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Pelvis » Female Pelvis (Gynecology)
Struma Ovarii (teratoma) with torsion
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Author(s) :
M. Goubaa
 
Presentation This is a 70-year-old postmenopausal female presents with marked pelvic pain, nausea and vomiting. Physical examination showed a large pelvic mass which could be adnexal and/or uterine in origin. Transabdominal and transvaginal scans were performed.
 
 
 
Caption: Transabdominal scan of the right adnexa
Description: There is a complex solid-cystic seen anterior to and apparently separate from the uterus. The mass has a predominant cystic component as marked and the solid part of mass is also as seen. The right ovary could not be identified separate from the mass.
 
 
 
Caption: Transabdominal scan of the right adnexa
Description: This is another view of the solid-cystic mass that is seen in the right adnexa.
 
 
 
Caption: Transabdominal scan
Description: A thin septum is seen traversing the cystic component of the mass.
 
 
 
Caption: Transabdominal color Doppler scan
Description: The solid portion of the mass demonstrates vascularity.
 
 
 
Caption: Transabdominal color Doppler scan
Description: The solid component of the complex mass shows significant areas of vascularity.
 
 
 
Caption: Endovaginal view of the mass
Description: This image demonstrates the internal characteristics of the complex right adnexal mass. A small amount of free fluid is also visualized.
 
Differential Diagnosis Haemorrhagic ovarian cyst
Teratoma
Fibroma and fibrothecoma
Arrhenoblastoma
Granulosa cell tumour
Mucinous or serous cystadenomas or cystadenocarcinoma
Endometroid carcinoma
Adenocarcinoma without serous or mucous collection
Krukenberg's tumors and 
Lymphoma of ovaries
 
Final Diagnosis Struma Ovarii (teratoma) with torsion
 
Discussion

Struma ovarii belongs to the group of monodermic and highly specific teratomas. It comprises less than 5% of mature teratomas. Struma ovarii is an uncommon type of teratomas, difficult to identify without histopathological examination.
Struma ovarii could be hormonally active and can manifest clinical symptoms of thyroid hyperactivity or thyrotoxicosis. Postoperative complications in hormonally active struma ovarii have also been reported. Struma ovarii may be associated with ascites and pleural effusion, known as "pseudo - Meigs syndrome". In the majority of reported cases tumor excision led to complete remission. Malignant changes in struma ovarii are uncommon.

Clinical Features:
* The most frequently symptom is abdominal pain (50 %) though a high percentage (40 %) of patients were asymptomatic.
* 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 struma present with clinical hyperthyroidism. 30 % of patients have associated and significant thyroid function abnormalities.

Sonography:
Preoperative diagnosis of struma ovarii is difficult because ultrasonography and the other imaging modalities such as CT and MRI are not specific enough. 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 ovarii consisting largely of thyroid tissue is highly suspected (3).

 
Case References

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.

 
Follow Up A right oopherectomy was performed. Histopathological examination confirmed struma ovarii, with follicular, fetal and embryonic forms of thyroid tissue. There was no evidence of any metastases or malignancy.
 
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