Bilateral Mature Cystic Teratomas of the Ovary with Endometrial Cancer: A Rare Case Presentation

Introduction

Amature cystic teratoma, also known as a dermoid cyst, is a germ-cell tumor arising from three germ-cell lines, namely, the ectoderm, mesoderm, and endoderm. In an ovarian dermoid cyst, ectodermic differentiation occurs more frequently. These tumors account for 10%–20% of all ovarian neoplasms, with a peak incidence at 20–40 years of age. These tumors are mostly unilateral; bilateral presentation is seen in only 10% of cases. ¹ Furthermore, the occurrence of a malignancy along with bilateral dermoid cysts is extremely rare. This article reports on a case of bilateral dermoid cysts with endometrial cancer in a postmenopausal woman.

Case

A 62-year-old woman, para 3, live 3, presented to a gynecologic outpatient department with complaint of postmenopausal bleeding of 1½ months' duration. She had attained menopause 13 years prior. Her family and personal history were negative for gynecologic, breast, and colorectal cancers. On examination, her body mass index was 27 kg/m². Per abdomen and per speculum examinations were unremarkable. A bimanual examination revealed masses in both fornices of ∼6–7 cm and 7–8 cm in the right and left sides, respectively. Laboratory findings were: CA-125, 21.40 IU/mL; preoperative hemoglobin,10g/dL; blood urea, 30; and serum creatinine, 0.8 mg/dL. On transvaginal ultrasound, both ovaries appeared to be bulky. There were large, unilocular cystic lesions that had internal echoes with hyperechoic contents. The cysts measured 7.1 × 5.8 cm on the right side and 5.8 × 6.8 cm on the left side, which was suspicious of dermoid cysts, with mild hypoechoic collection in the endometrial cavity. Her uterus was normal. Her Papanicolaou smear was normal, and endometrial sampling showed inflammatory changes.

She underwent an exploratory laparotomy through a lower midline vertical incision. During the laparotomy, 7 × 7–cm bilateral ovarian tumors with smooth capsules and cystic consistency were detected, while her uterus and bilateral fallopian tubes were normal (Fig. 1). Peritoneal washings were collected. Clockwise intra-abdominal palpation did not reveal any abnormalities. Peritoneal and omental biopsies were taken. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. On cut section of both ovarian masses, sebaceous material emerged and teeth were identified. Her uterus contained thickened endometrium.

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FIG. 1.

Intraoperative view of bilateral dermoid cysts of the ovaries with smooth capsules and a normal-appearing uterus.

Results

This patient was discharged on the tenth postoperative day, with her postoperative period being uneventful. A histopathologic report confirmed the diagnosis of moderately differentiated endometrial cancer invading less than half of the myometrium (Fig. 2), with the uterocervical junction being free from infiltration. Her cervix showed chronic cervicitis, her ovaries had bilateral mature cystic teratomas (Fig. 3), while the peritoneum and omentum were free from tumor infiltration. Peritoneal washings were negative for malignant cells.

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FIG. 2.

A 10 × 2 microscopic picture of moderately differentiated endometrial cancer with less than half thickness of invasion in the myometrium (H&E).

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FIG. 3.

A 4 × 2 microscopic picture showing a mature cystic teratoma of the ovary (H&E).

Discussion

Teratomas can be mature or immature. Both mature and immature types of teratomas are benign, but an immature teratoma has a more-aggressive course. ² The disease occurs in patients of almost any age, from childhood to postmenopause, although the peak incidence is reported in women age 20–40. ³ Mature cystic teratomas are usually slow-growing, with an estimated growth rate of 1.8 mm/year, ⁴ and have arrested growth after menopause. Bilaterality is usually seen in 10%–15% of cases. In adults, dermoid cysts are asymptomatic in 64.5% of cases ⁵ and are commonly incidental findings during imaging or surgical procedures for other reasons, whereas, in children and adolescents, these cysts usually present with abdominal pain and distension.

Torsion is the most common complication, whereas rupture and suppuration are uncommon, due to the tumors' thick capsules. ⁵ Malignant changes are uncommon and occur in 0.1%–0.2% of cases. ⁶ Squamous-cell carcinoma (SCC) is the most common malignant change. Predictors of malignant change are elevated CA-125 levels, older age, large tumor masses, and postmenopausal status. ⁷

Some of the associations found in the literature on bilateral dermoid cysts are hemolytic anemia, ⁸ endometriosis, and ectopic pregnancy. ⁹ There is only one report so far regarding SCC arising from a mature cystic teratoma of the ovary with synchronous endometrial adenocarcinoma. ¹⁰ Although the dermoid cysts in the current case had risk factors for malignant transformation—such as older age, postmenopausal status, and large size—there was no focus of SCC arising from the cysts. Instead, there was coexisting endometrial cancer. Thus, there can be a possibility that dermoid cysts have the potential to stimulate residual ovarian stroma for estrogen production and, consequently, lead to endometrial cancer. Further studies are needed to confirm this speculation. However, the combination of bilateral mature cystic teratomas and endometrial cancer is unique and, to the best of the current authors' knowledge, this has not been previously reported in the English-language medical literature.

Conclusions

Bilateral mature cystic teratomas and endometrial cancer are incidental findings. In all cases of postmenopausal bleeding with bilateral dermoid cysts, a strong suspicion of endometrial cancer must be kept in mind. Magnetic resonance imagine could have probably helped to make a preoperative diagnosis of endometrial cancer and myometrial invasion, and to determine the exact characterization of the ovarian masses.