CA S E R E PO R T
Teratomas are germ cell tumours commonly composed of
multiple cell types derived from one or more of the three
germ layers. Teratomas range from benign, well-differentiated
(mature) cystic lesions to those that are solid and malignant
(immature) (1). Arising from totipotential cells, they can be
gonadal or extra gonadal tumours occurring in midline or
paraxial. The most common location is sacrococcygeal but also
commonly encountered in ovary. Cystic teratomas arising from
the sequestered embryonic cell rest are less frequent and seen in
mediastinal, retroperitoneal, cervical, and intracranial (2). We
report a rare case of 28 years old asymptomatic lady diagnosed
incidentally during health check up, harbouring synchronous
mature cystic teratomas in her ovary and mediastinum (3).
A 28 years old newly married lady during her routine medical
health check up before leaving to Middle east was found to have
right paracardiac shadow in her chest X-ray (Figure 1). She had no
complains of breathlessness, abdominal pain, nausea, vomiting,
loss of appetite or weight and bowel/bladder disturbances. She
Double whammy - mediastinal and ovarian teratoma: a rare clinical
Leo Francis Tauro, Prathvi Shetty, Aruna Kamath, Ashok Shetty
Father Muller Medical Collage and Hospital, Mangalore, Karnataka, India
Teratomas are germ cell tumours arising as the result of abnormal development of totipotential cells. They are commonly
encountered in the gonads and occasionally found in mediastinum. We report a case of asymptomatic 28 years old lady
with concomitant mature cystic teratoma in her mediastinum and left ovary which was diagnosed incidentally during health
check up. This case is reported because of its rare and unusual coexistence.
Mediastinal tumour; ovarian tumour; teratoma; cystic tumour
J Thorac Dis 2012;4(4):434-436. DOI: 10.3978/j.issn.2072-1439.2012.03.09
Corresponding to: Prathvi Shetty, MS. Department of Surgery, Father Muller Medical
Collage and Hospital, Kankanady, Mangalore 575002, Karnataka, India. Tel: +91-824-
2238297; Fax: 0824- 2437402/2436352. Email: firstname.lastname@example.org.
Submitted Dec 13, 2011. Accepted for publication Feb 23, 2012.
Available at www.jthoracdis.com
© Pioneer Bioscience Publishing Company. All rights reserved.
had regular menstrual cycle. A physical examination revealed a
firm mobile non tender swelling in the hypo gastric region.
Ultrasound (USG) abdomen showed large encapsulated
cystic mass lesion measuring approximately 22 cm × 20 cm ×
10 cm seen in the pelvis and extending in to the abdomen. Her
blood parameters were within normal limits so was her Alfa-feto
protein (AFP), CA 125 and Beta-human chorionic gonadotropin
(b-HCG) values. Further evaluating, Computerised Tomography
of chest and abdomen (Figure 2A,2B) revealed a well
encapsulated solid-cystic mass lesion 9 cm × 6.5 cm × 6.6 cm in
the anterior mediastinum in the right paracardiac region with
smooth thick wall and area of focal calcification. The contents of
the cystic lesion are hetrogenous with predominant fat density
with no signs of chest wall or pericardial invasion suggesting of
mediastinal mature teratoma and large heterogeneous, sharply
marginated cystic lesion arising from the left ovary.
She underwent left oopherectomy with right thoracotomy with
a gap of 3 weeks between the surgery. On thoracotomy a large
paracardiac mass extending from thymus up to diaphragm, adherent
to pericardium, right lung was found. Tumour was excised in total.
Both lesion on histopathological examination (Figure
3A,3B) was found to be a mature cystic teratoma. Patient had an
uneventful post operative period recovery. On 6 month follow up
she is asymptomatic.
Teratomas commonly are classified using the Gonzales - crussi
grading system, regardless of location in the body with 0 for benign
(Mature) and 3 frankly malignant (Immature). This indicates
whether chemotherapy or radiation therapy may be needed in
Journal of Thoracic Disease, Vol 4, No 4 August 2012
addition to surgery. They are classified as mature or immature on
the basis of the presence of immature neuroectodermal elements
within the tumor. The more immature elements within the tumour
the more chances of them being malignant (4).
The anatomic distribution of the tumours along the lines of
migration of the primordial germ cells from the yolk sac to the
primitive gonads supports the parthenogenic theory hence they
occur both in gonadal and extra gonadal location (1).
Sacrococcygeal teratomas are most common and seen
in newborns. Mature cystic ovarian teratoma are also quite
common nearly forming 20% of ovarian neoplasm usually seen in
second and third decade of life while testicular benign teratomas
are quite rare (5,6). The same can be said of mediastinal tumours
which are rare representing 8% of all tumours of this region
occurring most commonly in adults aged 20-40 years (7).
AFP and B HCG are usually within reference range in benign
teratomas and elevated levels may be indicative of malignancy.
Work up for cystic teratomas is largely radiographic and their
appearance is similar despite varying locations. USG findings
show regionally bright echos, hyper echoic lines and flat lines.
CT usually reveals complex appearance with dividing septas,
internal debris, fat attenuation and distinct calcification, as was in
our case which leads to the diagnosis of benign mature teratoma
of mediastinum and ovary (8). MRI can sufficiently differentiate
lipid from other fluids also useful adjunct for diagnosis. These
tests helped us differentiate it from ectopic pregnancy, benign
Figure 2. A. CT scan Axial view of chest at level of cardia showing a well defined cystic mass in right para cardia with smooth thick wall and area of
focal calcification. The cystic content are heterogeneous with predominant fat density; B. Coronal section CT scan showing large cystic lesion in pelvis
and lower abdomen and mass lesion in the mediastinum.
Figure 1. Chest X-ray showing right para cardiac shadow.
Tauro et al. Co-existence of mediastinal and ovarian teratoma
Cite this article as: Tauro LF, Shetty P, Kamath A, Shetty
A. Double whammy-mediastinal and ovarian teratoma:
a rare clinical co-existence. J Thorac Dis 2012;4(4):434-
436. DOI: 10.3978/j.issn.2072-1439.2012.03.09
Figure 3. A. Microphotograph of mature teratoma showing stratified squamous epithelium, dermal adnexal structures, adipose tissue and blood
vessels. [Haematoxylin & Eosin stain ×5X]; B. Another foci of the same displaying nodules of immature cartilaginous tissue, glandular tissue,
adipocytes and fibrocollagenous tissue. [Haematoxylin & Eosin stain ×5X].
or malignant lesion of ovary, ovarian cyst and mediastinal cyst,
neurogenic tumours of the mediastinum.
Mature cystic teratomas of the ovary are often discovered as
incidental findings on physical examination, during radiographic
studies, or during abdominal surgery performed for other
indications. Asymptomatic mature cystic teratomas of the ovaries
have been reported at rates of 6-65% in various series. When
symptoms are present, they may include abdominal pain, mass
or swelling, and abnormal uterine bleeding. Bladder symptoms,
gastrointestinal disturbances, and back pain are less frequent.
Complications of ovarian teratomas include torsion, rupture,
infection, hemolytic anemia, and malignant degeneration. These
mature teratomas are removed by simple cystectomy and in
its entirety. If immature elements are found the patient should
undergo a standard staging procedure (5,6).
Mediastinal teratomas are also often asymptomatic occasionally
discovered incidentally on chest radiograph (9), as had happen in
our case. When symptoms are present, they relate to mechanical
effects including chest pain, cough, dyspnea, or symptoms related
to recurrent pneumonitis. They are cured by surgical resection
alone as they do not have the metastatic potential as observed in
gonadal teratoma (9,10). Complete resection results in long term
cure with little chance of recurrence.
Disclosure: The authors declare that they have no conflicts of interest
with respect to the authorship and/or publication of this article.
1. Kumar V, Abbas AK, Fausto N. Robbins and cotran pathologic basis of
disease. 7th ed. Philadelphia: Elsevier Saunders;2005.
Comerci JT Jr, Licciardi F, Bergh PA, et al. Mature cystic teratoma: a
clinicopathologic evaluation of 517 cases and review of the literature.
Obstet Gynecol 1994;84:22-8.
Driss M, Limaiem F, Mrad K, et al. Malignant degeneration of benign
cystic teratoma of the ovary with synchronous mediastinal teratoma. A case
report. Rev Med Interne 2009;30:369-71.
Gonzalez-Crussi F. Extragonadal Teratomas. In: Atlas of Tumor Pathology,
Second Series, Fascicle 18. Washington, DC: Armed Forces Institute of
Stany MP, Hamilton CA. Benign disorders of the ovary. Obstet Gynecol
Clin North Am 2008;35:271-84.
Templeman CL, Fallat ME, Lam AM, et al. Managing mature cystic
teratomas of the ovary. Obstet Gynecol Surv 2000;55:738-45.
Lewis BD, Hurt RD, Payne WS, et al. Benign teratomas of the mediastinum.
J Thorac Cardiovasc Surg 1983;86:727-31.
Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumor types and
imaging characteristics. Radiographics 2001;21:475-90.
Moran CA, Suster S. Primary germ cell tumors of the mediastinum: I.
Analysis of 322 cases with special emphasis on teratomatous lesions and
a proposal for histopathologic classification and clinical staging. Cancer
10. Dulmet EM, Macchiarini P, Suc B, et al. Germ cell tumors of the
mediastinum. A 30-year experience. Cancer 1993;72:1894-901.