Teratoma

Ans. is d i.e. Dermoid cyst

An ovarian mass with radio opaque shadow on X-ray points towards dermoid cyst as the diagnosis. Causes of Pelvic Calcification are :

1. Fibroids : popcorn type
2. Dermoid cyst : it is the commonest ovarian mass to calcify
3. Other ovarian masses : cystadenoma / carcinoma, fibromas
4. Pseudomyxoma peritonei
5. Fallopian tube calcification (rare) : suggest TB

Uterine i.e. endometrial calcification from chronic endometritis.

Extra Edge : Dermoid cyst : • Dermoid cyst is a benign teratoma.

• Teratomas are the most common germ cell neoplasm. On the basis of maturity teratoma can be divided into :

a. Mature (Benign) teratoma = dermoid cyst

Most common benign tumour of ovary in reproductive age group.°

—                                    Most common benign neoplasm diagnosed during pregnancy.°

—                                    Bilateral in 10′;’0 to 15`’.0 of cases

—                                    Characteristically they are unilocular cyst containing hair and cheesy sebaceous material, teeth, bones, ).1:40(18

thyroid tissue and cartilage.

—                                    About 1% of the dermoids undergoes malignant transformation of one of the component element (e.g., thyroid carcinoma, melanoma, but most commonly squamous cell ca).

b. Immature (Malignant) teratoma

—                                    Rare, mostly solid, differ from benign teratomas in the component tissue which resembles that observed in the fetus or embryo rather than mature adult tissue.

—                                    Tumour occur chiefly in prepubertal adolescents and ^young women.

—                                    Tumour grade is correlated with prognosis and extra-ovarian spread.

c. Monodermal or specialized teratomas = (Struma ovarii and carcinoid)

—                         Rare group of tumour, struma ovarii composed entirely of mature thyroid tissue which is hyperfunctional.

—                         Patients usually present with hyperthyroidism.

—                         Most of the tumours are innocent, but malignant thyroid tumour have been recorded.

Also Know :

• Dermoid cyst may attain a size of 20 cms.
• Lining epithelium is stratified squamous epithelium (if dermoid cyst undergoes malignant change – Squamous cell Ca is seen).
• Most common tissue element in dermoid cyst is Ectodermal.°
• It is the most common tumour to undergo torsion.°
• If hone or teeth are seen in X-ray in adenaxal mass, it is pathognomic.°
• Dermoid cyst frequently arise in association with mucinous cystadenoma :

—   Age for combined tumour is 20 – 30 years.

Age for simple dermoid cyst is 40 – 50 years.

Ans. is a. b, and c i.e. It is teratoma; Frequently undergo torsion; X-ray is diagnostic; and Contains sebaceous material and hairs

Dermoid cyst (mature teratoma) :

• Most comon benign ovarian neoplasm.
• Mostly affect women of reproductive age group.
• Morphologically dermoid cyst is unilocular with smooth surface.
• On cross section — cysts are unilocular and typically contain are area of localised growth that prottectes into the cystic cavity called as Rokintansky protuberance / dermoid process.
• It contains sebaceous material and hair with teeth. bone, cartilage, thyroid tissue.
• If teeth or bone are seen in X-ray in adnexal mass, this finding is pathognomic for teratoma.
• Dermoid cyst are bilateral in 12% to 15% and frequently arise in association with mucinous cystadenomas.

Malignant change in a dermoid cyst occurs in 0.5 — 2% cases in patients > 40 years. Most common malignancy which develop is. squamous cell carcinoma.

Ans. is c i.e. Dermoid cyst                                

“A benign cystic teratoma is the most common neoplasm to undergo torsion, and it to the M/C benign tumor diagnosed during pregnancy.”

A benign cystic teratoma is synonymous with a dermoid cyst.

Remember :

• The most common ovarian tumor in pregnancy is serous cystadenoma but mostly remains undiagnosed.
• The incidence of a dermoid cyst is increased two-fold during pregnancy and it is the most common neoplasm diagnosed during pregnancy.
• Hingorani sign seen: – In ovarian tumor during pregnancy.

Trendelenburg’s position can elicit the groove between two separate swellings. Used to distinguish between ovarian tumors and fibroid.

All

Dermoid cyst

Option  c

Totipotent cells

10% are B/L & malignant

CEA REF: Harrison’s 17^th ed p. 551

CEA is not a testicular tumor marker

Teratoma is a non seminomatous tumor of testis.

Malignant REF: Robbin’s ^7th ed p. 1044

In children differentiated mature teratoma may be benign

In post pubertal males all teratoma are regarded as malignant and capable of metastasis regardless the elements may be immature or mature.

Well-formed teeth are commonly seen in mature cystic teratoma and not in any of the other lesions.

Complications associated with mature cystic teratoma are torsion, rupture, infection, hemolytic anemia and development of malignancy. Torsion and rupture of teratoma are more likely to occur during pregnancy.

At 14-16 weeks of pregnancy

Ans. is ‘d’ i.e., Teratoma

o All Tumors, benign or malignant, have two basic components -*

1. Proliferative neoplastic cells —> constiture parenchymes.
2. Supportive stroma                    —> made up of connective tissue and blood vessels.

o The name of tumor is usually based on the cell, e.g. smooth muscle cell tumor —> leiomyoma or leiomyosarcoma, skeletal muscle cell tumor rhabdomyosarcoma.

o Benign tumors

         In general, benign tumors are designed by attaching the suffix – oma, e.g tumor of fibroblasts —> fibroma, tumor of cartilagenous cells —> chondroma.

o Malignant tumors

         Malignant tumors arising in mesenchymal cell origin are usually called sarcoma, e.g. fibrosarcoma, liposarcoma, leiomyosarcoma, rhabdomyosarcoma.

         Malignant tumors of epithelial cell origin are called carcinoma.

         Carcinoma may be further classified one with glandular growth pattern, i.e. adenocarcinoma and the other one producing recognizable squamous cells of epithelium, i.e. squamous cell carcinoma.

o Germ layers and tumor

         Great majority of the neoplasm are composed of cells representative of a single germ layer.

         Teratomas, in contrast, are made up of a variety ofparenchymal cell types representative of more than one germ layer, usually all three.

They arise from totipotent cells and so are principally encountered in the gonads. These totipotent cells differentiate along various germ lines, that can be identified as skin, fat, muscle, tooth structure, hair or any other tissue of the body. Example is dermoid cyst of ovary is a benign teratoma (note –> mature teratoma is benign, while immature teratoma is malignant).

Note-There are some exceptions to above general rules, i.e. malignant neoplasms with suffix – oma –> Melanomas, seminoma, hepatoma (hepatocellular Ca), mesotheloma, lymphoma.

Ans. is ‘b’ i.e., Teratoma

Teratoma

Teratomas are divided into three categories:

(1) Mature (benign):

• Most benign teratomas are cystic and are known as dermoid cysts.
• These neoplasms are presumably derived from the ectodermal differentiation of totipotential cells.
• They are bilateral in 10% to 15% of cases.
• Characteristically, they are unilocular cysts containing hair and cheesy sebaceous material. On section, they reveal a thin wall lined by an opaque, gray-white, wrinkled, apparent epidermis.
• Generally, in one area of the cyst wall, a solid prominence is seen known as Rokitansky’s protuberance where tissue elements such as tooth, bone, cartilage & various other odd tissues are present.
• On histologic examination, the cyst wall is composed of stratified squamous epithelium with underlying
• sebaceous glands, hair shafts, and other skin adnexal structures. In most cases, structures from other germ layers can be identified, such as cartilage, bone, thyroid tissue, and other organoid formations.
• Dermoid cysts are sometimes incorporated within the wall of a mucinous cystadenoma.
• About 1% of the dermoids undergo malignant transformation of any one of the component elements ( but most commonly, squamous cell carcinoma).

(2) Monodermal or Specialized Teratomas

• The rare group of tumors, the most common of which are struma ovarii and carcinoid.
• They are always unilateral, although a contralateral teratoma may be present.
• Struma ovarii is composed entirely of mature thyroid tissue. Interestingly, these thyroidal neoplasms may hyperfunction, causing hyperthyroidism.
• The ovarian carcinoid, which presumably arises from intestinal epithelium in a teratoma, might in fact be functioning, particularly in large tumors, producing 5-hydroxytryptamine and the carcinoid syndrome.

(3) Immature Malignant Teratomas

• These are rare tumors that differ from benign teratomas in that the component tissue resembles that observed in the fetus or embryo rather than in the adult.
• The tumor is found chiefly in prepubertal adolescents and young women.
• These grow rapidly and frequently penetrate the capsule with local spread or metastases.
• On microscopy, there are varying amounts of immature tissue differentiating toward cartilage, glands, bone, muscle, nerve, and others.
• An important risk for subsequent extraovarian spread is the histologic grade of tumor, which is based on the proportion of tissue containing immature neuroepithelium.

Ans. is ‘b’ i.e., Dermoid cyst

Epidermal dermoid cyst (dermoid) is by for the most common orbital cystic lesion in children, accounting for over 40% of all orbital lesions of childhood and for 89% of all orbital cystic lesions of childhood that come to biopsy or surgical removal.

Most important secondary cyst is a mucocele that can occur in children with cystic fibrosis.

beta HCG (Tumour shown: Sacrococcygeal teratoma

Sometimes, remnants of the primitive streak persist in the sacrococcygeal region. These clusters of pluripotent cells proliferate and form tumors, known as sacrococcygeal teratomas that commonly contain tissues derived from all three germ layers. This is the most common tumor in newborns, occurring with a frequency of one in 37,000. These tumors may also arise from primordial germ cells that fail to migrate to the gonadal ridge 

Organ shown in the picture above represents ovary.

The most common germ cell tumour of ovary is benign, most commonly benign cystic teratoma or dermoids, however most common malignant germ cell tumors would be dysgerminoma.

This cyst is dermoid cyst

Ans. is a. b, and c i.e. It is teratoma; Frequently undergo torsion; X-ray is diagnostic; and Contains sebaceous material and hairs

Dermoid cyst (mature teratoma) :

• Most comon benign ovarian neoplasm.
• Mostly affect women of reproductive age group.
• Morphologically dermoid cyst is unilocular with smooth surface.
• On cross section — cysts are unilocular and typically contain are area of localised growth that prottectes into the cystic cavity called as Rokintansky protuberance / dermoid process.
• It contains sebaceous material and hair with teeth. bone, cartilage, thyroid tissue.
• If teeth or bone are seen in X-ray in adnexal mass, this finding is pathognomic for teratoma.
• Dermoid cyst are bilateral in 12% to 15% and frequently arise in association with mucinous cystadenomas.

Ans: B.)Teratoma.

The image shows Mature cystic teratoma (dermoid cyst) of the ovary. A ball of hair (bottom) and a mixture of tissues are evident.

OVARIAN TUMORS

• Tumors may arise from the epithelium, sex cord-stromal cells, or germ cells.

• Epithelial tumors are the most common malignant ovarian tumors and are more common in women older than 40 years of age.

• The major types of epithelial tumors are serous, mucinous, and endometrioid. Each has a benign, malignant, and borderline (low malignant potential) counterpart.

• Sex cord-stromal tumors may display differentiation toward granulosa, Sertoli, Leydig, or ovarian stromal cell type. Depending on differentiation, they may produce estrogens or androgens.

• Germ cell tumors (mostly cystic teratomas) are the most common ovarian tumor in young women; a majority are benign.

• Germ cell tumors may differentiate toward oogonia (dysgerminoma), primitive embryonal tissue (embryonal), yolk sac (endodermal sinus tumor), placental tissue (choriocarcinoma), or multiple fetal tissues (teratoma).

TERATOMA

Benign (Mature) Cystic Teratomas.

• Almost all benign (mature) cystic teratomas are marked by the presence of mature tissues derived from all three germ cell layers: ectoderm, endoderm, and mesoderm.
• Usually, these tumors contain cysts lined by epidermis replete with adnexal appendages—hence the common designation dermoid cysts.
• Most are discovered in young women as ovarian masses or are found incidentally on abdominal radiographs or scans because they contain foci of calcification produced by tooth-like structures contained within the tumor. About 90% are unilateral, with the right side more commonly affected.
• Rarely do these cystic masses exceed 10 cm in diameter.
• On cut section, they often are filled with sebaceous secretion and matted hair that, when removed, reveal a hair-bearing epidermal lining.
• Sometimes there is a nodular projection from which teeth protrude. Occasionally, foci of bone and cartilage, nests of the bronchial or gastrointestinal epithelium, and other tissues also are present.

Immature Malignant Teratomas .

• Malignant (immature) teratomas are found early in life, the mean age at clinical detection being 18 years.
• They differ strikingly from benign mature teratomas insofar as they often are bulky, predominantly solid on cut section, and punctuated by areas of necrosis; uncommonly, cystic foci are present that contain sebaceous secretion, hair, and other features similar to those of mature teratomas.
• On microscopic examination, the distinguishing feature is the presence of immature elements or minimally differentiated cartilage, bone, muscle, nerve, or other tissues.