The approach to ovarian dermoids in adolescents and young women

The Importance of Follow-Up in Adolescent Patients With a History of Ovarian Dermoid Cysts: A Case Report

Ovarian dermoid cysts (ODCs), also known as mature cystic teratomas, are the most common ovarian neoplasms in children and adolescents. While typically asymptomatic, ODCs can present with a range of symptoms, including neuropsychiatric disturbances due to paraneoplastic encephalitis. The absence of universally accepted guidelines for post-operative surveillance poses a significant challenge in managing these cases, particularly in adolescent patients. We report the case of a previously healthy 12-year-old girl who initially presented with altered mental status and psychosis, leading to the discovery of bilateral ODCs. Despite successful laparoscopic ovarian-sparing resections of the initial lesions, as well as a laparoscopic ovarian-sparing resection of a unilateral recurrence one year later, the patient was lost to follow-up and did not undergo routine surveillance. She eventually presented several years later with severe abdominal distention and frequent seizures, which an abdominal ultrasound revealed were due to recurrent bilateral ODCs that encompassed the entirety of the abdomen. Upon evaluation with MRI, no normal ovarian tissue was identified. After discussion with the patient and her mother, she ultimately underwent a bilateral salpingo-oophorectomy at age 20, resulting in premature menopause. This case underscores the necessity of standardized follow-up protocols for adolescents with ODCs that prioritize regular imaging and clinical monitoring to identify recurrent lesions and prevent adverse outcomes. Additionally, it emphasizes the importance of multidisciplinary care and patient education to ensure adherence to follow-up recommendations. Our findings suggest that a more consistent approach to post-operative surveillance could prevent severe complications and improve long-term outcomes for adolescent patients with ODCs.

Management of an Incidentally Discovered Ovarian Teratoma in an Adolescent Patient

Mature ovarian teratomas are a benign subset of germ cell tumors (GCT) often diagnosed during reproductive years and are the most common GCT among children and adolescents. Many are found incidentally on unrelated imaging. There are no definitive guidelines on the management of these teratomas, particularly in the pediatric population. This case presents the management of an adolescent patient with an incidentally found ovarian teratoma. A discussion of contemporary literature also identifies a significant gap in the literature for definitive guidelines in pediatric patients with mature teratomas.

Approaches to the Diagnosis and Management of Paediatric Ovarian Tumours and Oncological Outcomes in a Single-centre Study. Evidence in Support Of IPSO Reccomendations

BACKGROUND

Approaches to paediatric ovarian tumours vary. Cross-sectional imaging is reliable but not always performed. Laparoscopic tumourectomy, although popular, is not recommended by International Paediatric Surgical Oncology Society (IPSO); tumour spillage remains the main concern. We aimed to investigate the reliability of preoperative evaluation and identify perioperative factors associated with adverse outcomes.

METHODS

Single-centre retrospective study (2015-2022) of clinical presentation, preoperative investigation, operative approaches and oncological outcomes in all females <18 years treated for ovarian tumours. Logistic regression was used to identify predictors of malignancy and of second disease events. Data are presented as median (IQR) or rates.

RESULTS

Sixty girls aged 12.5 (10-15) years with follow-up of 51 (30.5-76.3) months were included. Incidence of malignant and low malignant potential tumours was 19/60 (32%). Tumour size and consistency proved predictive of malignancy. Clinical assessement, tumour markers and cross-sectional imaging combined showed 75% sensitivity, 100% specificity and 7% misclassified malignancy rate. Second disease events (11/60, 18%) were associated with misclassified malignancy (2/11 vs. 1/49, p = 0.04) and positive margins (4/11 vs. 5/49, p = 0.02). Ovarian-sparing surgery did not influence second events (5/11 vs. 28/49, p = 0.48). There was no significant association between second events and laparoscopic tumourectomy (3/11 vs. 20/49, p = 0.40); spillage rate was however more frequent with laparoscopy (5/11 vs. 2/32, p = 0.008).

CONCLUSION

Misclassified malignancy, noted in 7% of patients undergoing optimal work-up, adversely impacted outcomes, highlighting the importance of oncological principles in both oophorectomy and ovarian-sparing surgery. Malignancy incidence and misclassification can be underestimated when tumours with malignant behaviour potential, such as immature teratomas and borderline tumours, are grouped as benign. There was no direct association between operative approaches and second events. Laparoscopy, however, failed to maintain oncological principles more frequently than open surgery and hence risks upstaging of paediatric ovarian pathology.

LEVEL OF EVIDENCE

III.

Bilateral Dermoid Ovarian Cysts in a Young Woman - A Case Report and Literature Review

Background/Aim

Ovarian tumors are a common type of neoplasm in women, with mature cystic teratomas being the most frequent variant. These tumors occur bilaterally in approximately 10% of cases. However, bilateral and multiple occurrences are rarely reported.

Case Report

A 22-year-old nulliparous woman presented with amenorrhea and sudden, generalized, dull lower abdominal pain. Diagnostic imaging, including ultrasound and computed tomography (CT) scans, revealed large solid-cystic lesions in both ovaries, with internal hyperechoic foci consistent with fat and calcification, along with thin internal septations. A laparoscopic cystectomy was successfully performed, preserving ovarian function. Histopathological examination confirmed the presence of stratified keratinized squamous epithelium, sebaceous glands, hair follicles, mature adipose tissue, blood vessels, and lymphatic vessels within the resected cysts, with no evidence of malignancy.

Conclusion

This unique case provides valuable insights into the understanding and management of bilateral dermoid cysts, highlighting the importance of preserving ovarian function in young women.

Analysis of Various Laparoscopic Pediatric Urology Surgeries: Five-Year Experience of a Single Institution

Background In this study, we aim to report our single-center experience with laparoscopic pediatric urological surgeries. We aim to determine the feasibility of various urological and urogenital laparoscopic procedures and the tricks that increase surgical success. Methodology Data from 98 patients who underwent laparoscopic urological and/or urogenital procedures for diagnostic and therapeutic purposes in our clinic between June 2018 and February 2023 were retrospectively analyzed. All surgeries were performed by the same surgical team. Laparoscopic procedures included orchidopexy, gonadectomy, vaginoplasty, hysterectomy, pyeloplasty, nephrectomy/partial nephrectomy, ureteroneocystostomy, bladder diverticulum excision, renal cyst excision, proximal ureter stone removal, oophorectomy, ovarian detorsion, oophoropexy, and lymph node excision for diagnostic purposes. The surgical planning of the patients was based on the decisions of the pediatric nephrology, pediatric endocrinology, and pediatric oncology departments and the multidisciplinary council. Demographic characteristics of the patients, surgical indications, and intraoperative data, as well as postoperative pathological diagnoses and complications, were recorded. All patients underwent a transperitoneal approach. The duration of the operation was obtained from anesthesia records and defined as the time from the beginning of the surgical incision to the closure of the skin incision. Results Of the patients, 54 were males and 44 were females. The median age was 7.8 years. No complications other than grade 1 according to the Clavien-Dindo classification were observed in our patients. As different types of surgeries were analyzed, the mean operative duration was estimated. Conclusions The laparoscopic method should be performed by surgeons experienced in advanced surgeries in pediatric urology. It is critical to consider the difference in the size of pediatric patients in preparation for laparoscopic surgery to minimize technical and ergonomic problems. We believe that each surgery has its specific tricks and that these should be a part of laparoscopy training. Moreover, developing and sharing this information would be very useful for pediatric urologists.

Amplifications of EVX2 and HOXD9-HOXD13 on 2q31 in mature cystic teratomas of the ovary identified by array comparative genomic hybridization may explain teratoma characteristics in chondrogenesis and osteogenesis

BACKGROUND

Teratomas are a common type of germ cell tumor. However, only a few reports on their genomic constitution have been published. The study of teratomas may provide a better understanding of their stepwise differentiation processes and molecular bases, which could prove useful for the development of tissue-engineering technologies.

METHODS

In the present study, we analyzed the copy number aberrations of nine ovarian mature cystic teratomas using array comparative genomic hybridization in an attempt to reveal their genomic aberrations.

RESULTS

The many chromosomal aberrations observed on array comparative genomic hybridization analysis reveal the complex genetics of this tumor. Amplifications and deletions of large DNA fragments were observed in some samples, while amplifications of EVX2 and HOXD9-HOXD13 on 2q31.1, NDUFV1 on 11q13.2, and RPL10, SNORA70, DNASE1L1, TAZ, ATP6AP1, and GDI1 on Xq28 were found in all nine mature cystic teratomas.

CONCLUSIONS

Our results indicated that amplifications of these genes may play an important etiological role in teratoma formation. Moreover, amplifications of EVX2 and HOXD9-HOXD13 on 2q31.1, found on array comparative genomic hybridization, may help to explain the characteristics of teratomas in chondrogenesis and osteogenesis.

Imaging features of intra-abdominal and intra-pelvic causes of hirsutism

Hirsutism is a relatively common disorder which affects approximately 5% to 15% of women. It is defined by excessive growth of terminal hair in women, which primarily affects areas dependent on androgens, such as the face, abdomen, buttocks, and thighs. Hirsutism can be caused by a variety of etiologies, which are most often not lifethreatening. However, in some cases, hirsutism can be an indicator of more serious underlying pathology, such as a neoplasm, which may require further elucidation with imaging. Within the abdomen and pelvis, adrenal and ovarian pathologies are the primary consideration. The goal of this manuscript is to review the etiologies and imaging features of various intra-abdominal and intra-pelvic causes of hirsutism.

Chronic constipation and abdominal distension in a patient with adult Hirschprung's disease and bilateral ovarian teratomas

Hirschprung's disease is a congenital disorder characterized by aganglionic bowel, usually diagnosed in infancy. Here, we present a unique case of Hirschprung's disease diagnosed in a 29-year-old female with acute on chronic constipation. As part of her work up, a computerized tomography of her abdomen and pelvis revealed large, bilateral dermoid cysts. A diagnostic and therapeutic colonoscopy allowed manual disimpaction and decompression of her bowel, as well as biopsy attainment. Histopathology revealed absence of ganglionic cells on haematoxylin and eosin stain and calretinin immunostaining. This case underscores the diagnostic challenges of Adult Hirschprung's disease and how this impacts patient quality of life, as well as the work up and management of concurrent causes abdominopelvic conditions.

Ovarian Masses in Children and Adolescents: A Review of the Literature with Emphasis on the Diagnostic Approach

Most abdominal masses in the pediatric population derive from the ovaries. Ovarian masses can occur in all ages, although their incidence, clinical presentation and histological distribution vary among different age groups. Children and adolescents may develop non-neoplastic ovarian lesions, such as functional cysts, endometrioma, torsion, abscess and lymphangioma as well as neoplasms, which are divided into germ cell, epithelial, sex-cord stromal and miscellaneous tumors. Germ cell tumors account for the majority of ovarian neoplasms in the pediatric population, while adults most frequently present with epithelial tumors. Mature teratoma is the most common ovarian neoplasm in children and adolescents, whereas dysgerminoma constitutes the most frequent ovarian malignancy. Clinical manifestations generally include abdominal pain, palpable mass, nausea/vomiting and endocrine alterations, such as menstrual abnormalities, precocious puberty and virilization. During the investigation of pediatric ovarian masses, the most important objective is to evaluate the likelihood of malignancy since the management of benign and malignant lesions is fundamentally different. The presence of solid components, large size and heterogenous appearance on transabdominal ultrasonography, magnetic resonance imaging and computed tomography indicate an increased risk of malignancy. Useful tumor markers that raise concern for ovarian cancer in children and adolescents include alpha-fetoprotein, lactate dehydrogenase, beta subunit of human chorionic gonadotropin, cancer antigen 125 and inhibin. However, their serum levels can neither confirm nor exclude malignancy. Management of pediatric ovarian masses needs to be curative and, when feasible, function-preserving and minimally invasive. Children and adolescents with an ovarian mass should be treated in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome.

Giant Benign Struma Ovarii with High-Grade Fever, Elevated CA 125, and Hormonal Function in an Adolescent Patient

Struma ovarii (SO) is a monodermal teratoma containing at least 50% thyroid tissue. Classically, SO is a hormonally inactive benign neoplasm that occurs in premenopausal women, and has unspecific clinical and imaging features. Its treatment is surgical and its diagnosis is established histopathologically. We report the case of a euthyroid 16-year-old girl presenting with abdominal girth increase. An abdomino-pelvic ultrasound showed a giant multicystic mass with transonic content and multiple septa, and magnetic resonance imaging suggested the diagnosis of right ovarian mucinous cystadenoma. Blood tests showed inflammatory syndrome, iron deficiency anemia, mild hepatocytolysis, and elevated serum CA 125 levels. High-grade fever occurred on the third day of hospitalization, but none of the preoperative tests could identify its origin. Cystectomy was performed, and the histopathological examination revealed benign SO with a few small cysts with purulent content. The patient developed hypothyroidism postoperatively. In conclusion, this case report reunites most of the uncommon features of SO and confirms the superiorityof histopathology in its definitive diagnosis, as well as the suitability of ovarian sparing techniques, as the best treatment option for cystic ovarian pathology in pediatric patients, even in cases of large tumoral size and elevated serum CA 125 levels.

Mature Cystic Teratoma: An Integrated Review

Ovarian dermoid cysts, also called mature cystic teratomas (MCTs), account for 69% of ovarian germ cell tumors in young women. The tumors are formed by tissues derived from three germ layers, and sebaceous materials are most commonly seen. The origin of MCTs is widely considered to be the germ cell origin, which completes meiosis I. The clinical symptoms vary widely, but 20% of tumors could be asymptomatic. The diagnosis of MCTs is usually made without difficulty by ultrasound and confirmed by histopathology post-operatively. The imaging findings have a high diagnostic value. The typical characteristics present in the sonographic images, including a dermoid plug or Rokitansky nodule, are considered strong evidence for a teratoma. Although the malignant transformation of MCTs is rare, it can occur in some cases, especially in women of advanced age. The treatment of MCTs depends on the risk of malignancy, the age of the patient, and the patient's fertility reserve requirement. In this article, we review the epidemiology, clinical symptoms, diagnosis criteria, cellular origin, and treatment of mature cystic teratomas.

The Female Genital Tract on MDCT: A Pictorial Review of Normal Anatomy and Incidental Abnormalities

Purpose This article aims to review the pertinent anatomy and the incidental abnormalities involving the female genital tract on multidetector computed tomography (MDCT) through a pictorial review.

Methods The review is based on critical analysis of the existing literature as well as our experience in dealing with incidental lesions involving the female genital tract.

Results The lack of awareness regarding the normal appearances of the female pelvis on MDCT can puzzle the inexperienced radiologist and create management dilemmas for the treating clinician. It is important for radiologists to recognize normal appearances of the female genital tract on MDCT to prevent misinterpretation as pathology. The identification of incidentalomas of the female genital tract on CT can further guide whether additional workup is required or not. This pictorial review familiarizes radiologists with the normal appearances of the female genital tract on MDCT and a few common incidentalomas.

Conclusion It is imperative for a clinical radiologist to be familiar with the anatomy and common incidental lesions involving the female genital tract.

Multi-Institutional Review of the Preoperative Diagnostic Accuracy for Pediatric Ovarian Mature Cystic Teratomas

STUDY OBJECTIVE

To assess the preoperative imaging impression and surgeon diagnostic accuracy for pediatric ovarian mature cystic teratomas (MCTs) DESIGN: Retrospective review SETTING: Eleven pediatric hospitals PARTICIPANTS: Patients ages 2 to 21 who underwent surgical management of an ovarian neoplasm or adnexal torsion with an associated ovarian lesion INTERVENTION: None MAIN OUTCOME MEASURES: Preoperative imaging impression, surgeon diagnosis, tumor markers, and pathology RESULTS: Our cohort included 946 females. Final pathology identified 422 (45%) MCTs, 405 (43%) other benign pathologies, and 119 (12%) malignancies. Preoperative imaging impression for MCTs had a 70% sensitivity, 92% specificity, 88% positive predictive value (PPV), and 79% negative predictive value (NPV). For the preoperative surgeon diagnosis, sensitivity was 59%, specificity 96%, PPV 92%, and NPV 74%. Some measures of diagnostic accuracy were affected by the presence of torsion, size of the lesion on imaging, imaging modality, and surgeon specialty. Of the 352 masses preoperatively thought to be MCTs, 14 were malignancies (4%). Eleven patients with inaccurately diagnosed malignancies had tumor markers evaluated and 82% had at least 1 elevated tumor marker, compared with 49% of those with MCTs.

CONCLUSIONS

Diagnostic accuracy for the preoperative imaging impression and surgeon diagnosis is lower than expected for pediatric ovarian MCTs. For all ovarian neoplasms, preoperative risk assessment including a panel of tumor markers and a multidisciplinary review is recommended. This process could minimize the risk of misdiagnosis and improve operative planning to maximize the use of ovarian-sparing surgery for benign lesions and allow for appropriate resection and staging for lesions suspected to be malignant.

Laparoscopy versus laparotomy for pediatric ovarian dermoids

BACKGROUND

With increased surgeon comfort using laparoscopy, we hypothesized resection of pediatric ovarian dermoids using laparoscopy would yield a shorter length of stay and no increase in morbidity or recurrence compared to laparotomy.

METHODS

A retrospective review was performed amongst eleven pediatric hospitals. Patients aged 2 to 21 who underwent resection of an ovarian dermoid from 2010 to 2020 were included. Patient characteristics, operative details, and outcomes by approach were evaluated using Chi-squared and Wilcoxon-Mann tests.

RESULTS

466 patients were included, with a median age of 14.4 and median follow-up of 4.0 months. 279 patients underwent laparoscopy (60%), 139 laparotomy (30%), and 48 laparoscopy converted to laparotomy (10%). There were no differences in rates of tumor spillage by approach (p = 0.15). 65% underwent ovarian-sparing surgery and 35% underwent oophorectomy. Length of stay was significantly shorter amongst patients who underwent laparoscopy (1 day versus 2 days for laparotomy and converted, p<0.0001). There were no differences in rates of suspected recurrence or reoperation (p = 0.19 and p = 0.57, respectively).

CONCLUSION

Patients who underwent laparoscopy experienced no differences in the rates of tumor spillage, recurrence, or reoperation and had a shorter length of stay compared to laparotomy. Laparoscopy is an acceptable approach for resection of pediatric ovarian dermoids.

Lessons from a large nationwide cohort of 350 children with ovarian mature teratoma: A study in favor of ovarian-sparing surgery

BACKGROUND

Ovarian mature teratoma (OMT) is a common ovarian tumor found in the pediatric population. In 10%-20% of cases, OMT occurs as multiple synchronous or metachronous lesions on ipsi- or contralateral ovaries. Ovarian-sparing surgery (OSS) is recommended to preserve fertility, but total oophorectomy (TO) is still performed.

DESIGN

This study reviews the clinical data of patients with OMT, and analyzes risk factors for second events. A national retrospective review of girls under 18 years of age with OMTs was performed. Data on clinical features, imaging, laboratory studies, surgical reports, second events and their management were retrieved.

RESULTS

Overall, 350 children were included. Eighteen patients (5%) presented with a synchronous bilateral form at diagnosis. Surgery was performed by laparotomy (85%) and laparoscopy (15%). OSS and TO were performed in 59% and 41% of cases, respectively. Perioperative tumor rupture occurred in 23 cases, independently of the surgical approach. Twenty-nine second events occurred (8.3%) in a median time of 30.5 months from diagnosis (ipsilateral: eight cases including one malignant tumor; contralateral: 18 cases; both ovaries: three cases). A large palpable mass, bilateral forms, at diagnosis and perioperative rupture had a statistical impact on the risk of second event, whereas the type of surgery or approach did not.

CONCLUSION

This study is a plea in favor of OSS as the first-choice treatment of OMT when possible. Close follow-up during the first 5 years is mandatory considering the risk of 8.3% of second events, especially in cases with risk factors.

Synchronous Breast Carcinoma, Uterine Myoma, and Ovarian Teratoma in a Single Woman

Multiple primary tumors in a patient diagnosed with invasive ductal breast cancer are rarely reported in the literature. Here we present a case of invasive ductal carcinoma of the breast in a 42-year-old lady, with synchronous uterine leiomyoma (UL), ovarian teratoma and with prior history of follicular adenoma of thyroid in the same patient. The clinical presentation and management plan is discussed with a review of the literature. Breast cancer is the most common cancer in women where the concomitant occurrence of multiple primary tumors is a diagnostic and therapeutic challenge. In low- and middle-income countries, where facilities of genetic screening in all patients of synchronous neoplasia are limited due to scarcity of resources, strong clinical suspicion, multidisciplinary management, and follow-up remain important.

Successful surgical management of massive ovarian teratoma in a rhesus macaque (Macaca mulatta)

A 5 years-old Rhesus macaque was presented with abdominal enlargement. The clinical, radiographic and ultrasonographic findings suggested that a massive mass occupying the whole of the abdomen. The mass was surgically removed, and histopathology confirmed ovarian teratoma. The macaque recovered uneventfully; however, the management to avoid self-mutilation of skin sutures was challenging.

Spontaneously Ruptured Dermoid Cysts and Their Potential Complications: A Review of the Literature with a Case Report

Spontaneous ruptures of dermoid cysts are a rare occurrence due to their thick capsules. This is the first systematic review on spontaneously ruptured dermoid cysts. A comprehensive literature search was performed from PubMed, Google Scholar, and MEDLINE. The cases were analysed for patient demographics, presenting signs and symptoms, imaging modalities used, management methods, and outcomes. The majority of cases report an idiopathic cause with symptoms of abdominal pain, distension, and fever. Computed tomography is the most accurate in detecting ruptured dermoid cysts. We also report a case of a 66-year-old who presented with sudden abdominal pain and a low-grade temperature. Imaging showed a 10 cm well-circumscribed hyperechoic mass consistent with a dermoid cyst with no suggestive signs of rupture. She was planned for a laparoscopic bilateral salpingo-oophorectomy. However, intraoperatively, a ruptured dermoid cyst was found with bowel adhesions and chemical peritonitis as cyst contents covered the entirety of the intra-abdominal cavity. Her operative course was complicated by inadvertent iatrogenic small bowel injury, unsuccessful laparoscopy, needing conversion to laparotomy. Despite their benign nature, complications from ruptured dermoid cysts include peritonitis, bowel obstruction, and abscesses. Surgical management by both laparoscopy and laparotomy is successful, with laparotomies more likely to be performed. Complications have mostly no long-term sequelae.

Conservative treatment versus surgical excision of ovarian dermoid cysts: Impact on ovarian stimulation and IVF cycle success

OBJECTIVE

To analyze outcomes of IVF treatment among women diagnosed with an ovarian dermoid cyst (DC).

METHODS

Retrospective analysis of women with an ovarian DC who underwent IVF with fresh blastocyst transfer at a single center in New York from January 2010 to March 2018. Outcomes were compared between women with conservative treatment and those with surgical excision of the DC. Multivariate logistic regression was used to assess associations between variables and the presence of a DC during treatment.

RESULTS

Overall, 119 women with a DC were included. No differences were found in demographic characteristics, controlled ovarian hyperstimulation parameters, and IVF outcomes between women with an intact DC (n=65, 54.6%) and those who underwent cystectomy (n=54, 45.4%) (all P<0.05). Similarly, there was no difference in anti-Mϋllerian hormone and basal antral follicle count among women with a DC (respectively, β=-0.1, P=0.8, and β=-1.0, P=0.28) or resected DC (respectively, β=0.9, P=0.07, and β=1.5, P=0.08) as compared with control women with no DC (n=352).

CONCLUSION

Ovarian reserve, embryo implantation and IVF success rates were not lower in the presence of an ovarian DC. Surgical therapy, if indicated, can be safely postponed until family planning goals have been achieved.

Factors Associated With Management of Pediatric Ovarian Neoplasms

BACKGROUND

Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was to characterize the surgical management of pediatric ovarian neoplasms across 10 children's hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions.

METHODS

A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy.

RESULTS

Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%-49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty (P = .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status (P = .02), preoperative suspicion for malignancy (P < .0001), larger lesion size (P < .0001), and presence of solid components (P < .0001). Preoperative findings independently associated with malignancy included increasing size (P < .0001), solid components (P = .003), and age (P < .0001).

CONCLUSIONS

The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.

Ultrasonographically diagnosed dermoid cysts do not influence ovarian stimulation response in an in vitro fertilization cycle

To determine if patients with a DC respond similarly to ovarian stimulation when compared to patients without a DC. Infertility patients with a DC that underwent IVF between January 2009 and December 2016 were included. A cystic mass with mixed echogenicity, internal echoes similar to thick bands, fatty-fluid level, or an echogenic tubercle with acoustic shadow (Rokitansky nodule) within two years of the cycle characterized the diagnosis. The z-score compared the standard deviations (SDs) in patients with/without a DC and were compared to a nomogram (expected oocytes minus oocytes obtained divided by the SD), adjusted for age and number of oocytes retrieved, built utilizing cycles from noninfertile female patients. Thirty-nine patients with DC and 7839 patients without DC were identified. The mean number of oocytes (8.6 ± 5.8 vs. 8.5 ± 7.7, p = .43) and MIIs (6.7 ± 4.7 vs. 7.0 ± 6.7, p = .74) retrieved were similar. When cycles with and without a DC were compared to the nomogram (z-score of 0), cycles with a DC presented a z-score for ovarian response of 0.1921 SDs from the mean, and patients without DC presented a z-score of -0.2065 SDs from the mean (similar and less than -1.0). After building a population 'normal' response as a template, patients with and without a DC responded similar to COS.

Effects of mature cystic teratoma on reproductive health and malignant transformation: A retrospective analysis of 80 cases

Objective:

To examine cases of mature cystic teratoma (MCT) that were diagnosed and treated in our clinic regarding their association with fertility, and to detect the rate of malignant degeneration and the types of malignancies.

Material and Methods:

Patients who underwent surgery due to adnexal mass between April 2012 and August 2017 and were diagnosed as having MCT were retrospectively examined. The mean age of the 80 patients who met the inclusion criteria was 30.60±10.5 years. Nine had infertility according to hospital records. Sixty-seven percent of these (n=6) had accompanying endometriosis and MCT was bilateral in 55.5% (n=5). Malignant degeneration was present in 6.25% (n=5), all were monodermal tumors. Malignant degeneration was more common among patients with larger diameter adnexal masses (9.1±2.9 cm) and in those of postmenopausal age. Tumor markers were within the normal range for patients who developed malignancy. Malignant degeneration was not present among infertile patients with endometriosis.

Results:

Although MCTs do not seem to negatively affect the ovarian reserve, infertility is prominent in patients with concurrent endometriosis. During assessment, concurrent endometriosis should be considered. Imaging findings, large adnexal masses, and postmenopausal period are important for the assessment of MCT concerning malignant degeneration. It should not be overlooked because tumor markers may be normal.

Conclusion:

MCTs can be present concurrent with endometriomas. In such cases, infertility is more distinct. In MCT malignant degeneration, mass diameter, complex mass internal structure, and postmenopausal status are important factors.

Chemical peritonitis resulting from spontaneous rupture of a mature ovarian cystic teratoma: a case report

Background

Mature cystic teratomas (dermoid cysts) are the most common germ cell tumours with 10-25% incidence of adult and 50% of paediatric ovarian tumours. The aetiology of dermoid cysts is still unclear, although currently the parthenogenic theory is most widely accepted. The tumour is slow-growing and in the majority of cases it is an accidental finding. Presenting symptoms are vague and nonspecific. The main complication of a dermoid cyst is cyst torsion (15%); other reported complications include malignant transformation (1-2%), infection (1%), and rupture (0.3-2%). Prolonged pressure during pregnancy, torsion with infarction, or a direct trauma are the main risk factors for a  spontaneous dermoid rupture that can lead to acute or chronic peritonitis. The diagnosis of mature cystic teratoma is often made in retrospect after surgical resection of an ovarian cyst, because such imaging modalities as ultrasound, computer tomography, or magnetic resonance imaging cannot yet accurately and reliably distinguish between benign and malignant pathology.

Materials and methods

We present a report of a clinical case of a 35-years-old female, who was referred to the hospital due to abdominal pain spreading to her feet for three successive days. She had a history of a normal vaginal delivery one month before. Abdominal examination revealed mild tenderness in the  lower abdomen; no obvious muscle rigidity was noted. Transvaginal ultrasound showed a multiloculated cystic mass measuring 16 × 10 cm in the pelvis. In the absence of urgency, planned surgical treatment was recommended. The next day the patient was referred to the hospital again, with a complaint of stronger abdominal pain (7/10), nausea, and vomiting. This time abdominal examination revealed symptoms of acute peritonitis. The ultrasound scan differed from the previous one. This time, the transvaginal ultrasound scan revealed abnormally changed ovaries bilaterally. There was a large amount of free fluid in the abdominal cavity. The patient was operated on - left laparoscopic cystectomy and right adnexectomy were performed. Postoperative antibacterial treatment, infusion of fluids, painkillers, prophylaxis of the thromboembolism were administered. The patient was discharged from the hospital on the seventh postoperative day and was sent for outpatient observation.

Results and conclusions

Ultrasound is the imaging modality of choice for a dermoid cyst because it is safe, non-invasive, and quick to perform. Leakage or spillage of dermoid cyst contents can cause chemical peritonitis, which is an aseptic inflammatory peritoneal reaction. Once a rupture of an ovarian cystic teratoma is diagnosed, immediate surgical intervention with prompt removal of the spontaneously ruptured ovarian cyst and thorough peritoneal lavage are required.

Ovarian teratoma in children: a plea for collaborative clinical study

Background

Although teratomas are the most common histologic subtype of childhood ovarian germ cell tumors, their appropriate treatment in this age group still remains unclear. Paucity of research dedicated exclusively to both mature and immature teratomas of the ovary, contribute to decision making difficulties.

Therefore, we decided to review retrospectively our experience in treatment of pediatric ovarian teratomas in order to assess the epidemiology, presenting features, and diagnostic as well as surgical management of these lesions.

Results

The study comprised 58 patients. Fifty percent of patients were between 9 and 15 years old. Mature teratoma was diagnosed in 55(94.83%) patients, while 3(5.17%) patients presented with immature teratoma. Twenty eight (50.91%) girls with mature teratoma had laparotomy and 23 (41.82%) had laparoscopy performed as an initial operative approach. Ovarian tissue sparing technique (preservation of the ovarian tissue of the affected gonad) was applied in only 11.11% of patients operated in the first study period (years 1999–2003) and increased to 40.54% in the second half of our study (years 2004–2016). The extent of gonadal resection was not related with the size of the lesion. Bilateral lesions were noted in 8 patients with mature teratoma. All girls with immature teratoma were subjected to formal laparotomy. Two patients had stage III of the disease and one had stage IV. They underwent at least resection of the affected gonad. Adjuvant chemotherapy was given to all girls with immature teratoma after the surgery.

Conclusions

Under particular conditions ovarian-sparing surgery might be successfully applied in children with mature teratoma. Laparotomy is the treatment of choice in large masses, suspicious for malignancy and if surgical staging is required. High quality prospective multi-institutional studies are required in order to get an objective insight into biology and prognostic factors of teratomas in children.

Ovarian Teratoma Associated with Coexisting Anti-N-Methyl-D-Aspartate Receptor and Glial Fibrillary Acidic Protein Autoimmune Meningoencephalitis in an Adolescent Girl: A Case Report

BACKGROUND

Ovarian teratomas are rarely associated with paraneoplastic autoimmune meningoencephalitis. In addition to the well known N-methyl-D-aspartate receptor (NMDA-R) antibody, the glial fibrillary acidic protein (GFAP) antibody is a novel biomarker of autoimmune meningoencephalitis that might be seen in patients with ovarian teratoma.

CASE

A 13-year-old girl with acute-onset meningoencephalitis and incidental finding of ovarian teratoma was found to have coexisting anti-NMDA-R and GFAP antibodies present in her cerebrospinal fluid.

SUMMARY AND CONCLUSION

NMDA-R and GFAP autoimmune encephalitis should be considered in adolescent patients with neurologic or psychiatric symptoms and an ovarian teratoma. Prompt diagnosis and surgical resection increase the likelihood of full neurologic recovery.

Intraoperative Rupture of Ovarian Dermoid Cysts in the Pediatric and Adolescent Population: Should This Change Your Surgical Management?

STUDY OBJECTIVE

(1) To determine the incidence of chemical peritonitis after cystectomy for ovarian dermoid cysts with intraoperative cyst rupture in the pediatric and adolescent population; and (2) to examine the intraoperative and postoperative outcomes of cystectomies performed for ovarian dermoid cysts using laparoscopy and laparotomy, especially those with intraoperative cyst rupture.

DESIGN

A retrospective cohort study of female patients who underwent ovarian cystectomy with proven ovarian dermoid pathology between July 2007 and July 2015.

SETTING

Texas Children's Hospital, Houston, Texas.

PARTICIPANTS

One hundred forty-four patients between the ages of 1 and 21 years who underwent an ovarian cystectomy with proven benign ovarian dermoid histology on the basis of pathology reports.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Occurrence of spill of cyst contents, chemical peritonitis, postoperative complications, and hospital readmissions.

RESULTS

One hundred forty-four female patients underwent cystectomy (38 laparotomy and 106 laparoscopy) resulting in benign ovarian dermoid histology. Their mean age was 12.4 ± 4.1 years (range, 1-21), mean cyst size was 9.2 ± 6.4 cm (range, 1-30 cm), no patients had elevated tumor markers, 42 (29.1%) presented with torsion, 73 (50.7%) had cyst fluid spill, and there were no cases of chemical peritonitis. Few significant differences were found between cases performed via laparoscopy and laparotomy and those with and without intraoperative cyst rupture resulting in spill of contents. Laparotomy cases were found to have larger mean cyst size (P < .001), estimated blood loss (P = .003), and presence of bilateral cysts (P = .017) compared with laparoscopic cases. Cyst fluid spill occurred in more laparoscopic cases ([67/106] 63.2% vs [6/38] 15.8%; P < .001), and risk increased with cyst size greater than 5 cm (P < .001). In the laparoscopy group, cyst size greater than 5 cm was more likely to present with torsion (P < .001). There was no significant difference in the repeat cystectomy rate between the laparoscopy and laparotomy groups even with cyst rupture (P = .394). Only 5 cases presented to the emergency room postoperatively and 2 were admitted postoperatively for umbilical port site dehiscence and pyelonephritis.

CONCLUSION

Laparoscopic cystectomy of ovarian dermoid cysts is associated with greater intraoperative cyst rupture. However, cyst rupture is rarely associated with complications, therefore minimally invasive surgical management of ovarian dermoid cysts is a reasonable surgical approach.

An Uncommon Case of Adolescent Ovarian Teratoma Incarcerated in Inguinal Hernia

Mature cystic teratoma is the most frequent benign ovarian neoplastic lesion in adolescents and is generally composed of fully differentiated tissue arising from multipotential three germinal layers. It accounts for approximately 50% of benign ovarian tumors in childhood. Rarely, a bilateral, synchronous, or metachronous presentation can be observed, supporting a conservative approach as the first surgical approach. We report a case of an ovarian mature cystic incarcerated in indirect inguinal hernia in a 15-year-old girl undergoing ovary-sparing surgery. To our knowledge this is the first case of such lesion incarcerated in an inguinal hernia reported in literature.

The recurrence rate of ovarian dermoid cysts in pediatric and adolescent girls

STUDY OBJECTIVE

To assess the rate of recurrence of ovarian dermoid cysts in pediatric and adolescent girls at the Hospital for Sick Children.

DESIGN

A retrospective chart review of all dermoid cysts surgically managed at the hospital for Sick Children from January 2003 to June 2012.

SETTING

The Hospital for Sick Children, Toronto, Canada.

PARTICIPANTS

66 adolescent and pediatric patients <18 years old treated with ovarian cystectomy of their dermoid cysts by either laparoscopy (n = 40) or laparotomy (n = 26).

MAIN OUTCOME MEASURES

Total dermoid cyst recurrence, recurrence after laparoscopy versus laparotomy, follow-up imaging completed and ultrasonographic identification of other ovarian cysts in follow-up. Data was assessed with Fisher exact test where appropriate (P < .05).

RESULTS

The mean age of patients at time of surgery was 12.9 years (range 2.5-18.1). 25/66 (38%) of patients received no follow-up, 6/66 (9%) were followed by a single ultrasonography and 35/66 (53%) were followed with annual ultrasonography for up to 5 years. 35 patients completed their initial ultrasonography where 19/35 (54%) patients had new ovarian cysts diagnosed including: 6 functional/hemorrhagic, 3 dermoid, and 10 unspecified cysts. All new dermoids were suspected at first follow-up ultrasonography (6/35), but 3 required a second follow-up ultrasonography for confirmation. Overall, 7/66 (11%) patients had recurrent or persistent dermoid cysts of which 2 (3%) required repeat surgery. There was no significant impact on the type of surgery and dermoid recurrence.

CONCLUSION

The incidence of recurrent dermoid cysts in a pediatric and adolescent population following ovarian cystectomy is 10.6% where only 3% will recur and require further surgical management.

Bilateral dermoid ovarian cyst in an adolescent girl

A 19-year-old unmarried woman with regular menstrual cycles presented with symptoms of vague abdominal pain of 1 month duration. General condition fair. Per abdomen-a firm, non-tender mass corresponding to 26 weeks of gestation with smooth surface, upper and lateral borders well defined, lower border not palpable was observed. Ultrasonography: left ovarian tumour 28×19 cm with mixed echogenicity was seen in the pelvis extending superiorly into the abdominal cavity with fat, fluid contents, multiple septations. Right ovary measures 6×4 cm with 3.7 cm focal hyperechoic lesion. Uterus anteverted, normal size. No free fluid seen. CT confirmed the ultrasonography findings. Cancer antigen (CA) 125 was 52 IU/mL. Exploratory laparotomy followed by left ovariotomy and salpingectomy and right ovarian cystectomy was performed, leaving behind a significant amount of normal ovarian tissue. Cut section of the gross specimen of the left ovarian tumour-dermoid cyst-plenty of sebaceous fluid and a large tuft of hair. The right ovarian cystectomy revealed a dermoid cyst with hair and pellets of sebum. Histopathology showed bilateral dermoid ovarian cyst.

[Presumed ovarian benign tumors and fertility]

We reviewed the studies about fertility-sparing in young patient presenting a benign ovarian tumor. It appears that more than the histologic nature of the ovarian cysts, it is the surgical treatment of the cyst which may decrease fertility. Some good practice of surgical procedures must be kept in mind when one manages a benign ovarian tumor in a young patient wishing to preserve her fertility: surgery should be avoided as much as possible; kystectomy is better than oophorectomy; no radical surgery should be done without pathological certitudes; electrocoagulation must be avoided on the cyst walls. In some situations, fertility is specially endangered: bilateral ovarian cysts, recurrence or strong probability of recurrence (endometriomas), poor ovarian reserve (previous chemo- or radiotherapy, age>35, premature ovarian failure). In these situations, a pre-operative assessment of the ovarian reserve could be useful. Beside the surgical 'good procedures', gamete cryopreservation procedures could be used. Cryopreservation of mature oocytes (after ovarian hyperstimulation) or in vitro mature oocytes (after antral follicle retrieval) can be proposed. Ovarian tissue cryopreservation is another option. Oocyte (or embryos) cryopreservation can be proposed before or after the surgery. The global management of benign ovarian tumors in young patients should be decided between surgeons and specialists in reproductive biology.

Metachronous bilateral ovarian teratoma: a germ-line familial disorder and review of surgical management options

BACKGROUND

Germ cell tumors in females are uncommon, and bilateral metachronous ovarian teratoma is even exceptional, with sporadic cases described in the literature.

CASE

We report on a girl in whom a metachronous ovarian teratoma occurred 6 years after the first. The simultaneous onset of germ-line anomalies in other members of the family supports the existence of genetic or environmental factors conferring susceptibility to germ cell lesions.

SUMMARY AND CONCLUSION

The case here illustrated reminds the issue of the appropriate follow-up of these patients and of their families.