Cystic teratoma of the ovary: CT detection

Mature cystic teratoma and their malignant transformation

Mature cystic teratomas (MCT) are benign germ cells tumors which are fairly common and are often diagnosed incidentally. In most cases they don't present a significant risk to survival, but in some rare cases they can progress to a malignant phenotype. In such cases the treatment must be adjusted to the new conditions and tailored to suit the malignant phenotype. In this review, we aim to describe the main clinical and biological features of various types of recorded malignant transformations and/or complications, as well as stress their differences in clinical behavior and therapeutic options. The management of benign vs. malignant MCT differs greatly and a specific subtype of transformation should be taken into consideration when designing therapy, as it can greatly improve the survival and quality of life.

Size threshold as a risk for malignant transformation in typical ovarian dermoid lesions: a scoping review

PURPOSE

The O-RADS malignancy risk stratification of typical ovarian dermoid cysts by using a 10 cm threshold is based on expert consensus rather than analysis of objective clinical data. This comprehensive scoping review consolidated all currently available studies evaluating typical benign ovarian dermoid cyst size and risk for malignant transformation.

METHODS

A systematic review of MEDLINE, Embase, Scopus and the Cochrane library was performed from inception to January 14, 2024, using PRISMA-ScR guidelines. A grey literature search and forward searching of reference lists from included studies were performed. Case reports and case series evaluating dermoid cyst size and malignant transformation as defined by a pathological reference standard were included. Data synthesis was provided as a qualitative review of the existing literature.

RESULTS

Twenty-five studies were included in qualitative synthesis comprising 6 case reports and 19 retrospective studies with a total of 15,295 dermoid cysts. Of these, 215 lesions demonstrated malignant transformation. Studies reporting dermoid size with malignant transformation ranged from 1 to 32 cm with 46/173 (27%) total malignant transformation lesions measuring < 10 cm. Solid enhancing components were infrequently reported but all measured > 1 cm when described.

CONCLUSION

More than 25% of dermoid cysts with malignant transformation may be classified as "almost certainly benign" with the current 10 cm O-RADS malignancy risk threshold. Although surveillance of O-RADS 2 dermoid cysts may improve sensitivity, modifying a caveat recommendation for MRI O-RADS +/- gyn-oncologist referral when potentially solid components are present in otherwise typically benign dermoid cysts may be appropriate.

MR diagnosis of SCC arising within ovarian cystic teratomas: analysis of mural nodule characteristics

PURPOSE

This study aims to evaluate and identify magnetic resonance (MR) findings of mural nodules to detect squamous cell carcinoma arising from ovarian mature cystic teratoma (SCC-MCT).

METHODS

This retrospective study examined 135 patients (SCC-MCTs, n = 12; and benign MCTs, n = 123) with confirmed diagnoses across five different institutions between January 2010 and June 2022. Preoperative MR images for each patient were independently assessed by two experienced radiologists and analyzed following previously reported findings (PRFs): age, tumor size, presence of mural nodules, size of mural nodule, and the angle between mural nodule and cyst wall (acute or obtuse). Furthermore, this study evaluated four mural nodule features-diffusion restriction, fat intensity, Palm tree appearance, and calcification-and the presence of transmural extension.

RESULTS

There were significant differences between the SCC-MCT and benign MCT groups in terms of all PRFs and all mural nodule findings (p < 0.01). Among the PRFs, "tumor size" demonstrated the highest diagnostic performance, with a sensitivity of 83.3% and a specificity of 88.6%. A combination of the aforementioned four mural nodule findings showed a sensitivity and specificity of 83.3% and 97.6%, respectively, for the diagnosis of SCC-MCT. Regarding diagnosis based on a combination of four mural nodule findings, the specificity was significantly higher than the diagnosis based on tumor size (p = 0.021). Based on these mural nodule findings, three SCC-MCT patients without transmural invasion could be diagnosed.

CONCLUSION

Mural nodule MR findings had a higher diagnostic performance than PRFs for SCC-MCT and can potentially allow early detection of SCC-MCTs.

Computed tomographic findings in a canine ovarian teratoma

A 2-year-old, intact female, Labrador Retriever was referred for progressive abdominal distension, assessed by emergency clinicians as being extrauterine in origin on AFAST. Abdominal radiographs and ultrasound identified a large, lobulated, partially mineralized, soft tissue, mid-abdominal mass and gravid uterus. Contrast-enhanced CT identified a mixed fat to soft tissue attenuating mass with a complex internal mineralized matrix, heterogeneous contrast enhancement, receiving blood from the left ovarian artery. Histology confirmed a left ovarian teratoma, diffuse endometrial hyperplasia, and fetal implantation. The patient had a good post-operative outcome for 2 years, but was later diagnosed with primary cranial mediastinal neuroendocrine carcinoma.

Mature cystic teratoma without intratumoral fat: A diagnostic dilemma

Teratomas are the most common benign ovarian neoplasms in young women. Typical computed tomography imaging findings include fat, fat fluid level, tooth or calcification, rokitansky nodule, floating balls sign, and tufts of hair. They can have unusual imaging features leading to diagnostic dilemmas. Studies have shown the presence of intratumoral fat to be specific to ovarian cystic teratoma. However, there are reports in the literature of mature cystic teratoma that do not contain fat in the lumen of the cyst which can hinder an accurate diagnosis. They can be associated with various complications like torsion, rupture, malignant transformation, infection, and autoimmune hemolytic anemias. Presented here is a case of mature cystic teratoma without visible intracystic fat which underwent torsion.

Beyond the Norm: Unveiling a Dermoid Cyst in an Inguinal Hernia Case

This case report focuses on a rare presentation of a dermoid cyst within an inguinal hernia in a 15-year-old male patient. The patient presented with a four-day history of a persistent, non-reducible, physical exertion-related bulge in the left groin area, which improved upon lying supine. Ultrasound investigations revealed a complex cystic structure resembling a dermoid cyst within a left direct inguinal hernia. Post-operative histopathology confirmed the dermoid cyst with no signs of malignancy. This case emphasizes the need for a high degree of suspicion when dealing with inguinal swellings, as rare entities like epidermal cysts may mimic more common conditions like inguinal hernias.

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.

Adnexal Lesion Imaging: Past, Present, and Future

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

High-Grade Endometrioid Stromal Sarcoma of the Ovary: Malignant Transformation of Ovarian Mature Cystic Teratoma

We report an extremely rare case of ovarian high-grade endometrioid stromal sarcoma arising from a mature cystic teratoma with clinicopathologic features, and then we briefly review the pertinent literature. A 62-year-old nulliparous woman presented with lower abdominal pain that had begun 6 months earlier. Magnetic resonance imaging showed two adnexal masses with fat components, which suggested that they were mature cystic teratomas. The eccentric thick rim of the left mass showed irregular invasion of the uterus, which was suggestive of malignancy. Positron emission tomography/computed tomography demonstrated high fluorodeoxyglucose uptake in the corresponding area. The patient underwent debulking cytoreductive surgery. The diagnosis was of an International Federation of Obstetrics and Gynecology stage IIIC high-grade endometrioid stromal sarcoma arising from a mature cystic teratoma. After surgery, the patient received adjuvant chemotherapy with three courses of doxorubicin regimen. The cancer recurred 3 months after surgery, and the patient died of progressive disease. It might be helpful for clinicians to be aware of this rare disease and the poor prognosis when it is at an advanced stage.

Stage Ia squamous cell carcinoma as the malignant transformation of giant and unusual mature teratoma of the ovary in an elderly patient

Background

Mature cystic teratomas of the ovary (MCTO) are a type of germ cell tumor that may contain well-differentiated tissues developed from three germ cell layers and constitute about 20% of ovarian germ cell tumors. They are rare ovarian tumors with an annual incidence variable from 1.2 to 14.2 cases per 100,000 that occur mainly in women of reproductive age. They are frequently benign with a slow growth rate, even if they can undergo a malignant transformation in about 1–2% of cases.

Case presentation

Here, we present the case of an elderly woman referred to gynecological first aid for acute abdominal pain and showing a giant and unusual MCTO at rapid growth with malignant transformation in squamous cell carcinoma (FIGO stage Ia). The patient underwent pelvic mass removal trough emergency longitudinal midline laparotomic incision with intraoperative frozen pathologic examination. A complete surgical staging during the first surgery was performed. After about 9 years of follow-up, she died of non-oncological reasons without recurrence.

Conclusions

Present case highlights that CMTO with malignant transformation should always be suspected in elderly women in presence of pelvic mass at rapid growth, even if in absence of other clinical and ultrasonographic signs of malignancy. An intraoperative frozen pathologic examination may drive the best treatment.

Ovarian teratomas: clinical features, imaging findings and management

Ovarian teratomas are the most common type of germ cell tumors. There are three major subtypes of ovarian teratomas including mature, immature, and monodermal teratomas. Ultrasound, computed tomography and magnetic resonance imaging can demonstrate specific imaging findings for mature teratoma. Imaging features of immature and monodermal teratomas are less specific, but a combination of clinical features and imaging findings can help in the diagnosis. Imaging is also very helpful in guiding management. In this article, we review the epidemiology, histopathology, clinical presentation, imaging features and management of ovarian teratomas.

CT and MRI characteristics of ovarian mature teratoma in patients with anti-N-methyl-D-aspartate receptor encephalitis

PURPOSE

The purpose of this study was to determine the computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of ovarian mature teratoma in patients with anti-N-methyl-d-aspartate receptor encephalitis (NMDAR-E).

MATERIALS AND METHODS

A total of 125 women (mean age, 40.9±17.8 [SD] years; age range: 12-85 years) with 146 histopathologically or radiologically proven ovarian mature teratomas who underwent preoperative CT and MRI examinations were retrospectively included. Eight patients with 11 teratomas had NMDAR-E, whereas 117 patients with 135 teratomas did not have NMDAR-E. CT and MRI examinations were retrospectively reviewed and teratomas in patients with NMDAR-E were compared to those in patients without NMDAR-E. Comparisons were performed using Mann-Whitney U test or Fisher exact test.

RESULTS

In patients with NMDAR-E, maximum diameter of teratomas (26.1±9.3 [SD] mm), prevalence of teeth/calcification (36%) and rate of occupation by fat components (26%) were lower than those in patients without NMDAR-E (67.0±37.6 [SD] mm [P<0.01]; 75% [P<0.05]; and 65%[P<0.01], respectively). More than 75% of space was occupied by fat components in 76/135 teratomas (56%) in patients without NMDAR-E, whereas this was not observed in any teratoma in patients without NMDAR-E.

CONCLUSION

By comparison with teratomas in patients without NMDAR-E, teratomas in patients with NMDAR-E are smaller, have few teeth/calcification, and the amount of space occupied by fat components is smaller.

Ovarian teratoma in a woodchuck (Marmota monax) with hepatocellular carcinoma: radiologic and pathologic features

Background

Teratomas are germ cell neoplasms composed of a wide variety of tissues. In the woodchuck, only one testicular teratoma has been described in the literature. The objective of this report was to describe the radiologic and pathologic findings in a female woodchuck (Marmota monax) with an ovarian teratoma consisting of mature tissues originating from all three germ layers.

Case presentation

A 2-year-old female woodchuck that had been infected at birth with woodchuck hepatitis virus and subsequently developed hepatocellular carcinoma was incidentally discovered to have a mobile 6.6 × 4.8 × 4.7 cm abdominal mass on computed tomography (CT) imaging. The tumor was predominantly solid and heterogenous on CT with soft tissue, fat, and areas of dense calcification. The teratoma did not enhance with intravenous contrast administration. On ultrasound, the tumor was solid with heterogeneous echogenicity, reflecting the fat content and areas of calcification. Sonolucent areas were present that may have represented cysts. There was heterogeneously increased signal on T1-weighted magnetic resonance imaging (MRI) and heterogeneous hyperintensity in T2-weighted imaging. Fat was evident within the tumor. At necropsy, the tumor was attached to the distal end of the right uterine horn. Histopathology showed mature tissue types representing all three germ layers.

Conclusions

Ovarian teratoma should be considered in the differential diagnosis of ovarian or abdominal masses in woodchucks. The tumor displayed mature tissue derived from all three germ layers. CT, ultrasound, and MRI findings were presented in detail and matched the typical imaging appearance of teratomas.

Mature cystic ovarian teratoma without intracystic fat: Case report with the "fat within the wall" sign

Mature cystic teratoma is the most common ovarian neoplasm among young females. Diagnosed through radiological imaging as it exhibits typical radiological features; typically, fat. However, complete cystic teratoma without visible fat is a very rare and challenging diagnosis. It is difficult to distinguish it from malignant neoplasm, due to the presence of enhancing components, for example, Rokitansky nodule and the presence of diffusion restriction from keratinized products. We present a case of an incidental mature cystic teratoma without visible intracystic fat, where the correct diagnosis based on imaging was failed. Mature cystic teratoma was then confirmed upon histologic examination.

Meningioma in mature cystic teratoma of the ovary: clinical and computed tomography findings

Background

Mature cystic teratoma (MCT) with meningioma of the ovary is a very rare benign tumor. There is only 3 reports of this disease until June 2019. The aim of the present study was to describe a ovarian mature cystic teratoma containing meningioma and nests of neuroblasts in a 15-year-old girl.

Methods

The method used in the present study consists of description of the clinical history, image lab features, and pathological result.

Results

The patient complained of a 2-month history of irregular vaginal bleeding. Abdominal computed tomography (CT) showed a large oval cystic-solid mass with septations and fat density shadow, in abdomen pelvic cavity. The cystic part was the main component in the mass. The tumoral solid parts and its internal division could be seen intensified from slight to moderate on contrast-enhanced CT images compared with those on precontrast images, and the solid parts showed heterogeneous enhancement. Neighbouring intestinal tract and the uterus displaced by compression. The pathological examination confirmed the diagnosis.

Conclusions

The clinical feature of ovarian mature cystic teratoma with meningioma includes a lack of specificity. Only meticulous recording of the gross features, histopathological examination including immunohistochemistry and supportive clinical and radiological findings to arrive at a correct diagnosis in case of unconventional tumours. If necessary, preoperative puncture can be performed.

Adnexal incidentalomas on multidetector CT: how to manage and characterise

Although CT is not considered the examination of choice for the detection and characterisation of adnexal diseases, adnexal masses may be incidentally detected during CT examination performed for other clinical indications. Most adnexal incidentalomas are benign, and therefore may not require further investigation, follow-up or intervention; however, few of them may prove malignant. Multidetector CT has improved the diagnostic performance of the technique in the detection and differentiation of adnexal mass lesions. Radiologists should be able to recognise the normal CT appearance of the ovaries and the CT characteristics of various adnexal incidentalomas. This may obviate unnecessary imaging evaluation and allow optimal treatment planning. Regarding the management of adnexal lesions incidentally found on CT, recommendations based on the collective experience of the members of the American College of Radiology Incidental Findings Committee II have recently been presented.

Ovarian neoplasms of childhood

Ovarian neoplasms are rare in children. Although usually asymptomatic, they sometimes present with abdominal pain, abdominal distension or palpable mass. The distribution of neoplasms in the pediatric population is different from in adults; benign mature cystic teratoma is the most common ovarian tumor in children. Radiologists should be familiar with the variable sonographic, CT and MRI findings of ovarian neoplasms. Although the less frequently encountered ovarian malignancies cannot be reliably distinguished by imaging alone, it does play an important role in workup. This review discusses the imaging and relevant clinical manifestations of the more commonly encountered pediatric ovarian neoplasms.

Ovarian dermoid cyst complicated by small bowel obstruction, entero-ovarian fistula formation, and malignant degeneration

Dermoid cysts, or mature cystic teratomas, are complicated by malignant degeneration in only 1-2% of cases. Rarely, dermoid cysts result in complications of small bowel obstruction or entero-ovarian fistula formation. In the current report we present the case of a 59-year-old female with a known dermoid cyst who presented with leukocytosis and was discovered to have a small bowel obstruction at the level of an ileo-ovarian fistula. The patient was taken to the operating room and was treated with total abdominal hysterectomy, bilateral salpingo-oopherectomy, and short segment small bowel resection. Review of the surgical pathology revealed areas of malignant degeneration within the dermoid cyst to squamous cell carcinoma. To our knowledge, this is only the second reported case of an ovarian dermoid cyst complicated by small bowel obstruction, entero-ovarian fistula formation, and malignant degeneration.

A Spectrum of Entities That May Mimic Abdominopelvic Abscesses Requiring Image-guided Drainage

A variety of entities may mimic drainable abscesses. This can lead to misdiagnosis of these entities, unnecessary percutaneous placement of a pigtail drainage catheter, other complications, and delay in appropriate treatment of the patient. Types of entities that may mimic drainable abscesses include neoplasms (lymphoma, gallbladder cancer, gastrointestinal stromal tumor, ovarian cancer, mesenteric fibromatosis, ruptured mature cystic teratoma, recurrent malignancy in a surgical bed), ischemia/infarction (liquefactive infarction of the spleen, infarcted splenule), diverticula (calyceal, Meckel, and giant colonic diverticula), and congenital variants (obstructed duplicated collecting system). Postoperative changes, including expected anatomy after urinary diversion or Roux-en-Y gastric bypass and small bowel resection, may also pose a diagnostic challenge. Nonpyogenic infections (Mycobacterium tuberculosis, Mycobacterium avium complex, echinococcal cysts) and inflammatory conditions such as xanthogranulomatous pyelonephritis and gossypiboma could also be misinterpreted as drainable fluid collections. Appropriate recognition of these entities is essential for optimal patient care. This article exposes radiologists to a variety of entities for which percutaneous drainage may be requested, but is not indicated, and highlights important imaging findings associated with these entities to facilitate greater diagnostic accuracy and treatment in their practice. ^©RSNA, 2018.

The application of 18F-FDG PET/CT in ovarian immature teratomas when pathological examination results contradict clinical observations: a case report

RATIONALE

Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) could reveal potential lymph node involvement and assisted locating sample sites for pathological examinations.

PATIENT CONCERNS

Help choose the right treatment strategies for patients. To better stage immature ovarian teratomas with 18F-FDG PET/CT when lymphatic metastasis is suspected while lymph node biopsy results are negative.

DIAGNOSES

The ultimate pathological diagnosis was left ovarian cancer, an immature teratoma (IMT) Grade 1.

INTERVENTIONS

Surgery was the initial treatment option. Chemotherapy (BEP scheme: Bleomycin 30 mg d1, 7 + Etoposide 100mg d1-6 + Cisplatin 50mg d1-3) was then administered.

OUTCOMES

The post-operational pathological examination additionally showed a small number of tumor cells in para-aortic lymph nodes. The end-of-treatment disclosed no recurrent tumors and serum levels of AFP (2.9 ng/mL), hCG (0.12 mIU/L), and CA-125 (11.4 IU/mL) were normal.

LESSONS

18F-FDG PET/CT successfully detected lymphatic metastasis when lymph node biopsy results were negative, which would be of great significance in detecting metastasis and monitoring reoccurrence of ovarian immature teratomas.

Huge teratoma in a teenager

Mature cystic teratoma is the most common ovarian tumor in young females. We are presenting a 13-year-old African–American female with abdominal distension. Computed tomography of the abdomen showed midline cystic mass. Diagnosis was confirmed after laparoscopic left salpingo-oophorectomy. Malignant transformation of mature cystic teratoma is rare.

A possible Echinococcus granulosus calcified cyst found in a medieval adult female from the churchyard of Santo Domingo de Silos (Prádena del Rincón, Madrid, Spain)

Calcification, or mineralisation, can occur as part of a natural process, or by pathological processes. The purpose of this work is to examine an unidentified semi-spherical and perforate hollow mass, found near the pelvis of an adult female, dated 12th-13th century AD, exhumed of the Church of Santo Domingo de Silos (Prádena del Ricón, Madrid, Spain). The mass was examined by SEM and Energy Dispersive X-Ray Spectroscopy. These procedures revealed a heterogeneous inner surface with both smooth and irregular areas. A larger spherical and several smaller crescent-shaped perforations were noticed. X-ray microanalysis revealed the presence of the elements C, K, P, Ca, Al, Si, Fe, and Mg. The co-localisation of Ca and P suggests that they may be combined in a mineral matrix, likely formed in vivo. Other minerals probably came from the soil, although Fe could be related to the presence of blood. The macroscopic and microscopic appearances, chemical composition, and location of the calcified mass point to a possible hydatid cyst from Echinococcus granulosus, common in agricultural populations. This study used a suite of analytical techniques that are useful in the diagnosis of unknown calcified masses and can, therefore, be recommended for use in future analytical work.

Imaging Patterns of Intratumoral Calcification in the Abdominopelvic Cavity

Intratumoral calcification is one of the most noticeable of radiologic findings. It facilitates detection and provides information important for correctly diagnosing tumors. In the abdominopelvic cavity, a wide variety of tumors have calcifications with various imaging features, though the majority of such calcifications are dystrophic in nature. In this article, we classify the imaging patterns of intratumoral calcification according to number, location, and morphology. Then, we describe commonly-encountered abdominopelvic tumors containing typical calcification patterns, focusing on their differentiable characteristics using the imaging patterns of intratumoral calcification.

Mature cystic teratoma of the ovary: a cutting edge overview on imaging features

Mature cystic teratoma (MCT) is the most common neoplasm of the ovary and includes at least two well- differentiated germ cell layers. Different combinations of mature tissue derivatives with varying arrangements in the tumour cause a wide spectrum of radiological presentation ranging from a purely cystic mass to a complex cystic mass with a considerable solid component. In different imaging modalities, each radiological feature reflects a specific pathologic equivalent that forms because of diverse compositions of histological components. Understanding uncommon findings as well as the classic signs with basic knowledge of pathological equivalents permits a more accurate diagnosis and guides adequate treatment. In this review, radiological features of MCT in different imaging modalities (US, CT, MR imaging) including specific signs and useful radiological artefacts with brief emphasis on pathological basics are discussed.

Teaching points

• Ovarian mature cystic teratomas (MCTs) have a wide spectrum of radiological presentation.

• Each radiological feature of MCT reflects a specific pathologic equivalent.

• Understanding radiological signs with basic knowledge of pathology can permit a more accurate diagnosis.

Management of Familial Ovarian Teratoma: The Need for Guidance

Ovarian teratomas in prepubertal females are uncommon, but familial ones are exceedingly rare. We report an ovarian teratoma in an 8-year-old girl, her mother, and her maternal grandmother. The risk of a metachronous tumor and subsequent complications (such as torsion) in the contralateral ovary remain unclear. There is no clear guidance on follow-up management of patient and family members in the literature. We have reviewed the literature and discuss the challenges for the pediatric surgeon arising from such cases.

Benign enhancing components of mature ovarian teratoma: magnetic resonance imaging features and pathologic correlation

The purpose of this work was to evaluate cases of benign ovarian mature teratoma (MT) with enhancing solid components on pelvic magnetic resonance imaging (MRI) and to correlate the MRI findings with the pathology reports. We retrospectively reviewed MRI findings and pathologic reports of 126 patients with pathologically confirmed ovarian MT. Enhancing solid components were observed in 24 (18.8%) of 128 benign MTs. The largest diameter ranged from 5.9 to 42.2 mm. The appearance was variable. Of 24 tumors, 19 (79.2%) had regular borders. On pathologic analysis, solid components of benign MTs were identified as glial tissue, thyroid tissue, fibrous stroma, or vessels.

An Evaluation of the Incidence of Right-Sided Ovarian Cystic Teratoma Visualized on Sonograms

This study set out to determine the incidence of right-sided ovarian cystic teratoma. The author examined 270 cases of ovarian cystic teratoma. In this series, ovarian dermoids were more frequently found on the right ovary than the left ovary. The primary data were obtained over two decades and include both retrospective and prospective review. The data included the clinical history of each patient, pelvic sonography examination, and microscopic and/or surgical findings reports. Data used were limited to proven cases of ovarian cystic teratoma shown by sonography and confirmed by histology. Results demonstrate that 195 dermoids (72.22%) were located on the right ovary, 47 dermoids were found on the left side (17.41%), and 28 dermoids were found bilaterally (10.37%). The results indicate that the incidence of unilateral dermoids occurs more often on the right side.

A series of malignant ovarian cancers arising from within a mature cystic teratoma: a single institution experience

BACKGROUND

Mature cystic teratoma (MCT) is the most common germ cell tumor. It accounts for 10% to 20% of all ovarian masses. The likelihood of malignancy arising from within an MCT is low, and prognosis is poor.

METHODS

A single-institution retrospective chart review was completed of all cases of MCT from 2004 to 2012. Multiple variables were examined including procedure performed, residual disease after surgery, surgical stage, histologic type, site of primary disease, date of recurrence, whether or not adjuvant chemotherapy was given, and whether or not there was death secondary to disease.

RESULTS

During the study period, 1.2% of MCTs exhibited malignant transformation. The average age at presentation was 53.7 years. Mean follow-up time was 23 months. The most common presenting symptoms were bloating and abdominal pain. The average tumor size was 18 cm. Of note, 33% of cases were at least surgical stage IIIC at the time of presentation, whereas the remainder were stage IC or lower. Four (44.4%) of the 9 cases were identified as mucinous adenocarcinoma in addition to 1 case each of malignant melanoma, squamous cell carcinoma, and poorly differentiated adenocarcinoma. Only 1 patient experienced recurrence. One patient had a known MCT that was being managed expectantly and exhibited malignant transformation to a mucinous adenocarcinoma.

CONCLUSIONS

A large ovarian mass that is suspected to be a mature teratoma should be managed more aggressively in older patients. Our data suggest that although malignancy arising from mature teratomas is rare, it is more likely when patients are older than 40 years, the mass is greater than 18 cm, and there is any suspicion for a mucinous tumor. Like most ovarian tumors, these tumors most often present at later stages and, thus, can be difficult to treat. It is unclear what role chemotherapy or radiation plays in the management of these tumors.

Imaging features of complex solid and multicystic ovarian lesions: proposed algorithm for differential diagnosis

Complex solid and multicystic ovarian lesions are broad-spectrum diseases, ranging from benign to malignant. This article describes the broad-spectrum and imaging features of complex solid and multicystic ovarian lesions and illustrates an algorithmic approach to such lesions, focusing on the ultrasonography and magnetic resonance imaging features that allow one to hone the differential diagnosis. Multimodality imaging workup plays an important role in the characterization and differential diagnosis of these diseases. Also, knowledge of the clinical setting and imaging features for the spectrum of complex solid and multicystic ovarian lesions can lead to appropriate management.

Ovarian Dermoid Cyst Causing Distal Ureteral Obstruction

A case of a 45-year old woman with an ovarian dermoid cyst causing ureteric colic secondary to distal ureteral obstruction is reported. The dermoid cyst was observed on computed tomography to be adjacent to and compressing the distal left ureter and this was confirmed at surgical exploration. Following oophorectomy, the patient's symptoms completely resolved and the excised ovarian cyst was confirmed on pathological evaluation to be a dermoid cyst. This appears to be the first reported case of ureteral obstruction caused by an ovarian dermoid cyst in the English medical literature.

Ovarian malignant germ cell tumors: cellular classification and clinical and imaging features

Ovarian malignant germ cell tumors (OMGCTs) are heterogeneous tumors that are derived from the primitive germ cells of the embryonic gonad. OMGCTs are rare, accounting for about 2.6% of all ovarian malignancies, and typically manifest in adolescence, usually with abdominal pain, a palpable mass, and elevated serum tumor marker levels, which may serve as an adjunct in the initial diagnosis, monitoring during therapy, and posttreatment surveillance. Dysgerminoma, the most common malignant germ cell tumor, usually manifests as a solid mass. Immature teratomas manifest as a solid mass with scattered foci of fat and calcifications. Yolk sac tumors usually manifest as a mixed solid and cystic mass. Capsular rupture or the bright dot sign, a result of increased vascularity and the formation of small vascular aneurysms, may be present. Embryonal carcinomas and polyembryomas rarely manifest in a pure form and are more commonly part of a mixed germ cell tumor. Some OMGCTs have characteristic features that allow a diagnosis to be confidently made, whereas others have nonspecific features, which make them difficult to diagnose. However, imaging features, the patient's age at presentation, and tumor markers may help establish a reasonable differential diagnosis. Malignant ovarian germ cell tumors spread in the same manner as epithelial ovarian neoplasms but are more likely to involve regional lymph nodes. Preoperative imaging may depict local extension, peritoneal disease, and distant metastases. Suspicious areas may be sampled during surgery. Because OMGCTs are almost always unilateral and are chemosensitive, fertility-sparing surgery is the standard of care.

Three cases of immature teratoma diagnosed after laparoscopic operation

While mature cystic teratoma of the ovary is the most common ovarian tumor in young women, immature teratoma is a very rare tumor, representing only 1% of all ovarian cancers. In the three cases presented here, young women who were suspected to have mature cystic teratoma, based on CT scan and MRI, were ultimately diagnosed with immature teratoma Ic (b) G1 after laparoscopic operation. They underwent salpingo-oophorectomy of the affected side only and have shown no sign of recurrence during follow-up. We sometimes encounter patients with immature teratoma who have no findings pointing to malignancy on CT or MRI. Generally, if the components of immature nerve cells that represent immature teratoma are very few, it is difficult to diagnose the entity as immature teratoma with imaging evaluations such as CT or MRI. In many hospitals, laparoscopic surgery is selected for patients with ovarian mature teratoma. Therefore, it is essential to attempt as much as possible not to disseminate the fluid content of the tumor into the intra-abdominal space during laparoscopic operation, because in rare cases the tumor turns out not to be benign mature teratoma.

Misdiagnosis of a giant intrapelvic schwannoma: A case report

Presacral schwannomas are a rare disease. The current case report presents a case of giant schwannoma with severe abdominal pain, constipation and dysuresia. The patient was initially diagnosed with an ovarian teratoma, which is an extremely common disease. The pain pattern and accompanying symptoms were the major factors indicating a teratoma. Abdominal computed tomography (CT) scans were the main tools of differential diagnosis, but the unsharpness of CT often disturbs diagnosis. Diagnosis of the tumor was confirmed by histopathology and immunohistochemistry, revealing a benign presacral schwannoma. The patient underwent complete resection and recovered well, albeit with a large amount of blood loss. The tumor was 25×15×10 cm³ in size and in contact with the sacrum. The aim of the present study was to review the diagnostic techniques of careful radiological examination. A follow-up was performed 2 years following the surgery and the patient remained alive and a CT scan demonstrated no evidence of recurrence. However, the long term efficacy of this process requires continuous observations of the patient.

Value of dynamic contrast-enhanced MRI for tissue characterization of ovarian teratomas: correlation with histopathology

AIM

To analyse the value of double contrast-enhanced (DCE) magnetic resonance imaging (MRI) in addition to conventional MRI to characterize ovarian teratomas subtypes with histological correlation.

MATERIALS AND METHODS

From January 2005 to December 2008, 38 women undergoing MRI and subsequent resection of ovarian teratomas were identified [40 mature cystic teratomas (MCT), two struma ovarii, three immature teratomas]. MRI images were analysed blindly by two radiologists according to morphological and vascular abnormalities. An experienced histopathologist reviewed all slides to determine the presence and histological composition of Rokitansky protuberances.

RESULTS

Thirty-one MCT (77%) had at least one small, regular Rokitansky protuberance presenting at an acute angle with the cyst wall. Ten out of 31 MCT did not display any enhancement on contrast-enhanced MRI related to sebaceous glands, adipose lobules, keratin, and pilosebaceous adnexa at histology. Three different time-intensity curve (TIC), types 1, 2, and 3, were related to presence of smooth muscular cells and fibrous, neuroglial, or thyroid tissue, respectively, found at histology of MCT. Type 3 TIC was also present in one struma ovarii and two immature teratomas.

CONCLUSION

TIC types are related to the specific content of the solid tissue of ovarian teratomas but cannot be used to differentiate benign and malignant ovarian teratomas.

Computed Tomography Imaging of the Acute Pelvis in Females

Sonography is the primary imaging modality for the evaluation of pelvic pain in female patients, especially if gynaecological pathology is suspected. However, computed tomography (CT) is frequently used in patients who present to emergency departments (and elsewhere) with otherwise nonspecific abdominal and pelvic pain and may be the first imaging modality to demonstrate an acute gynaecological abnormality. Computed tomography can also be used prospectively in selected patients to further evaluate findings initially identified on sonography, although to reduce radiation exposure, magnetic resonance imaging is being used more frequently in this situation. The purpose of this article is to discuss the spectrum of gynaecological findings of the acute female pelvis that may be identified on CT by the emergency radiologist and by the general radiologist, with a brief review of the imaging literature of each specific diagnosis.

Multimodality imaging of ovarian cystic lesions: Review with an imaging based algorithmic approach

Ovarian cystic masses include a spectrum of benign, borderline and high grade malignant neoplasms. Imaging plays a crucial role in characterization and pretreatment planning of incidentally detected or suspected adnexal masses, as diagnosis of ovarian malignancy at an early stage is correlated with a better prognosis. Knowledge of differential diagnosis, imaging features, management trends and an algorithmic approach of such lesions is important for optimal clinical management. This article illustrates a multi-modality approach in the diagnosis of a spectrum of ovarian cystic masses and also proposes an algorithmic approach for the diagnosis of these lesions.

Management of giant ovarian teratoma: A case series and review of the literature

The management of ovarian teratomas in normal conditions is well established, but in rare giant cases (tumor diameter over 15 cm), the choice of management, such as laparotomic or laparoscopic approaches, are controversial and may be therapeutically challenging for surgeons. The aims of the current study were to analyze the clinical features of giant ovarian teratoma and to discuss its management. The clinical data of 330 patients with giant ovarian teratoma (of whom 1 patient was treated by the authors and 329 were admitted to the Second Affiliated Hospital of Zhejiang University Medical College between January 1st 2000 and December 31st 2010) were reviewed and analyzed. The patients had an age range of 6 to 83 years and a mean tumor size of 24.9±7.1 cm. Of the 330 patients, 102 (30.9%) were asymptomatic and the majority (69.1%, 228/330) reported symptoms. There were more patients in the laparotomic group than the laparoscopic group, especially for the emergency cases (5.5 vs. 0%, P<0.05). Accidental cyst rupture was more frequent when a laparoscopic approach was used (31.5 vs. 19.6%, P<0.05). These results suggest that laparotomic resection may be preferred for the en bloc mass removal, adequate abdominal cavity irrigation and avoidance of accidental mass rupture in the management of giant ovarian teratomas. Familiarity with the imaging features of giant ovarian teratomas effectively aids preoperative diagnosis and differentiation.