Clinical evaluation of squamous cell carcinoma antigen in squamous cell carcinoma arising in mature cystic teratoma of the ovary

Malignant transformation of mature cystic teratoma of the ovary

Mature cystic teratoma is the most common ovarian germ cell neoplasm. Malignant transformation is a rare occurrence, accounting for 1.5%-2% of cases. Malignant changes can arise from any constituent tissue of a teratoma; however, squamous cell carcinoma is the most common histologic type seen, followed by adenocarcinoma and sarcoma respectively. Tumor marker concentration levels, age, and the tumor maximum diameter are predictive indicators for malignant transformation. Proper diagnosis includes recognizing the possibility of malignant transformation versus excluding other differential options, such as metastasis. Primary cytoreductive surgery, adjuvant chemotherapy, and radiotherapy are the current treatment methods. The aim of the review is to discuss the clinical and pathologic features of malignant transformation within mature cystic teratomas, while reviewing the reported malignant types, differential diagnoses, and treatment options. Data sources include review of pertinent peer-reviewed literature on malignant transformation of mature cystic teratoma and cases seen in authors' institutional practice. Mature cystic teratomas are a commonly encountered benign ovarian tumor. However, the possibility of malignant transformation should remain in consideration, especially with given clinical or pathologic features: increased patient age, tumor size, or tumor marker levels. Thorough sampling of solid tumor foci can help identify malignant components. Awareness and proper diagnosis, along with early detection and clinical management, shows improved patient outcomes.

Squamous cell carcinoma arising in a partially ruptured giant mature cystic teratoma: A case report

Mature cystic teratomas are the most common ovarian germ cell tumors and represent 70% of the benign ovarian tumors occurring in women under age 30. In less than 2% of cases, these tumors can transform into malignancies. Squamous cell carcinoma arises most frequently from these tumors (in 80% of cases). Intra-peritoneal rupture accounts for approximately 1%-2% of cystic teratoma complications with most ruptures occurring either intraoperatively during laparoscopic surgery or due to trauma. This case report describes the common presentation, imaging, and pathologic findings of a mature cystic teratoma with 2 uncommon associated complications.

Malignant transformation of ovarian mature cystic teratoma into squamous cell carcinoma: a Taiwanese Gynecologic Oncology Group (TGOG) study

Objective

The malignant transformation (MT) of ovarian mature cystic teratoma (MCT) to squamous cell carcinoma (SCC) is very rare. This study analyzed cases from multiple medical centers in Taiwan to investigate the clinicopathologic characteristics, treatment, and prognostic factors of this disease and reviewed related literature.

Methods

Pathological reports of 16,001 patients with primary ovarian cancer who were treated at Taiwan medical centers from 1990 to 2011 were reviewed. In total, 52 patients with MT of MCT to SCC were identified.

Results

Among all ovarian MCTs, the incidence of MT to SCC is 0.2%. The median age of patients was 52 years (range, 29–89 years), and the mean tumor size was 10.5 cm (range, 1–40 cm). We analyzed the patients in our study and those in the literature and determined that early identification and complete surgical resection of the tumor are essential for long-term survival. In addition, adjuvant chemotherapy or concurrent chemoradiotherapy can be used to treat this malignancy. Old age, large tumor size (≥15.0 cm), and solid components in MCTs are suitable indicators predicting the risk of MT of MCT to SCC.

Conclusion

Similar to general epithelial ovarian cancers, the early detection of MT of MCT to SCC is critical to long-term survival. Therefore, older patients with a large tumor or those with a tumor containing a solid component in a clinically diagnosed MCT should be evaluated to exclude potential MT to SCC.

Relevance of frozen sections and serum markers in invasive squamous cell carcinoma arising from ovarian mature cystic teratoma: two case reports

BACKGROUND

Ovarian mature cystic teratoma (MCT) is a common neoplasm in women. While malignant transformation of MCT is relatively rare, squamous cell carcinoma is the most frequent malignant neoplasm arising from MCT. Some tumor markers have been reported to be useful for prediction of MCT malignant transformation prior to operation. However, widely accepted use of these markers remains to be established. In the present study, we report the usefulness of frozen section assessment during operation, as well as preoperative measurement of tumor marker levels.

CASE PRESENTATION

We present two cases of squamous cell carcinoma arising from ovarian MCT. The first case was a 45-year-old Asian woman referred to our hospital after her periodical company medical checkup, due to possible ovarian tumor. Image analysis suggested a dermoid cyst, and left salpingo-oophorectomy was performed. Because the cyst was histologically diagnosed as an invasive squamous cell carcinoma arising from an MCT, our patient underwent an additional preventative operation. The TNM classification and FIGO stage were T1aNXM0 and Ia, respectively. The second case was a 53 -year-old Asian woman who visited our hospital due to complaints of abdominal pain and urinary retention. Image analysis and laboratory data showing high serum levels of SCC antigen (normal range: < 1.5 ng/mL) and CA19-9 (normal range: < 37 U/mL), which strongly suggested malignant transformation of MCT. Frozen sections obtained during the operation were histologically analyzed to confirm malignancy, and our patient underwent an additional operation. The TNM classification and FIGO stage were T1aNXM0 and Ia, respectively.

CONCLUSIONS

We report the usefulness of frozen section assessment during operation, as well as preoperative measurement of tumor marker levels.

[Complications of presumed benign ovarian tumors]

The main risk factor of adnexal torsion is a previous adnexal torsion (LE3). There is no clinical, biological or radiological sign that may exclude the diagnosis of adnexal torsion (LE3). The presence of flow at color Doppler imaging does not allow exclusion of the diagnosis (LE2). An emergent laparoscopy is recommended for adnexal untwisting (Grade B), except in postmenopausal women where oophorectomy is recommended (grade C). A persistent black color of the adnexa after untwisting is not an indication for systematic oophorectomy (grade C), since a functional recovery is possible (LE3). Ovariopexy is not routinely recommended following adnexal untwisting (grade C). The clinical signs of intra-cystic hemorrhage and those of rupture of the corpus luteum are not specific (LE4). MRI is not recommended to confirm the diagnosis of intra-cystic hemorrhage (grade C). Malignant transformation of an ovarian cyst is very rare. The presence of a benign ovarian cyst is not associated with an increased risk of ovarian cancer at long-term follow-up (LE2). For these women, an ultrasound follow-up is not recommended (grade C). Dermoid ovarian cyst containing nerve tissue can trigger the production of pathogenic auto-antibody-anti-NMDA, leading to encephalitis. A high proportion of thyroid tissue in a mature teratoma (struma ovarii) may cause hyperthyroidism.

Squamous cell carcinoma arising from mature cystic teratoma of the ovary with synchronous endometrial adenocarcinoma

Squamous cell carcinoma arising from a mature cystic teratoma of the ovary is a rare event representing only 1-2% of all mature cystic teratomas. Furthermore, the synchronous occurrence of a second malignancy in this setting is extremely rare. A 63-year-old woman presented with a pelvic mass which was diagnosed as a left ovarian mature cystic teratoma preoperatively by ultrasonography. The frozen section of the mass revealed a left ovarian mature cystic teratoma with a focus of squamous cell carcinoma. Subsequently surgical staging procedure for ovarian cancer was performed. The final pathologic diagnosis was squamous cell carcinoma in mature cystic teratoma of the ovary, and synchronous endometrial adenocarcinoma with a mixture of endometrioid and mucinous subtypes as an incidental finding. The combination of these two synchronous cancers is unique and to the best of our knowledge, this has not been previously reported in the English language literature.

Squamous-cell carcinoma in mature cystic teratoma of the ovary: systematic review and analysis of published data

Up to a quarter of ovarian masses originate from germ cells, and many of these are mature cystic teratomas. The secondary development of malignancy is a rare but well-known phenomenon in patients with ovarian teratomas. Squamous-cell carcinoma accounts for 80% of secondary malignant transformations of ovarian teratomas. We aimed to do an up-to-date systematic review of this rare malignant transformation. 64 suitable studies provided information on 277 patients. Squamous-cell carcinoma in mature cystic teratoma was mainly found in women aged more than 50 years, with high concentrations of squamous-cell-carcinoma antigen and cancer antigen CA125, and with ovarian tumours more than 100 mm in size. Patients with FIGO stage Ia tumours had better survival than those with more advanced disease. Complete resection together with hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy for patients with advanced disease, followed by adjuvant chemotherapy with an alkylating drug was associated with higher survival, radiotherapy was not. We make proposals for investigation and treatment of this rare disorder.

Malignant transformation of mature cystic teratoma of the ovary: experience at a single institution

OBJECTIVES

Malignant transformation of mature cystic teratoma (MCT) of ovary is very rare. Therefore, the clinicopathologic characteristics, treatment and prognostic factors are not yet well established. The aim of this study was to review our experience with this malignancy and previously published reports in the literature.

STUDY DESIGN

A review of pathologic reports for 2019 patients with ovarian MCT and 937 patients with primary ovarian cancer who were treated at the Asan Medical Center, Korea, from 1989 to 2007 identified 16 patients with malignant transformation from MCT. A retrospective chart review of these patients and a review of the literature were performed.

RESULTS

The incidence rate of malignant transformation was 0.8% of all ovarian MCT. It accounted for 1.7% of all primary ovarian cancer. Squamous cell carcinoma was the most common histologic type, comprising 75%. The median age of the 16 patients was 50 years (range, 29-75 years). Mean tumor size was 14.5 cm (range, 5-26 cm). Twelve patients had some solid portions in the cyst containing fat fluid, hair, and/or calcification. According to the review of the patients in our study and of the literature, early detection and complete surgical resection are important for long-term survival. It seems that adjuvant chemotherapy or concurrent chemoradiation therapy have roles in treating this malignancy.

CONCLUSIONS

Early detection is important for long-term survival. Old age, large tumor size, and solid portion in mature cystic teratoma seem to predict the malignant transformation of mature cystic teratoma.

[Degeneration of dermoid cysts: a case study of malignant transformation]

Malignant transformation of ovarian dermoid cyst (mature cystic teratoma) is rare and most often established in postmenopausal women after surgery by sample anatomopathological analysis. We report the case of a 58-year-old woman showing abdominal pain associated with constipation episodes. The diagnosis of dermoid cyst was established upon ultrasonographic and tomodensitometric criteria. Its histopathological analysis confirmed the presence of a well differentiated epidermoid carcinoma. In line with the literature, our study highlights the importance of the age of the patient, the size of dermoid cyst and its growth rate as well as squamous cell carcinoma (SCC) antigen serum level. These date are collected in order to establish a correct diagnosis and provide an appropriate cure. When a cyst is discovered these data must pathological event, mostly observed in menopaused women. Certainty diagnosis is collected in order to establish a correct diagnosis and provide an appropriate cure.

Malignant transformation in mature cystic teratoma of the ovary: report of five cases and review of the literature

The incidence of malignant transformation in mature cystic teratoma (MCT) of the ovary is less than 2% as reported in gynaecological and pathological literature. Here we present a series of five patients, who developed malignant transformation in MCT of the ovary, over a 6-year period (1999-2004). The morphological and clinico-pathological features of malignant transformation in MCT of the ovary are discussed.

Malignant transformation within a dermoid cyst: a case report and literature review

Malignant transformation within a dermoid cyst is a rare event. The most common transformation is to squamous cell carcinoma. Patients are often elderly and present with advanced disease. The prognosis tends to be very poor. We present a case of locally invasive squamous cell carcinoma arising from a dermoid cyst in a 48-year-old lady. She underwent debulking surgery with no gross residual disease remaining. Within 2 months of the surgery she had recurrent disease and this was resistant to single agent carboplatin chemotherapy. She died 4 months after her initial surgery. We discuss the difficulties in diagnosing such tumours, the poor prognosis and review the various adjuvant treatment strategies that have been used in attempt to improve the outcome.

Squamous cell carcinoma arising from dermoid cyst: Case reports and review of literature

Malignant transformation of a dermoid cyst is rare, with squamous cell carcinoma (SCC) being the most common type. During a 10-year period in our institution, we encountered only four cases of SCC out of 425 cases of dermoid cyst, an incidence of 0.94%. Two were of old age, in menopausal status (63 and 74 y), while the other two were in their early forties. Three cases presented with pelvic masses while the other one had nonspecific wasting symptoms and later diarrhea. Three were in early stage and have survived to date without evidence of disease at 8, 12, and 116 months after diagnosis. The other case, in stage III, had suboptimal surgery and responded partially to chemotherapy, subsequently progressed after cessation of the drug, and finally died within a year after diagnosis.

Clinical significance of combined use of macrophage colony-stimulating factor and squamous cell carcinoma antigen as a selective diagnostic marker for squamous cell carcinoma arising in mature cystic teratoma of the ovary

OBJECTIVES

Mature cystic teratoma of the ovary transforms into malignant tumors, mostly squamous cell carcinomas, at an incidence of approximately 2%. Preoperative diagnosis of squamous cell carcinoma arising in mature cystic teratoma of the ovary is a difficult task. The present study aims to assess whether combined use of two serum tumor markers, macrophage colony-stimulating factor (M-CSF) and squamous cell carcinoma antigen (SCC), is effective in preoperatively diagnosing squamous cell carcinoma arising in mature cystic teratoma of the ovary, distinguishing it from mature cystic teratoma without malignant transformation.

METHODS

Serum levels of M-CSF and SCC were assayed using blood samples collected preoperatively from 31 patients with squamous cell carcinoma arising in mature cystic teratoma of the ovary and 133 patients with mature cystic teratoma of the ovary without malignant transformation.

RESULTS

In 22 of the 31 (71.0%) patients with squamous cell carcinoma arising in mature cystic teratoma of the ovary, the serum M-CSF levels exceeded the upper limit of the normal level (1056 U/ml). This positive incidence of the elevated serum M-CSF levels was significantly higher compared with that (13.5%, 18/133) observed in patients with benign cystic teratoma of the ovary (P < 0.0001). Regarding the serum levels of SCC, 13 of 31 (41.9%) patients with malignant tumors showed positive values exceeding the cutoff value of 2.0 ng/ml. Again, this incidence of positive cases was significantly higher compared with that (15.0%, 20/133) observed in patients with benign tumors (P < 0.01). There was no correlation between the serum levels of M-CSF and SCC among patients with squamous cell carcinoma arising in mature cystic teratoma of the ovary. Patients with malignant tumors testing positive for elevated M-CSF did not necessarily test positive for SCC. Patients with positive values for excess M-CSF and/or SCC constituted 87.1% of the total (27/31). Even when patients were restricted to those with stage I tumors, a value as high as 83.3% (15/18) was still obtained for those testing positive for elevated M-CSF and/or SCC.

CONCLUSION

Serum M-CSF was proven to be useful as a tumor marker for detecting squamous cell carcinoma arising in mature cystic teratoma of the ovary. Combined use of serum M-CSF and SCC as a marker seemed to be useful in the selective diagnosis of mature cystic teratoma of the ovary harboring malignant squamous carcinoma, discriminating it from that without malignant carcinoma.

Transvaginal color Doppler ultrasonic characterization of benign and malignant ovarian cystic teratomas and comparison with serum squamous cell carcinoma antigen

BACKGROUND

The preoperative diagnosis of squamous cell carcinoma (SCC) arising in mature cystic teratoma of the ovary remains difficult. The purpose of this study is to examine the usefulness of transvaginal color Doppler ultrasound (TV-CDU) in differentiating malignant (SCC) from benign cystic teratoma of the ovary.

METHODS

Eighty-eight patients with an ovarian tumor showing gray scale sonographic appearances of mature cystic teratoma were preoperatively evaluated for the presence or absence of intratumoral blood flow by TV-CDU. The blood flow characteristics of the tumor vessels were analyzed using the resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV). The serum levels of SCC antigen were also randomly examined preoperatively in 50 patients.

RESULTS

Intratumoral blood flow was significantly detected in malignant teratomas (SCCs) (80.0%; 4 of 5) compared with benign teratomas (20.5%; 17 of 83) (P < 0.01). All malignant teratomas with intratumoral blood flow showed both RI less than 0.4 and PI less than 0.6, whereas no benign teratomas showed any such value except for 1 case with struma ovarii. In addition, both the mean RI and the mean PI values in the tumor vessels were significantly lower in the malignant teratomas (RI: 0.31 +/- 0.07; PI: 0.40 +/- 0.16) than in the benign teratomas (RI: 0.62 +/- 0.13; PI: 1.06 +/- 0.44) (P < 0.001). However, the mean PSV value of the malignant teratomas (PSV: 20.6 +/- 8.33) was not significantly different from the benign teratomas (PSV: 18.1 +/- 9.9). Elevation of serum SCC was found in 4 of 5 patients (80%) with malignant teratomas, whereas the elevation was found in 11 of 45 patients (24.4%) with benign teratomas (P < 0.05). The diagnostic accuracy using the RI (cutoff value 0.4) as well as the PI (cutoff value 0.6) was thus 95.2%, which was significantly superior to that obtained by using the serum SCC (76%) (cutoff value, 1.5 ng/mL).

CONCLUSIONS

Evaluating the presence or absence of intratumoral blood flow, together with blood flow resistance, in tumor vessels using TV-CDU thus may be more useful to differentiate malignant (SCC) from benign cystic teratomas of the ovary than by measuring serum SCC levels.

Malignant transformation of an ovarian mature cystic teratoma presenting as a rectal mass

BACKGROUND

Squamous cell carcinoma arising from malignant degeneration of a mature cystic teratoma is rare with a reported incidence of approximately 1-3%. The most common presenting symptoms are lower abdominal pain and increasing abdominal girth of several months' duration. Approximately 50% of the patients present with FIGO stage I while 35-38% present with stage III diseases.

CASE

The case described herein represents an unusual presentation and initial diagnostic dilemma of locally aggressive squamous cell carcinoma arising in an ovarian dermoid cyst, with invasion into the distal rectum and anal canal causing rectal bleeding similar to the presentation of anal squamous cell carcinoma. Despite aggressive surgical management with posterior exenteration and optimal tumor debulking followed by 5040-cGy pelvic radiation utilizing 25-MV photons, the patient developed pelvic recurrence at the vaginal cuff 6 weeks after completion of her adjuvant radiotherapy. She subsequently failed cis-platinum single-agent chemotherapy and died 9 months after her initial surgery and diagnosis.

CONCLUSION

Squamous cell carcinoma in the anal canal, diagnosed by colonoscopy or proctoscopy, could be an unusual presentation of that arising from malignant degeneration of an ovarian dermoid cyst. This tumor may behave in a locally aggressive manner and be resistant to pelvic radiation or single-agent chemotherapy of cis-platinum. The current experience of adjuvant treatment after comprehensive staging and cytoreductive surgery reported in the world literature is limited, and the optimal management of the malignancy remains unclear.

[Mediastinal mature teratoma with elevated serum SCC levels--a report of 2 cases]

This is a report of two cases of mature mediastinal teratoma associated with elevated serum SCC levels. The first patient was a 17-year-old female admitted to our hospital for severe left chest pain. Chest x-ray film and CT scan showed a mediastinal tumor. The preoperative serum SCC level was elevated. Resection was performed and the pathological diagnosis was mature teratoma. The second patient was a 32-year-old male admitted to our hospital for severe anterior chest pain. A chest CT scan showed a mediastinal tumor. The preoperative serum SCC level was high. Surgery was performed and the pathological diagnosis was mature teratoma. The cause of the high serum SCC levels was unclear, but we suspect that the pulmonary atelectasis may have caused it.

Diagnosis of squamous cell carcinoma arising from mature cystic teratoma of the ovary

BACKGROUND

The prognoses of patients with squamous cell carcinoma of the ovary are quite poor. However, preoperative diagnosis is difficult due to the rarity of this tumor and its similarity to mature cystic teratoma (MCT). The objective of this study was to assess the value of tumor markers and clinical characteristics in making a differential diagnosis between MCT and squamous cell carcinoma arising from MCT.

METHODS

Between September 1979 and June 1996, 37 patients with ovarian squamous cell carcinoma arising from MCT were treated by the Tokai Ovarian Tumor Study Group. The authors evaluated tumor markers, tumor size, and age as parameters for differentiation between MCT and squamous cell carcinoma arising from MCT. Diagnostic efficiency was calculated as the sensitivity multiplied by the specificity.

RESULTS

There were significant differences (P < or = 0.0002) in age, tumor size, and levels of squamous cell carcinoma antigen (SCC), CA125, and CEA, as well as a significant difference (P < or = 0.0396) in the CA19-9 level between MCT and squamous cell carcinoma arising from MCT. Diagnostic efficiency was highest for SCC (63.0%), followed by CA125 (50.7%). Receiver operating characteristic (ROC) curves demonstrated that CEA was the best screening marker for squamous cell carcinoma arising from MCT, whereas age and tumor size were better markers than CA125 or CA19-9. The optimal cutoff values for age and tumor size were 45 years and 99 mm, respectively, according to ROC analysis.

CONCLUSIONS

These findings demonstrate that age and tumor size are important factors in making a differential diagnosis. In addition, SCC and CEA levels should be measured in patients age 45 years or older who have an MCT-like ovarian tumor larger than 99 mm in greatest dimension.

Macrophage colony-stimulating factor as a marker for malignant germ cell tumors of the ovary

We assessed the usefulness of macrophage colony-stimulating factor (M-CSF) as a serum marker for malignant germ cell tumors of the ovary. Serum levels of M-CSF were measured in 49 patients with malignant germ cell tumors and in 64 patients with mature benign cystic teratoma by an enzyme-linked immunosorbent assay. CA125 was measured by radioimmunoassay. The serum level of M-CSF was above normal (>1056 U/ml) in 44 (90%) of 49 patients with malignant germ cell tumors; the CA125 level was above the cutoff value (35 U/ml) in 34 patients (69%) (P < 0.05). The serum level of M-CSF was elevated in 20 (87%) of 23 patients with stage I disease and in all 16 patients with dysgerminoma. Only 7 (11%) of 64 patients with mature benign cystic teratoma had elevated levels of M-CSF. These results suggest that M-CSF is highly sensitive and specific for malignant germ cell tumors of the ovary, especially for dysgerminoma.