0266 5 An unusual_PEPE:-
13-05-2014
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Pagina 75
G Chir Vol. 35 - n. 3/4 - pp. 75-77 March-April 2014
clinical practice
An unusual case of multiple and bilateral ovarian dermoid cysts. Case report F. PEPE¹, S. LO MONACO¹, F. RAPISARDA¹, G. RACITI¹, C. GENOVESE1, P. PEPE²
SUMMARY: An unusual case of multiple and bilateral ovarian dermoid cysts. Case report. F. PEPE, S. LO MONACO, F. RAPISARDA, G. RACITI, C. GENOVESE, P. PEPE Objective. Multiple and bilateral ovarian dermoid cysts constitute a very unusual report. We report an rare case of a woman with three ovarian dermoid cyst, two localized in the same ovary, detected by US examination and removed by laparoscopy. Case report. A patient aged 29 years, para 0, gravida 0, was referred to our hospital with pain of the right adnexal region. Gynaecological examination showed an antiverted uterus with normal volume; on the right side a mobile mass approximately 7 cms in diameter was palpable, moreover the left ovary was normal. Ultrasound examination
showed a normal uterus. The right ovary presented two complex masses of 7 and 3 cm in diameter, respectively; moreover, the left ovary showed a hyperechogenic complex mass of 3 cm in diameter. The ultrasound pattern was compatible with bilateral ovarian dermoid cysts. On laparoscopy abdominal cavity and uterus were normal, while the right ovary presented two masses and the left ovary a small mass which were enucleated and removed. The patient had an uncomplicated postoperative recovery and was discharged two day after laparoscopy. Pathologic examination confirmed the diagnosis of ovarian dermoid cysts. A one year follow-up showed no evidence of recurrence. Conclusion. The case reported shows that exceptionally multiple and bilateral dermoid cysts may be detected underlining the importance of an accurate preoperative diagnostic imaging. Some recurrence of ovarian dermoid cists may be due to undiagnosed small dermoid cists during preoperative imaging and/or surgical exploration.
KEY WORDS: Ovarian tumor - Dermoid cyst - Surgery - Pelvic pain - Ovary - Pelvic ultrasound.
Introduction Dermoid cyst or mature teratoma is the most common benign ovarian neoplasm in young and middleaged women. It accounts for approximately 20% and 50% of adult and pediatric ovarian tumors (1); moreover, malignant transformation occurs in 1-3% of cases, usually into a squamous cell cancer (2). Although most mature teratomas are asymptomatic, abdominal pain or nonspecific symptoms occur in a small subset of patients.
¹ Obstetrics and Gynecology Unit, “Santo Bambino” Hospital, Catania, Italy ² Urology Unit, “Cannizzaro” Hospital, Catania, Italy Corresponding author: Franco Pepe, e-mail: [email protected] © Copyright 2014, CIC Edizioni Internazionali, Roma
In very rare cases symptoms are related to hormonal secretion (estrogens, prolactin, etc) or paraneoplastic syndrome (3, 4). At ultrasound (US) evaluation, mature teratomas could be detected as cystic or solid masses with areas of fat and calcification; moreover, they may be entirely cystic, solid (with macroscopic fat) or mixed. Macroscopic fat and calcification of mature teratomas are found in about 90% and 50% of the cases, respectively. At MRI fat is depicted as a zone with high signal intensity on T1-T2-weighetd images; moreover, MRI findings could include Rokitansky nodules and “floating ball” imaging. The majority of dermoid cysts are monolateral with equal frequency in both ovaries; moreover, bilateral tumors are found approximately in 10% of cases (2, 5). Multiple ovarian dermoid cysts constitute a very unusual report; sometime they could be detected during the first operation and in other cases many years later from surgery. 75
0266 5 An unusual_PEPE:-
13-05-2014
14:45
Pagina 76
F. Pepe et al.
We report an unusual case of a woman with three ovarian dermoid cyst, two localized in the same ovary, detected by US examination and removed by laparoscopy.
Case report A patient aged 29 years, para 0 gravida 0, was referred to our hospital with pain in the right adnexal region. Gynaecological examination showed an antiverted uterus with normal volume; on the right side a mobile mass approximately 7 cms in diameter was palpable and the controlateral ovary was normal with a diameter of about 5 cm. Abdominal and transvaginal US showed a normal uterus; the right ovary presented two complex masses of 7 and 3 cm in diameter localized in different ovarian regions, respectively. Left ovary showed normal parenchyma with a hyperechogenic complex mass of 3 cm in diameter. The US evaluation was compatible with the presence of multiple ovarian dermoid cysts. The woman underwent laparoscopy to remove the ovarian masses; abdominal cavity and uterus were normal, the right and left ovaries presented two and one masses suspicious for dermoid cysts, respectively. The tumors were enucleated, placed in an endobag and removed (Figure 1). The patient had an uncomplicated postoperative recovery and was discharged two day from laparoscopy. Definitive pathologic examination confirmed the diagnosis of bilateral ovarian dermoid cysts. A one year follow-up showed no evidence of recurrence.
Discussion Dermoid cyst is a frequent tumour of the ovary; usually it is monolateral but sometime it could be co-existence with parasitic intraabdominal dermoid cysts (6) or localized in other sides such as in the omentum, in the pouch of the Douglas (7) or in the uterosacral ligament (8). In about 10-15% of the cases ovarian dermoid cysts may be bilateral and/or multiple (9): Bournas et al. (10) described a woman with 4 dermoid cysts within the right ovary and 1 in the contralateral ovary; Sinha et al. (11) reported a patient with 7 and 3 dermoid cysts in the left and right side, respectively. Finally, Walid et al. (12) reported a case of bilateral dermoid cysts in a pregnant woman. In rare cases the recurrence of a dermoid cyst may be due to its incomplete enucleation during primary surgery, especially if rupture of the dermoid cyst occurred. It has been showed that the ultrasound features of incidentally dermoid cyst have a variety of textural patterns, but quite similar to those encountered in large and symptomatic lesions. The increased resolution of transvaginal US has increased detection of small and non palpable ovarian dermoid (< 3 cm) allowing to plane adequate surgical removal (13). During enucleation of the ovarian dermoid cyst the remaining ovarian tissue as well controlateral ovary should be carefully palpated when performing laparotomy or inspected when performing laparoscopy. It 76
Fig. 1 - Three dermoid cysts removed by laparoscopy.
should also checked the existence of accessory ovaries that in very rare cases may be sites of dermoid cysts, even bilaterally (14). Song et al. (15) in 20 women submitted to conservative treatment reported a recurrence rate equal to 2.5% after a mean period from surgery of 8 ± 7 years. The case reported shows that exceptionally multiple and bilateral dermoid cysts may be detected underlining the importance of an accurate preoperative diagnostic imaging. The surgical approach remains particularly important especially in young women in whom fertility and best cosmetic results should be mandatory. Nowadays the majority of the surgeons usually perform laparoscopy, but other surgeons consider a minilaparotomy procedure (16), although the risk of adhesion formation after laparoscopy is not as high as by laparotomy (17). Anyway preservation of the ovarian tissue is mandatory in the presence of one or more dermoid cysts as well a complete enucleation of the masses avoiding rupture during surgical procedure. Adequate preoperatory imaging may show small ovarian dermoid cysts that may be difficult to diagnose during surgical exploration. Some cases of recurrent ovarian dermoid cyst may be due to undiagnosed small dermoid cist coexistent with a big one.
Conclusion The case reported shows that exceptionally multiple and bilateral dermoid cysts may be detected underlining the importance of an accurate preoperative diagnostic imaging. Some recurrence of ovarian dermoid cists may be due to undiagnosed small dermoid cists during preoperative imaging and/or surgical exploration.
0266 5 An unusual_PEPE:-
13-05-2014
14:45
Pagina 77
An unusual case of multiple and bilateral ovarian dermoid cysts. Case report
References 1. Prat J. Female Reproductive System. In: Damjanov I, Linder J, Anderson WAD eds. Anderson’s pathology. 10th ed. St. Louis, Mo: Mosby, 1996; 2231-2309. 2. Comerci JT, Licciardi F, Berghi PA, Gregori C, Breen JL. Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature. Obstet Gynecol. 1994;84: 2228. 3. Kim I, Lee JY, Kwon JH, Jung JY, Song HH, Park YI, Ro E, Choi KC. A case of autoimmune haemolytic anemia associated with an ovarian teratoma. J Korean Med Sci. 2006;21:365-367. 4. Nokura K, Yamamoto H, Okawara Y, Koga H, Osawa H, Sakai K. Reversible limbic encephalitis caused by ovarian teratoma. Acta Neurol Scand. 1997;95:367-373. 5. Pepe F, Panella M, Pepe G, Panella P, Pennisi F, Arikian S. Dermoid cysts of the ovary. Eur J Gynaecol Oncol. 1986;7:186-191. 6. Sinha R, Sunduram M, Lakhotia S. Multiple intraabdominal parasitic cystic teratomas. J Minim Invasive Gynecol. 2009;16:789791. 7. Tokunaga M, Seta M, Yamada M, Nishio M, Yamamoto K, Koyasu Y. Coexistent dermoid cysts of the pouch of the Douglas and ovary resected by laparoscopy. Asian J Endosc Surg. 2012;5:3133. 8. Moawad NS, Starks D, Ashby K. Ectopic ovarian teratoma of the uterosacral ligament associated with a large ovarian dermoid. J Minim Invasive Gynecol 2008;15:523-524. 9. Al-Fozan H, Glassman J, Caspi B, Appelman Z, Tulandi T. Lateral distribution of ovarian dermoid cyst. J Am Assoc Gynecol Laparosc 2003;10:489-90.
10. Bournas N, Varras M, Kassanos D, Chrelias Ch, Tzaida O, Salamalekis E. Multiple dermoid cysts within the same ovary: our experience of a rare case with review of the literature. Clin Exp Obstet Gynecol 2004;31:305-08. 11. Sinha R, Sethi S, Mahajan C, Bindra V. Multiple and bilateral dermoids: a case report. J Minim Invasive Gynecol 2010;17:23538. 12. Walid MS, Boddy MG. Bilateral dermoid cysts of the ovary in a pregnant woman: case report and review of the literature. Arch Gynecol Obstet. 2009;279:105-08. 13. Serafini G, Quadri PG, Gandolfo NG, Gandolfo N, Martinoli C, Derchi LE. Sonographic features of incidentally detected small, non palpable ovarian dermoids. J Clin Ultrasound 1999;27:369-373. 14. Gabbay-Moore M, Ovaida Y, Neri A. Accessory ovaries with bilateral dermoid cysts. Eur J Obstet Gynecol Reprod Biol 1982;14:171-173. 15. Song YN, Zhu L, Lang JH. Recurrent mature ovarian teratomas: retrospective analysis of 20 cases. Zhonghua Yi Xue Za Zhi. 2007;87:1184-1186. 16. Bolla D, Deseö N, Sturm A, Schöning A, Leimgruber C. Minilaparotomy a good option in specific cases: a case report of bilateral ovarian germ cell tumor. Case Rep Obstet Gynecol 2012 2012:589568. doi: 10.1155/2012/589568. Epub 2012 Mar 5. 17. Briones-Landa CH, Ayala-Yáñez R, Leroy-López L, Anaya-Coeto H, Santarosa-Pérez MA, Reyes-Muñoz E. Comparison of laparoscopic vs. laparotomy treatment in ovarian teratomas. Ginecologia y Obstetrica de Mexico 2010;78:527-532.
77
13-05-2014
14:45
Pagina 75
G Chir Vol. 35 - n. 3/4 - pp. 75-77 March-April 2014
clinical practice
An unusual case of multiple and bilateral ovarian dermoid cysts. Case report F. PEPE¹, S. LO MONACO¹, F. RAPISARDA¹, G. RACITI¹, C. GENOVESE1, P. PEPE²
SUMMARY: An unusual case of multiple and bilateral ovarian dermoid cysts. Case report. F. PEPE, S. LO MONACO, F. RAPISARDA, G. RACITI, C. GENOVESE, P. PEPE Objective. Multiple and bilateral ovarian dermoid cysts constitute a very unusual report. We report an rare case of a woman with three ovarian dermoid cyst, two localized in the same ovary, detected by US examination and removed by laparoscopy. Case report. A patient aged 29 years, para 0, gravida 0, was referred to our hospital with pain of the right adnexal region. Gynaecological examination showed an antiverted uterus with normal volume; on the right side a mobile mass approximately 7 cms in diameter was palpable, moreover the left ovary was normal. Ultrasound examination
showed a normal uterus. The right ovary presented two complex masses of 7 and 3 cm in diameter, respectively; moreover, the left ovary showed a hyperechogenic complex mass of 3 cm in diameter. The ultrasound pattern was compatible with bilateral ovarian dermoid cysts. On laparoscopy abdominal cavity and uterus were normal, while the right ovary presented two masses and the left ovary a small mass which were enucleated and removed. The patient had an uncomplicated postoperative recovery and was discharged two day after laparoscopy. Pathologic examination confirmed the diagnosis of ovarian dermoid cysts. A one year follow-up showed no evidence of recurrence. Conclusion. The case reported shows that exceptionally multiple and bilateral dermoid cysts may be detected underlining the importance of an accurate preoperative diagnostic imaging. Some recurrence of ovarian dermoid cists may be due to undiagnosed small dermoid cists during preoperative imaging and/or surgical exploration.
KEY WORDS: Ovarian tumor - Dermoid cyst - Surgery - Pelvic pain - Ovary - Pelvic ultrasound.
Introduction Dermoid cyst or mature teratoma is the most common benign ovarian neoplasm in young and middleaged women. It accounts for approximately 20% and 50% of adult and pediatric ovarian tumors (1); moreover, malignant transformation occurs in 1-3% of cases, usually into a squamous cell cancer (2). Although most mature teratomas are asymptomatic, abdominal pain or nonspecific symptoms occur in a small subset of patients.
¹ Obstetrics and Gynecology Unit, “Santo Bambino” Hospital, Catania, Italy ² Urology Unit, “Cannizzaro” Hospital, Catania, Italy Corresponding author: Franco Pepe, e-mail: [email protected] © Copyright 2014, CIC Edizioni Internazionali, Roma
In very rare cases symptoms are related to hormonal secretion (estrogens, prolactin, etc) or paraneoplastic syndrome (3, 4). At ultrasound (US) evaluation, mature teratomas could be detected as cystic or solid masses with areas of fat and calcification; moreover, they may be entirely cystic, solid (with macroscopic fat) or mixed. Macroscopic fat and calcification of mature teratomas are found in about 90% and 50% of the cases, respectively. At MRI fat is depicted as a zone with high signal intensity on T1-T2-weighetd images; moreover, MRI findings could include Rokitansky nodules and “floating ball” imaging. The majority of dermoid cysts are monolateral with equal frequency in both ovaries; moreover, bilateral tumors are found approximately in 10% of cases (2, 5). Multiple ovarian dermoid cysts constitute a very unusual report; sometime they could be detected during the first operation and in other cases many years later from surgery. 75
0266 5 An unusual_PEPE:-
13-05-2014
14:45
Pagina 76
F. Pepe et al.
We report an unusual case of a woman with three ovarian dermoid cyst, two localized in the same ovary, detected by US examination and removed by laparoscopy.
Case report A patient aged 29 years, para 0 gravida 0, was referred to our hospital with pain in the right adnexal region. Gynaecological examination showed an antiverted uterus with normal volume; on the right side a mobile mass approximately 7 cms in diameter was palpable and the controlateral ovary was normal with a diameter of about 5 cm. Abdominal and transvaginal US showed a normal uterus; the right ovary presented two complex masses of 7 and 3 cm in diameter localized in different ovarian regions, respectively. Left ovary showed normal parenchyma with a hyperechogenic complex mass of 3 cm in diameter. The US evaluation was compatible with the presence of multiple ovarian dermoid cysts. The woman underwent laparoscopy to remove the ovarian masses; abdominal cavity and uterus were normal, the right and left ovaries presented two and one masses suspicious for dermoid cysts, respectively. The tumors were enucleated, placed in an endobag and removed (Figure 1). The patient had an uncomplicated postoperative recovery and was discharged two day from laparoscopy. Definitive pathologic examination confirmed the diagnosis of bilateral ovarian dermoid cysts. A one year follow-up showed no evidence of recurrence.
Discussion Dermoid cyst is a frequent tumour of the ovary; usually it is monolateral but sometime it could be co-existence with parasitic intraabdominal dermoid cysts (6) or localized in other sides such as in the omentum, in the pouch of the Douglas (7) or in the uterosacral ligament (8). In about 10-15% of the cases ovarian dermoid cysts may be bilateral and/or multiple (9): Bournas et al. (10) described a woman with 4 dermoid cysts within the right ovary and 1 in the contralateral ovary; Sinha et al. (11) reported a patient with 7 and 3 dermoid cysts in the left and right side, respectively. Finally, Walid et al. (12) reported a case of bilateral dermoid cysts in a pregnant woman. In rare cases the recurrence of a dermoid cyst may be due to its incomplete enucleation during primary surgery, especially if rupture of the dermoid cyst occurred. It has been showed that the ultrasound features of incidentally dermoid cyst have a variety of textural patterns, but quite similar to those encountered in large and symptomatic lesions. The increased resolution of transvaginal US has increased detection of small and non palpable ovarian dermoid (< 3 cm) allowing to plane adequate surgical removal (13). During enucleation of the ovarian dermoid cyst the remaining ovarian tissue as well controlateral ovary should be carefully palpated when performing laparotomy or inspected when performing laparoscopy. It 76
Fig. 1 - Three dermoid cysts removed by laparoscopy.
should also checked the existence of accessory ovaries that in very rare cases may be sites of dermoid cysts, even bilaterally (14). Song et al. (15) in 20 women submitted to conservative treatment reported a recurrence rate equal to 2.5% after a mean period from surgery of 8 ± 7 years. The case reported shows that exceptionally multiple and bilateral dermoid cysts may be detected underlining the importance of an accurate preoperative diagnostic imaging. The surgical approach remains particularly important especially in young women in whom fertility and best cosmetic results should be mandatory. Nowadays the majority of the surgeons usually perform laparoscopy, but other surgeons consider a minilaparotomy procedure (16), although the risk of adhesion formation after laparoscopy is not as high as by laparotomy (17). Anyway preservation of the ovarian tissue is mandatory in the presence of one or more dermoid cysts as well a complete enucleation of the masses avoiding rupture during surgical procedure. Adequate preoperatory imaging may show small ovarian dermoid cysts that may be difficult to diagnose during surgical exploration. Some cases of recurrent ovarian dermoid cyst may be due to undiagnosed small dermoid cist coexistent with a big one.
Conclusion The case reported shows that exceptionally multiple and bilateral dermoid cysts may be detected underlining the importance of an accurate preoperative diagnostic imaging. Some recurrence of ovarian dermoid cists may be due to undiagnosed small dermoid cists during preoperative imaging and/or surgical exploration.
0266 5 An unusual_PEPE:-
13-05-2014
14:45
Pagina 77
An unusual case of multiple and bilateral ovarian dermoid cysts. Case report
References 1. Prat J. Female Reproductive System. In: Damjanov I, Linder J, Anderson WAD eds. Anderson’s pathology. 10th ed. St. Louis, Mo: Mosby, 1996; 2231-2309. 2. Comerci JT, Licciardi F, Berghi PA, Gregori C, Breen JL. Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature. Obstet Gynecol. 1994;84: 2228. 3. Kim I, Lee JY, Kwon JH, Jung JY, Song HH, Park YI, Ro E, Choi KC. A case of autoimmune haemolytic anemia associated with an ovarian teratoma. J Korean Med Sci. 2006;21:365-367. 4. Nokura K, Yamamoto H, Okawara Y, Koga H, Osawa H, Sakai K. Reversible limbic encephalitis caused by ovarian teratoma. Acta Neurol Scand. 1997;95:367-373. 5. Pepe F, Panella M, Pepe G, Panella P, Pennisi F, Arikian S. Dermoid cysts of the ovary. Eur J Gynaecol Oncol. 1986;7:186-191. 6. Sinha R, Sunduram M, Lakhotia S. Multiple intraabdominal parasitic cystic teratomas. J Minim Invasive Gynecol. 2009;16:789791. 7. Tokunaga M, Seta M, Yamada M, Nishio M, Yamamoto K, Koyasu Y. Coexistent dermoid cysts of the pouch of the Douglas and ovary resected by laparoscopy. Asian J Endosc Surg. 2012;5:3133. 8. Moawad NS, Starks D, Ashby K. Ectopic ovarian teratoma of the uterosacral ligament associated with a large ovarian dermoid. J Minim Invasive Gynecol 2008;15:523-524. 9. Al-Fozan H, Glassman J, Caspi B, Appelman Z, Tulandi T. Lateral distribution of ovarian dermoid cyst. J Am Assoc Gynecol Laparosc 2003;10:489-90.
10. Bournas N, Varras M, Kassanos D, Chrelias Ch, Tzaida O, Salamalekis E. Multiple dermoid cysts within the same ovary: our experience of a rare case with review of the literature. Clin Exp Obstet Gynecol 2004;31:305-08. 11. Sinha R, Sethi S, Mahajan C, Bindra V. Multiple and bilateral dermoids: a case report. J Minim Invasive Gynecol 2010;17:23538. 12. Walid MS, Boddy MG. Bilateral dermoid cysts of the ovary in a pregnant woman: case report and review of the literature. Arch Gynecol Obstet. 2009;279:105-08. 13. Serafini G, Quadri PG, Gandolfo NG, Gandolfo N, Martinoli C, Derchi LE. Sonographic features of incidentally detected small, non palpable ovarian dermoids. J Clin Ultrasound 1999;27:369-373. 14. Gabbay-Moore M, Ovaida Y, Neri A. Accessory ovaries with bilateral dermoid cysts. Eur J Obstet Gynecol Reprod Biol 1982;14:171-173. 15. Song YN, Zhu L, Lang JH. Recurrent mature ovarian teratomas: retrospective analysis of 20 cases. Zhonghua Yi Xue Za Zhi. 2007;87:1184-1186. 16. Bolla D, Deseö N, Sturm A, Schöning A, Leimgruber C. Minilaparotomy a good option in specific cases: a case report of bilateral ovarian germ cell tumor. Case Rep Obstet Gynecol 2012 2012:589568. doi: 10.1155/2012/589568. Epub 2012 Mar 5. 17. Briones-Landa CH, Ayala-Yáñez R, Leroy-López L, Anaya-Coeto H, Santarosa-Pérez MA, Reyes-Muñoz E. Comparison of laparoscopic vs. laparotomy treatment in ovarian teratomas. Ginecologia y Obstetrica de Mexico 2010;78:527-532.
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