CASE REPORT |
https://doi.org/10.5005/jp-journals-11003-0134 |
Unusual Case of Mature Cystic Teratoma Showing Rare Tissues: A Case Report
1,2Department of Pathology, Army College of Medical Sciences, Delhi, India
3Maulana Azad Medical College, Delhi, India
Corresponding Author: Archna Rautela, Department of Pathology, Army College of Medical Sciences, Delhi, India, Phone: +91 9582700591, e-mail: drarchnarautela@gmail.com
Received: 03 November 2023; Accepted: 25 November 2023; Published on: 30 December 2023
ABSTRACT
Background: Teratomas are known to show a wide variety of tissues in their microscopic analysis; however, the most common types are lined by skin-like structures and are known as dermoid cysts. The immature and monodermal types show immature neuroectodermal tissue and specialized tissue like thyroid respectively.Case description: We describe an unusual case of a 32-year-old female with an ovarian cystic mass, which was diagnosed as mature cystic teratoma, which showed a significant proportion of thyroid tissue and retinal pigmented epithelium. Conclusion: These tissues are mostly associated with specialized (monodermal) and immature teratomas. The fact that they were seen in this case of mature cystic teratoma prompted this case report.
How to cite this article: Rautela A, Dudani S, Dudani S. Unusual Case of Mature Cystic Teratoma Showing Rare Tissues: A Case Report. J Med Acad 2023;6(2):69–71.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Case report, Mature cystic teratoma, Retinal, Thyroid tissue
INTRODUCTION
Teratomas are the most common germ cell tumors affecting the ovary and one of the common ovarian tumors constituting 10–20% of all ovarian neoplasms, second to serous cystadenoma in the reproductive age group. They are classified as mature, immature and monodermal on histopathological examination. Almost 99% of them are of the mature cystic type commonly known as dermoid cysts.1,2
These tumors may contain biphasic or triphasic components of embryonic germ layers. We report clinicopathological findings of a 32-year-old female with an ovarian mature cystic teratoma who presented with complaints of abdominal pain. Histopathological examination revealed presence of rare tissues like retinal and thyroid tissue.
CASE DESCRIPTION
A 32-year-old female came with complaints of pain abdomen and was investigated. She had a past history of deviated nasal septum and nasal polyp. No history of chronic disease was elicited.
Ultrasound sonography of the abdomen revealed a right adnexal cystic mass of a size approximately 5.4 × 4.7 × 4.7 cm with a volume of 63 cc. The mass was round to oval, with no internal echoes or septa. The right ovary could not be visualized separately, and there was no evidence of free fluid in the abdomen. Uterus size ~ 5.8 × 4.2 × 3.1 cm, endometrial thickness was 4.2 mm. The left adnexa was within normal limits, with the left ovary measuring 18 × 14 mm in size.
Magnetic resonance imaging of the abdomen showed an 8 × 6.6 × 6.4 cm rounded, thick-walled T1 hypointense and T2 short tau inversion recovery hyperintense cystic lesion with an eccentric area of fat signal intensity and subtle blooming. The gradient echo sequence seen in the right adnexa arising from the right ovary is suggestive of the right adnexal cyst, which is likely to be a dermoid cyst.
The patient’s vitals were stable. Complete blood count and Liver function test were within normal limits. Other serum markers were done to rule out a mixed germ cell tumor.
Lactate dehydrogenase, 217 U/L; α-fetoprotein <0.605 ng/mL; β-human chorionic gonadotropin <0.098 mIU/mL; carbohydrate antigen 19-9 = 28 U/mL; cancer antigen 125 = 17.8 U/mL; thyroid-stimulating hormone = 1.05 mIU/mL.
Pap smear was negative for intraepithelial lesion or malignancy.
Surgical removal of cyst was planned and per operatively, there was an 8 × 6 cm sized cyst in the right ovary.
Gross examination revealed a predominantly cystic mass with a wall thickness of 0.5 cm filled with pultaceous foul-smelling material. Some solid areas were noted, which were yellowish in color, and few hair shafts were seen. No teeth/bone seen on gross examination (Fig. 1).
Fig. 1: Gross appearance of cut open cystic mass in the right ovary with different areas which are solid, yellowish, and contain hair shafts
Microscopy
Hematoxylin and eosin (H&E) stained sections from the cyst wall showed the lining of stratified squamous epithelium with sebaceous glands and hair follicles adjacent to it, along with overlying abundant flakes of lamellated keratin. Multiple sections taken from the solid areas within the cyst wall showed a wide variety of tissues derived from all three germ layers. Yellowish areas from the cyst wall showed the presence of adipose tissue. Interspersed within the connective tissue in the cyst wall were areas of mature glial tissue with ganglion cells and cell bodies of neurons (Fig. 2). There was a single focus showing retinal pigmented epithelium (Fig. 3). Other areas showed lining of pseudostratified ciliated columnar epithelium with mucus glands mimicking respiratory epithelium with mucinous glands, hyaline cartilage and few areas with serous acini were noted. A large area adjacent to this showed the presence of numerous thyroid follicles within the cyst wall. Interspersed amongst these areas were multiple bundles of smooth muscle (Fig. 4).
Fig. 2: Hematoxylin and eosin (H&E), 400×; glial fibrillary tissue
Fig. 3: Hematoxylin and eosin (H&E), 400×; retinal pigment epithelium, adipose, and thyroid tissue
Fig. 4: Hematoxylin and eosin (H&E), 100×; mature and immature cartilage, smooth muscle, and respiratory epithelium
Further sections were examined for the presence of immature neuroepithelium, any mixed germ cell component and any malignancy which may be originating from any of the components in the cyst.
The cystic mass was reported as mature cystic teratoma. The patient was asymptomatic postoperatively.
DISCUSSION
A literature search reveals that one of the oldest pieces of evidence of teratoma dates back to as early as 2000 BC. The first case of mature cystic teratoma was reported by Johannes Scultetus in 1659 while recording the autopsy findings of a young woman who died of an ovarian tumor described as a ”dermoid cyst of the ovary.” In 1863, Rudolf Virchow introduced the term ”teratoma,” derived from the Greek word ”teras,” meaning monster.
According to literature, many studies have reported abdominal pain to be the most common presenting symptom and state that a good majority may even be asymptomatic.3,4
Grossly, the cysts tend to be unilateral and unilocular most often, as reported in this case.3,4
Teratomas are known to have derivatives of three germ layers, but in mature cystic teratomas, the likelihood of finding components from mesoderm to ectoderm is higher. According to an Indian retrospective study over 25 years after the evaluation of 223 cases of mature cystic teratoma, endodermal derivatives were seen in around 26% of cases.4
Amongst tissue derivatives of ectoderm, mostly squamous epithelium, sebaceous glands, hair follicles and neuroectoderm are identified. One may encounter neuroectoderm as well, in which structures that are commonly seen are ganglion cells and glial tissue. Retinal tissue has been reported in some cases.
Mesodermal derivatives commonly found are cartilage, smooth muscle, adipose tissue, and blood vessels.
Endodermal derivatives usually seen are respiratory epithelium, thyroid gland and gastrointestinal tissue. Thyroid tissue is reported in around 5–20% of teratomas.5,6
Tissues that are reported to be rarely present (<5% cases) in mast cell tumors are the retina, kidney, liver, cardiac muscle, striated muscle and prostate.7,8
This case was unique in terms of the presence of a well-defined area of thyroid tissue and retinal tissue found in the tumor. It prompted us to search extensively for immature neuroepithelium, which was not seen even after repeat sectioning from thicker parts of the cyst wall. The patient was investigated thoroughly for the presence of a mixed component of germ cell tumor ovary and for immature teratoma ovary, but evidence was not found.
A diagnosis of mature cystic teratoma with descriptive details of various tissues was given, and the patient was advised to follow- up. The patient is asymptomatic at 3 months follow-up.
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