You say “Yes”, “There is hair etc. in you”.
The patient looks at you with puzzled eyes, before she manage to digest that sentence, you say “Sometimes tooth and skull are found in it as well. If the skull needs to be removed, an open surgery is needed because it is difficult to be separated from the ovary”. Upon this sentence, she becomes speechless and stares at you with the eyes asking “how an ovarian cyst is this?”.
A tiny barrel full of tiny pickles. This is one of the first riddles that we learned in our chieldhood. We start asking this to each other when we are about 5-6 years old, and wait with mischievous eyes for our friend’s answer.
Whenever I hear about dermoid cyst, I always remember this riddle and our beloved surgical nurse Müfted.
Ever since the time, when I entered the magical world of gynecology and meet dermoid cysts, the answer to thi riddle is “dermoid cyst”, also known as “mature cystic teratoma”, for me.
As for nurse Müfted, you know some of us cannot touch a peach due to its fuzzes that titillate us. Dermoid cysts create the same sensation for Müfted. Worse than that, when she see the hair and fat “masses” taken out of the cyst after it is opened during a dermoid cyst surgery, she feels nauseous and says “I feel nauseous”. Upon that, we exempt her from dermoid cyst surgeries, whenever possible.
You really see hair, fat masses, teeth and even skull and cartilage taken out of these cysts. It belongs to a class of tumors known as Teratomas that means “monster tumor” in Greek. When we look at what are takne out of it, we can say it deserve its name 🙂
For as long as I’ve known, thye have attracted my attention, and even I liked such ovarian cysts, from which all kinds of “freaky” things are taken out. However, the ones taken out of the ovaries should be distinguished from others. One of the most beautiful articles about this was published on Medscape on 27 January 2014.
At the begining of that compilation, there were the following sentences: “If asked, all of these clinicians would most probably define and describe dermoid cysts differently. For example, gynecologists and general pathologists might say that a dermoid cyst is a cystic tumor of the ovary. In contrast, neurosurgeons tend to view a dermoid cyst is associated with a congenital cyst of the spine or an intracranial congenital cyst. For pediatricians and dermatologists, dermoid cyst means subcutaneous cysts, which are usually congenital”, whereby the writers normally emphasize interdisciplinary and etiological differences.
Patients often do not understand how can such a cyst containing keratinized tissues such as long hair and fat masses etc. exists in the ovaries. Human beings in the womb consist of 3 different embryonic leaves, layers.
These three embryonic layers are the followings, respectively: Endoderm (interior), mesoderm (let’s say middle) and ectoderm (located outside). These embryonic tissues somehow can exist (in the form of residues) in the tissue containing reproductive cells, which is the ovary in a woman.
And these “residues”, which are the embryonic tissue fragments, try to create a human in their own way. But they have the ability to create only the easiest “doable” tissue parts that we call “keratinized” parts such as hair, cartilage, etc.
The million-dollar question is “what ‘signal’ activates these residues, and when”. We still do not know. Therefore, we may see it sometimes in a newborn baby, and sometimes in a 60-year-old patient. Maybe these residues exist in every woman’s ovaries but they are asleep.
If you look at the acaddemic gossips, studies show that ovarian dermoid cysts originate as a result of aberrant (let’s say abnormal:-)) meiosis of germinal cells in ovaries (2). The problem is that when and how pathological signals triggering this abnormal cell division emerge is still unknow.
You know, there are some simple cysts, about which that mothers say “Honey, you can discharge that cyst by means of menstruation”. We call these corpus luteum or follicular cysts. They are simple. No matter you use birth control pill or not, the regress and disappear within 3 to 6 months, i.e. “you can discharge them by means of menstruation”.
You exclude these simple cysts. 33% of benign ovarian tumors are dermoid cysts. They are seen commonly to a stunning extent. If you take into account the malignant ones, 20-25% of all ovarian tumors are dermoid cyst, and this is a great proportion.
Most importantly, they are the most common ovarian tumors encountered during childhood and maidenhood. Families come often when they are in panic. They are benign. Yes, your little girl has to have a surgery but please don’t worry. Eventually, the ovary will definitely be protected and she will not encounter any fertility problems, after an appropriate surgery :-). You all need to know is that the ovary will not be removed. Regardless of the surgery method (open or laparoscopic), as much ovarian tissues as possible should be left intact.
This has only one exception. Ovaries that got torsioned in the newborn period, rotate around their own axes, and are detected in the mother’s womb. Unfortunately it is not possible to save the ovaries during these periods.
50 – 60% of these do not show any symptoms. If they show symptoms, they appear often with groin pain and pain in the lower abdomen. The problem is that they rotate around their own axes (getting torsioned), and cause a severe pain. Torsion prevalence between 3% and 11% was reported in various publications. Let’s say it is averagely 6-7%, and don’t let us offend each other for three to five percentage points.
Oh, I almost forgot the question that you ask most frequently: “Can they get torn, doctor?” Of course, but with a possibility less than 1% in the series. In fact, what makes the both complication (torsion and tearing) important is the fact that they often emerge during pregnancy.
In other words, dermoid cysts detected in pregnant women are more likely to be torn and rotate around their own axes. Therefore, surgery is a good option for a pregnant woman after the first 3 months, during the 14th – 20th weeks of pregnancy.
Do they become malignant? The answer is “yes”, but this is an extremely low probability. If a malignant tumor will develop with a dermoid cyst, it happens with dermoid cysts seen in women over 40 years of age, and the prevalence is below 1%.
Final diagnosis is made by means of Contrast-Enhanced (with medicine) Fat-Suppressed magnetic resonance (MR) imaging”. Ultrasonography is a good option, as well. However, because some dermoid cysts have a high fat content, they are often mixed with bowel contents. If the gynecologists not so sure about the diagnosis, he/she should definitely request an MR.
It may exists in the both sides, with a probability rate of about 15%; or dermoid cyst (mature cystic teratoma) may appear in the other ovary in the long term. There are publications suggesting that dermoid cyst can recur in the operated ovary.
Before the surgery, the patient and/or her family should definitely be warned about the possibility that a cyst may appear in the other ovary in the long term. The other ovary is evaluated with MRI; and by this way, any unnecessary incision on the intact ovary is avoided during the surgery.
The most important thing to know about the treatment is that the ovary should not be removed. Such a misfortune may be encountered due to complications that may emerge during the surgery; but eventually, this is a rarely seen case. Regardless of the surgical method, the aim is always to protect the ovary and leave as much healthy tissue as possible.
Laparoscopic surgery should be preferred particularly for children and young girls. When the cyst is removed laparoscopically, it should definitely be removed in the bag. The cyst may burst during the surgery, and this can happen both in an open and laparoscopic surgery. The important thing is to wash off the the fatty content spilled into the abdomen, with plenty of fluid, and then take it away from the environment.
Eventually, surgery is a necessity for the treatment, and today it gives beatific results.
Anyway, this time it is a highly “medicinal” text but perhaps I managed to change the answer to that famous riddle in your mind 🙂
Note: By the way, when speaking about riddles, I can share J.R.R.Tolkien’s 3 famous riddle, can’t I?:
“A box without hinges, key or lid, Yet golden treasure inside is hid.”
“Alive without breath,
As cold as death;
Never thirsty, ever drinking,
All in mail never clinking,”
“This is a thing that is devoured by all things;
flowers, trees, beasts, birds; bites steel, gnaws iron;
grinds hard stone to meal;
beats mountain down,
ruins town and slays king”
I will not give the answers. You give them. Stay with love…
2. Sabol M., Car D, Musani V et. al The Hedgehog signaling pathway in ovarian teratoma is stimulated by Sonic Hedgehog which induces internalization of Patched. Int J Oncol. 2012;41(4):1411-1418.
3. Katz V.L. Benign Gynecologic Lesions In: Comprehensive Gynecology (5th ed). edited by Katz, Lentz, Lobo, Gershenson Mosby Elsevier Inc. 2007; 419 – 472 (Chapt 18). (Information in the writing has been obtained from this source).