Goubaa Mohamed MD Djerba Tunisia

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This is a 70-year-old female (postmenopausal) who presents with marked pelvic pain, nausea and vomiting. Physical examination showed a large pelvic mass which could be adnexal and/or uterine in origin. Patient have both transabdominal and transvaginal examinations. C'est une patiente ménopausée, âgé de 70 ans, qui s'est présenté pour des douleurs pelviennes intenses, nausée et vomissements. L'examen physique a révélé la présence d'une grande masse pelvienne qui pourrait être d'origine anexielle et/ou utérine. La patiente a subit un examen échographique par les 2 voies : abdominale et endovaginale.




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There is a complex, predominantly cystic mass measuring 10 x 10 cm anterior and apparently separate from the uterus. The solid part of mass has a 7 x 3 cm. The right ovary could not be identified.
The pathologist finds only thyroid tissue in the mass(struma ovarii = ovarian goiter).
Il existe une masse principalement kystique mesurant 10 x 10 centimètres et apparemment séparé de l'utérus. La partie solide de la masse mesure 7 x 3 centimètres. L'ovaire droit n'est pas identifiable.
L'anatomo-pathologiste trouve uniquement du tissu thyroïdien dans la masse (goitre ovarien).


Struma Ovarii (teratoma) with torsion. Goitre ovarien (tératome) avec torsion.


Struma ovarii

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Struma ovarii belongs to the group of monodermic and highly specific teratomas. It comprises less than 5% of mature teratomas (4,5). Our study covers one patient with the diagnosis of struma ovarii. simple oophorectomy were preformed. Histopathological examination confirmed struma ovarii, with follicular, fetal and embryonic forms of thyroid tissue, without metastases and malignancy. Struma ovarii is an uncommon type of teratomas, difficult to identify without histopathological examination.

Clinique :
* The most frequently symptom is abdominal pain (50 %) though a high percentage (40 %) of patients were asymptomatic (1).
* A struma always occurs as a pelvic mass, which may be palpable on physical examination, depending upon size and location.
* Pleural effusion and ascites are sometimes present.
* Only 8% of patients with strumas present with clinical hyperthyroidism. 30 % of patients have associated and significant thyroid function abnormalities.
Struma ovarii could be hormonally active and manifest clinical symptoms of thyroid hyperactivity or thyrotoxicosis. Postoperative complications in hormonal active struma ovarii were reported as well. Struma ovarii may be associated with ascites and pleural effusion, known as "pseudo - Meigs syndrome" (6). In the majority of reported cases tumor excision led to complete remission. Malignant changes in struma ovarii are uncommon.

Sonography :
Preoperative diagnosis is very difficult because ultrasonography (and computer tomography, and nuclear magnet resonance) is not specific enough. With this technique we can only see adnexal mass consisting of solid and cystic parts. Ultrasound show a multicystic mass with a well-vascularized solid part (2). Only preoperative scintigraphy with iodine ( 131 I) could show active thyroid tissue in small pelvis.
However 75 % of cystic teratomas are avascular, if the solid components of an apparent benign cystic teratoma have vascular flow, a struma ovarii consisting largely of thyroid tissue should be considered.
Dermoid cysts of the ovary are devoid of blood flow, with flow detection rate being only 25% from the cyst capsule. When apparently vascularized solid tissue is detected in the central part of a sonographically suspected benign cystic teratoma, struma ovary is highly suspected (3).

Differential :
* Haemorrhagic ovarian cyst.
* Other Solid teratoma and dermoid cysts.
* Fibroma and fibrothecoma.
* Arrhenoblastoma.
* Granulosa cell tumour.
* Mucinous or serous cystadenomas or cystadenocarcinoma.
* Endometroid carcinoma.
* Adenocarcinoma without serous or mucous collection.
* Krukenberg's tumeurs.
* Lymphoma of ovaries.

Most cases are unilateral and benign : simple oophorectomy is appropriate for most patients. Ablation with iodine-131 has been advocated as adjunctive therapy if pathological examination or staging suggests malignant transformation.

* 1: Morillo Conejo M, Martin Canadas F, Munoz Carmona V, Gonzalez-Sicilia Munoz E, Gonzalez Sicilia Cotter E, Carrasco Rico S. [Ovarian mature teratoma. Clinico-pathological study of 112 cases and review of the literature] Ginecol Obstet Mex. 2003 Sep;71:447-54. Review. Spanish.
* 2: Van de Moortele K, Vanbeckevoort D, Hendrickx S. Struma ovarii: US and CT findings. JBR-BTR. 2003 Jul-Aug;86(4):209-10.
* 3: Zalel Y, Caspi B, Tepper R. Doppler flow characteristics of dermoid cysts: unique appearance of struma ovarii. J Ultrasound Med. 1997 May;16(5):355-8.
* 4. Carvalho RB, Cintra ML, Matos PS, Campos PS. Cystic struma ovarii: a rare presentation of an infrequent tumor. Sao Paulo Med J 2000;118(1):17-20.
* 5. Alfie Cohen I, Castillo Aguilar E, Sereno Gomez B, Martinez Rodriguez O.Struma ovarii: a variety of monodermic teratoma of the ovary. Report of 8 cases. Ginecol Obstet Mex 1999;67:153-7.
* 6. Kawahara H. Struma ovarii with ascites and hydrothorax. Am J Obstet Gynecol 1963;85:85