Recurrent Mature Cystic Ovarian Teratoma in Adolescence: Atypical Case of the Growing Teratoma Syndrome

Rare case of perplexing ovarian endometriosis

OBJECTIVE

To document a rare case of coexisting endometriosis and mature cystic teratoma in the same ovary.

DESIGN

Case report.

SETTING

Gynecology unit in a tertiary training and teaching hospital in Cape Town, South Africa.

PATIENT(S)

A 30-year-old healthy nulligravida woman with a large ovarian tumor.

INTERVENTION(S)

After a basic examination, a diagnostic and management laparotomy was performed. A unilateral oophorectomy and staging laparotomy were performed.

MAIN OUTCOME MEASURE(S)

Final diagnosis of a complex ovarian tumor.

RESULT(S)

Histologic analysis confirmed endometriosis of the pelvis and concomitant compound pathology in the right ovary, which included endometriosis, mature teratoma, and mucinous cystadenoma.

CONCLUSION(S)

Co-existence of varied pathology in a single organ presents a challenge to the pathologist and the clinician. Accurate clinical (i.e., surgical) assessment and decisive histologic verification forms a critical part in this process. This case of coexisting endometriosis and teratoma in a single ovary is, to our knowledge, only the third case reported in literature.

Germ cell tumors of the ovary

PURPOSE

Malignant ovarian germ cell tumors (MOGCTS) are rare but curable at all stages of disease. This review gives an outline of the management of this disease.

METHODS

We performed a literature search in the PubMed of almost all relevant articles concerning MOGCTs on pathology, prognostic factors, surgery, post-operative therapy and late effects of therapy. The available literature is mainly composed of retrospective reviews and articles.

RESULTS

Prognostic factors include stage, amount of residual tumor, histologic type and raised tumor markers. For patients with early stage disease, cure rates approach 100%, while for those with advanced-stage disease are at least 75%. Appropriate surgical treatment for patients where fertility needs to be preserved consists in laparotomy with unilateral salpingo-oophorectomy (USO) and resection of all visible disease. For patients with advanced-stage disease, the role and the extent of debulking surgery remain controversial despite its routine use. However, it is suggested a benefit from minimal residual disease at completion of primary surgical cytoreduction with both non-platinum and platinum-based chemotherapy regimens. Second-look surgery clearly is not indicated in patients with early stage non-dysgerminoma or in all patients with dysgerminoma. However, teratoma patients may benefit from secondary cytoreduction. Three courses of bleomycin, etoposide and cisplatin (BEP) is the current standard adjuvant chemotherapy and four courses of BEP are recommended in case of bulky residual tumor after surgery. More evidence is required to show that surveillance is a safe option. There is a hint that high-dose chemotherapy may play a role in relapsed patients. The majority of MOGCTs patients who undergo fertility-sparing surgery and chemotherapy retain their gonadal and reproductive function. There is an increasing concern about life-threatening long-term effects of treatment.

CONCLUSION

MOGCTs are rare neoplasms that affect girls and young women and have excellent prognosis at all stages of disease with optimal therapy. The majority of MOGCTs patients retain their reproductive function.

Controversies in the management of germ cell tumours of the ovary

PURPOSE OF REVIEW

Ovarian germ cell tumours are rare, but curable at all stages of disease. This review gives an outline of the main controversies regarding the management of this disease.

RECENT FINDINGS

Pelvic malignancies are very rare during pregnancy, which should avoid the need for radical surgery or termination in these patients. Also during pregnancy, AFP-L2 looks to be a promising tumour marker in detecting relapse. Malignant transformation of mature teratomas may be predicted by preoperative squamous cell antigen and tumour size. OCT4 immunohistochemistry has been shown to be a very useful adjunct in the diagnosis of dysgerminomas. The traditional method for grading immature teratomas is challenged by a new classification. Patients receiving cisplatin-based chemotherapy are at a higher risk of developing cardiovascular risk factors. There is a hint that high-dose chemotherapy may play a role in relapsed patients.

SUMMARY

Rarity of the disease means many controversies are difficult to resolve, with much reliance on using data from testicular cancer studies. Many clinicians still advocate adjuvant chemotherapy for stage I nondysgerminomatous tumours of grade 2 and above despite good evidence that surveillance is a safe option, and increasing concerns about life-threatening long-term effects of treatment.