Immature teratoma is a germ cell tumour that is extremely rare accounting for 1-3% of all ovarian cancers. These are usually diagnosed in girls and young women up to their early twenties.
Here is a report of a case of huge immature teratoma in an 11-year-old child diagnosed by 3D Ultrasound imaging using IOTA criteria ( International Ovarian Tumour Analysis ). Based on the USG findings, the ovarian lesion was characterised as a “probably malignant tumour.“
An 11-year-old child with no previous health problems, with the age of first menstruation at 10 years was admitted for fever and for further evaluation. The child was well built and nourished with all vitals being stable. On abdominal examination, we found a large solid mass palpable occupying the entire abdomen extending up to the xiphisternum.
On a detailed workup, her baseline investigations were normal. Ultrasound revealed a large multiloculated cystic mass of 30.2 * 20.2 * 10 cm ( vol 3457cc ) with solid areas, calcifications with posterior shadowing and a vascular score of 3-4.
Another multilocular mass 7.4 * 6.2 * 7.3 cm ( vol 174cc ) posterior to the uterus. Both ovaries cannot be imaged separately. The uterus appeared normal along with a normal endometrial cavity. CECT Abdomen is consistent with the above findings and no lymphadenopathy was found. The right pleural effusion was moderate. All tumour markers were within normal limits.
After counselling the parents about the nature of the tumour, its malignant potential and the need for chemotherapy, histopathological confirmation and grading, the laparotomy was scheduled. The parents were also explained of the need for the frozen section from another ovary intraoperatively (if necessary).
At laparotomy, a huge multiloculated mass of approx 30*20 cm in dimensions, with a smooth surface arising from the right ovary (weight 4kg ) was found. The tube could not be traced out. The right salpingo-oophorectomy was done and the cyst was removed intact without spillage. Uterus, left ovary and tube were normal.
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Multiple peritoneal deposits were present including the Pouch of Douglas. An omental biopsy was done. Pelvic node sampling was also done. Peritoneal fluid was collected for cytology. The patient stood the procedure well and the postoperative period was uneventful.
Finally, a histopathology report supported by immunochemistry reinforced the diagnosis of an immature teratoma with peritoneal gliomatosis.
Histology – high grade, FIGO – Stage II B.
The patient was referred to Medical Oncologist for adjuvant chemotherapy.
In young patients, fertility-sparing surgery (conservative) should be the initial treatment for germ cell malignancies. The potential risks and compliance for regular follow up should be discussed. Unilateral salpingo-oophorectomy with preservation of contralateral ovary and uterus is now considered an adequate surgical treatment for patients with GCT, even in cases of advanced disease because of sensitivity of the tumour to chemotherapy. No systematic ovarian biopsy is needed when the contralateral ovary is macroscopically normal.
Approximately 75% of GCT recurrences occur within the first two years after initial treatment. Follow up by history, physical exam and tumour markers are to be done every three months. After two years, the follow up by history and physical exam are to be done yearly. Pelvic Ultrasound should be performed every six months in patients who undergo fertility-sparing surgery.
Overall the 5-year survival rate for patients with all stages of pure immature teratoma is 70-80%. For high-grade tumours (2,3), adjuvant chemotherapy is generally recommended.
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