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Images
in Women's Health
April 2003
Case A 25-year-old
woman, G1P0010 with a history of endometriosis diagnosed by laparoscopy
in 1999, presents for evaluation of possible infertility. On examination,
she is incidentally found to have an adnexal mass.
Past Medical History
In 1999, the laparoscopy was notable for endometriosis and an ovarian
cyst. She was then controlled with continuous oral contraceptive pills.
She stopped the birth control pills approximately 5 weeks prior to presenting.
However, she was concerned about her history of endometriosis and its
impact on her fertility.
Additionally, her past medical history was significant for an abnormal
pap (CIN III) in 1998, which was treated with a Loop Electro Excisional
Procedure in 1999. She had an elective first trimester termination in
1994 without complication.
She works in a polymer company but denied exposure to any of the chemicals.
Her husband works as a software engineer. Her review of systems was otherwise
unremarkable.
Physical Examination
Her physical examination was essentially normal until the pelvic examination.
On pelvic examination, there was a fluctuant and tender right adnexal
mass. There was no rebound tenderness or radiation of pain. She denied
fever, nausea, emesis, constipation, diarrhea, or vaginal discharge.
The external genitalia, vagina, cervix, uterus, and left adnexa were
within normal limits.
Ultrasound
Ultrasound revealed a normal uterus and left ovary. The right adnexa
consists of a complex mass measuring 7.09 x 5.32 x 7.91 cm. There is
a hyperechoic area anteriorly with shadowing below it. There are three
circular masses adjacent to one another within the cystic area, and there
are low-level echoes at the base of the mass. There was no color flow
within the mass, and there was some free fluid surrounding the mass.
(Figures 1 through 3).
Laboratory
Her laboratory evaluation revealed a hemoglobin of 15.0, CA-125 of 17.0,
negative cultures, and normal pap smear. Her husband had a normal semen
analysis.
Laparoscopy
Laparoscopy revealed an enlarged ovary with a smooth outer capsule (Figure
4). There were no ascites present. The uterus, tubes, and left ovary
appeared normal. There was no sign of endometriosis. A cystectomy was
performed and the mass was placed in an endoscopic bag for removal. However,
the mass would not compress to exit the inferior suprapubic incision.
The endoscopic bag was brought to the surface and the cyst was ruptured
within the bag to remove the presumed mature teratoma. At rupture, there
was hair and sebaceous material. Yet, the mass was still not compressible.
A ring forceps could not grasp this mass securely. The incision was extended
to about 4 cm and the mass was removed.
| FIGURE 4 |
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FIGURES 5 and 6. |
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Pathology
The gross description: The specimen consists of a 5.5 x 3.5 x 3.0-cm
mass with the surface covered partly with skin and multiple hair follicles,
while the remainder is covered by a soft pinkish-red tissue. Cut sections
reveal half of the mass consisting of bony material and the other half
being yellowish and soft. There is a 4.0 x 4.0-mm blackish discoloration
seen adjacent to the bone (Figures 5 and 6).
Pathologic Diagnosis: Mature Cystic Teratoma
Microscopic slides revealed prominent ectodermal differentiation characterized
by abundant skin and hairs. Other findings include abundant adipose tissue,
thyroid tissue and nerves, neuroglial tissue, bronchial epithelium, striated
muscle, retinal tissue, bone, and hyaline cartilage (These microscopic
slides can be viewed at www.femalepatient.com).
Clinical Course
This patient recovered from surgery well. The pelvic tenderness resolved.
The couple will resume their attempts at conception after appropriate
recuperation.
Discussion
This case represents some of the common findings on ultrasound for dermoids.
In particular, many dermoids may present with a simple cyst with a hyperechoic
tubercle with shadowing below it. Some present with a mix of hypoechoic
and hyperechoic areas; others present with a simple cyst. An excellent
description of ultrasound characteristics of dermoids is found in the
article by Cohen.1
In addition, this case is unusual by the mere number of tissue types
that were represented in this specimen. Of course, mature teratomas consist
of embryonic tissue that can differentiate into any tissue type as this
case well demonstrates. However, most dermoids consist mainly of hair,
sebaceous material, with or without bony tissue.
References:
- Cohen L, Sabbagha R. Echo-patterns of benign cystic teratomas
by transvaginal ultrasound. Ultrasound Obstet Gynecol. 1993;3:120-123.
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