Indian Journal of Radiology Indian Journal of Radiology  

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Year : 2003  |  Volume : 13  |  Issue : 1  |  Page : 43-44
Malignant degeneration in ovarian cystic teratoma - a case report


Dept. of Radiodiagnosis, Manipal Teaching Hospital, P.O. Box No. 341, Pokhara, Nepal

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How to cite this article:
Smiti S, Tiwari P K. Malignant degeneration in ovarian cystic teratoma - a case report. Indian J Radiol Imaging 2003;13:43-4

How to cite this URL:
Smiti S, Tiwari P K. Malignant degeneration in ovarian cystic teratoma - a case report. Indian J Radiol Imaging [serial online] 2003 [cited 2019 Oct 14];13:43-4. Available from: http://www.ijri.org/text.asp?2003/13/1/43/28626
A fifty year old female was referred from the Obstetric and Gynecology Department for ultrasound examination with the clinical diagnosis of Ovarian tumour. The patient had presented with abdominal distension for a year and pain in the abdomen for 3 months. History of postmenopausal bleeding was also present.

Per abdominal examination showed a large mass extending obliquely from the right iliac fossa to the epigastric region. The mass was hard in consistency and had well defined margins.

Ultrasound examination of the abdomen and pelvis [Figure - 1][Figure - 2] was done which showed a well defined, round mass lesion measuring 16.7x15.1cms in size extending from the supero-lateral portion of the uterine fundus up to the inferior surface of the liver. The mass was however separate from the uterus which was normal in size and pushed postero-laterally. A fat fluid level was seen within the mass which moved with change in the patient's position. An echogenic mass with posterior acoustic shadowing was also seen within it suggestive of a dermoid plug. Massive para-aortic, periceliac and bilateral iliac lymphadenopathy was seen. Ascites with floating bowel loops were also noted. CT Scan abdomen [Figure - 3][Figure - 4] further confirmed the above findings. Based on the above imaging features a diagnosis of cystic teratoma with malignant degeneration was made.

The patient underwent total abdominal hysterectomy with bilateral salpingo-oopherectomy. Left iliac node dissection and infracolic omentectomy was also done.

Histopathology revealed a cystic teratoma with malignant transformation to undifferentiated carcinoma.


   Discussion Top


Cystic teratomas make up approximately 15 to 25 percent of ovarian neoplasms, They are composed of well-differentiated derivatives of 3 germ layers, ectoderm, mesoderm and endoderm. Cystic teratomas are more commonly seen in active reproductive years but can occur at any age and are frequently seen in postmenopausal women. Malignant transformation is uncommon and is seen in approximately 2 percent of cases, usually in older women.[1]

Sonographically Cystic teratomas have a variable appearance but certain features are specific which are as follows,

  1. Fat fluid or hair fluid level.
  2. Cystic mass with echogenic mural nodule, the "dermoid plug". Dermoid plug contains hair, teeth or fat and frequently cast an acoustic shadow.
  3. Dermoid mesh which is made up of hair fibres floating with in the cyst.


Malignant transformation of benign cystic teratoma is rare, the most common malignancy being squamous cell carcinoma[2]. The diagnosis is rarely made preoperatively and prognosis is usually poor. The most common presenting symptoms are lower abdominal pain and increasing abdominal girth of several months duration.

Adenocarcinomas are the second most common malignancy described[3]. Sarcomas alone or in combination with squamous cell carcinomas have also been reported.

Primary lymphatic dissemination of malignant elements is an atypical way in which malignant elements metastasize to lymph node with out evidence of intraperitoneal dissemination[4]. In another study CT findings were compared with plain abdominal radiograph, HSG, Ultrasound and MRI[5]. CT imaging showed the presence of fat, tooth or calcification, Rokitansky protuberance, tuft of hair and fat fluid level.

These features allowed definitive diagnosis of ovarian cystic teratomas in 98 percent of cases. Malignant degeneration showed a large mass (greater than 10cms) along with plugs and cauliflower appearance with irregular borders. This study demonstrated that CT was the best imaging procedure for the diagnosis of cystic teratomas.

MRI appearances of dermoid cyst with malignant transformation have also been described in another study[6]. This study showed that squamous cell carcinomas could be differentiated from other ovarian neoplasm by their mode of spread, which include transmural extension and local invasion.

 
   References Top

1.Shia Salem, The Uterus and Adnexa In Diagnostic Ultrasound by Carol M Rumack, Stephanie R, Second Edition, Volume 1,Eds.Carol M Rumack,Stephanie R, Mosby Publications, Missouri , 1997 ; 557-558  Back to cited text no. 1    
2.Lee YC, Abulfia O, Montalto N et al , Malignant Transformation of an Ovarian Mature Cystic Teratoma presenting as a rectal mass ; Gynecol Oncol 1999 Dec ; 75 (3): 499-503.  Back to cited text no. 2    
3.Arora DS, Haldane S et al , Carcinosarcoma arising in a Dermoid Cyst of Ovary ; J Clin Pathol 1996 Jun; 49 (6) : 519-21.  Back to cited text no. 3    
4.Kung E, Parhan GP et al, Primary Lymphatic dissemination of malignant elements in a mature cystic Ovarian teratoma, Gynecol Oncol 1995 May ; 57(2) :250-3.  Back to cited text no. 4    
5.Buy JN , Ghossain MA , Cystic teratoma of the Ovary : CT detection ; Radiology 1989 Jun;171 (3) : 697-701.  Back to cited text no. 5    
6.Kido A, Togashi K, Konishi I et al, Dermoid cysts of Ovary with Malignant transformation : MR Appearance. AJR Am J Roentgenol 1999 Feb; 172 (2): 445-9.  Back to cited text no. 6    

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Correspondence Address:
S Smiti
Dept. of Radiodiagnosis, Manipal Teaching Hospital, P.O. Box No. 341, Pokhara
Nepal
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Source of Support: None, Conflict of Interest: None


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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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