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Struma Ovarii Mimeting Malignant Ovarian Tumor in Preoperative Examinations
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BACKGROUND Struma ovarii is a rare ovarian teratoma with non-specific clinical presentation that can mimic malignancy, especially when combined with the presence of ascites. Since the surgical procedures performed for benign and malignant tumors are quite different, pre-operative differential diagnosis is key. In this case report we compare the levels of biomarkers CA 125 and HE4 in the differential diagnosis of a suspicious ovarian tumor. CASE REPORT A 75-year-old woman with a palpable mass at the left adnexa, ascites, and high levels of CA 125, underwent a subtotal abdominal hysterectomy and bilateral salpingo-oophorectomy. Histology reported benign struma ovarii. CONCLUSIONS Even though transvaginal ultrasound and CA 125 levels suggested malignancy, HE4 measurements correctly diagnosed benignity.
Background
The present of malignant transformation in struma ovarii is exceedingly rare. Malignant struma ovarii is usually asymptomatic and infrequently diagnosed preoperatively. Because of its rarity, there is no consensus about diagnosis and management in the literature.
Case presentation
A 40-year-old female presented for her obstetric examination with an incidental finding of a pelvic mass. Patient was asymptomatic at presentation. A follow-up ultrasound confirmed the presence of a 3-cm mass in the left adnexa. Patient underwent a cytoreductive surgery (hysterectomy, bilateral salpingectomy and oophorectomy, omentectomy, appendectomy, and pelvic lymphadenectomy). Histopathology revealed a malignant struma ovarii with a focus of papillary thyroid carcinoma and the omentum metastasis. The patient with stage FIGO IIIc received 6 cycles of paclitaxel/carboplatin regimen after surgery. The patient subsequently had a thyroid scan that was normal with normal thyroid function. At a follow-up of 12 months, she is alive, in good clinical condition, and disease-free.
Conclusions
Because of the rarity of these tumors and their lack of firm prognostic factors, treatment decisions should be made individually, based on pathologic and clinical parameters.
To evaluate the clinical characteristics of struma ovarii.
Twenty-five cases of struma ovarii were reviewed retrospectively from June 1994 to April 2007. The presenting clinical, radiologic, and pathologic features of the patients were reviewed.
The mean age of the patients in this study was 45.3 years. The majority was of premenopausal status. Sixteen patients had clinical symptoms such as low abdominal pain, palpable abdominal mass and vaginal bleeding. Although one patient had an abnormal thyroid function test, the laboratory findings normalized after operative treatment. CA-125 levels were elevated in 6 cases. Diagnosis by preoperative imaging studies were 8 dermoid cysts, while only 3 cases were diagnosed as struma ovarii. There were 4 cases of malignant struma ovarii, and no patients with recurrent disease.
Struma ovarii is a rare tumor. The presented clinical, laboratory and radiological findings of patients are very diverse. The diagnosis was confirmed by pathologic findings. The treatment of benign struma ovarii is surgical resection only. The cases of malignant struma ovarii may need adjuvant treatment, but recurrence is uncommon.
Struma ovarii represents about 1.0% of all ovarian tumours. While management involves surgery, there is a paucity of data regarding the extent and approach of surgery, and postoperative management. This study aimed to delineate the management of struma ovarii, its associated complications, and postoperative follow-up and investigations.
We retrospectively reviewed cases of benign struma ovarii treated at KK Women's and Children's Hospital, Singapore, between January 2000 and May 2011.
A total of 68 patients underwent surgical removal of ovarian cyst or mass (24 cystectomy, 20 salpingo-oopherectomy and 24 total hysterectomy and bilateral salpingo-oopherectomy). Of the 68 surgeries, 39 (57.4%) included intraoperative frozen section sampling or procedures for staging of ovarian malignancy. The majority (73.5%) of surgeries were laparotomies. Histology revealed benign struma ovarii in all (98.5%) but one patient. Only 7 (10.3%) patients had postoperative complications - 3 wound-related, 2 thyroid-related, 1 incisional hernia and 1 nonspecific. The mean length of hospital stay was 4.2 days. During follow-up, 45 (66.2%) patients required no additional investigations. The most common investigation done was ultrasonography (n = 18, 26.5%). While no recurrences were diagnosed histologically, two patients were subsequently found to have complex/dermoid ovarian cysts on the ipsilateral side of the previous struma ovarii on ultrasonography.
Simple surgery is recommended for patients with struma ovarii, especially if they have fertility potential. Laparoscopic surgery is the recommended approach due to its shorter recovery time and lower morbidity. Most patients do not require extended periods of follow-up or postoperative investigations.
We describe clinicopathologic features, laboratory data, and imaging and therapeutic management of a rare case of Hashimoto thyroiditis arising in struma ovarii. The patient was a 38-year-old woman with clinical symptoms of hyperthyroidism. Laboratory data showed elevated levels of total and free thyroxine, low thyrotropin level, and positive specific antithyroid antibodies without ultrasound evidence of morphologic abnormalities of the thyroid gland. Pelvic ultrasonography and magnetic resonance imaging of the abdomen showed bilateral solid ovarian masses containing cystic and fat areas diagnostic of teratoma. The performance of a 131I whole-body scan demonstrated a focus of intense uptake in the pelvis with minimal residual thyroid gland. The patient had a bilateral oophorectomy, and histologic examination revealed thyroid tissue in both masses with all the features of Hashimoto thyroiditis in the right ovary. Symptoms of hyperthyroidism diminished after the surgery, and the thyroid hormone levels and antithyroid antibodies were in the normal range in 1 month. The present case further confirms the rare occurrence of Hashimoto thyroiditis in struma ovarii. This diagnosis should be suggested in the differential diagnosis of patients with symptoms of thyroid disease and a normal thyroid gland.
We report three cases of cystic struma ovarii not associated with any solid component. One case was a thin-walled unilocular mass, and the other two cases were multilocular cystic masses. An area of signal void on T2-weighted images and intermediate intensity on T1-weighted images was noted in the two multilocular cases. Preoperative diagnosis was difficult in each case, but struma ovarii should be included in differential diagnoses even in the case of a completely cystic ovarian mass.
Ovarian teratomas include mature cystic teratomas (dermoid cysts), immature teratomas, and monodermal teratomas (eg, struma ovarii, carcinoid tumors, neural tumors). Most mature cystic teratomas can be diagnosed at ultrasonography (US) but may have a variety of appearances, characterized by echogenic sebaceous material and calcification. At computed tomography (CT), fat attenuation within a cyst is diagnostic. At magnetic resonance (MR) imaging, the sebaceous component is specifically identified with fat-saturation techniques. The US appearances of immature teratoma are nonspecific, although the tumors are typically heterogeneous, partially solid lesions, usually with scattered calcifications. At CT and MR imaging, immature teratomas characteristically have a large, irregular solid component containing coarse calcifications. Small foci of fat help identify these tumors. The US features of struma ovarii are also nonspecific, but a heterogeneous, predominantly solid mass may be seen. On T1- and T2-weighted images, the cystic spaces demonstrate both high and low signal intensity. Familiarity with the US, CT, and MR imaging features of ovarian teratomas can aid in differentiation and diagnosis.
Struma ovarii is rare ovarian tumor that is characterized by the presence of at least 50% thyroid tissue on histologic examination. This usually benign neoplasm is predominantly found in women between the ages of 40 and 60 years and infrequently in the pediatric age group. In the foregoing report, we present an unusual case of a large struma ovarii in a 16-year-old adolescent girl with abdominal pain and increasing abdominal girth. Removal of the mass was achieved via a laparoscopic approach. We conclude that the diagnosis of struma ovarii should be considered in adolescent girls presenting with large cystic ovarian masses and that a laparoscopic approach to management is the treatment of choice.
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