ABSTRACT
To examine cases of mature cystic teratoma (MCT) that were diagnosed and treated in our clinic regarding their association with fertility, and to detect the rate of malignant degeneration and the types of malignancies.
Patients who underwent surgery due to adnexal mass between April 2012 and August 2017 and were diagnosed as having MCT were retrospectively examined. The mean age of the 80 patients who met the inclusion criteria was 30.60±10.5 years. Nine had infertility according to hospital records. Sixty-seven percent of these (n=6) had accompanying endometriosis and MCT was bilateral in 55.5% (n=5). Malignant degeneration was present in 6.25% (n=5), all were monodermal tumors. Malignant degeneration was more common among patients with larger diameter adnexal masses (9.1±2.9 cm) and in those of postmenopausal age. Tumor markers were within the normal range for patients who developed malignancy. Malignant degeneration was not present among infertile patients with endometriosis.
Although MCTs do not seem to negatively affect the ovarian reserve, infertility is prominent in patients with concurrent endometriosis. During assessment, concurrent endometriosis should be considered. Imaging findings, large adnexal masses, and postmenopausal period are important for the assessment of MCT concerning malignant degeneration. It should not be overlooked because tumor markers may be normal.
MCTs can be present concurrent with endometriomas. In such cases, infertility is more distinct. In MCT malignant degeneration, mass diameter, complex mass internal structure, and postmenopausal status are important factors.
Keywords: Mature cystic teratoma, malignant degeneration, infertility treatment
Introduction
Mature cystic teratomas (MCTs) are the most common benign germ cell tumors during the adolescent and reproductive period. Histologically, they may include tissues differentiated from each of the three germ layers (ectoderm, mesoderm and endoderm). They are seen predominantly in the reproductive period; however, they are also seen in childhood and the postmenopausal period. MCTs account for 20-25% of all benign ovarian tumors and bilaterally rates are about 10-15% (1). The most common signs are abdominal pain and findings of a pelvic mass, but they can be detected incidentally as well.
Complications occur in 20% of patients with MCT (2). These complications include torsion, rupture, infection, and malignant transformation. Malignant transformation is quite rare and predominantly detected in the postmenopausal period, whereas other complications may cause undesirable reproductive outcomes concerning the age period when they occur.
Our purpose in this article was to examine the cases of MCT that were diagnosed and treated in our clinic regarding the effects on fertility, rates of malignant transformation, and clinicopathologic features.
Material and Methods
Files of patients who underwent surgery due to a prediagnosis of adnexal mass with a histopathologic diagnosis of MCT between April 2012 and August 2017 were retrospectively reviewed. Permission was obtained from the medical director of the hospital to access file information and computer records and from the ethics committee to use patient data. Patients who were diagnosed as having MCT after histopathologic evaluation and had sufficient demographic and medical information in their files were included in the study.
The inclusion criteria for our study were as follows: patients who were clinically evaluated, surgically treated, and diagnosed as having MCT in our hospital; patients who were not pregnant at the time of diagnosis; with a confirmed pathologic diagnosis of MCT; and adequate demographic and medical information in the case files. Diagnosis and treatment in another clinic, diagnosis during pregnancy, the presence of all other malignant and benign ovarian masses that received a different histopathologic diagnosis during the final evaluation, diagnosis such as tubo-ovarian abscess, and lack of sufficient information in the case file were set as criteria for exclusion.
Patient histories and file records were reviewed for patients with MCT, regarding the presence of any symptoms/reports of infertility before or during admission. In addition, the number of pregnancies and births were also taken into consideration. Imaging methods, tumor markers, and additional pathologies accompanying MCT were reviewed for all cases.
Concerning malignant transformation in MCT, the patient files were reviewed in terms of age, parity, family history, and malignancies of other organs.
Result
The records of 93 patients who underwent surgery due to an adnexal mass and were diagnosed as having MCT between April 2012 and August 2017 were accessed. Thirteen of which were excluded mostly due to a lack of sufficient medical history and different histopathologic diagnoses. Eighty patients formed our study group and the mean age was 30.60±10.50 (range, 14-65) years. Seven patents (8.75%) were of postmenopausal age (age >45 years), 91.25% (n=73) were of premenopausal age (age ≤45 years). The most common symptom before admission was pelvic pain accompanied by abdominal distention in 76.25% (n=61) of the patients. The remaining 23.75% (n=19) were detected incidentally.
The most commonly performed imaging technique was abdominopelvic ultrasonography (USG). After an initial evaluation of all patients with USG, 13 patients were evaluated using computed tomography (CT), 33 patients with magnetic resonance imaging (MRI), and 2 patients with both CT and MRI.
The most frequently requested tumor markers to evaluate the malignancy potential of the adnexal mass were as follows: CA125 (n=80), CA19-9 (n=63). The mean value of CA125 was 24.23±16.10 IU/mL (normal reference range: 0-35 IU/mL); the mean value of CA 19-9 was 32.43±89.10 IU/mL (normal reference range: 0-35 IU/mL). When the cut-off value of 35 U/mL was accepted for both tumor markers, CA125 and CA19-9 were detected as high in 17.50% (n=14) and in 19.04% (n=12) of the patients, respectively. Both tumor markers were high in only 4.76% (n=3) of patients.
Fifty of the 80 patients were multiparous, the mean gravida was 1.78, parity was 1.12. Thirty patients were nulliparous. When all patients were evaluated according to the initial symptom, 9 had infertility. Among these 9 patients who underwent surgical treatment, apart from a dermoid cyst, endometriosis was found in six and one had hydrosalpinx (Table 1). The mean CA125 and CA19-9 levels of these 6 patients, who had infertility and diagnosed as having both MCT and endometriosis, was 39.16±16.60 IU/mL and 19.33±14.40 IU/mL, respectively. The CA125 level was above the threshold value in 4 of these six patients (66.67%); the CA19-9 level was also above the threshold in one patient. In 5 of these six cases, bilateral teratomas were present and the mean diameter of tumor mass was 5.10±1.80 cm according to the USG measurement.
Malignant degeneration was observed in 6.25% (n=5) of the patients. All malignant degeneration was monodermal-specialized tumor. Malignant degeneration was observed in 4.10% (3 of 73 patients) in the premenopausal period and in 28.57% (2 of 7 patients) in the postmenopausal period (Table 2). Among the patients with malignant degeneration, the mean mass diameter was 9.10±2.90 cm and no bilateral cases were observed. The mean values for tumor markers were 24.32±9.50 IU/mL for CA125, and 11.02±8.70 IU/mL for CA19-9, which were within normal reference values. Malignant degeneration was not observed in patients with infertility (Table 2).
