Although ovarian mature cystic teratoma is seen at any ages, it is mostly seen at ages ranging from 20 to 40.
As for its symptoms, in plain words, dermoid cyst itself does not often show symptoms. If it shows symptoms, it has either excessively grown or caused one of the complications that we will detail below.
It has been shown that 6-65% of different series of dermoid cysts did not show any symptoms and were detected during an examination or surgery intended for another reason. For example, you can detect a dermoid cyst in the ovary when you perform a caesarean section or during an ultrasound or CT scan performed for another reason (1, 2).
In the clinical context, the typical example that we see is as follows: the cross-section images obtained during a MRI (magnetic resonance imaging), intended for herniated lumbar disc, covers also the ovaries where cysts are detected.
The article published by Ali Ayhan Hoca 15 years ago contains a very nice series related to the subject (2). The average age in a serial containing 501 cases was 35. 21% of the cases were asymptomatic dermoid cysts, i.e. cysts that do not show any symptom.
Symptomatic cysts, i.e. cysts that show symptoms are commonly large tumors that put pressure on the groin or bladder in women. The patient applies to the hospital with the complaint of a pain in the groin or a mass that can be felt with hand. He/she may consult a doctor due to the feeling of pressure and pain that is sometimes felt in the back.
The common complications of dermoid cysts, mature cystic teratomas, can be listed as torsion, rupture, i.e. rupture of the dermoid cyst, infection (inflammation), hemolytic anemia, and malignant transformation.
Torsion of a Dermoid Cyst: Torsion is the most common complication caused by dermoid cysts. Ovarian torsion refers to the rotation of the ovary with cyst around its own axis that cause the blood vessels feeding the ovary to be squeezed in a sense and show symptoms. The frequency of torsions caused by dermoid cysts varies between 3-11%. The literature gives very different figures (1, 2, 3).
Although it is said that the risk of torsion increases in parallel to the increase in the size of the dermoid cyst, the risk of torsion is thought to relatively decrease because rotation of a very large (e.g. 20 cm) cyst around its own axis would be very difficult. You see a dermoid cyst that has undergone torsion, and rotated around its own axis.
Torsioned cyst causes the patient to suffer a serious pain. The pain is severe and the scene is very “tumultuous” for both the patient and his/her family. Even if the cyst is torsioned, any ovary that seems to be excessively necrosed (even if it is black-and-blue like a rotten egg) should not be removed. After removing the cyst, the ovary should be brought to its normal position and then should be left there. The ovary should not be removed unless there is a very special circumstance (bleeding, advanced age, etc.)
The necessity of avoiding the removal of a torsioned ovary has been clearly demonstrated especially with the study carried out by Oelsner et. al (4).
You see below the surgery performed after the detorsion of a torsioned and necrosed dermoid cyst. After the removal of its cyst, the ovary is brought to its normal position, and then it is left there (not removed).
In case of a rupture, acute chemical peritonitis (accompanied by peritoneal inflammation) causes the cases of shock and bleeding. Especially since its content is released into the abdomen, a severe shock condition occurs. The fatty tissues that it contains trigger the chemical peritonitis. Althoug the scene is bad, results are often satisfactory. But the patient should be quickly taken into operation and a very good abdominal cleaning should be performed. Otherwise, a “granulomatous peritonitis” condition appears, and very tight adhesions occur. However, such complications are very rare. For example, these are the conditions that we have not encountered for so many years at Istanbul Faculty of Medicine.
What needs to be emphasized at this point is the fact that, peritoneal inflammation occurring in the rupture could be caused by us, the surgeons, iatrogenically during the surgery. A rupture-like condition may occur in consequence of a rupture that occurs in the cyst (which may occur but normally does not cause problems) during the surgical removal of the dermoid cyst, if it is not followed by a proper abdominal cleaning for the content released into the abdomen. In case of rupture of the cyst during surgery (no matter whether the operation is an open or laparoscopic surgery), an abdominal cleaning should definitely be performed, and the surgeon should make sure that the sebaceous content is completely removed, regardless of the time required for this. The details of the subject are described in the treatment section.
Infection of mature cystic teratoma: It is a complication encountered with a prevalence of less than 1%, and commonly involves the detection of coliform bacteria, according to the literature.
Dermoid cysts and Autoimmune hemolytic anemia: Although it is are in patients with mature cystic teratoma, autoimmune hemolytic anemia may be encountered. The main reasons for this may be the followings: 1. The body produces antibodies (i.e. fighters) against certain substances secreted by the tumor, and these antibodies eliminate the body’s own blood cells. 2. Antibodies produced directly by the dermoid cyst attack the patient’s blood cells (1). Patients completely get over the disease after the removal of the dermoid cyst.
Malignant Transformation In Mature Cystic Teratoma: Malignancy is a very rare case seen in pure dermoid cysts. Normally they never become malignant. The problem is that a malignant transformation occurs in the tissues that they contain. According to the literature, it occurs in 0.2-2 % of the cases (2, 5, 6). Dermoid cysts, in which malignant transformation has been detected, are seen often in people aged 45 and older. In the studies carried out by Park et all., a large tumor diameter, an advanced age and a high amount of solid component in the content constitute the risk group, in terms of malignancy (6).
2. Ayhan A, Bukulmez O, Genc C, Karamursel BS, Ayhan A. Mature cystic teratomas of the ovary: case series from one institution over 34 years. Eur J Obstet Gynecol Reprod Biol. 2000: 88(2):153-7
3. Benjapibal M, Boriboonhirunsarn D, Suphanit I, Sangkarat S. Benign cystic teratoma of the ovary : a review of 608 patients. J Med Assoc Thai. 2000; 83(9):1016-1020.
4. Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol. 2006; 49(3):459-463.
5. Comerci J.T. Jr., Licciardi F., Bergh P.A., Gregori C., Breen J.L. Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature. Obstet Gynecol. 1994; 84(1):22-28.
6. Park JY, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. Malignant transformation of mature cystic teratoma of the ovary: experience at a single institution. Eur J Obstet Gynecol Reprod Biol. 2008; 141(2): 173-178.