Boba sign: a novel sign for floating balls within a mature cystic teratoma

Ruptured ovarian dermoid causing chemical peritonitis: a case report

Spontaneous rupture of ovarian dermoid cysts is uncommon. We describe a case of a 32-year-old female who presented to the emergency room with abdominal pain and distension. The patient was discovered to have a ruptured dermoid cyst which caused chemical peritonitis and was managed surgically.

Adnexal masses: a compendium of established radiological signs

Adnexal masses are frequently encountered in general practice. Whether employing CT, US, or MRI, imaging plays a pivotal role in guiding appropriate treatment for patients with adnexal masses, potentially minimizing the need for surgery in benign cases and expediting the management of those with suspected malignancy. Accurately distinguishing benign from malignant adnexal masses can be challenging due to the confined pelvic space and the proximity of organs, making it difficult to determine their organ of origin or to distinguish tissue characteristics and imaging features. Radiologists have identified a myriad of classic adnexal imaging signs that are pathognomonic of certain diagnoses. Often named analogously to familiar objects, such as the "boba sign," familiarity with these signs can contribute to an accurate diagnosis, avoiding additional imaging tests. This pictorial review is a compendium of known radiological signs of adnexal pathologies, reiterating their role in making an accurate diagnosis, and guiding the next steps in management.

"Floating ball sign" in the diagnostic imaging of mature ovarian teratomas in children

The "floating ball sign" (FBS) is a rarely described visual phenomenon found in mature ovarian teratoma imaging. It is characterized by the presence of movable, spherical areas within the cystic component of a tumor. Such visualization is possible both in cross-sectional imaging and ultrasonography. To evaluate the incidence of FBS in the pediatric population with regard to patients' age and tumor size. This is a retrospective study of pediatric patients operated on in a tertiary pediatric surgical center between January 2009 and December 2022 due to mature ovarian teratoma; the medical records were reviewed for the age at diagnosis, recurrences, tumor size, and their characteristics in preoperative imaging. Eighty-three patients (mean age 14, range 0-17) out of 91 met the inclusion criteria for the analysis. Eighty-seven operations on 90 ovaries were performed. Preoperatively 38 patients underwent CT, 13 MRI, and 39 received only the ultrasound examination. The FBS was identified in preoperative imaging diagnostics in 3 (3.3%) girls (14, 16 and 17 years of age). The average largest tumor dimension and volume were 142 mm and 1268 cc in the FBS group, and 73 mm and 252 cc in the remaining group, respectively. FBS tumors usually reach large sizes. Although the sign is rare in children, there are no scientific reports of its occurrence in the first life decade. Color flow mapping and cross-sectional imaging play a pertinent role in distinguishing this uncommon pattern from a malignant mass and enable the selection of an appropriate surgical approach.

Stage Ia squamous cell carcinoma as the malignant transformation of giant and unusual mature teratoma of the ovary in an elderly patient

Background

Mature cystic teratomas of the ovary (MCTO) are a type of germ cell tumor that may contain well-differentiated tissues developed from three germ cell layers and constitute about 20% of ovarian germ cell tumors. They are rare ovarian tumors with an annual incidence variable from 1.2 to 14.2 cases per 100,000 that occur mainly in women of reproductive age. They are frequently benign with a slow growth rate, even if they can undergo a malignant transformation in about 1–2% of cases.

Case presentation

Here, we present the case of an elderly woman referred to gynecological first aid for acute abdominal pain and showing a giant and unusual MCTO at rapid growth with malignant transformation in squamous cell carcinoma (FIGO stage Ia). The patient underwent pelvic mass removal trough emergency longitudinal midline laparotomic incision with intraoperative frozen pathologic examination. A complete surgical staging during the first surgery was performed. After about 9 years of follow-up, she died of non-oncological reasons without recurrence.

Conclusions

Present case highlights that CMTO with malignant transformation should always be suspected in elderly women in presence of pelvic mass at rapid growth, even if in absence of other clinical and ultrasonographic signs of malignancy. An intraoperative frozen pathologic examination may drive the best treatment.