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Snapshot
  • A 20-year-old G1P0 woman presents to clinic with 3 months of lower left quadrant pain. Her menstrual cycle is regular and occuring every 30 days. She uses a copper IUD for contraception which was placed 2 years ago. She has no significant medical or surgical history. Her temperature is 98.6°F (37.0°C), blood pressure is 118/78 mmHg, pulse is 65/min, and respirations are 16/min. Pelvic exam is positive for left adnexal fullness. A urine β-hCG test is negative and a transvaginal ultrasound demonstrates a 3.5 cm hypoechogenic cystic mass with calcifications. The patient's mass is removed surgically and she diagnosed with a mature cystic teratoma. A photograph of the removed lesion is taken. 
Introduction
  • Overview
    • teratomas are germ cell tumors most often benign that can contain tissue from all 3 different germ cell layers
      • treatment usually involves surgery and possibly chemotherapy depending on whether the tumor is malignant or not
  • Epidemiology
    • incidence
      • most common germ cell tumor
      • approximately 15% of ovarian neoplasms are teratomas
    • demographics
      • women aged 10-30 years of age
    • location
      • mostly in ovaries
      • teratomas can also be found in testis, mediastinum, cranium, and sacrococcygeal area
    • risk factors
      • for malignant transformation
        • age ≥ 45 years of age
        • tumor diameter ≥ 10 cm
        • rapid tumor growth
    • Pathogenesis
      • failure of complete migration of pluripotent stem cells during embryogenesis
        • should normally migrate from yolk sac endoderm to urogenital ridge 
    • Prognosis
      • most are benign
      • 2% become malignant
Classification
 
Ovarian Teratomas
Types and Features 
Type Prevalence Histopathology Potential for Malignancy


Mature (dermoid)  


  • 95% of ovarian teratomas 
  • Differentiated tissue 
    • ectodermal
    • mesodermal
    • endodermal
  • Hair, teeth, and sebaceous glands 
  • Cystic

  • Most are benign
  • 0.2-2% malignant transformation
Immature
  • < 1% of ovarian teratomas
  • Immature and mature tissue
    • ectodermal
    • mesodermal
    • endodermal
  • High potential for malignancy
  • Over 1/3 of all malignant ovarian germ cell tumors 


Monodermal

  • Uncommon
  • Specialized and mature cell types
    • struma ovarii (thyroid tissue)
      • can cause clinical hyperthyroidism
    • carinoid tumors
    • neural differentiation
  • Most are benign
 
Presentation 
  • Symptoms
    • common symptoms
      • pain
      • location
        • lower abdomen
      • severity
        • often asymptomatic
        • depends on tumor size
  • Physical exam
    • inspection
      • visible masses may be seen
      • swelling of tailbone in newborn
    • motion
      • tumor may be palpable
Imaging
  • Ultrasound
    • indications
      • suspected ovarian mass
    • views
      • transvaginal
    • findings
      • hyerechoic areas
      • fluid-fluid levels
      • bright echoes
      • shadowing echo densities
    • sensitivity and specificity
      • sensitivity
        • ~85%
      • specificity
        • ~98%
  • CT 
    • indications
      • adjunct to ultrasound
      • surgical planning
    • findings
      • complex
      • septa
      • internal debris
      • fat attenuation
      • calcification
 Studies
  • Serum labs
    • AFP
    • LDH
    • β-hCG
  • Urine labs
    • β-hCG
  • Invasive studies
  • Histology
    • immunohistochemistry
Differential
  • Ectopic pregnancy
    • key distinguishing factor
      • positive urine β-hCG test
  • Ovarian adenocarcinoma   
    • key distinguishing factors
      • typically older age of onset
      • fatigue
      • bloating and lack of appetite
      • more solid appearance on ultrasound
Treatment
  • Medical
    • chemotherapy
      • indications
        • malignancy
  • Surgical
    • ovarian cystectomy
      • indications
        • all patients with teratomas and future childbearing plans
    • salpingo-oopherectomy 
      • indications 
        • those who do not want to bear further children
Complications
  • Ovarian torsion
    • incidence
      • 5-15% of patients with teratomas experience ovarian torsion
    • risk factors
      • ovarian masses
      • long ovarian ligaments 
      • pregnancy
      • tubal ligation
    • treatment
      • surgery 
  • Cyst rupture
    • incidence
      • rare 
      • 0.3-2.5%
    • risk factors
      • pregnancy
      • torsion
      • trauma
  • Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis 
    • incidence
      • almost 60% of patients with anti-NMDA receptor encephalitis have ovarian teratomas
    • risk factors
      • neural components in teratoma

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