A case of ovarian clear cell carcinoma arising from ovarian mature cystic teratoma

MRI findings of malignant transformation arising from mature cystic teratoma of the ovary: comparison with benign mature cystic teratoma

OBJECTIVE

This study aimed to evaluate the efficacy of MRI findings to differentiate malignant transformation arising from mature cystic teratoma (MT-MCT) of the ovary from benign mature cystic teratoma (BMCT).

MATERIALS AND METHODS

This study included 11 patients with histopathologically proven MT-MCT and 50 with BMCT. Overall, 7 patients with MT-MCT and all 50 with BMCT underwent unenhanced and contrast-enhanced MRIs and 4 with MT-MCT only underwent unenhanced MRIs. The MRI findings were evaluated and compared between the two diseases.

RESULTS

The median age (55 vs. 38 years, p < 0.01) and maximum diameter (109 vs. 65 mm, p < 0.01) were higher in MT-MCT than in BMCT. Fat component occupancy was lower in MT-MCT than in BMCT (median, 5% vs. 63%, p < 0.01). Only MT-MCT exhibited irregular tumor margins (64%), peritoneal dissemination (18%), and abnormal ascites (27%). The solid components were more commonly observed in MT-MCT than in BMCT (100% vs. 32%, p < 0.01) on contrast-enhanced images. The maximum diameter of solid components in MT-MCT was larger than that in BMCT (median, 61 mm vs. 14 mm, p < 0.01). In MT-MCT, the common configuration of solid components was endophytic or exophytic sessile (85%), whereas in BMCT, it was endophytic papillary (88%).

CONCLUSION

Compared with BMCT, MT-MCT demonstrated a larger maximum diameter, lower occupancy rate of fat components, and sessile solid components. The characteristic configuration of solid components was endophytic or exophytic sessile in MT-MCT and endophytic papillary in BMCT.

Ovarian Masses in Children and Adolescents: A Review of the Literature with Emphasis on the Diagnostic Approach

Most abdominal masses in the pediatric population derive from the ovaries. Ovarian masses can occur in all ages, although their incidence, clinical presentation and histological distribution vary among different age groups. Children and adolescents may develop non-neoplastic ovarian lesions, such as functional cysts, endometrioma, torsion, abscess and lymphangioma as well as neoplasms, which are divided into germ cell, epithelial, sex-cord stromal and miscellaneous tumors. Germ cell tumors account for the majority of ovarian neoplasms in the pediatric population, while adults most frequently present with epithelial tumors. Mature teratoma is the most common ovarian neoplasm in children and adolescents, whereas dysgerminoma constitutes the most frequent ovarian malignancy. Clinical manifestations generally include abdominal pain, palpable mass, nausea/vomiting and endocrine alterations, such as menstrual abnormalities, precocious puberty and virilization. During the investigation of pediatric ovarian masses, the most important objective is to evaluate the likelihood of malignancy since the management of benign and malignant lesions is fundamentally different. The presence of solid components, large size and heterogenous appearance on transabdominal ultrasonography, magnetic resonance imaging and computed tomography indicate an increased risk of malignancy. Useful tumor markers that raise concern for ovarian cancer in children and adolescents include alpha-fetoprotein, lactate dehydrogenase, beta subunit of human chorionic gonadotropin, cancer antigen 125 and inhibin. However, their serum levels can neither confirm nor exclude malignancy. Management of pediatric ovarian masses needs to be curative and, when feasible, function-preserving and minimally invasive. Children and adolescents with an ovarian mass should be treated in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome.

Malignant transformation of mature cystic teratoma of the ovary

Mature cystic teratoma is the most common ovarian germ cell neoplasm. Malignant transformation is a rare occurrence, accounting for 1.5%-2% of cases. Malignant changes can arise from any constituent tissue of a teratoma; however, squamous cell carcinoma is the most common histologic type seen, followed by adenocarcinoma and sarcoma respectively. Tumor marker concentration levels, age, and the tumor maximum diameter are predictive indicators for malignant transformation. Proper diagnosis includes recognizing the possibility of malignant transformation versus excluding other differential options, such as metastasis. Primary cytoreductive surgery, adjuvant chemotherapy, and radiotherapy are the current treatment methods. The aim of the review is to discuss the clinical and pathologic features of malignant transformation within mature cystic teratomas, while reviewing the reported malignant types, differential diagnoses, and treatment options. Data sources include review of pertinent peer-reviewed literature on malignant transformation of mature cystic teratoma and cases seen in authors' institutional practice. Mature cystic teratomas are a commonly encountered benign ovarian tumor. However, the possibility of malignant transformation should remain in consideration, especially with given clinical or pathologic features: increased patient age, tumor size, or tumor marker levels. Thorough sampling of solid tumor foci can help identify malignant components. Awareness and proper diagnosis, along with early detection and clinical management, shows improved patient outcomes.

Diagnosis Difficulties and Minimally Invasive Treatment for Ovarian Masses in Adolescents

About 1% of childhood tumors can be malignant ovarian tumors and differential diagnosis with benign ones is sometimes difficult before surgery. Concerning the management of such tumors in adolescents for which future fertility is a concern, there is specific interest in their malignant potential and the possible use of ovarian-sparing operative techniques, as well the suitability of chemotherapy. To exemplify the difficulties of preoperative differential diagnosis, personalized approach and the difficulties of deciding to preserve the affected ovary, we report a rare case of a 14-year-old female adolescent with a growing abdominal painless mass and without any other chronic diseases. After physical examination and imaging investigations, laparoscopic surgical procedure is performed, the peritoneal cavity is explored and the well-delimited gigantic tumor is removed. Considering the normally looking pelvis and absence of adenopathy, as well as the patient's age and wish to have children, both ovaries are preserved. Laparoscopy has become the gold standard in the management of this condition, although there are few studies that report this approach in children; the differential diagnosis between a benign and a malignant tumor cannot be established exactly until after the histological examination, which revealed in our case a cystic teratoma with mature tissues. A better understanding of clinical features and evolution of giant ovarian masses in adolescents could help clinicians better diagnose and treat such lesions.