|Year : 2021 | Volume
| Issue : 1 | Page : 76-78
Omental dermoid mimicking as an adnexal mass
Kavya Abhilashi, Pratibha Kumari, Jyotsana Rani, Sangeeta Pankaj
Department of Gynecological Oncology, State Cancer Institute, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Submission||22-Mar-2021|
|Date of Decision||25-Mar-2021|
|Date of Acceptance||31-May-2021|
|Date of Web Publication||28-Jun-2021|
Professor, Gynecological Oncology, SCI, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, - 800 014
Source of Support: None, Conflict of Interest: None
Dermoid cysts are one of the most frequently occurring ovarian tumor; parasitic dermoids however are extremely rare. Most of the omental teratomas appear to have developed from self-amputation of cysts in the ovary followed by their re-implantation into the omentum. Omental teratomas can be located in the pelvis and mimic as an adnexal mass. Preoperative diagnostic imaging methods may not provide adequate information. We present here a case of menopausal female who presented with pain abdomen and preoperative evaluation suggested an adnexal mass. However, when surgery was performed, there was no adnexal pathology; however, there was an omental dermoid. Thus, gynecologists should always keep in mind the possibility of intraabdominal ovarian teratomas in the differential diagnosis of suspicious adnexal masses during surgery. The awareness among the surgeons of such masses may help prevent misdiagnosis and delayed treatment.
Keywords: Dermoid, omentum, teratoma
|How to cite this article:|
Abhilashi K, Kumari P, Rani J, Pankaj S. Omental dermoid mimicking as an adnexal mass. J Indira Gandhi Inst Med Sci 2021;7:76-8
| Introduction|| |
In contrast to dermoid cysts, which is a frequently encountered ovarian tumor, teratomas of extragonadal origin tend to be extremely rare entity, accounting for only 0.4% of teratomas. The most common extragonadal site of origin is omentum. The first omental dermoid cyst was described by Lebert way back in 1734. Omental dermoids are more common in women. We present here a case of parasitic omental dermoid in a menopausal female.
| Case Report|| |
A 60-year-old menopausal female presented to the gynecologic oncology outpatient department with abdominal pain. Her pelvic examination revealed a firm mobile nontender mass of 6 cm × 6 cm through right fornix; uterus was small and felt separately from the mass. Per abdominal examination and other systemic examination were normal. The patient was subjected to radiological evaluation (contrast-enhanced computed tomography pelvis and abdomen) which showed 7 cm × 6 cm thick walled cystic lesion with calcified foci and fat density occupying right adnexa suggestive of right ovarian dermoid [Figure 1]. CA-125 and other tumor marker were assayed and found to be within normal limit (CA-125-8.1U/ml, CA19-9-5.3 ng/ml, carcinoembryonic antigen-4.08 ng/ml, alpha-Fetoprotein-2.6U/ml, Human chorionic gonadotropin-5.5 mIU/ml, and Lactate dehydrogenase-192U/L).
|Figure 1: Computed tomography scan film showing heterogeneous mass with calcification|
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Patient was planned for oophrectomy as she had attained menopausal and had ovarian tumor of 7 cm × 6 cm with symptom of pain abdomen. She underwent laparotomy and upon opening the abdominal cavity uterus and bilateral adnexa were found to be normal. Further abdominal exploration was done and a firm to hard mass was seen in the omentum approximately 5 cm from the transverse colon [Figure 2]. Bowel and solid organs such as liver, spleen, and kidneys were found to be healthy. There was no ascites, and lymph nodes were also not enlarged. Total omentectomy with removal of mass was done along with hysterectomy and bilateral salpingoophrectomy. On cutting the specimen thick putaceous mucinous material with hairs were seen [Figure 3]. Calcified areas along with teeth were also noted. The uterus, bilateral adnexa and omentum with the tumor were sent for histopathological evaluation. The Histopathological Examination (HPE) report of the tumor attached to the omentum was suggestive of mature teratoma and that of uterus and adnexa were unremarkable.
| Discussion|| |
Extragonadal teratoma can occur anywhere along the midline of the body because of the migration of germ cells in embryonic life. However, extragonadal teratomas in the abdominal cavity are extremely rare, and the most common extragonadal site is the omentum. The mechanism for the development of teratoma in the omentum is not clear yet; however, there are three theories on the probable mechanism for its occurrence:
- Omental teratomas might develop within a supernumerary ovary
- It might develop from germ cells that may have been displaced
- It might develop due to the self-amputation of a dermoid cyst in the ovary, and then become re-implanted into the omentum.
The third theory of autoamputation is widely accepted as the etiology of extragonadal teratomas in the abdominal cavity. The omentum because of its role in the intra-abdominal inflammatory defense process is probably the primary location for reimplantation of the autoamputated ovary. The dermoid cyst in the index case might have been detached from its initial position after losing its blood supply and had moved to the present location where it had gained a new blood supply. The clinical presentation of parasitic dermoid is abdominal pain; however, it may also be associated with uncommon sign such as abdominal distension. The only symptom present in our patient was pain abdomen. Omental teratoma may presents as a palpable mobile abdominal lump; however, it can also be located in the pelvis and it might be mistaken as an adnexal tumor. Our patient showed a mobile mass in the right adnexa during her pelvic examination.
A preoperative diagnosis is often difficult. Radiology can aid in establishing the diagnosis. Although ultrasonography and computerized tomography might help in the diagnosis, for determining the exact location of intraabdominal ovarian parasitic teratomas color flow Doppler is often used. However, a definite diagnosis usually requires histopathological examination which helps distinguish immature from mature teratomas. Although omental teratomas are benign in majority of the cases, malignant omental teratomas have also been reported. Standard treatment is either laparoscopy or laparotomy with tumor excision along with partial omentectomy in most of the cases. Although the tumor was located in the omentum in our case, total hysterectomy and bilateral salpingoophrectomy was also done along with total omentectomy and removal of tumor as the patient was menopausal and had consented for the same. Intraoperative frozen section was not performed as complete surgical excision was performed. The treatment of omental teratoma is determined on the tumor's level of maturity, with total surgical excision providing adequate treatment for mature teratomas, whereas adjuvant chemotherapy with bleomycin, etoposide, and cisplatin is needed for immature teratomas.
In conclusion, parasitic omental dermoid may present a diagnostic dilemma preoperatively. Surgical removal is always necessary and laparoscopy is the best approach. Most of them are mature but immature teratomas may occur which necessitate the need for further chemotherapy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]