Minimal Laparotomy Management of a Giant Asymptomatic Ovarian Teratoma in a Woman of Reproductive Age: A Case Report
Abstract
Background: The majority of giant teratomas are symptomatic. The preoperative evaluation for possible malignancy is challengeable, as is the surgical approach. A consensus has not yet been drawn regarding the optimal treatment approach in cases of exceptionally large teratomas.
Case presentation: We report a rare case of minimal laparotomy management of a giant ovarian cystic teratoma in a 32-year-old asymptomatic multiparous woman. The patient was diagnosed while performing a fitness-to-work checkup where the physician noted a suspicious abdominal swelling. Subsequently, she was referred to us for further evaluation. Her CA125 level was raised, and an abdominal contrast computed tomography revealed a huge teratoma. After appropriate counselling, laparotomy and adenectomy were performed. Histopathological examination diagnosed a mature cystic teratoma with no malignant transformation. The patient had an uneventful recovery and was discharged on the third post-operative day.
Conclusions: We conclude that dermoid cysts can reach enormous sizes in the absence of serious symptoms or evidence of malignancy, although the size is a well-known risk factor for malignant transformation.
Keywords: Giant teratoma; Pelvic mass; Laparotomy; Computed tomography
Abbreviations: AFP: α-Fetoprotein; CEA: Carcino Embryonic Antigen; CT: Computed Tomography; SCC Ag: Squamous Cell Carcinoma Antigen
Background
Ovarian tumors can originate from any of its different layers. The three major histological types are: epithelial tumors, sex cord stromal cell tumors, and germ cell tumors, which constitute approximately 25% of all ovarian tumors (Figure 1) [1].
Teratomas are slow-growing tumors, composed histologically of diverse tissues, such as bone, skin, sebaceous glands, etc., owing to its cell of origin. Pathologically, teratomas are classified into benign mature, malignant immature, and mono-dermal types that are composed of one type of tissue [2]. In 10-17% of cases, both ovaries are involved [3].
Ovarian teratomas rarely exceeds the diameter of 15cm. Teratomas that exceed this size have an increased likelihood of malignant transformation. Other risk factors include elevated tumor markers and advanced age [4]. Giant teratomas usually present with complications, including torsion, pressure symptoms, and rupture. Here, we report a rare case of an asymptomatic giant teratoma in a 32-year-old multiparous woman. The CARE guidelines were followed for this case report [5].
A 32-year-old multiparous woman was referred for further evaluation of a suspicious abdominal mass. During a discussion of the patient’s medical history, the patient admitted to the existence of this mass for more than one year in association with vague, intermittent abdominal pain. She reported no changes in her menstrual cycle or bowel habits. There was no other significant medical or family history. On inspection of the abdomen, a clear bulge was evident approximately 20×30cm in size in the periumbilical region. It was soft, and no area of tenderness could be detected (Figure 2).
Due to its huge size, an extensive workup was performed to assess the possible risks of malignancy. The levels of serum tumor markers α-fetoprotein (AFP), carcinoembryonic antigen (CEA), and β-human chorionic gonadotropin, were normal. However, the patient’s CA125 level was abnormally high at 50 U/ml (normal range, <35 U/ml). Abdominal contrast computed tomography (CT) revealed a 25×20×14cm pelviabdominal cystic multilocular mass with fluid/fat density and internal nodules of fat and calcific teeth (Rokitansky nodules) suggestive of a dermoid cyst, originating from the left ovary. Displacement of the surrounding bowel loops and diffuse anterior abdominal wall contour bulge were also noted (Figure 3). There was no evidence of enlarged lymph nodes, ascites, or tumor deposits in the abdomen or pelvis.
Other blood test findings were within the normal ranges, and liquid base cytology was negative for malignant cells. The radiological and laboratory findings were discussed in detail with the patient, and the possible risks of malignancy were highlighted. Written informed consent for surgery was obtained.
A mini-midline laparotomy was performed. A huge mass was seen originating from the left ovary, extending to the liver, with an approximate size of 20×40×20cm. The fallopian tube was stretched out by the mass. The cyst was aspirated completely without spillage in the peritoneal cavity. A total 5 L of thick, yellowish fluid was aspirated. No ascites or organ infiltrate was noted. Complete adenectomy was performed due to the absence of a cleavage line between the cyst and the ovary; the ovarian tissue was completely destroyed by the mass (Figure 4a). However, the contralateral tube and uterus were normal. The patient had an uneventful recovery and was discharged on the third post-operative day.
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