|Year : 2022 | Volume
| Issue : 1 | Page : 60-62
Mature cystic teratoma in a peripubertal girl: Is it uncommon?
Pratibha Kumari1, Satya Kumari1, Jyotsna Rani1, Kavya Abhilashi1, Sangeeta Pankaj1, Vijayanand Choudhary2, Supriya Jaiswal3
1 Department of Gynecological Oncology, SCI, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Pathology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
3 Specialist Sub-Divisional Hospital, Hilsa Nalanda, Bihar, India
|Date of Submission||26-Aug-2021|
|Date of Acceptance||13-Nov-2021|
|Date of Web Publication||12-Feb-2022|
SCI, Indira Gandhi Institute of Medical Sciences, Patna - 800 014, Bihar
Source of Support: None, Conflict of Interest: None
Giant ovarian mature cystic teratomas (MCTs) are sparsely reported and that too at extreme of age like in premenarchal or postmenopausal age group. We hereby report a case of huge MCT in a 11-year-old premenarchal girl who presented with abdominal pain and lump. Ovarian tumor in adolescent may have malignant potential and requires appropriate and vigilant preoperative work-up and counseling for optimal management with concern of preservation of fertility and potential for childbearing.
Keywords: Mature cystic teratoma, ovarian tumor, peripubertal, tumor marker
|How to cite this article:|
Kumari P, Kumari S, Rani J, Abhilashi K, Pankaj S, Choudhary V, Jaiswal S. Mature cystic teratoma in a peripubertal girl: Is it uncommon?. J Indira Gandhi Inst Med Sci 2022;8:60-2
|How to cite this URL:|
Kumari P, Kumari S, Rani J, Abhilashi K, Pankaj S, Choudhary V, Jaiswal S. Mature cystic teratoma in a peripubertal girl: Is it uncommon?. J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2022 Jul 3];8:60-2. Available from: http://www.jigims.co.in/text.asp?2022/8/1/60/338362
| Introduction|| |
Mature cystic teratomas (MCTs) are the most common ovarian tumor found in adolescents and account for 50% of pediatric tumors. These are benign form of germ cell tumor arising from ovarian totipotent cells with potential to develop into fully differentiated ectoderm, mesoderm, and endoderm. MCTs are slow-growing tumor with average growth of 1.8 mm per year. They are mostly asymptomatic and discovered incidentally on clinical examination or during radiological investigation of the patient. There are only few case reports of giant dermoid tumor in young girls. We hereby report a case of huge ovarian dermoid in a peripubertal girl who presented with abdominal pain and lump.
These ovarian tumors are prone to torsion and may present as medical emergency. Ovarian torsion is the fifth most common gynecological emergency condition and delayed diagnosis leads to disastrous consequences including ovarian infarction and necrosis. This patient was fortunate not to present with torsion and medical emergency even with such huge ovarian tumor.
| Case Report|| |
In August 2020, when the whole world was facing the calamity due to corona pandemic, an 11-year-old premenarchal girl presented to our outpatient Department of Gynaeoncology, IGIMS, Patna, with chief complaints of lower abdominal pain on and off for 6 months. The pain was dull aching, nonradiating, mainly localized at the right lower quadrant of the abdomen and was infrequently associated with nausea and vomiting also. Due to COVID pandemic and nation-wise lockdown, her parents consulted local physician for relief of her pain abdomen. She had no significant past medical or family history. On general examination, she had average built and normal vitals. Abdominal examination revealed abdominopelvic mass corresponding to the size of 20 weeks of gestation on palpation. The mass was cystic, nontender, and freely mobile and had no ascites or hepatosplenomegaly. Her CT scan revealed a well-defined heterogenous lesion (16 cm × 13 cm × 12 cm) on the right side, arising from pelvis and mid abdomen with fat and calcification present inside and with no free collection of fluid. The other ovary and the uterus were of normal size. Her routine blood investigation was within normal limit. On evaluation of tumor markers, her serum level of CA125 was found to be 186 UI/ml, β-HCG – 0.40 mIU/ml, AFP – 144 U/ml, LDH – 256U/l, CEA – 12.21 ng/ml, CA-19-9-798 ng/ml, and HE4 –49.7pmol/l. Following appropriate and adequate investigation, she was suspected to have germ cell tumor of right ovary and probably immature teratoma. The patient and her parents were counseled for staging laparotomy and possibility of oophorectomy. Laparotomy was performed under general anesthesia through a left paramedian incision, which revealed a huge heterogeneous mass originating from the right ovary and was adherent to the omentum. The mass was of 16 cm × 14 cm [Figure 1] size with intact capsule along with overstretched ipsilateral fallopian tube adherent to its surface. Healthy ovarian tissue was not identifiable. An ovarian tumor in an 11-year-old girl with raised multiple tumor markers may also have potential for malignant transformation, so right salpingo-oophorectomy was done. Left ovary and tube along with uterus were normal. Cut section of tumor showed sebaceous material along with hair and tooth-like hard structure. Histopathological examination revealed MCT of right ovary. Postoperatively, the patient was stable and her course of recovery was unremarkable.
| Discussion|| |
Literature is scarce and sparse on dermoid tumor in girls of peripubertal age group. A retrospective study on 283 cases of MCT quoted the youngest age of patient as 12 years while maximum number of patients belonged to 20–30 years of age. Matsumoto et al. reported the ovarian dermoid in a 20-month-old infant girl causing urinary retention, however, in index case, the girl was premenarchal presenting at 11 years of age.
When multiple tumor markers are elevated in serum of adolescent girl and females of reproductive age group, possibility of immature teratoma precedes in comparison to MCT, and increasing the sensitivity to 71.4% by combined detection of CA125, CA153, and AFP. Raised serum level of CA 19-9 has also been reported in association with MCT of the ovary and is correlated with larger tumor diameters and higher torsion rates. In index case, her CA19-9 was unusually elevated probably due to large tumor size.
A large ovarian tumor in a peripubertal girl may have risk of occult germ cell malignancy especially when her serum levels are elevated for multiple tumor markers (CA-125, CA19-9, AFP) and may warrant for salpingo-oophorectomy akin to the present case. However, literature supports cystectomy as the first-line treatment in ovarian tumors that are preoperatively consistent with teratoma. The present case becomes more intriguing, as its HPE labeled it as benign MCT despite raised serum level of multiple tumor markers (CA-125, AFP, and CA-19-9).
Laparoscopic route is being preferred over laparotomy for surgery of benign ovarian tumors with added advantage of a shorter hospital stay, lesser postoperative pain, and fewer adverse events of surgery. However, in patients with unrecognized neoplasms, laparoscopy has its own limitations and may be associated with increased risk of dissemination due to intraperitoneal spillage of tumor cells and consequently advancing and progression in disease stage. Henceforth, adequate and vigilant preoperative workup for ovarian tumor in girls of peripubertal age cannot be overemphasized.
| Conclusion|| |
This case highlights the rare but possible presentation of huge dermoid tumor in prepubertal girls. Delay in diagnosis can lead to a potentially life-threatening condition if complication as torsion or rupture supervenes. Preoperative vigilant investigations and elevated tumor marker assay prove to be a useful tool for differentiating the ovarian tumor of immature teratoma type to a mature one which significantly affect and guide the management option.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ayhan A, Bukulmez O, Genc C, Karamursel BS, Ayhan A. Mature cystic teratomas of the ovary: Case series from one institution over 34 years. Eur J Obstet Gynecol Reprod Biol 2000;88:153-7.
Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med 2005;159:532-5.
Wu RT, Torng PL, Chang DY, Chen CK, Chen RJ, Lin MC, et al.
Mature cystic teratoma of the ovary: A clinicopathologic study of 283 cases. Zhonghua Yi Xue Za Zhi (Taipei) 1996;58:269-74.
Matsumoto M, Watanabe T, Uekado Y, Ohkawa T. A case of urinary retention due to ovarian dermoid cyst in a female infant. Hinyokika Kiyo 1993;39:85-7.
Chen C, Li JD, Huang H, Feng YL, Wang LH, Chen L. Diagnostic value of multiple tumor marker detection for mature and immature teratoma of the ovary. Ai Zheng 2008;27:92-5.
Steinberg WM, Gelfand R, Anderson KK, Glenn J, Kurtzman SH, Sindelar WF, et al.
Comparison of the sensitivity and specificity of the CA19-9 and carcinoembryonic antigen assays in detecting cancer of the pancreas. Gastroenterology 1986;90:343-9.
Cass DL, Hawkins E, Brandt ML, Chintagumpala M, Bloss RS, Milewicz AL, et al.
Surgery for ovarian masses in infants, children, and adolescents: 102 consecutive patients treated in a 15-year period. J Pediatr Surg 2001;36:693-9.
Sandoval C, Strom K, Stringel G. Laparoscopy in the management of pediatric intraabdominal tumors. JSLS 2004;8:115-8.