Wandering Dermoid Cyst of Ovary: A Case Report

BACKGROUND

Mature cystic teratomas also known as dermoid cysts, are the most common germ cell neoplasia of the ovary. They are derived from one or more of the three germ cell layers.¹ Their incidence ranges from 5 to 25% of all ovarian tumors.² Torsion of the pedicle is the most frequent complication of dermoid cysts and is seen in 16.1% of all cases.² Torsion interferes with the blood supply and may thus result in venous congestion and aseptic inflammation of the tumor wall. In acute torsion, the ovary or the entire adnexa may undergo necrosis due to ischemia, whereas in subacute or chronic torsion the dermoid cyst or ovary could adhere to adjacent structures and develop a new collateral circulation.² In rare situations, the cyst or the entire ovary along with the cyst may completely detach from its primary pedicle and form a parasitic dermoid or ovary. The reported incidence of this entity is as low as 0.4% of all ovarian teratomas.² We describe one such case of a wandering dermoid diagnosed and managed laparoscopically.

CASE DESCRIPTION

A 38-year-old woman, with previous three cesarean deliveries, presented with a complaint of pain in the right lower abdomen since a month. The pain was described to be dull in nature with radiation to the back and thigh. Menstrual history was unremarkable with no significant medical history. There were no urinary- or bowel-related complaints.

On examination, her abdomen was soft with minimal tenderness in right iliac region with no rebound tenderness. Per vaginal examination revealed bulky, mobile, anteverted uterus with right forniceal fullness.

Pelvic ultrasound revealed a large adnexal mass lesion with the right ovary not separately visualized from the lesion. The lesion had solid and cystic components with thick walls showing internal debris and marginal echogenic focus. The routine hematological and biochemical markers were within normal limits. CA-125 concentration was found to be 79.1 U/mL (normal values 0–35 U/mL) with other tumor markers including CEA (0.35), beta hCG (<0.1), and AFP (1.01) within normal limits.

Magnetic resonance imaging was suggested for further evaluation but patient who suffered claustrophobia, opted to avoid it. Instead a detailed evaluation of the abdomen and pelvis was undertaken using contrast-enhanced computerized tomography (CECT). The scan revealed a solid cystic mass lesion in the pouch of Douglas with the right ovary lying anterosuperior to the lesion. The lesion showed well-defined margins with minimal enhancement of the solid component along with fat tissue and calcific foci within it. The fat planes with adjacent pelvic organs were maintained with no obvious pelvic or abdominal lymphadenopathy. These features were consistent with mature cystic teratoma (Figs 1 and 2).

The procedure of laparoscopic ovarian cystectomy was planned and undertaken following an informed consent and a discussion regarding possible findings and treatment.

Four-port laparoscopy revealed bulky uterus with torsion of right ovary and fallopian tube having flimsy adhesions to the pouch of Douglas (Fig. 3). The left ovary and the fallopian tube appeared normal with flimsy adhesion to the posterior wall of the uterus. Careful adhesiolysis with detorsion of right ovary and fallopian tube was undertaken (Fig. 4). A dermoid cyst measuring 10 x 8 cm was found to be located in the pouch of Douglas without any attachment to right ovary (Fig. 5). The dermoid cyst was retrieved using an endobag, avoiding any spillage of its contents (Fig. 6). The procedure was uneventful and the patient was discharged within 36 hours of surgery. The histopathologic diagnosis confirmed it to be a benign mature cystic teratoma with diffuse hemorrhagic infarction and areas of necrosis with features considered consistent with torsion.

DISCUSSION

Lefkowitch et al.³ reported the first such case in 1978, in which a woman had presented with urinary retention. Under the impression of a fibroid uterus, laparotomy was performed and a benign cystic teratoma of the retrouterine pouch of Douglas was found.

Dermoid cysts arise from germ cells that originate in the mature gonads. In embryonic life, migration of the germ cells occurs along the route of the mesentery toward the primitive gonads. These cells in future life might give rise to spectrum of tissues originating from the three primitive embryonic layers, including the dermoid cysts.² Torsion of the pedicle, rarely, may lead to autoamputation and reimplantation of the ovarian dermoid or even the ovary forming the parasitic tumor.²

In this index case, CT scan and pelvic sonography revealed the cyst being in close contact with the right ovary without obvious evidence of torsion. However, laparoscopy findings included no demonstrable attachment of the tumor to the right ovary as the adnexal torsion was unwound. The lesion was seen lying free in the pouch of Douglas showing a hemorrhagic pedicle suggesting recent detachment and auto amputation. Ovarian torsion was confirmed on laparoscopy and histopathology.

Review of literature suggests most common location of parasitic dermoids is the omentum (32 reported cases) followed by the pouch of Douglas (12 reported cases) signifying the rarity of this condition.⁴ Few other ectopic sites reported are the urinary bladder⁵ and fimbrial end of the fallopian tube.⁶ One case of parasitic dermoid in median umbilical fold was reported where a non-pregnant women presented with perception of something moving in her abdomen.⁷

Dermoid cysts are generally seen in the reproductive age-group but a few cases of parasitic dermoids have been reported in extremes of age. A 9-year-old girl presented with dull aching huge lump in right flank since 3 months. X-ray of abdomen and contrast-enhanced CT scan revealed large intraperitoneal mass with variable density and solid, cystic, and fatty components.

At laparotomy, huge nodular, highly vascular mass that was attached to omentum with a vascular pedicle but free from the other surrounding tissues was found and confirmed to be benign cystic teratoma on histopathology.⁸ Other patient was 61 years who presented with lower abdominal pain and ultrasound diagnosed two adnexal cysts. On laparoscopy, one was a right adnexal simple cyst and the second was a dermoid cyst found in cul-de-sac with flimsy adhesions to the peritoneum of the pouch of Douglas.⁹

In three cases, parasitic dermoids were found during cesarean section in women who presented with obstructed labor. One patient had an auto amputated ovary with vascular pedicle connecting dermoid cyst to the omentum and the intestine without any ligamentous connection with the pelvic organs.¹⁰ Another patient had an impending uterine rupture with a large dermoid cyst impacted in the pouch of Douglas separate from the adnexa.¹¹

The third patient presented with obstructed labor and intra-uterine fetal demise. Exploration revealed a dermoid cyst adherent to the urinary bladder.⁵

One case of parasitic dermoid has been reported whose etiology has been attributed to previous dermoid cystectomy where there was spillage of contents in the abdomen.⁹

Intraoperatively, dermoid cyst spill may result in chemical peritonitis or a recurrence of similar lesion in future.¹ Utmost care should be taken to prevent this or else generous suction irrigation will help to avoid future complications.

In our case, the whole cystic mass was retrieved in an endobag without any spillage of contents onto the surrounding structures. Three-year follow-up of the patient has not shown any recurrence of the lesion.

REFERENCES

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