Department of Surgical, General Hospital of Komotini "Sismanoglio", Komotini 69100, GreeceGreece
Department of Radiology, General Hospital of Komotini "Sismanoglio", Komotini 69100, GreeceGreece
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Cystic ovarian teratomas, also known as dermoid cysts, are the most common benign ovarian germ cell tumors. They typically occur during reproductive age. Due to the readable accessibility to ultrasonography, the finding of large cystic teratomas over 10 cm is an unusual event.
Cystic ovarian teratomas, especially mature cases (dermoid cysts), constitute 10-13% of all ovarian tumors and are the most common benign ovarian germ cell tumors.1 They are composed of well-differentiated tissues derived from three germ cell layers: endoderm, mesoderm and ectoderm. They may contain skin, hair follicle, and sweat gland, bones, nail and teeth. Dermoid cysts may be asymptomatic or present with abdominal 2,3 swelling, discomfort, and pain2,3 and typically occur during reproductive age (mean age, 27 years).4
Ovarian cysts are labelled as large when they are over 5 cm in diameter and giant voluminous when they exceed 15 cm. According to bibliography mature cystic teratomas grow slowly at a mean average rate of 1.77±3.86 each year for the premenopausal women.5 A significant point in this case is the fact that although the cyst was large, it had not developed over a long period. No cystic mass existed five years ago, on transvaginal ultrasound performed forty days after the patient’s delivery.
Ovarian teratomas can be associated with various complications, including torsion (16%), rupture (1-4%), infection (1%), and autoimmune hemolytic anemia (<1%). Malignancy reported in teratomas ranges between 1-2%.6-8
The typical imaging finding of an ovarian teratoma is a cystic mass with intratumoral fat. At ultrasound, the most common finding of an ovarian teratoma is the Rokitansky nodule, i.e. a cystic mass with a densely echogenic tubercle projecting into the cystic lumen. The Rokitansky nodule or dermoid plug is described as a protrusion arising from the inner surface of a cyst, which may contain hair, teeth and fat causing acoustic shadowing.7 Negative attenuation of this intratumoral fat at Computed Tomography (CT) and the combination of T1-weighted imaging and fat-saturated T1-weighted imaging for fat diagnosis at Mental Retardation (MR), rend these two diagnostic modalities fairly 7,10-12 straightforward.
Advanced surgical techniques have established the use of ovarian cystectomy as a safe method for tumor removal in the adult and pediatric population and as the first line of treatment in lesions that are preoperatively consistent with teratoma, i.e. without malignant characteristics in radiological and laboratory
13,14 evaluation.
Taking under consideration the patient’s age and cyst’s characteristics, cystectomy versus oophorectomy was preferred. Contrary to appearances, the thinned cortical tissue that remains after cystectomy contains numerous viable follicles which can serve for future hormonal production and oocytes for reproduction. After laparoscopic ovarian biopsy in women 11-34 years th 2 old each was found that in 1 mm2 of surface ovarian tissue contained approximately 35 primordial follicle.14 Functioning ovarian tissue on follow-up supported our surgical approach.
A mature cystic teratoma could grow at an average rate of up to 4 cm per year. Despite dimension, cystectomy should be the recommended surgical approach in women of reproductive age with negative pre-operative indications of malignancy.
The authors declare that they have no conflics of interest.
The patient has provided written permission for publication of the case details.