Bilateral mature cystic teratoma of ovary: A rare case presentation

Abstract

Mature cystic teratomas are ovarian neoplasms derived from two to three germ cell layers i.e. ectoderm, mesoderm and endoderm. Ovarian teratomas are usually benign tumours of the reproductive age group. They usually have right-sided predisposition. However, only 10-20% of these neoplasms may have bilateral presentation. Here, we present a rare case of bilateral mature cystic teratoma of ovaries in a 32 years old multigravida female who presented with pain lower abdomen from one month. Ultrasonography showed bilateral solid-cystic adnexal lesions along with calcifications in the left adnexal mass. Serum level of CA-125 was within normal range. Laparoscopic bilateral oophorectomy was done along with bilateral tubal ligation. The histopathological examination confirmed the diagnosis of bilateral mature cystic teratoma of the ovaries.

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Case Report DOI: 10.18231/2394-6792.2018.0132
Indian Journal of Pathology and Oncology, October-December, 2018;5(4):692-694 692
Bilateral mature cystic teratoma of ovary: A rare case presentation
Akansha Bajaj1, Mohammad Jaseem Hassan2,*, Sabina Khan3, Nehal Ahmad4, Sujata Jetley5
1Demonstrator, Dept. of Pathology, ESI Medical College, Faridabad, Haryana, 2,3Associate Professor, 4Assistant Professor,
5Professor, Dept. of Pathology, Hamdard Institute of Medical Sciences and Research (HIMSR), Jamia Hamdard,
New Delhi, India
*Corresponding Author: Mohammad Jaseem Hassan
Email: jaseemamu@gmail.com
Received: 13th June, 2018 Accepted: 20th June, 2018
Abstract
Mature cystic teratomas are ovarian neoplasms derived from two to three germ cell layers i.e. ectoderm, mesoderm and
endoderm. Ovarian teratomas are usually benign tumours of the reproductive age group. They usually have right-sided
predisposition. However, only 10-20% of these neoplasms may have bilateral presentation. Here, we present a rare case of
bilateral mature cystic teratoma of ovaries in a 32 years old multigravida female who presented with pain lower abdomen from
one month. Ultrasonography showed bilateral solid-cystic adnexal lesions along with calcifications in the left adnexal mass.
Serum level of CA-125 was within normal range. Laparoscopic bilateral oophorectomy was done along with bilateral tubal
ligation. The histopathological examination confirmed the diagnosis of bilateral mature cystic teratoma of the ovaries.
Keywords: Benign, Cyst, Dermoid, Ovary, Teratoma.
Introduction
The term “teratoma” is derived from a Greek word
“teraton” meaning monster. The term was initially
coined and used by Virchow in the year 1863. In the
year 1831, Leblanc coined the term “dermoid cyst” for
these neoplasms. In some cases of teratomas,
Rokitansky’s protuberance can be seen. It is an area of
projection covered by skin, sebaceous glands and
sometimes bone and teeth may also be seen.
Histological sections from this area must be taken.
Dermoid neoplasms of the ovary are usually
asymptomatic tumours of the reproductive age group
females. Rarely, they can present as bilateral neoplasm
and in such cases the chances of tumour recurrence are
also increased. Here, we present a case of 32 year old
multigravida female who presented with bilateral
mature cystic teratoma of ovaries.
Case Report
A 32 year female patient presented with pain lower
abdomen for one month and pain in both the legs for
last 2 years. The patient was multigravida, para 3 and
had normal, regular menstrual cycles. Per abdomen
examination revealed soft abdomen with mild
tenderness. On per speculum examination, the cervix
was hypertrophied. On per vaginal examination, the
uterus was anteverted and a mass was felt through the
right fornix, measuring 4cm in diameter whereas the
left fornix was clear. Pap smear taken was reported as
Negative for Intraepithelial Lesions or Malignancies
(NILM). Complete blood counts, urine examination,
serum electrolytes, liver function test and renal function
tests were normal. Ultrasonography showed bilateral
solid-cystic adnexal lesions along with calcification in
the left adnexal mass. Serum level of CA-125 was
within normal range (29.2U/mL). Laparoscopic
bilateral oophorectomy was done along with bilateral
tubal ligation. Both the ovaries were sent in separately
labelled containers for histopathological evaluation.
Right ovary measured 2.5x2.3x2 cm. Left ovary was
received in 2 pieces measuring 4x3x2.6cm and
3x2.6x1cm. Grossly, both the ovaries were cystic and
on cut section lumens were filled with sebaceous
material and tufts of hair. A tooth was identified
attached to the left ovarian outer surface. [Fig 1 & 2]
Microscopic examination of both the ovaries showed
ovarian cyst walls lined by stratified squamous
epithelium, pseudostratified columnar epithelium,
adnexal structures like hair follicles, pilo-sebaceous
units, sheets of foamy macrophages along with foci of
mature cartilage and mature adipocytes. The cyst cavity
contained keratinous material. The wall showed
mononuclear inflammatory infiltrate, foreign body giant
cell reaction and large areas of haemorrhage. Thus, on
histopathological examination the diagnosis of bilateral
mature cystic teratoma of the ovaries was rendered.
[Fig. 3 & 4]
Fig. 1: Right ovary was grossly cystic and on cut
section the lumen was filled with sebaceous material
and tufts of hair

Akansha Bajaj et al. Bilateral mature cystic teratoma of ovary: A rare case presentation
Indian Journal of Pathology and Oncology, October-December, 2018;5(4):692-694 693
Fig. 2: Left ovary was grossly cystic and on cut
section lumen is filled with sebaceous material and
tufts of hair. A tooth was identified attached to the
left ovarian outer surface
Fig. 3: Microscopic examination of the Right
ovarian cyst wall show lining of stratified squamous
epithelial cells along with presence of pilo-sebaceous
unit, hair follicle and mature adipocytes. (H&E
X100)
Fig. 4: Microscopic examination of the Left ovarian
cyst wall show presence of pilo-sebaceous unit,
lining of pseudo-columnar epithelial; cells, mature
cartilage and adipocytes. (H&E X100)
Discussion
Dermoid cyst contains tissues from all the three
germ cell layers, these are ectoderm, mesoderm and
endoderm with preponderance of ectodermal tissue.
Thus, the term dermoid cyst is a misnomer. Teratomas
account for 10-20% of all the ovarian neoplasms.1 Only
10-20% of these neoplasms are bilateral.2 Teratomas are
usually benign and tumour size rarely exceeds more
than 10 cm. However, in 0.2-2% cases these neoplasms
may also undergo malignant transformation.3 They
usually contain thick sebaceous material, tufts of hair
and adnexal structures. Teeth, bone, mature cartilage,
thyroid tissue and bronchial mucosal membrane etc can
also be noticed. Teratomas are mostly noted in child
bearing age group and very rarely in adolescents
females. The lowest age of 9 years was reported in two
female patients. One of them had a unilateral mass
whereas the other had bilateral neoplasms. However,
the tumour size was less than 10cm in both these cases.
In a study, El-Agwany et al reported bilateral mature
cystic teratomas of more than 10 cm size in a 35 year
old female patient.4 Teratomas are mostly diagnosed by
ultrasonography. However, CT scan may also help
visualize the nature of neoplasm, when suspicion of
malignancy is being considered.5 Mature cystic
teratomas of ovaries are most often asymptomatic
neoplasms with an indolent course. These neoplasms
cause symptoms only rarely when they lead to pressure
symptoms resulting due to increase in tumour size or
rarely when they undergo torsion. An extremely rare
complication is rupture of the cystic neoplasm, which
may present in the form of perforation peritonitis.
Mostly cystectomy or oophorectomy are the modes of
patient management. Treatment depends on factors like
age, fertility, requirement of ovarian tissue preservation
and whether one or both the ovaries are involved.
Tumour recurrence may occur even after 1-15 years of
surgical removal. Major predictive factors for tumour
recurrence are young age, bilateral presentation and
tumour size more than 8cm. If a patient has all these
three factors the chances of tumour recurrence post
surgical removal increase by 21.6%.6,7
Conclusion
Although ovarian teratomas are common and have
an indolent course, we present this case because of its
rare bilateral presentation. Due to the increased chances
of recurrence, the patient should be advised for periodic
ultrasounds and regular check-ups in the future.
Conflict of Interest: None
References
1. Suclly RE, Young RH, Clement PB. Tumor of the ovary,
maldeveloped gonads, fallopian tube and broad ligament.
Atlas of tumor pathology. Third series, Fascile 23.
Wahington, DC: Armed Forces Institute of Pathology
1998.

Akansha Bajaj et al. Bilateral mature cystic teratoma of ovary: A rare case presentation
Indian Journal of Pathology and Oncology, October-December, 2018;5(4):692-694 694
2. Einarson JI, Edwards CL, Zurawin RK. Teratoma in
adolescence: A case report and review of literature. J
Pediatr Adolesc Gynecol. 2004;17:187-9.
3. Comerci JT Jr, Licciardi F, Bregh PA, Gregorgi C, Breen
JL. Mature Cystic Trtatoma: a clinicopathologic
evaluation of 517 cases and review of literature. Obstet
Gynecol. 1994;84:22-28.
4. El-agwany A, Moneim AA. Multiple bilateral huge
synchronous ovarian mature cytic teratomas: A rarely
encountered condition in practice. Egyption J Radiol
Nuclear Med. 2015;46:15-197.
5. Patel MD, Feldstein VA, Lipson SD, Chen DC, Filly RA.
Cystic teratoma of the ovary: diagnostic value of
sonography. AJR Am J Roentgenol. 1998;17:1061-1065.
6. Alanbay I, Coksuer H, Ercan M, Karashin E, Keskin
U. Multiple recurrent cystic teratoma of the same ovary:
Acase report and literature review. Med J Kocatepe.
2011;12:8-12.
7. Harda M, Osuga Y, Fujimoto A, Fujimoto A, Fujii T.
(2013) Predictive factors for recurrence of ovarian mature
cystic teratoma after surgical excisions. Eur J Obstet
Gynecol Reprod Biol. 2013;171:325-328.
How to cite this article: Bajaj A, Hassan M.
J, Khan S, Ahmad N, Jetley S. Bilateral
mature cystic teratoma of ovary: A rare case
presentation. Indian J Pathol Oncol.
2018;5(4):692-694.