A rare case of extremely large mature ovarian cystic teratoma

Abstract

Mature ovarian cystic teratoma, also known as the dermoid cyst, is one of the most common benign ovarian neoplasms that can occur in different age groups and could appear in various sizes. Diagnosing this problem as soon as possible is essential due to complications that can coincide, such as torsion, rupture, internal hemorrhage and malignant transformation. In this article, we reported a 66-year-old female patient with a single huge mature ovarian cyst teratoma who presented to the surgical ward with abdominal pain and swelling but did not see any doctor during that period and disregarded her problems for 4 years.

Introduction

One of the most common benign ovarian neoplasms derived from germ cells is mature ovarian cystic teratomas, also known as dermoid cysts.^1,2 Variable proportions of tissues compose these types of cysts, which originate from the ectoderm, mesoderm and endoderm. ² Although this type of cystic disease is usually seen in the active reproductive period of women’s lives, it can be seen in any age groups, even in the postmenopausal period. ³

Due to advances in imaging techniques, especially ultrasonography, diagnosing this disease is much easier today, and finding cysts larger than 10 cm is very rare.^2,4,5 In this article, we report an extremely large but not malignant mature ovarian cystic teratoma, estimated to develop in less than 4 years, as the patient’s signs appeared for the first time 4 years ago, in a 66-year-old postmenstrual female.

Case presentation

A 66-year-old female patient presented to the surgical department with a past medical history of hypertension in the last 5 years and complained of a 2-year right lower quadrant pain and severe swelling. The pain had been vague for the first 6 months and increased gradually. The pain had increased sharply in the last 3 days before hospitalization, and it was positional and getting worse when bending forward or lying down. The pain had been persistent and mild at first. It was not responsive to usual analgesics, and it had nothing to do with feeding or defecation. The patient had nausea and vomiting 3 times which contained eaten but undigested food, but she did not complain of constipation. She had normal defecation and gas passing. Due to the patient’s symptoms, she was referred to the surgical clinic and admitted to the surgical ward for more investigation. The patient had stable vital signs at the time of admission, and she did not have fever. The patient’s body mass index (BMI) was 33.2. Her weight increased gradually in the past 2 years and was uncontrollable, but she had not seen a doctor during that period. On physical examination, the stomach was symmetric but fatty and had mild to moderate distension. Epigastric and right lower quadrant tenderness were found, but rebound or guarding was not detected. The patient has used a 25 mg Losartan tablet daily, and her blood pressure was under control. She also had a history of cesarean section with a low-midline incision 40 years ago. For more investigation, she was asked to do an abdominal sonography. Sonography revealed a huge cystic area with approximate dimensions of 245 × 205 × 121 mm and an approximate volume of 3235 cm³, extending most of the abdominal area from the gastric area to the top of the uterus. Adjacent to the anterior area of the mentioned area, the image of a hypoechoic, heterogeneous and mass-like lesion with no vascularity measuring 33 × 80 mm was seen. On the contrary, multi-hypoechoic, heterogeneous and irregular areas were seen in the right lobe of the liver. The most significant lesions were 27 × 27 mm in the sixth liver segment and 23 × 13 mm in the seventh liver segment. The patient was asked to do an upright chest X-ray and supine abdominal X-ray for more investigation. Upright chest X-ray revealed nothing, but a dense mass-like lesion was seen in the left lower quadrant of the abdomen in supine abdominal X-ray, as can be seen in Figure 1. So, the patient was asked to do an abdominal computed tomography (CT) scan for more investigation, as can be seen in Figure 2. The CT scan report was as follows: the image of a large lesion with a diameter of 247 × 126 mm containing fat, cystic, calcification and teeth, as well as a solid 34 × 19 mm except in the lower, left posterior part at the beginning of the pelvic cavity extending to the abdominal cavity to the epigastrium is seen preferably on the left and midline of the abdomen. Dislocation of the small intestine loop is anterior and, according to the above evidence, can suggest cystic teratoma of the ovary (possibly from the left ovary). Moderate free fluid is found in the peripheral and paracolic gutters and pelvis. Multiple hypodense lesions are seen in the liver parenchyma with a maximum diameter of 30 mm. Delayed images show a compressive effect of the cystic lesion on the right middle ureter. Blood test analysis presented leukocytosis (white blood cell (WBC) = 17,400 mg/dL with neutrophil ratio of 90% and lymphocyte ratio of 7%), hemoglobin = 11.9 mg/dL, a high level of erythrocyte sedimentation rate (ESR) = 33 (the normal range is below 15 in female), positive C-reactive protein (CRP), aspartate aminotransferase (AST) = 85 (normally should be under 31 in female), alanine aminotransferase (ALT) = 95 (the normal range is under 31 in female) and metabolic acidosis, probably caused by decreased tissue perfusion. Other factors were in the normal range. In continuance, general tenderness was detected in physical examination during the patient’s hospitalization. So due to suspicion of a massive abdominal lesion and according to the clinical presentation and the results of blood tests and imaging reports, the patient underwent laparotomy. An abdominal midline incision was performed. After opening the patient’s abdomen, approximately 2 L of free fluid in the abdomen, containing pus and debris, which turned gray, was seen in the abdominal cavity and drained by suction. As can be seen in Figure 3, a large mass of right ovarian origin with numerous adhesions was seen. The adhesions were released, and the mass was completely removed from the patient’s abdomen by salpingo-oophorectomy. The mass was extremely large and about 10 kg. In addition, as can be seen in Figure 4, multi-lesions were seen in the right and left liver lips, and multi-biopsies were provided and sent to a laboratory for more investigation. After providing necessary hemostasis, the abdomen area was washed with 10 L of normal saline, a single drain was performed, and the abdomen was closed. The huge mass contained hair grafts and teeth. After the operation, the patient was transferred to the intensive care unit (ICU) and transferred to the surgery ward after 3 days. Ceftriaxone and metronidazole treatment was started and continued for 10 days. The patient was discharged from the surgery department in good general condition after PO tolerance and defecation. There was no complication in the 2-month follow-up. Finally, the pathology report revealed that the mass was a non-malignant mature ovarian cystic teratoma, as can be seen in Figures 5–7. In addition, section from cystic wall revealed ovarian tissue accompanied by mixture of mature tissue, including squamous epithelium, bony tissue, benign fatty tissue with fat necrosis accompanied by foci of foreign body type granulomatous reaction (numerous multinucleated giant cells), hair shafts, lymphoid aggregation and variable sized blood vessels. Furthermore, the report showed that the liver lesions did not contain any malignant tissue or cell; they just contained hyalinized tissue without any specific cells. In addition, the pathology report revealed nothing about free fluid that was sent for malignancy cell cytology.

Figure 1.

The green arrow shows the dense mass-like lesion.

Figure 2.

The green arrow shows the mature ovarian cystic teratoma. The red arrow shows the dense mass-like lesion.

Figure 3.

Huge mature ovarian cystic teratoma.

Figure 4.

The green arrow shows the liver’s lesion.

Figure 5.

Microscopic view of mature ovarian cystic teratoma.

Figure 6.

Microscopic view of the mature ovarian cystic teratoma.

Figure 7.

Microscopic view of the liver.

Discussion

Mature cystic teratoma is one of the most germ cell neoplasms that approximately includes 10%–20% of all ovarian neoplasms and 60% of all benign neoplasms. It is also known as benign cystic teratoma or dermoid cyst.^6,7 Ectodermal element derivations are the most predominant findings in the microscopic investigation of mature cystic teratoma, but endodermal and mesodermal elements also can be found. ² Mature cystic teratoma may contain hair follicles, skin, sweat glands, bones, teeth, nails, sebum and blood. Dermoid cysts may be asymptomatic or present with abdominal pain, discomfort and swelling due to cyst enlargement and compressive effect or cyst wall rupturing and secretion of its contents into the abdominal cavity.^1,8

According to advances in diagnostic methods, Mature Cystic Teratoma (MCT) over 10 cm is rare and unusual. Ovarian cysts larger than 5 cm are called large; if they grow more than 15 cm, they are called giant. MCT is a slow-growing cyst that can grow between 1.8 and 4 mm yearly.^2,9

Numerous complications can occur due to this disease, such as torsion (16%), rupture (1%–4%), malignancy (1%–2%), infection (1%) and autoimmune hemolytic anemia (<1%).^10,11 Some studies showed a relationship between size and the risk of malignant transformation; however, it is a rare condition and occurs in just 2% of cases, usually in older women. ²

There are several case reports that have reported extremely large mature ovarian cystic teratomas because of the importance of this issue and the complications that can occur following it.^5,9,11,12

There are different imaging methods to evaluate MCT, such as ultrasonography, CT scan and magnetic resonance imaging (MRI). However, the most widely used and available method is ultrasonography, which can help physicians diagnose and evaluate this problem early.^1,2

In this case, the surgical team faced an extremely large MCT, approximately 245 × 205 × 121 mm, which occupied a large space of the abdominal cavity from the right ovary to the epigastrium. After clinical investigation, and due to the patient’s clinical presentation and general tenderness which appeared during daily physical examination, which was caused by cystic wall rupture, and based on the patient’s age, the surgical team preferred salpingo-oophorectomy between other surgical methods and removed it completely.

Conclusion

As this study showed, it is rare to find voluminous MCTs significantly bigger than 10 cm for different reasons mentioned above. They could be benign and found suddenly during routine medical examinations. Symptoms should be examined quickly and carefully because not paying attention to them can cause cysts with enormous dimensions, leading to many complications such as malignancy and cause life-threatening conditions.