Case Report | Open Access | Full Text

¹Resident Physician, Department of Gynecology and Obstetrics at the Ibn Rochd University Hospital, Casablanca, Morocco
²Professor in the Department of Gynecology and Obstetrics at the Ibn Rochd University of Hospital in Casablanca Morocco

*Corresponding author: Sahel Imane, Resident Physician, Department of Gynecology and Obstetrics, at Ibno Rochd University Hospital, Casablanca, Morocco

Abstract

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Ovarian dermoid cysts, also known as mature cystic teratomas (MCTs), account for 69% of ovarian germ cell tumors in young women. These tumors are formed from tissue derived from the three germ layers, with sebaceous material being the most commonly observed. The origin of MCTs is widely considered to be germ cells that complete meiosis I. Clinical symptoms vary considerably, but 20% of tumors may be asymptomatic. Its association with pregnancy is rare. We report the case of a 29-year-old woman admitted for management of an abdominopelvic mass for which she underwent ultrasound supplemented by pelvic MRI, followed by conservative treatment based on adnexectomy with multiple biopsies, the pathological result of which was consistent with a mature ovarian teratoma.
Keywords: Mature Teratoma, Pregnancy, Radiological Examinations, Pathology, Treatment
Abbreviations: MCT: Mature Cystic Teratomas

Introduction

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Tumors are formed by tissues derived from fully differentiated cells originating from the three germ layers, namely the ectoderm, mesoderm, and endoderm [1]. Ectodermal tissues and sebaceous material are common and present in almost all cases. Thirty-eight percent of tumors contain only skin and nerve tissue, 30% contain exclusively skin tissue and dermal appendages, and the rest contain other completely differentiated histological tissues. A cystic ultrasound with an echogenic nodule characterized by echogenic sebaceous material and calcifications is the most common ultrasound appearance of a mature teratoma [2,3].
The possible cause of this tumor remains unclear. Reported risk factors include late menarche and long-term menstrual irregularities, a history of cystic teratoma, fewer pregnancies, infertility, excessive alcohol consumption, and intense physical exercise [4]. Recent studies have reported that the cellular origins of mature teratomas are diploid and contain sets of homozygous alleles.

Observation

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Ms. A.Z., aged 29, IG0P, with no particular medical history, consulted for an abdominal-pelvic mass discovered three months ago, gradually increasing in size, associated with chronic pelvic pain of a heavy type, in a pregnancy estimated at two months. The general examination revealed a parturient in good general condition with, on gynecological examination, an abdominal-pelvic mass reaching the level of the umbilicus. Pelvic ultrasound revealed a homogeneous, hyperechoic abdominal-pelvic mass measuring 20 x 20 cm in a single pregnancy of 8 weeks. Tumor markers were negative. Pelvic MRI confirmed the presence of a well-encapsulated, subumbilical, compartmentalized abdominal-pelvic mass measuring 18 cm in its longitudinal axis, likely of ovarian origin, with three components (tissue, fat, and calcium), suggestive of an immature teratoma-type germ cell tumor.
The parturient underwent laparotomy with exploration:
The fallopian tubes appeared normal, and the left ovary and pregnant uterus were normal. The right ovary had a tumorous appearance, measuring approximately 22 cm in its longitudinal axis, non-adherent, with a smooth surface, exophytic vegetation, a small amount of effusion, and no peritoneal tumor implants. A right adnexectomy with several biopsies was performed, as well as a lavage fluid sample. The pathological result was consistent with a mature, multitissue ovarian teratoma without immature components.

Discussion

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The frequency of ovarian tumors discovered during pregnancy ranges from 0.3 to 5.4%. The most common benign organic ovarian tumors during pregnancy are dermoid cysts and cystadenomas [5]. It has been hypothesized that hormonal changes associated with pregnancy may be responsible for an increase in the size of dermoid cysts. In a prospective series, Caspi et al. followed 49 young women with a known dermoid cyst smaller than 6 cm. During the 68 pregnancies that occurred, cyst size remained stable throughout pregnancy [6].
The main risk of complications from dermoid cysts during pregnancy is adnexal torsion, estimated at around 8%, particularly during the first trimester and early second trimester. No cases of malignant degeneration of dermoid cysts were reported in the two follow-up series conducted by Caspi et al. and Caruso et al. during pregnancy [5]. Tumor markers are not reliable during pregnancy for assessing the risk of malignancy. Ultrasound remains the gold standard for characterizing ovarian tumors during pregnancy. Its specificity is lower for the diagnosis of malignancy than outside of pregnancy. Pelvic MRI is a powerful tool in the diagnosis of ovarian tumors during pregnancy and provides additional information to ultrasound [7]. Laparoscopy is the gold standard for the management of this condition. Cystectomy is the best choice for preserving as much of the ovarian parenchyma as possible. An oophorectomy or adnexectomy may be necessary if the lesion affects the entire ovary and no recognizable parenchyma remains [8].
During the first trimester, surgery is recommended in cases of symptomatic ovarian tumors that suggest adnexal torsion [9]. In other cases, an ultrasound scan will be performed at the beginning of the second trimester to ensure that the tumor is still present. In cases of benign-looking ovarian tumors that do not increase in size and remain less than 6 cm, the risk of complications is low and watchful waiting is recommended. In cases of presumed benign ovarian tumors larger than 6 cm, there is insufficient data in the literature to decide between watchful waiting and surgery [10]. An increase in tumor size would be an indication for surgery. If surgery is decided upon, the risk of miscarriage is estimated at 2.8% and must be clearly explained to the patient. Subsequently, regardless of the trimester of pregnancy, the discovery of a symptomatic ovarian tumor presumed to be benign, raising concerns about adnexal torsion, remains an indication for surgery. It should be noted that after 20 weeks of pregnancy, the risk of torsion is rare and that after 23 weeks, the risk of obstetric complications (premature delivery) associated with surgery is higher. These data encourage postponing surgery until after delivery in cases of asymptomatic ovarian tumors presumed to be benign after 20-23 weeks of pregnancy [11].
Histology is essential to confirm the diagnosis of mature teratoma and to look for signs of malignant degeneration. The prognosis is excellent, and regular ultrasound monitoring, theoretically throughout the period of genital activity, should be considered [12].

Conclusion

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The prognosis for immature ovarian teratomas during pregnancy depends mainly on three factors: histological grade, anatomical stage, and αFP secretion. However, although management is still widely debated in the literature, current data support conservative surgical treatment that preserves fertility in young patients who wish to become pregnant. Laparoscopy is rarely used due to the size of the the tumor or the pregnant state. Adjuvant chemotherapy can be avoided in cases of stage IA grade 1 immature teratoma and remains debatable for other high-grade teratomas.

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