Goubaa Mohamed MD Djerba Tunisia

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--- Arabic
This is a 28-year-old female (virgin female) 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 transrectal examinations. C'est une patiente vierge âgée de 28 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 endorectale.

teratomas orarii ulrasound

échographie tératome kyste demoide

ultrasound ovary cyst

tumor tumeur ovary ovaire

tératome dermoide ovarien ovarii

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There is a complex, predominantly cystic mass measuring 12 x 8 cm anterior and apparently separate from the uterus. The solid part of mass has a 7 x 5 cm. The left ovary could not be identified.
The pathologist finds complex body tissue in the mass(ovarian teratoma).
Torsion of ovarian teratoma caused the pain of the patient.

Il existe une masse principalement kystique mesurant 12 x 8 centimètres et apparemment séparé de l'utérus. La partie solide de la masse mesure 7 x 5 centimètres. L'ovaire gauche n'est pas identifiable.
L'anatomo-pathologiste trouve du tissu varié de tout le corps dans la masse (tératome ovarien).
La douleur est en rapport avec la torsion du kyste.

Ovarian Teratoma Tératome ovarien


Ovarian Teratoma

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Teratomas are the most common ovarian neoplasm constituting 20% of all ovarian tumors and about 95% of germ cell tumors. These are common tumors in adolescent and young women but may also occur in the elderly. Malignant teratomas are rare (1% to 3% of cases). Between 10 and 15 percent of dermoids are bilateral. Cystic teratomas are usually composed of three germ cell layers: ectoderm, mesoderm, and endoderm, with ectoderm predominating. they often contain fat, teeth (40% of dermoids contain teeth), hair and bone fragments.

Clinical :
Cystic teratomas are commonly asymptomatic, although pain may result in the event of torsion or rupture. Larger lesions may produce an abdominal mass or swelling.

Ultrasonography :
Sonographically, dermoids can range from totally anechoic to a hyperechoic mass. Most commonly, they appear as complex masses. The majority of dermoids are very echogenic and they may shadow. Benign cystic teratomas characteristically show an anechoic cystic component and a shadowing density that corresponds to a dermoid plug. Strong acoustic attenuation occurs in the presence of bone, teeth, and hair in the plug, sometimes producing the "tip-of-the-iceberg" sign. This intensely echogenic focus is the cystic teratoma's most defining feature. Other distinctive sonographic features include a fat-fluid level and hyperechoic lines and dots generated by hair. The size of the dermoid plug varies from a few mm to that occupying the entire mass.
Color Doppler sonography may be helpful in differentiation of benign and malignant cystic teratomas. Blood flow in benign cystic teratomas is typically found only in the periphery because the cyst contains mostly avascular fat and hair. Conversely, malignant teratomas show intratumoral blood flow significantly more frequently than benign teratomas, with the exception of struma ovarii, a rare and typically benign form of cystic teratoma that contains highly vascular thyroid tissue .

Differential :
Benign cystic teratomas have variable appearances that may mimic hemorrhagic cysts, endometriomas, primary ovarian neoplasms, and metastatic tumors. Teratomas, however, often have two or more features characteristic of dermoids, and sonographically similar lesions usually have no more than one. Différential :

* Haemorrhagic ovarian cyst.
* Endometrioma.
* 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.

Treatment :
Cystic teratomas are often surgically removed, but because of their typically slow growth rate, patient fertility concerns may be considered. Wherever possible, lesions are excised without removal of the involved ovary; in fact, surgery can sometimes be delayed until patients have completed their families.

Reference :
* 1: Cass DL. Ovarian torsion. Semin Pediatr Surg. 2005 May;14(2):86-92.
* 2: Kocak M, Dilbaz B, Ozturk N, Dede S, Altay M, Dilbaz S, Haberal A. Laparoscopic management of ovarian dermoid cysts: a review of 47 cases. Ann Saudi Med. 2004 Sep-Oct;24(5):357-60.
* 3: de Silva KS, Kanumakala S, Grover SR, Chow CW, Warne GL. Ovarian lesions in children and adolescents--an 11-year review. J Pediatr Endocrinol Metab. 2004 Jul;17(7):951-7. Review.
* 4: Sait K, Simpson C. Ovarian teratoma diagnosis and management: case presentations. J Obstet Gynaecol Can. 2004 Feb;26(2):137-42.
* 5: Wu TT, Wang HC, Chang YC, Lee YC, Chang YL, Yang PC. Mature mediastinal teratoma: sonographic imaging patterns and pathologic correlation. J Ultrasound Med. 2002 Jul;21(7):759-65.
* 6: Zalel Y, Seidman DS, Oren M, Achiron R, Gotlieb W, Mashiach S, Goldenberg M. Sonographic and clinical characteristics of struma ovarii. J Ultrasound Med. 2000 Dec;19(12):857-61.
* 7: Serafini G, Quadri PG, Gandolfo NG, Gandolfo N, Martinoli C, Derchi LE. Sonographic features of incidentally detected, small, nonpalpable ovarian dermoids. J Clin Ultrasound. 1999 Sep;27(7):369-73.
* 8: Patel MD, Feldstein VA, Lipson SD, Chen DC, Filly RA. Cystic teratomas of the ovary: diagnostic value of sonography. AJR Am J Roentgenol. 1998 Oct;171(4):1061-5.
* 9: 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.