Ovarian Teratoma
Ovarian Teratoma Benign cystic
teratoma /
dermoid cyst
The germ cell Teratomas
family of ovarian
neoplasms. Immature Mature cystic
teratoma teratoma
Teratomas arise
Mature teratoma Mature solid
from a single germ teratoma
cell, and therefore
may contain any of Monodermal Fetiform
the three germ teratoma teratoma/homunculus
layers.
Dermoid Cyst
• 10-25% of all ovarian neoplasms.
• 60% of all benign ovarian neoplasms.
• Most common ovarian tumor in women in 2nd
and 3rd decade of life.
• Typically slow growing, and most measure
between 5 and 10 cm.
• Bilateral in approx. 10% cases.
When sectioned, most cysts appear unilocular
and typically contain one area of localized
growth, which protrudes into the cystic cavity.
Microscopic
• Endodermal/mesodermal derivatives
may be found, but ectodermal
elements usually predominate.
• Typically lined with keratinized
squamous epithelium and contains
abundant sebaceous and sweat
glands.
• Hair and fatty secretions are often
found within.
• At times, bone and teeth are also
identified.
This diverse tissue within teratomas don’t arise by fertilization of
an ovum by sperm. Instead, they are thought to develop from
genetic material contained within a single oocyte by asexual
parthenogenesis. As a result, almost all mature cystic teratomas
have a 46,XX karyotype.
Sign symptoms
• Most dermoid cyst cases are asymptomatic
• Abdominal pain or other nonspecific symptoms occur in the
minority of patients.
Diagnosis
• Complete pelvic examination, including rectovaginal examination
and Papanicolaou (Pap) test.
• After pregnancy is excluded sounding and measuring the depth
of the uterine cavity.
• Pelvic imaging; confirm the characteristics of the adnexal mass –
whether solid or cystic or mixed echogenicity.
• Lab studies that are indicated for women of reproductive age with
a pelvic mass include pregnancy test, cervical cytology, and
complete blood count.
Imaging Studies
• Pelvic USG; document the origin of the mass to determine
whether it is uterine, adnexal, bowel, or gastrointestinal.
• USG provides information about the size of the mass and
its consistency –unilocular cyst, mixed echogenicity,
multiloculated cyst, or solid mass.
• Large cysts and those that have multiloculations, solid
components, septa, papillae, and increased blood flow
should be suspected of neoplasia.
• The definitive diagnosis is histopathology.
• Mature cystic teratomas display several
characteristic ultrasound features;
1. Dermoid plug hyperechogenic nodule
inside the cyst due to a mixture of hair and
sebaceous material. No blood flow inside
the material, and it is usually associated
with a distal hypoechoic area known as
acoustic shadow.
Sometimes, the acoustic shadow is large and
they’re securing part of the dermoid plug tip
of ice berg sign
2. Dermoid mesh hyperechoic linear and
the pocketed echoes inside the dermoid
cyst which correspond to hair strands
3. Floating fat globules
Complications
• Risk of torsion with dermoid cysts • Risk factors for malignant
is approx. 15%. changes:
• Cyst rupture is rare, presumably - Age >45
their thick cyst wall resists rupture - Tumor size >10 cm
compared with other ovarian
neoplasms. - Rapid growth
• If cysts do spill, acute peritonitis is - The presence of low resistance
common. of flow
• Chronic leakage of teratoma
contents is rare but can lead to
granulomatous peritonitis.
• Malignant transformation: 0.06-
2% of cases and typically in older
women. Most malignant cases are
Management
• Surgical intervention is warranted in the presence of severe pain or the
suspicion of malignancy or torsion.
• When torsion is confirmed by laparoscopy, untwisting of the mass and
ovarian preservation rather than extirpation are generally indicated.
• The choice of surgical approach (laparotomy or laparoscopy) should be
based on the surgical indications, the patient’s condition, the surgeon’s
expertise and training, informed patient preference, and the most recent
data supporting the chosen approach.
• The role of laparoscopy is even more controversial in removal of dermoid
cysts than with other benign masses. Concern focuses on preventing the
spill of the cyst contents.
• Many trials have reported laparoscopy o Disadvantage of the laparoscopic
as a superior treatment in surgical approach:
management of dermoid cyst. o Longer duration of operation
• Advantages of the laparoscopic o Higher rate of spillage
approach:
o Higher rate of recurrence
o Less bleeding
o Higher cost (individually)
o Less postoperative pain
o Increased risk of surgery unique to
o Less need for postoperative laparoscopy
analgesic
• When should laparotomy be
o Shorter hospital stay considered in dermoid cyst
o Better cosmetic results management?
o Less cost (overall) o Large mass controversy exists in the
o Better magnification precise tumor size. Some authors
have recommended 10 cm as the
cut-off size for laparotomy.
o Bilateral cysts.
Selection of oophorectomy or cystectomy
• According to sources, cystectomy is considered as dermoid
cyst surgery of choice instead of oophorectomy.
• In the case of premenopausal women, the considerations
listed below affect the choice of treatment:
o Multiple dermoid cysts in the ovary
o Large dermoid cyst resulting in less ovarian tissue for
conservation
o Closeness to menopause in the patient
• In young women and children, preservation of ovarian tissue
is important for fertility and future sexual development.
Surveillance
• Although most of these masses are surgically removed, a few studies have
supported surveillance only for cysts measuring <6 cm in premenopausal
women, especially those desiring future fertility.
• These studies document slow tumor growth that averages less than
2mm/yr.
• If not removed, sonographic surveillance is recommended every 6 to 12
months initially.
Main References
• William’s Gynecology
• Berek’s Gynecology
• Moridi, A. 2016. Clinical Points in Dermoid Cyst Management: A Review Article.
• Dr. Alaa Esayed’s video
