A dermoid ovarian cyst is the commonest ovarian cystin women of reproductive age. We report a young woman who presented with a large abdominal mass. We discuss the differential diagnosis and surgical management of a large complex ovarian mass in a young woman.
Ovarian Cyst; Ovarian Cancer1. INTRODUCTION
Ovarian cancer is the fifth commonest cancer among women and the most lethal gynaecological malignancy [1]. Due to vague symptoms in the early stages of disease it often presents late, with abdominal distension due to a large mass or ascites [2].
The differential diagnosis of an ovarian mass includes both benign and malignant disease. In young women with a large ovarian mass borderline or malignant disease of the ovary is an important differential to consider [3]. However, in young women smaller complex ovarian masses could be an endometrioma, a haemorrhagic cyst or a dermoid cyst. It is important to consider these causes when deciding on the appropriate surgical management.
2. CASE REPORT
A 37 year old lady attended the gynaecology outpatient clinic with a three month history of abdominal swelling. She was parous, with a regular 28 day menstrual cycle, and a normal cervical smear within the last year. There was no family history of breast or ovarian cancer.
On examination there was a mobile 26 week pregnancy size abdominal mass arising from the pelvis. Her CA125 was normal. An ultrasound scan demonstrated a large abdominal mass extending into the pelvis containing solid and cystic areas. This was thought to be an ovarian tumour. The uterus was normal and visualised separate from the mass. A CT was then performed which confirmed a large right ovarian mass that was solid and cystic. There was no ascites or enlarged retroperitoneal lymph nodes, and no evidence of pleural effusion.
A midline laparotomy and right salpingo-oophrectomy was peformed. The operative findings were of a large complex right ovarian cyst with an intact capsule. The cyst had sebaceous material and hair content suggestive of dermoid aetiology. The uterus, left fallopian tube, peritoneal surfaces, omentum and liver all appeared healthy. The histology report confirmed a 23 × 16 × 14 cm smooth walled cyst, weighing 2.5 kg. The cyst contained teeth, hair and sebaceous fluid. The peritoneal washings contained benign mesothelial cells.
3. DISCUSSION
A dermoid cyst is a benign cyst composed of tissue differentiated from three germ cell lines. It often presents with abdominal pain. Complications include torsion, and rupture causing chemical peritonitis.
Laparoscopic management has been shown to be associated with less bleeding and a shorter hospital stay than laparotomy in patients with a dermoid cyst measuring < 12 cm [4]. However, minilaparotomy has been shown to be a good surgical technique for removal of a dermoid cyst due to shorter operating time than laparoscopy, the possibility of removing the mass from the abdominal cavity without rupture and the possibility to preserve more ovarian tissue [5].
Spillage of dermoid cyst contents is more common when removal is performed laparoscopically than by laparotomy [6]. Case reports have described chemical peritonitis following intraperitoneal spillage of dermoid cyst contents causing pelvic adhesions, bowel obstruction, abdominal wall abscess, and enterocutaneous fistula formation [7].
Women presenting with a large complex ovarian cyst are often referred for extensive surgical staging to ensure the correct diagnosis and treatment of a possible epithelial ovarian cancer [8].
This case represents one of the largest dermoid cysts ever reported and shows that in young women with a large complex mass it must be considered among the differential diagnoses.
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