approximately 15.00 cm
x 12.00 cm in the middle and lower abdomen. The mass
exhibited a hard texture, tenderness, and mobility. The
adolescent had her menarche one year ago and experienced no menstrual pain.
Ultrasound revealed a large cystic mass measuring
approximately 16.00 cm x 10.00 cm in the right adnexal
region, which was well demarcated from the ovary, andthe ovarian crescent sign was visible. Torsion of the ovary
secondary to pulling by the lesion. An enlarged ischemic
right ovary measuring approximately 8.40 cm x 3.80 cm
was detected next to the twisted tip, with no clear bloodflow signal.
CT revealed a giant cystic occupancy on the rightside of the pelvis, measuring approximately 16.50 cm x
11.84 cm. The fluid in the capsule was uniform in density, with a CT value of approximately 4 HU, and the wallof the capsule was slightly hyperdense. Its upper border
extended to the lower border of the liver, and its lower
border adjoined the right ovary and the right horn of
the uterus. The uterus was shifted to the right side. The
boundary between the cyst and the ovary was still clear,and there was a close local relationship. In addition, it
can be observed that the right fallopian tube has thickened and twisted (Fig. 3a and b, and 3c).
Surgery: Laparoscopic surgery was performed undergeneral anesthesia. Intraoperatively, the pneumoperitoneum was first estalished. Two trocars were placed lateral
to the left rectus abdomins muscles, 2 cm above and 2 cm
medial to the anterior superior iliac spine, respectively.
A drainage needle was used to extract some of the cystic
fluid to reduce the volume of the cyst and facilitate subsequent operations. Then, another trocar was placed at
the right reverse McBurney’s point. Laparoscopy showed
the cyst originated from the right tubal mesosalpinx,
approximately 16 cm in diameter. The cyst, together withthe right adnexa, was twisted for 2 turns along the infundibulopelvic ligament. The right ovary was ischemic andswollen, with a purplish-blue color, and the right adnexa
was reset to restore its blood supply. The ovary and thecyst were completely separated. Then, the cyst was completely stripped away.
Postoperative pathological microscopic findings: The
specimen showed a fibrous tissue capsule wall, lined withcolumnar epithelium, vascular dilatation and congestion,and plasma exudation in the capsule (Fig. 3d).

Chen et al. BMC Pediatrics(2024) 24:525

Page 3 of 7

Fig. 1 Imaging examination. (a) Ultrasound revealed a cystic echo (short arrow), poorly demarcated from the left ovary (slender arrow). (b and c) CT
showed a round-like cystic lesion (short arrow) closely related to the left ovary (slender arrow), and the uterus (yellow arrow) showed extrinsic compressive changes. (d) The MRI sagittal view showed a round-like high signal (short arrow), and the lesion was poorly demarcated from the left ovary (slender
arrow)

Discussion
Tubal mesosalpinx cysts are independent of the fallopian
tubes and ovaries. They originate from the broad ligament between the fallopian tube and the ovary and areeasily confused with cystic masses originating from theovary. They are histologically derived mainly from mesonephric duct remnant tissue, and their pathologic types
include paratubal cysts, mesonephric duct cysts, andmesothelial cysts [6, 7].

Most tubal mesosalpinx cysts are small in size and haveno obvious clinical symptoms. Painful symptoms occur
only when the cyst becomes larger and compresses theabdominal organs and tissues, but complications such as
hemorrhage, torsion, or rupture are also rare [6]. Whenthe diameter of the cyst is larger than 5 cm, the weight ofthe distal end of the fallopian tube increases, and the center of gravity changes, which may lead to torsion of themesangial root and/or ovary [8, 9]. Blockage of the blood

Chen et al. BMC Pediatrics(2024) 24:525

Page 4 of 7

Fig. 2 Operative findings during laparoscopy and postoperative pathological microscopic findings. (a and b) The left ovary appeared enlarged andpurplish-blue (black arrow). The left fallopian tube (slender arrow) and ovary (black arrow) twisted 2 turns along the pelvic funnel ligament. A mesentericcyst (short arrow) was observed adjacent to the left fallopian tube. (c) Postoperative pathological microscopic findings

Fig. 3 (a)The CT coronal view showed a large cystic mass (slender arrow) in the pelvis, whose upper border reached the inferior border of the liver. (b)The
lower border of the large mass (slender arrow) pulled the right ovary (short arrow) and the right horn of the uterus (bold arrow). (c)The CT sagittal view
showed the lower edge of the large mass (slender arrow) pulled the ovary (short arrow), causing it to deform and shift. (d) Postoperative pathologicalmicroscopic findings

supply artery can cause venous reflux obstruction, and insevere cases, it may cause ischemic necrosis of the ipsilateral fallopian tubes and ovaries [3]. Tubal mesosalpinx
cysts in adolescent females and pregnant women tend toincrease suddenly in size. It has been suggested that it
may be due to the elevated hormone levels in adolescentfemales and pregnant women, which cause increased
secretion of epithelial cells within the cysts. Therefore,

Chen et al. BMC Pediatrics(2024) 24:525

the accumulation of secretions within the cyst leads toan increase in its volume, and it easily merges with theself-torsion or accessory torsion of the cyst [10, 11]. In
this paper, both girls experienced tubal mesosalpinx cystswith adnexal torsion shortly after menarche, which may
also be related to increased hormone levels leading tocyst enlargement, consistent with the above literature.
Tubal mesosalpinx cysts are mostly benign, while junctional or malignant cysts are rare. They usually present as
unilocular cystic lesions with thin smooth walls. If there
is a papillary protrusion inside the cyst that is larger than
5 cm, the risk of malignancy increases [6, 12].
The fact that it is challenging to diagnose paratubal andparovarian cysts. Multiple studies have shown that only
30–44% of paratubal tube cysts are accurately diagnosed
preoperatively [3, 13, 14]. Ultrasound is the preferredexamination for detecting adnexal masses. If torsion issuspected, a color Doppler examination should be added[13]. Tubal mesosalpinx cysts are often located on one
side of the adnexal region or next to the uterorectal fossa.
When the cyst is larger, it may be located in the anterior
upper part of one side of the uterus, appearing circularor elliptical. The wall of the capsule is mostly thin andsmooth, and the capsule is characterized by anechoic liquid dark areas. There may be divisions within the cystic
mass, and when combined with bleeding, weak echoesof small light spots can be observed inside the cyst, evenpresenting as a cystic solid or as a fluid-filled plane. If
combined with tubal torsion, a thickened, twisted, andlocally dilated anechoic tubular structure can be seen
next to the cyst, and the torsion may display a “vortexsign”. The dilated tubes are located on the inner side of
the affected ovary and gradually become thinner towards
both ends, forming " beak signs” [3, 6, 15, 16]. If further
ovarian torsion occurs, it will manifest as significant
enlargement of the affected ovary, enhanced or reduced
echogenicity, and disappearance of blood flow signals
within the ovary. It should be noted that the presenceof blood flow signals in the ovary does not exclude thepossibility of torsion [13]. However, when the boundary
between the mesosalpinx cyst and surrounding tissues
is unclear, ultrasound is prone to missing diagnosis. The“ovarian crescent sign(OCS)” is a marker used in ultrasound to identify the nature of adnexal masses. Thisphenomenon is that normal ovarian tissue can be seen
next to the adnexal mass, which is of great value for preoperative differentiation of benign or malignant adnexal
masses. It can help to exclude invasive ovarian malignant tumors to some extent [5, 17, 18]. We reviewed
the ultrasound images of two patients in this study andfound the presence of OCS. Unfortunately, the primary
diagnosis doctor, due to the lack of experience and specialized training on how to evaluate OCS, did not accurately identify this sign. In the second case, ultrasoundPage 5 of 7

revealed a large cystic mass in the right adnexal region
pulling the ovary secondary to torsion, and an enlarged
ischemic right ovary was detected next to the torsion tip.
This patient was diagnosed by ultrasound with concomitant accessory torsion.
CT manifestations of mesosalpinx cysts are mainly
circular or quasi-circular cystic masses near the uterus,
with a few resembling sausages or serpentine cystic
shadows. Cysts are often solitary and thin-walled withsmooth margins and localized thickening of the cyst wallon enhancement scans. The capsule has a homogeneous
water density with no enhancement; the density may
increase when infection or bleeding occurs. The typical sign of tubal mesosalpinx cysts is the " holding ball”
sign of the broad ligament of the uterus. When the cyst islarge, it can compress and displace the abdominal organs.
The larger the cyst, the more prone it is to pedicle torsion
and rotation around the vascular pedicle axis. The mostdirect sign is the thickening and twisting of the fallopian
tubes. Multiplanar reconstruction is particularly helpful for assessing the relative positions of the ovary anduterus, with the uterus typically pulled toward the side of
torsion [3, 6, 19]. In addition, CT can help rule out othercauses of lower abdominal pain, such as appendicitis[13]. In this report, both CT scans revealed cystic masses
in the pelvic cavity, but the origin of the masses was difficult to determine and it was difficult to distinguish on
imaging whether the masses originated from the ovary,
fallopian tubes, or mesosalpinx.
MRI, with its advantages of high soft-tissue resolution,and multidirectional and multisequence imaging, candetect smaller lesions that are insensitive to ultrasoundand can initially determine the benign or malignant
nature of the lesions. Tubal mesosalpinx cysts on MRI
mainly appear as round or round-like cystic lesions witha watery signal that is low on T1WI and high on T2WI.
After enhanced scanning, the cyst wall shows enhancement, but there is no enhancement inside the cyst [20].
Compared with ultrasound and CT, MRI can moreclearly display signs such as dilated tubes, beak signs, andtwisted pedicles [8]. Especially if the patient is obese andthe cyst is large, it is difficult for the ultrasound to determine its position relative to the ovary. In this case, MRI
compensates for the shortcomings of ultrasound witha larger field of view showing the location of the cyst to
the ovary, and it is also easier to show the relative positions of the uterus and ovary, with the uterus shifted tothe side of the abnormality in the event of torsion [3,21]. Moreover, if there is no enhancement of the ovaryon MRI enhancement scans, it is strongly suspected thattorsion has caused ischemic necrosis of the ovary. In thefirst patient of this report, preoperative MRI revealed theenlarged ovary and upward flipping of the adnexa, which
ultrasound failed to clearly show. MR can compensate forChen et al. BMC Pediatrics(2024) 24:525

missed ultrasound findings. Unfortunately, the second
patient did not undergo MR examination.
The main imaging features of adnexal torsion include
twisted and thickened fallopian tubes, accompanied by
ovarian enlargement and displacement, and pulling of
the uterus to move towards the affected ovary side [3,22, 23]. In this paper, the preoperative MRI of the firstcase showed enlarged ovaries with upward flipping of
the adnexa. The second case showed the thickened andtwisted fallopian tube. The lower edge of the large cyst
pulled the ovary and the right horn of the uterus, causing deformation and displacement of the ovary, and pulling the uterus towards the twisted side. Both cases inthis paper were adnexal torsion due to tubal mesosalpinx
cysts, with the tubal thickening and torsion being more
pronounced.
Diseases predisposing to adnexal torsion includehydrosalpinx, paratubal cysts, ovarian teratomas, andcysts [8, 13]. Preoperative imaging to identify ovarian andtubal mesosalpinx cysts is challenging. When complications such as torsion or rupture occur, a clear diagnosis
is rare before surgery, and surgery and pathology are
required to make a clear diagnosis. In addition, the torsion of the hematosalpinx in patients with Mayer-Rokitanskt-Kuster-Hauser (MRKH) Syndrome is rare but still
possible [24]. Therefore, adolescents with adnexal torsion
should be aware of the presence of MRKH syndrome.

Conclusion
Tubal mesosalpinx cysts combined with adnexal torsion
are rare acute abdominal conditions, and improving theaccuracy of preoperative imaging diagnosis is crucial.
MRI, as a supplement to ultrasound and CT, provides abroader field of view and effective information, aiding
in comprehensive diagnosis and treatment, and reducing adverse outcomes. Imaging examinations should betimely, convenient, and precise, facilitating rapid diagnosis and guiding treatment to avoid delays. Nonetheless,laparoscopic exploration remains the gold standard for
diagnosis and treatment. Immediate surgery can prevent
damage to the ovaries and fallopian tubes, preserving
reproductive function.
Author contributions
J.C. contributed to the investigation, data curation, and writing the originaldraft; C.L. contributed to preparing and image analysis; H.Z. contributed
to surgical management and revising the work; D.L. contributed tothe investigation and data curation; and W.W. contributed to theconceptualization, methodology, validation, reviewing and editing the article,
and project administration. All the authors read and approved the final versionof the manuscript.
Funding
No funding.
Data availability
Data is provided within the manuscript.

Page 6 of 7

Declarations
Ethics approval and consent to participate
This is not applicable, as this is a case report.
Consent for publication
Informed consent was obtained from the patient’s parents for publication ofclinical information and photographs. The parents of the two patients havesigned the written informed consent forms.
Competing interests
The authors declare no competing interests.
Received: 7 May 2024 / Accepted: 8 August 2024

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