The Approach to Ovarian Dermoids in Adolescents and Young Women

Abstract

Background Mature cystic teratomas (MCTs) are the most common ovarian neoplastic lesions found in adolescents. MCTs are usually asymptomatic and are often discovered incidentally on exam or imaging. The recurrence rate of MCTs following cystectomy is 3–4% and incidence of malignant transformation is estimated to be 0.17–2%. Given the accuracy with which MCTs can be diagnosed preoperatively, studies suggest that these lesions can be treated surgically using laparoscopic techniques. The management of MCTs in the adolescent population poses unique challenges given the potential impact on sexual development and fertility. Case A 17 year-old female was found to have bilateral adnexal masses consistent in appearance with MCTs on computed tomography after a motor vehicle accident. She underwent exploratory laparotomy with pathology confirming the presence of bilateral ovarian MCTs. Three years later she returned to the office with occasional abdominopelvic pain. Ultrasound revealed bilateral complex cysts suggestive of recurrent MCTs. She was expectantly managed with serial ultrasounds and after 24 months, slow but visible growth of the MCTs was confirmed. The patient is now 22 years old and asymptomatic. What is the most appropriate management? Summary and Conclusion The risks of expectant management in women like the one presented are small. This suggests that although the traditional treatment for MCTs is laparoscopic ovarian cystectomy, in children and adolescents with MCTs we should consider close follow-up without intervention to preserve ovarian function and future fertility.

Clinico-pathological profile of ovarian cysts in a tertiary care hospital

“…10 The incidence of malignant transformation in teratoma is estimated to be 0.17-2%. 10 In the present study, there were 2 cases (2.0%) of teratoma with malignant transformation. Serous cystadenocarcinoma was the most common (5.9%) malignant cystic ovarian malignancy.…”

Dermoid cysts in adolescents

“…Although the correlation between the cyst size and the risk of torsion varies among studies, most authors agree that teratomas larger than 5cm should be removed [11,12]. Ovarian torsion may be associated with significant morbidity, including loss of the ovary and more rarely rupture, fistulization through the pelvic viscera and malignant degeneration [12]. Spontaneous rupture of the mature cystic teratoma occurs in less than 1% of cases.…”

“…The typical appearance seen on ultrasound is a cystic adnexal unilocular mass [21 & ]. A Rokitansky nodule, or dermoid plug, is a solid projecting protuberence, which is also often seen on ultrasound [12] and is pathognomonic for a dermoid cyst [3]. Dermoid mesh, also known as the dot-dash pattern, is another characteristic sonographic sign and is caused by hair fibres floating within the cyst that result in echogenic bands.…”

“…Laparotomy is often still chosen as the preferred surgical technique for patients who present with significantly larger (8.27 versus 5.94 cm) and bilateral cysts [27]. More recently, laparoscopy has become the preferred method for treating ovarian cysts [12,28]. In a retrospective analysis by Benezra et al [29], both the mean estimated blood loss and hospital stay were significantly lower in those who had underwent laparoscopic surgery for a dermoid cyst than laparotomy (N ¼ 108).…”

“…It is hypothesized that this may be due to incomplete resection or missed small mature ovarian cysts at the time of removal rather than a recurrence [12]. One study reported a 4.21% long-term recurrence rate in adult women who underwent laparoscopy versus 0% for laparotomy [27].…”