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Winthrop University Hospital Mineola, NY 11501
A 68-year-old gravida 1 para 1001 woman who was previously in good health presented with lower abdominal pain. The patient had a remote history of smoking, but her medical history was otherwise unremarkable. At physical examination, we identified a firm midline pelvic mass that extended from the suprapubic region to the umbilicus. A CT scan of the abdomen and pelvis revealed the cause of the mass to be an ovarian teratoma (Fig. 3A). The teratoma inferiorly contained a complex soft-tissue component with irregular margins that was invading the uterus posterior to it (Figs. 3B and 3C).
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Results of routine laboratory studies were normal, and chest radiography showed a tortuous aorta but clear lungs. However, the patient's CA-125 level was significantly elevated at 195 U/mL (normal range, 0-25 U/mL). At surgery, the left ovarian mass was found to be adherent to the uterus as identified on CT, and a hysterectomy and oophorectomy were performed, along with ovarian tumor staging. At pathologic examination, the left ovarian teratoma measured 17 x 13 x 11 cm, weighed almost 1500 g, and contained yellow grumous material along with hair. A firm 8-cm-wide soft-tissue area—which was tan on its cut surface and which corresponded to the heterogeneous soft tissue identified on CT in the right inferior aspect of the mass—invaded the right lateral uterine wall. This region contained well- to moderately differentiated squamous cell carinoma. Histopathologic examinations of the right ovary, bilateral pelvic lymph nodes, peritoneal and omental biopsies, and pelvic washings also revealed normal findings.
Mature cystic teratomas are common lesions that represent approximately 10-25% of all ovarian neoplasms [1]. They consist of well-differentiated derivatives of all three germ cell layers, with a predominance of skin elements [1, 2]. Malignant transformation of ovarian teratomas is quite rare, occurring in approximately 2% or less of all cases and almost exclusively in postmenopausal women [1, 2]. In 85% of the cases, the malignant elements are composed of squamous cell carcinoma arising from the squamous lining of the cyst wall [1]. Clinically, malignant transformation may not be easily recognized, and extensive local invasion or metastases may occur in up to two thirds of patients. The prognosis of such patients is therefore guarded [1].
A few ovarian teratomas with malignant transformation have been reported in the imaging literature [1,2,3,4]. In six cases described by Kido et al. [1] and two cases described by Buy et al. [3], malignant transformation was identified on pelvic MR imaging and CT, respectively, as an invasive growth of a large, irregularly marginated soft-tissue component through the teratoma wall. In addition, the contrast enhancement of the Rokitansky's protuberance should raise the possibility of malignant transformation [1,2,3]. Finally, in a recent retrospective series of 188 ovarian teratomas imaged with sonography, 11 were malignant [4]. In this series, the presence of a branching isoechoic component was a sign suggestive of malignancy [4].
Although rare, diagnostic findings of malignant transformation of an ovarian teratoma may be identified on cross-sectional imaging studies, including CT, and should prompt appropriate gynecologic oncology planning.
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  T. Ueno, Y. O. Tanaka, M. Nagata, H. Tsunoda, I. Anno, S. Ishikawa, K. Kawai, and Y. Itai Spectrum of Germ Cell Tumors: From Head to Toe RadioGraphics, March 1, 2004; 24(2): 387 - 404. [Abstract] [Full Text] [PDF]
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