Malignant Struma Ovarii – A Case Report and Review of the Literature

Struma Ovarii: Single Center Experience

Objectives

Struma ovarii (SO) accounts for approximately 1% of all ovarian tumors. The objective of our study is to contribute to the treatment algorithm by presenting our clinical experience in a comprehensive case series of patients diagnosed with SO, predominantly characterized by thyroid tissue within a monodermal teratoma.

Methods

Patients aged 17 years and older who underwent surgery due to ovarian masses and were histopathologically diagnosed with SO between January 2012 and January 2022 were included in the study. The patients' files were retrospectively reviewed. Demographic data, presenting complaints, radiological findings, tumor sizes, laboratory data, surgical procedures performed, pathology reports, additional treatments, and follow-up information were recorded.

Results

The median age of total 19 patients was 41.7 (17-74) years. Among them, malignant struma ovarii was present in 3 patients. In patients with histopathologically confirmed benign struma ovarii, no additional treatment was administered after tumor enucleation. In malignant cases, in addition to unilateral salpingo-oophorectomy, total thyroidectomy, radioactive iodine (RAI) ablation, and L-Thyroxine suppression were performed. No mortality occurred during the follow-up period.

Conclusion

Although conservative treatments are considered acceptable treatment in cases of benign struma ovarii, the management of cases with malignant struma ovarii is controversial. Fertility-sparing surgery followed by postoperative adjuvant thyroidectomy and radioactive iodine ablation may be preferred for young women.

Struma ovarii with Hashimoto's thyroiditis: case report and review of the literature

Background

Struma ovarii, a rare ovarian neoplasm originating from germ cells within mature teratomas, typically manifests benign characteristics. However, instances of malignant transformation have been documented.

Case description

This report discusses a 25-year-old woman who had surgery in May 2020 to remove teratomas from both ovaries. In 2023, an ultrasound showed a complex mass in her pelvis. Further imaging tests, including CT, MRI, and F-18 FDG PET/CT scans, along with high levels of the CA 125 protein, suggested a mass in her left ovary, initially thought to be ovarian cancer. However, a closer examination after surgery found thyroid tissue and several types of cell growth but no cancer, confirming the diagnosis of struma ovarii. The pathology of hypermetabolic thyroid nodules on F-18 FDG PET/CT confirmed Hashimoto's thyroiditis.

Conclusion

This case underscores the importance of considering struma ovarii in the differential diagnosis of ovarian masses, especially in patients with a history of teratomas. It highlights the challenges in distinguishing struma ovarii from ovarian cancer due to similar clinical signs and imaging. Struma ovarii can be associated with Hashimoto's thyroiditis.

Follicular Thyroid Carcinoma Arising from the Struma Ovarii Coexisting with Papillary Thyroid Carcinoma, Hashimoto's Thyroiditis and Polycystic Ovarian Syndrome-a Case Report and Literature Review

Purpose

Struma ovarii is a highly specialized teratoma consisting primarily of mature thyroid tissue. However, malignant struma ovarii coexisting with thyroid carcinoma, not to mention autoimmune disease, is uncommon. Malignant struma ovarii complicated with papillary thyroid carcinoma, Hashimoto's thyroiditis and polycystic ovarian syndrome has never been reported in literature.

Patients and Methods

A 32-year-old female was admitted to our hospital due to a history of abdominal distension and menolipsis over the past half a year. Physical examination touched a 6 × 6 cm mass with a clear boundary, normal movement, and no pressing pain in the right adnexal area, Imaging revealed a cystic solid mass of 6 × 7 cm in the right ovary and the level of tumor markers including CA125, CA199, CA153, CEA, AFP were normal, but with low TSH and increased TPOAb, TGAb, TRAb. Laparoscopic right ovary tumor resection was performed, followed by comprehensive staging surgery, as well as thyroidectomy after pathologic diagnosis. The patient was diagnosed with a combination of follicular thyroid cancer from struma ovarii, papillary thyroid carcinoma and Hashimoto's thyroiditis, along with polycystic ovarian syndrome. Immunohistochemical staining showed positivity for Ag, CK-pan, CK7, PAX8 and TTF-1 in the right ovarian mass, and the left thyroid was positive for the BRAF V600E mutation.

Results

The patient underwent thyroxine suppression therapy and radioactive iodine 131I therapy after operation. Serum thyroglobulin was undetectable, and no signs of recurrence or metastasis were detected in the imaging examination at the 2-year follow-up.

Conclusion

Malignant struma ovarii coexisting with thyroid carcinoma is rare. No report has been identified in literature review on the rare malignant struma ovarii coexisting with thyroid carcinoma, Hashimoto's thyroiditis and polycystic ovarian syndrome. Our case can offer experience of diagnosis and treatment to some extent for such rare case. Therefore, it is essential to consider the association between ovarian tumors and the endocrine system. This case is valuable in understanding the diagnosis and management of such an unusual complicated disease.

A case report of malignant struma ovarii with papillary thyroid carcinoma

Key clinical message

Struma ovarii (SO), is a rare and specialized ovarian teratoma. The treatment is controversial depending on the risk of recurrence and metastasis. Here a SO with papillary thyroid carcinoma is reported and the approach is thoroughly discussed.

Abstract

Struma ovarii (SO) is a highly specialized ovarian teratoma primarily composed of thyroid tissue. Clinical features associated with SO include lower abdominal discomfort, unusual vaginal bleeding, ascites, and hyperthyroidism. While SO rarely transforms into malignancy, the optimal degree of treatment remains controversial due to the varying risks of recurrence and metastasis. In this report, we present the case of a 64-year-old woman experiencing abdominal pain and diagnosed with SO, accompanied by papillary thyroid carcinoma. We thoroughly discuss the evaluation and management of this rare condition.

Struma Ovarii with Papillary Thyroid Carcinoma and Metastasis to the Appendix: A Case Report and Literature Review

Struma ovarii is an infrequent type of teratoma arising from the ovary accounting for only 2% of all ovarian teratomas. These tumors have a benign biology with rare malignant transformation in about 3% of cases. The most common malignant transformation that arises from struma ovarii is papillary thyroid carcinoma. These neoplasms act in the same way as those arising from the thyroid gland, but due to the rarity of their occurrence there is still a debate over therapeutic options. We present a case of a 41-year-old Ethiopian Para IX woman presented with abdominal swelling for four years, accompanied by dull pain, satiety, and weight loss. Her vital signs were normal, and her abdominal examination revealed a large abdominopelvic mass. Her CA-125 was elevated, and her blood count, organ function tests, and serum electrolyte levels were normal. Abdominal ultrasound revealed a complex abdominopelvic mass with cystic and solid components, possibly ovarian teratoma. The patient underwent surgery, revealing a 14 by 10 cm right ovarian mass and a 3×3 cm appendiceal mass. Subsequently, total abdominal hysterectomy, bilateral salpingo-oophorectomy, total omentectomy, and appendectomy was done. Histopathologic evaluation revealed follicular proliferation of enlarged cells, with no papillary growth pattern. The case was diagnosed as malignant struma ovarii, a follicular variant of papillary thyroid carcinoma (FVPTC) with secondary deposits on the appendix. A complete thyroidectomy was done after the histopathology diagnosis. Malignant struma ovarii is rare making it challenging to treat since there are no established prognosticating histopathologic or clinical characteristics. The tumor size and metastasis determine the surgical treatment scope. Large-scale investigations are essential for prognostication and treatment options considering pathologic traits.

Thyroid papillary cancer elements arising from struma ovarii with benign peritoneal strumosis: Utility of iodine-123 imaging in diagnostics and treatment planning

Key Clinical Message

In this case of struma ovarii a right-sided ovarian mass contained features of papillary thyroid cancer. Diagnostic iodine-123 revealed multiple foci of extraovarian spread, likely as a manifestation of concomitant peritoneal strumosis. Unilateral oophorectomy, partial peritonectomy, and adjuvant iodine-131 treatment were performed for successful curative treatment.

Abstract

Struma ovarii is a rare form of mature teratoma defined by a predominance of thyroid tissue. Approximately 5% of all ovarian strumae exhibit malignant transformation. Due to their extreme rarity, there has been a lack of consensus concerning uniform diagnostic criteria. Appropriate, risk-stratified treatment strategies also remain widely unelaborated, based only on a small number of cases reported in the literature. We describe the case of a 35-year-old female, who presented after undergoing unilateral oophorectomy for a right-sided ovarian mass. Histological workup revealed a struma ovarii containing papillary thyroid cancer (PTC). Postoperative I-123 scintigraphy with single photon emission computed tomography (SPECT) detected multifocal extra-ovarian spread to the peritoneum, containing likely benign strumosis upon pathological examination. The subsequent treatment strategy involved an ablative concept including total thyroidectomy and subsequent I-131 radioiodine therapy. Throughout a 3-year follow-up, the patient has remained without recurrence with thyroglobulin levels ranging below detection limits. Surgical resection with adjuvant radioiodine therapy is a curative therapeutic strategy in cases of struma ovarii with thyroid-type carcinoma and peritoneal strumosis. Its benefits lay in avoiding more extensive surgery, potentially maintaining fertility, facilitating follow-up, and minimizing the risk of recurrence. Reliable criteria for risk stratification are needed to identify patients who are most likely to benefit from this treatment approach.

Ovarian Germ Cell Tumors: Pictorial Essay

Ovarian germ cell tumors of the ovary represent a histologically heterogenous group of tumors with a high incidence at reproductive age. Patients with this pathology are very often young women with amenorrhea. The aim of this article is to present a pictorial essay of this rare pathology and to promote a national tumor registry and protocol. The treatment is individualized according to age, and fertility-sparing surgery is the actual standard of surgical treatment for young patients in early stage of the disease.

Case Report: Recurrent Malignant Struma Ovarii With Hyperthyroidism and Metastases, A Rare Case Report and Review of the Literature

Background: SO (Struma ovarii) is a rare form of ovarian teratoma which originates from ovarian dermoid cysts. Due to the rarity of this disease, relevant studies might not be sufficiently documented, especially cases with hyperthyroidism and multiple metastases.

Case Presentation: A 40-year-old female patient was admitted to our hospital due to management of early pregnancy along with a recurrent abdominal and pelvic mass. Contrast-enhanced CT images showed an irregular mass (10.7 × 8.6 × 12.8 cm) located in the right side from the hypogastrium to the pelvic cavity and another mass (3.8 × 3.7 cm) in the liver. Laboratory examination showed that CA125 (Carbohydrate Antigen-125) was 118.10 U/mL, Tg (thyroglobulin) was >300 ng/ml, FT4 (free thyroxine) was 22.11 pmol/L, and TSH (thyroid-stimulating hormone) was <0.004 mIU/L. She subsequently underwent liver mass dissection, omentectomy, tumor dissection, peritoneal nodule resection, as well as rectal anterior wall nodule resection. The patient was diagnosed with malignant SO (papillary type) along with multiple metastases. Also, we conducted a literature review based on 290 SO cases from 257 articles.

Conclusion: This study showed that malignant SO might be prone to relapse and metastasize (a metastatic rate of 52.94%) and therefore aggressive management might need to be recommended for malignant SO. Also, laparotomy might need to be recommended for large tumors that cannot be resected by laparoscopic surgery since these tumors might be prone to rupture and thus produce peritoneal implants. Furthermore, Graves’ disease might need to be considered in the differential diagnosis.

Metastatic follicular carcinoma arising from struma ovarii

Struma ovarii (SO) is an uncommon monodermal teratoma predominantly composed of mature thyroid tissue. Approximately 5% of SO are malignant; however, metastases are rare. A single female in her 40s, with a medical history of Graves' disease and bilateral cystectomy 10 years prior for right endometriotic cyst and left SO, presented with an enlarging abdominal mass for 4 months. Ultrasound pelvis showed a 13.8 cm left adnexal heterogeneous solid-cystic mass with internal septations and vascularity. She underwent open left salpingo-oophorectomy and resection of fibrous nodules from the right infundibulo-pelvic ligament and fallopian tube. Histology showed highly differentiated metastatic follicular carcinoma. She subsequently underwent total thyroidectomy, total hysterectomy, right salpingo-oophorectomy, tumour debulking and omentectomy followed by radioactive iodine treatment. Four-year follow-up did not show tumour recurrence or metastases. Due to its rarity, there are no well-established guidelines for the management and follow-up of metastatic follicular carcinoma arising from SO.

Malignant struma ovarii: From case to analysis

AIM

To evaluate the clinico-pathologic features, treatment options, prognostic factors, and survival outcomes of malignant struma ovarii based on a systematic literature review in association with our case study.

METHODS

A systematic review of the medical literature was performed to identify articles about malignant struma ovarii from January 1983 until July 2020. We evaluated 178 cases.

RESULTS

The 5-year progression-free survival (PFS) and overall survival (OS) of the entire cohort was 72.5% and 91%, respectively. In univariate analysis, younger age (<43 years), whole strumal cyst diameter >95 mm, presence of a histologic type other than papillary classic-type thyroid carcinoma within the tumor and lymphovascular space invasion were related to poor PFS. Patients who received radioactive iodine ablation (RIA) before the treatment failure had significantly higher PFS than those who did not receive RIA (94.9% vs. 64.8%, p = 0.041, respectively). In univariate analysis, PFS was significantly higher in patients who underwent gynecologic surgery followed by thyroidectomy and RIA compared with those who had surgical treatment only (94.5% vs. 64.3%, p = 0.05, respectively). However, this result could not be identified as an independent prognostic factor in multivariate analysis (p = 0.207). Younger age and absence of capsular involvement were related to significantly increased OS. Histologic type was the only independent prognostic factor for PFS (hazard ratio: 3.30, 95% confidence interval: 1.122-9.748; p = 0.030) CONCLUSION: The most common histologic subtype was the papillary classic type. The presence of a histologic type other than the classic papillary thyroid carcinoma within the tumor was an independent adverse prognostic factor.

The Clinical and Pathological Characteristics of Malignant Struma Ovarii: An Analysis of 144 Published Patients

The objective of this study is to summarize the clinical and pathologic characteristics of malignant struma ovarii to facilitate the early diagnosis and treatment of this disease. All 144 patients were females from 27 countries. The mean age of the patients at diagnosis was 42.6 years. Overall, 35.71% of the patients underwent unilateral oophorectomy, 58.57% of the patients underwent bilateral oophorectomy, 5.72% of the patients were not ovariectomized, and 38.57% of the patients received radioactive iodine treatment with an average dose of 158.22 mCI each time. “Impure” types accounted for 70.19% of the cases, while pure types accounted for 29.81% of the cases. Among these cases, papillary thyroid carcinoma accounted for 50.00%, follicular thyroid carcinoma accounted for 26.47%, follicular variant of papillary thyroid carcinoma accounted for 18.63%, papillary and follicular mixed thyroid carcinoma accounted for 2.94%, anaplastic carcinoma accounted for 0.98%, and medullary carcinoma accounted for 0.98%. In total, 21 patients (51.22%) had elevated CA125. More than half of the patients (51.94%) had metastasis outside the ovary. The most common metastatic site was the pelvic cavity. The misdiagnosis rate was 17.27%. Mortality was related to metastasis and the cancer type. Gene mutations were found in the NRAS, KRAS, BRAF, and KIT genes and were similar to those in thyroid carcinoma, but some patients (37.5%) did not exhibit any gene mutations. Regardless of the treatment received, the survival rate is high. Treatment could initially include ovariectomy; however, in cases with metastasis and iodine uptake of the metastatic tumor, thyroidectomy, radioactive iodine therapy, and thyroid hormone inhibiting therapy are indicated.

Malignant struma ovarii: surgical, histopathological and survival outcomes for thyroid-type carcinoma of struma ovarii with recommendations for standardising multi-modal management. A retrospective case series sharing the experience of a single institution over 10 years

PURPOSE

Struma ovarii is rare, accounting for 0.3-1% of ovarian tumours. Malignant transformation may occur, most often into papillary thyroid carcinoma. There is a paucity of data pertaining to malignant struma ovarii. This paper shares a decade of experience of a single institution in the management of this rare ovarian cancer, exploring the characteristics of this tumour and suggesting a standardised approach to treatment and follow-up.

METHODS

All patients treated for malignant struma ovarii within a large cancer centre over one decade were identified and data collected retrospectively on presentation, diagnosis, management, follow-up and survival outcomes. A literature review was also undertaken.

RESULTS

Eleven cases of malignant struma ovarii were managed in the Oxford Cancer Centre between 2010 and 2019, 6 of which were of papillary thyroid carcinoma sub-type. No cases were correctly diagnosed pre-operatively. All patients had stage I disease and were managed surgically-but with variation in radicality. Patients identified as high-risk based on final histopathology underwent additional thyroidectomy and radio-active iodine ablation therapy. One case of synchronous malignancy of the thyroid gland proper was identified. No disease recurrence occurred.

CONCLUSION

Malignant struma ovarii present a diagnostic challenge. Multi-disciplinary team (MDT) input is essential. Unilateral salpingo-oophrectomy may be adequate if stage I; reserving more radical surgery for advanced disease. Histopathological risk-stratification should be used to identify those most likely to benefit from adjuvant thyroid-targeting therapies. Patients require follow-up, anticipating an overall good prognosis.

Papillary Thyroid Carcinoma in Struma Ovarii

Struma ovarii is a variant of a germ cell tumor composed predominantly of thyroid tissue. It is most often unilateral. The incidence of malignancy arising in patients with struma ovarii is rare. Here, we present a case of struma ovarii in a female presented with abdominal distension. The patient was treated with a total hysterectomy and bilateral salpingo-oophorectomy, which revealed an enlarged cystically dilated ovary. Histopathologic examination showed mature thyroid follicles with abundant colloid consistent with struma ovarii and focal area with nuclear features of papillary thyroid carcinoma. No other teratomatous elements were identified. Thyroid hormone levels were within their respective reference ranges. A diagnosis of struma ovarii should be considered in the differential diagnosis of pelvic masses in peri- and postmenopausal patients.

Papillary Thyroid Cancer in a Struma Ovarii in a 17-Year-Old Nulliparous Patient: A case Report

Introduction: Struma ovarii accounts for 2% of mature teratomas. Struma ovarii is diagnosed when thyroid tissue accounts for >50% of the teratoma. Malignant transformation is rare, occurring in <5% of struma ovarii cases. Case presentation: A 17-year-old patient was diagnosed with papillary thyroid cancer in struma ovarii. The patient exhibited menstrual disorders. Abdominal and pelvic CT revealed a 17 cm mass in the left adnexa. Laparoscopic removal of the left adnexa with enucleation of right ovarian cysts was performed. Histopathological diagnosis was a follicular variant papillary carcinoma measuring 23 mm in diameter. Immunohistochemical positive expression of CK19, TTF-1, and thyroglobulin (Tg) confirmed the diagnosis. Molecular analysis detected the BRAF K601E mutation in ovarian tumor tissues. Preoperative serum Tg concentration was >300 ng/mL, which decreased to 38.2 ng/mL after gynecological surgery with undetectable anti-Tg antibodies. The patient underwent total thyroidectomy with no cancer detected on histopathological examination. The patient was treated with I-131 and showed no recurrence 4 years after the diagnosis. Conclusions: Malignant struma ovarii is diagnosed by surgery. Because papillary carcinoma in struma ovarii is rare and there are no guidelines regarding the management of this type of cancer, therapeutic decisions should be made individually based on clinical and pathological data.

Unusual Case of Malignant Struma Ovarii and Cervical Thyroid Cancer Preceded by Ovarian Teratoma: Case Report and Review of the Literature

Objective

To present a rare case of malignant struma ovarii (MSO) and synchronous thyroid cancer, review the medical literature, and present the latest trends in management.

Methods

The case of a woman with MSO and concomitant thyroid cancer is presented, including clinical presentation, treatment, and follow-up care. A search of the English-language literature was conducted using MEDLINE and Google Scholar data bases.

Results

We found 10 publications (one abstract) describing 10 patients with MSO and concomitant thyroid cancer. Six additional patients were reported by a study that analyzed the SEER (cancer registry) database. The median age of women was 42 years, with the majority of them presenting with abdominal symptoms. Histologically, most tumors were papillary carcinomas in both organs. In 5 patients, there was extrathyroidal tumor extension at time of surgery.

Conclusion

MSO can occasionally coexist with highly aggressive eutopic thyroid cancer. Although this concurrence is even rarer than MSO, clinicians should routinely investigate for possible synchronous thyroid cancer in all cases of MSO and also consider aggressive postoperative treatment including thyroidectomy and radioiodine ablation therapy in cases of MSO.

Precise preoperative diagnosis of struma ovarii with pseudo-Meigs' syndrome mimicking ovarian cancer with the combination of 131I scintigraphy and 18F-FDG PET: case report and review of the literature

Background

Struma ovarii is a rare ovarian neoplasm that often appears malignant on conventional imaging. Pseudo-Meigs’ syndrome with ascites, pleural effusion, and elevated serum CA 125 levels is much rarer and leads to misdiagnosis of ovarian cancer and unnecessary extended surgery.

Case presentation

A 50-year-old woman with abdominal distention and dyspnoea was referred to our hospital. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) showed a polycystic ovarian tumor with a solid component, pleural effusion, and massive ascites with negative cytology. Her serum CA 125 level was 1237 U/ml, indicating the presence of ovarian cancer. Based on increased uptake of ¹³¹I but no uptake of ¹⁸F–FDG in the tumor, the preoperative diagnosis was struma ovarii with pseudo-Meigs’ syndrome, which was confirmed histologically. She had no evidence of ascites and pleural effusion six months after surgery.

Conclusions

To date, there have been no systematic reviews focused on preoperative diagnosis with imaging modalities. The combination of ¹³¹I scintigraphy and ¹⁸F–FDG PET/CT in addition to conventional imaging modalities can provide the precise preoperative diagnosis of struma ovarii with pseudo-Meigs’ syndrome mimicking ovarian cancer, leading to the appropriate treatment strategy.

A Rare Case: Struma Ovarii in a 14-Year-Old Girl

Ovarian tumors presented with ovarian mass in childhood and adolescence are uncommon but an important part of gynecological cases. Struma ovarii is one of the rare cystic benign ovarian tumors that is observed predominantly in women who are between the ages of 40 and 60 years old. It is extremely rare in adolescents. Herein, we present a 14-year-old adolescent girl with struma ovarii who presented to the emergency room with abdominal pain.

Pathogenesis of Hyperthyroidism

Hyperthyroidism is a form of thyrotoxicosis in which there is excess thyroid hormone synthesis and secretion. Multiple etiologies can lead to a common clinical state of "thyrotoxicosis," which is a consequence of the high thyroid hormone levels and their action on different tissues of the body. The most common cause of thyrotoxicosis is Graves' disease, an autoimmune disorder in which stimulating thyrotropin receptor antibodies bind to thyroid stimulating hormone (TSH) receptors on thyroid cells and cause overproduction of thyroid hormones. Other etiologies include: forms of thyroiditis in which inflammation causes release of preformed hormone, following thyroid gland insult that is autoimmune, infectious, mechanical or medication induced; secretion of human chorionic gonadotropin in the setting of transient gestational thyrotoxicosis and trophoblastic tumors; pituitary thyrotropin release, and exposure to extra-thyroidal sources of thyroid hormone that may be endogenous or exogenous. © 2017 American Physiological Society. Compr Physiol 7:67-79, 2017.

Management dilemma of thyroid nodules in patients with malignant struma ovarii

Struma ovarii is a rare type of ovarian teratoma comprised of at least 50% thyroid tissue. While most are benign, 70% of malignant cases are diagnosed as papillary carcinoma. Management of patients with thyroid nodules following gynecologic surgery remains controversial and variable. Historically, the treatment of choice has been surgical removal to rule out ovarian carcinoma. Thyroid follow-up and further treatment options are guided by tumor characteristics. The patient in this case presented to the endocrine surgeon with multiple thyroid nodules, dysphagia and a history of struma ovarii that was surgically treated at an outside hospital. Fine needle aspiration demonstrated benign histology. However, due to compressive symptoms and uncertainty of other nodules, the patient underwent a total thyroidectomy. Due to limited published data and treatment guidelines regarding thyroid nodules in patients with a history of malignant struma ovarii, surgery was recommended to rule out papillary thyroid carcinoma and relieve the patient's dysphagia. More research focused on treatment and outcomes of struma ovarii patients with thyroid nodules is essential to establish treatment guidelines for these patients.

Novel BRAF and KRAS Mutations in Papillary Thyroid Carcinoma Arising in Struma Ovarii

Papillary carcinomas of thyroid type rarely arise within struma ovarii. There are limited data on the immunohistochemical and molecular features of these tumors. Three cases of papillary carcinoma arising in struma ovarii (PCSO) were identified. The clinicopathological features were reviewed and immunohistochemical staining for HBME-1, cytokeratin (CK) 19, and CD56 was performed. Tumor DNA was sequenced for somatic mutations using a panel of 26 oncogenes, with a particular focus on BRAF and KRAS mutations. The patients were aged 22, 48, and 55 years. All cases were FIGO stage IA. Two tumors were of classical histological type, and one was a follicular variant papillary carcinoma. All tumors expressed HBME-1 and two were positive for CK19. CD56 was negative in all three cases. One tumor demonstrated a BRAF G469A mutation in exon 11, and in a second case, a KRAS Q61K double base mutation in exon 3 was detected. These mutations have not been described previously in PCSO. No mutations were detected in the benign follicular components of the tumors adjacent to the malignant papillary tissue. None of the patients had tumor recurrence on clinical follow-up (range 11 months to 8½ years). HBME-1, CK19, and CD56 are useful immunohistochemical markers of PCSO. Novel BRAF and KRAS mutations were identified in two of three tumors suggesting that mutations in PCSO may differ from those commonly identified in papillary carcinoma of the eutopic thyroid. The clinical significance of these mutations is uncertain but follow-up data in this small series support the generally good prognosis of PCSO.

A case report of thyroid carcinoma confined to ovary and concurrently occult in the thyroid: is conservative treatment always advised?

INTRODUCTION

Struma ovarii is an ovarian teratoma, represented in more than 50% by thyroid tissue. Five percent of struma ovarii cases have been proven to be malignant and, as in the thyroid gland, papillary thyroid carcinoma is the most common histotype arising in struma ovarii. Because of the unusual occurrence of this tumor, its management and follow-up after pelvic surgery is still controversial. Usually, total thyroidectomy followed by radioiodine treatment is the choice treatment in metastatic malignant struma ovarii, while these procedures are still controversial in non-metastatic thyroid cancer arising in struma ovarii.

CASE PRESENTATION

We report a female with follicular variant of papillary thyroid carcinoma arising in struma ovarii. After pelvic surgery, thyroid morphofunctional examinations were performed and a single nodular lesion in the left lobe was discovered. The patient underwent total thyroidectomy and histological examination showed a papillary carcinoma. Radioiodine-ablation of residual thyroid tissue was performed and levothyroxine mildly-suppressive treatment was started.

CONCLUSIONS

A more aggressive treatment should not be denied for malignant struma ovarii without any evidence, even when apparently confined into the ovary. However, in selected cases, aggressive treatment may be advisable to decrease the risk of recurrence and to allow an accurate follow-up.

Long-term survival in metastatic malignant struma ovarii treated with oral chemotherapy: A case report

Malignant struma ovarii is a rare type of ovarian tumor. Metastasis from malignant struma ovarii is rare and has only been documented in 5–6% of cases. The natural history and optimal treatment strategy for malignant struma ovarii remains controversial due to its rarity. The current report presents the case of a 45-year-old female who presented with a tumor of the rib bone. Following resection, the postoperative diagnosis was a metastasizing thyroid carcinoma. No abnormality was detected in the thyroid gland, however, computed tomography revealed a tumor in the left ovary. The patient underwent a left salpingo-oophorectomy and a wedge resection of the right ovary. The postoperative diagnosis was determined as a mature cystic teratoma with malignant struma ovarii (thyroid type, follicular carcinoma) of the left ovary and mature cystic teratoma of the right ovary. Four years subsequent to the initial diagnosis, multiple lung metastases were detected. The following chemotherapies were administered sequentially and intermittently: Tegafur-uracil, paclitaxel/carboplatin and oral etoposide. During this period, the metastatic lesions extended into the bone and progressed slowly. The patient continues to survive with the disease and 24 years have passed since the initial diagnosis, 20 years following the diagnosis of multiple lung metastates. The present report describes a rare case of malignant struma ovarii in which surgical resection and pathological examination of a metastatic rib tumor resulted in the identification of the primary ovarian lesion. The clinical behavior of malignant struma ovarii does not necessarily indicate a histological malignancy, therefore, prediction of future metastasis is difficult and the optimal treatment strategy for malignant struma ovarii is controversial. The present case indicates that the long-term use of oral anticancer agents may facilitate the maintenance of tumor dormancy.

131I therapy using rhTSH stimulation and dosimetry in metastatic malignant struma ovarii

A 38-year-old woman with metastatic malignant struma ovarii, including massive liver metastases and retroperitoneal lymphadenopathy, underwent ovarian resection and retroperitoneal lymph nodes excision, partial hepatectomy, and radiofrequency ablation for liver metastases. She underwent thyroidectomy and received three I treatments using recombinant human thyrotropin stimulation and radioiodine dosimetry. posttherapy I imaging, anatomic images, and thyroglobulin levels showed significant diminution in the tumor burdens and remarkable decline in thyroglobulin levels. This case provided valuable information on recombinant human thyrotropin-assisted I ablation in conjunction with dosimetry in an unusual presentation of iodine-avid malignant struma ovarii with bulky metastases.

Laparoscopic excision of malignant struma ovarii and 1 year follow-up without further treatment

OBJECTIVE

To report the case of a patient with malignant struma ovarii, which was excised endoscopically.

DESIGN

Case study and literature review.

SETTING

Hospital outpatient clinic with subsequent hospitalization.

PATIENT(S)

A 40-year-old gravida 5, para 3 with an incidental ultrasonographic finding of a solid right adnexal mass.

INTERVENTION(S)

Endoscopic resection and 1-year follow-up.

MAIN OUTCOME MEASURE(S)

Treatment options and differential diagnosis.

RESULT(S)

The tumor was excised endoscopically.

CONCLUSION(S)

Malignant struma ovarii is a very rare, highly specialized form of mature ovarian teratoma, in which thyroid tissue is the predominant element. Because of the nonspecific symptoms and a lack of specific features in imaging studies, preoperative diagnosis is very difficult, and there is no standard treatment. Struma ovarii, which is potentially malignant, should be included in the differential diagnosis of an ovarian mass with cystic, solid, or mixed cystic and solid structure. Standardized treatment of malignant struma ovarii still remains undefined; currently the laparoscopic removal of the tumor may be a treatment option, and thyroidectomy and radiotherapy with 131I should be offered.

A case of papillary thyroid carcinoma in struma ovarii and review of the literature

Malignancy in struma ovarii is a rare form of ovarian germ cell tumour. Because of its rarity, the diagnosis and management of the tumour have not been clearly defined. We present a case of 67- year-old female with papillary carcinoma arising in struma ovarii and review the literature on malignancy in struma ovarii cases, focusing on management of these cases.