J Radiol Sci 2015; 40: 61-64
Ruptured Ovarian Cystic Teratoma with Peritoneal Reaction:
a case report
Hsiu-Wen Kuo CHeng -Yi CHan Kun-eng Lim Hsu-CHao CHang
Department of Radiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
AbSTRACT
Although ovarian teratomas are the most common neoplasms in younger patients, ruptured teratomas are rare.
Ruptured teratomas may mimic malignant tumors, and chronic rupture may result in granulomatous peritonitis.
We report a case of ruptured teratoma with peritoneal seeding in a 31-year-old woman without a significant
history complained of progressive abdominal fullness. Abdominal computed tomography and 1.5-Tesla magnetic
resonance imaging revealed a large cystic tumor in the right adnexa with diffuse fat implants in the peritoneum. In
addition, dense calcifications and fat inclusions were observed within the tumor. The right ovarian tumor and most of
the peritoneal implants were surgically excised. Follow-up computed tomography performed 4 years after resection
showed no lesion recurrence, although some residual fat implants were observed in the peritoneum.
Mature cystic teratomas account for 10-20% of all
ovarian neoplasms and occur mostly in young adults. Spontaneous rupture of a mature cystic teratoma is uncommon
(1-2% of all complications) because it usually has a thick
capsule [1, 2]. Ovarian teratomas may rupture into the peritoneum, urinary bladder, small bowel, rectosigmoid colon,
or vagina.
We describe the imaging and immunohistochemical
characteristics of a case of ruptured teratoma with peritoneal reaction that was successfully treated with surgery.
CASE REPORT
A 31-year-old woman, gravida 1, presented to our hospital with a 3-week history of progressive abdominal fullness and associated weight loss. She had been previously
healthy with normal menstrual cycles and without histories
of major systemic disease, gastrointestinal and gynecological symptoms, or trauma or accident.
Physical examination revealed a markedly distended
abdomen without tenderness or rebound pain. Abdominal
ultrasonography revealed massive ascites without definite
mass. On abdominal computed tomography (CT), a cystic
tumor with calcification and fat inclusions in the right
adnexa (Fig. 1a), and diffuse fat implants in the perihepatic
and subphrenic regions were detected (Fig. 1b-1c). Associated ascites and peritoneal thickening were also observed
(Fig. 1c). These findings were suggestive of a ruptured right
ovarian teratoma with peritoneal reaction.
On 1.5-Tesla magnetic resonance imaging (MRI), fat
implants presented as T1 hyperintensity, while a prominent macroscopic fat signal was detected within the tumor
and peritoneal cavity on fat-suppressed T1-weighted MRI
(Fig. 2a-2b). These findings indicate a fat-containing tumor
in the right adnexa and peritoneal fatty implants. In addition, massive ascites and prominent enhancement of the
peritoneum were noted (Fig. 2c). Accordingly, ruptured
ovarian teratoma with peritoneal reaction was diagnosed,
and laparotomy was performed.
Correspondence Author to: Hsiu-Wen Kuo
Department of Radiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
No. 289, Jian-Guo Road, New Taipei 231, Taiwan
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Ruptured ovarian cystic teratoma
Figure 1
1a
1c
1b
Figure 1. a. Post-contrast abdominal computed tomography scan showing a right adnexal tumor with a fatty component
and calcification (arrow), suggestive of a right ovarian teratoma. b. Post-contrast abdominal computed tomography scan
showing fat implants in the perihepatic region (arrow). c. Reformed post-contrast coronal computed tomography image
showing the right ovarian teratoma (arrow head) with fat implants (arrows) in the subphrenic and perihepatic regions, along
with associated ascites and peritoneal thickening.
Preoperative analysis of serum tumor markers revealed
a cancer antigen 125 (CA-125) level of 121 U/mL (reference
range, 0-35 U/mL). The alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), and b-human chorionic gonadotropin (β-HCG) levels were unremarkable.
During laparotomy, massive, mucinous, jelly-like, yellowish, and sticky fat implants were observed in the whole
abdominal cavity. The total volume was approximately
2000 cc. A ruptured right ovarian tumor was found. The
external surface appeared gel-like with mucoid material
over the elastic surface. On incision, some sebum and calcified hairs were also visible. On microscopic examination,
teratoma components, including mature bone, skin with
appendages, and sebum, were observed.
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She was symptom-free postoperatively without further
treatment. Follow-up with CT studies over a period of 4
years showed that some residual fat implants were noted
in the subphrenic and perihepatic regions without interval
change. The CA-125 levels remained within the reference
range.
DISCUSSION
Spontaneous rupture of a mature cystic teratoma is
uncommon (1–2% of all complications) because it usually
has a thick capsule [1, 2]. Acute rupture may occur during
pregnancy, delivery, iatrogenesis, or trauma [3, 4]. However,
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Ruptured ovarian cystic teratoma
Figure 2
2a
2b
2c
2d
Figure 2. a. Axial T1-weighted magnetic resonance image showing hyperintense implants in the peritoneum (arrow).
b. Axial fat-suppressed T1-weighted magnetic resonance image showing macroscopic fat signal. c. Post-contrast fatsuppressed T1-weighted magnetic resonance image showing diffuse peritoneal enhancement (arrow). d. Axial T2-weighted
magnetic resonance image showing right adnexal heterogeneous tumor (arrow) and massive intraperitoneal fluid.
chronic rupture may cause slow leakage of intratumoral
materials through small tumor perforation.
Nader et al. and Suprasert et al. reported cases of
ruptured ovarian teratoma with abdominal distention and
weight loss [3, 4], which were also observed in our case.
The reported symptoms were abdominal pain, peritonitis,
and hemoperitoneum [5]. These symptoms are associated
with acute or chronic rupture.
Patients with suspected gynecological malignancies
should undergo preoperative examination of tumor markers.
In our review of previous studies on ruptured teratomas,
we found that serum CA-125 levels were either elevated or
normal. In cases of preoperatively elevated CA-125 levels
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that subsequently return to normal, follow-up assessments
of serum CA-125 levels should be performed. We presumed that our reported case was a stable disease based on
the normal postoperative CA-125 level and stationary CT
findings.
Ovarian teratomas may rupture into the peritoneum,
urinary bladder, small bowel, rectosigmoid colon, or vagina
[1, 6]. The most common site of rupture is the peritoneal
cavity. Mature cystic teratomas have typical imaging characteristics with fatty and calcified components within the
tumor. Presence of extratumoral and intraperitoneal fatty
nodules is suggestive of a ruptured teratoma. Ruptures
lead to parasitic peritoneal implants, usually involving the
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Ruptured ovarian cystic teratoma
Figure 3
Most teratomas are benign and asymptomatic. Symptoms result from the following complications: torsion,
rupture, infection, and malignant change. The massive ruptured materials in symptomatic ruptured teratomas must
be completely removed surgically. In our case, the ruptured materials were not removed completely. However,
this is sometimes difficult. For the present case, no further
management was conducted because it was histologically
benign and symptom-free postoperatively.
We report a rare case of ruptured cystic ovarian teratoma with peritoneal reaction that was successfully treated
with surgery. We recommend that surgery be performed
in cases of suspected spontaneous rupture of an ovarian
teratoma for symptom relief and to prevent development
of peritonitis and malignant transformation. For postoperative residual peritoneal implants in cases of histologically
benign ruptured teratoma, further treatment may not be a
necessary action.
REFERENCES
Figure 3. Postoperative follow-up. Post-contrast abdominal
computed tomography scan showing fat implants in the
subphrenic and subhepatic regions (arrows).
greater omentum, cul-de-sac of Douglas, and perihepatic
region [2]. Ruptured tumors may cause chemical or granulomatous peritonitis [2, 7]. Fatty nodules are common in
the subphrenic and perihepatic regions (Fig. 1a), probably
because of the lower density of fat than those of intraperitoneal fluid and other materials. Most reported cases
were diagnosed as ruptured teratoma based on results of
CT studies. One of the reasons is that CT studies on clinically suspected intra-abdominal tumor are easier to find.
Another reason is that detection of the calcification and
fatty components on CT is not difficult. Fatty implants are
also clearly visible on fat-saturated MRI scans.
The malignant transformation rate of cystic ovarian
teratoma is approximately 1-2%. Malignant transformation
of ruptured cystic teratoma is even rarer. Radiological findings of benign and malignant cystic teratomas often overlap
[8]. Sometimes, ruptured ovarian teratomas with diffuse
peritoneal reaction mimic disseminated ovarian malignancies. Therefore, surgery is recommended to relieve symptoms and treat a possible malignancy when spontaneous
rupture of an ovarian teratoma is suspected. Timely aspiration of spilled ovarian cyst fluid is necessary to prevent
prolonged chemical peritonitis [7]. If an associated malignant transformation is observed, further chemotherapy may
be necessary. Synthetic adrenal corticosteroid, immunosuppressive antimetabolite, and conservative treatments of
peritonitis in cases of ruptured cystic ovarian teratoma have
been reported [8].
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