|Year : 2013 | Volume
| Issue : 3 | Page : 180-182
A huge dermoid cyst with thrombocytosis and preoperative intraperitoneal rupture: An unusual presentation
Ramya Shankar, Sujata Narendra Datti, Jayanta Kumar, Rangahanumaiah Manjushree
Department of Obstetrics and Gynecology, MVJ Medical College and Research Hospital, Karnataka, India
|Date of Web Publication||19-Oct-2013|
No 34, 20th Main, 18th cross, Vijayanagar, Bangalore, Karnataka - 560 040
Source of Support: None, Conflict of Interest: None
Benign cystic ovarian teratoma is the most common ovarian neoplasm accounting for 10-25% of ovarian tumors.They affect women of all age and particularly women of reproductive age group.They may present with a variety of symptoms ranging from being asymptomatic to pain abdomen, dysmenorrhea, pelvic pain, nausea, vomiting, fever, anorexia, loss of weight and shortness of breath. The complications associated with benign cystic teratoma are torsion (16%), malignant degeneration (2%), rupture (1-2%), and infection (1%). Its spontaneous or iatrogenic intraperitoneal rupture is associated with chemical peritonitis. A dermoid cyst has been associated with thrombocytosis in 30% of the cases.
Hereby we present a case of huge ovarian dermoid cyst associated with thrombocytosis and spontaneous preoperative rupture with chemical peritonitis.
Keywords: Chemical peritonitis, dermoid cyst, thrombocytosis
|How to cite this article:|
Shankar R, Datti SN, Kumar J, Manjushree R. A huge dermoid cyst with thrombocytosis and preoperative intraperitoneal rupture: An unusual presentation. J Sci Soc 2013;40:180-2
|How to cite this URL:|
Shankar R, Datti SN, Kumar J, Manjushree R. A huge dermoid cyst with thrombocytosis and preoperative intraperitoneal rupture: An unusual presentation. J Sci Soc [serial online] 2013 [cited 2020 Sep 22];40:180-2. Available from: http://www.jscisociety.com/text.asp?2013/40/3/180/120063
| Introduction|| |
Dermoid cysts constitutes about 10-25% of all benign ovarian neoplasms and are the most common germ cell tumors in women of reproductive age. , Spontaneous rupture, although rare occurs in <1% of cases which requires immediate intervention. Further, rupture leads to intraperitoneal spillage of its contents resulting in chemical peritonitis with protracted recovery phase.  Though thrombocytosis has been reported in 30% of the cases of dermoid cysts in a study  there has been no case report showing this association. Hence, we are presenting a rare case of huge dermoid cyst with thrombocytosis and preoperative intraperitoneal rupture.
| Case Report|| |
A 25years old nulliparous lady with a married life of 7 years presented with abdominal pain of six months duration more since one month, abdominal distension noticed since one month, oligomenorrhoea since one year (menses once in two to three months for one day with scanty flow). Had significant weight loss (25 kilograms over last 6 months), anorexia, breathlessness and easy fatigability.
On examination, patient was afebrile, comfortable in propped up position, had moderate pallor, preoperative weight of 55 kilograms (weight along with huge ovarian mass) and BMI of 26 kg/meter.  On palpation mass arising from pelvis corresponded to 36weeks gravid uterus size and clinically measured 34 × 28 cms. It had variable consistency and restricted mobility in both vertical and horizontal plane. On per vaginal examination the mass was felt through all the fornices with minimal tenderness. Rectal examination revealed that the rectal mucosa and parametrium was free of nodularity or indurations.
Haemoglobin-7.4g/dl, PCV-24.4%, WBC-8000/cu mm, platelet count-600,000/μL, peripheral smear- dimorphic anemia with thrombocytosis, urine routine and culture- normal, RFT and LFT, blood sugars were normal. Tumor markers CA 125: 158.70U/ml, LDH - 137.79U/L.
Abdominopelvic Ultrasound revealed a uterine size of 7.3 × 3.8 × 4.4 cm, with endometrial thickness of 6 mm, a well defined cystic lesion of 24 × 15 × 20 cm with diffusely or partially echogenic mass with posterior sound attenuation owing to sebaceous material and hair seen within the cyst cavity (the tip of the iceberg sign). There was no evidence of internal vascularity. The two ovaries could not be seen separately. Impression: A large ovarian dermoid cyst.
CT Scan showed a well circumscribed rounded soft tissue density lesion in right adnexa measuring 28.4 × 12.5 × 14.9 cms. The lesion showed predominately cystic areas with interspersed fat within, a 4 mm nodular calcific focus was noted in the anterior wall. There was evidence of mass effect in the form of displacement of uterus and urinary bladder. Impression: Right sided dermoid cyst.
Pre operatively two pint packed cells were transfused and anemia corrected. Simultaneously was evaluated for thrombocytosis, bone marrow biopsy was advised but patient refused. During the course of preoperative preparation she developed acute breathlessness and pain abdomen, spontaneous rupture was suspected and was taken for emergency laparotomy. During surgery a very thick peritoneal surface was noted which looked inflammed. On opening the parietal peritoneum, a thick yellowish fluid of about 1.5 litres which had collected in the paracolic gutters and subhepatic spaces was suctioned [Figure 1]. A left ovarian mass of 30 × 20 cm (weighing 10 kilograms) was noted [Figure 2] with thick yellowish fluid oozing from the ruptured site. This huge ovarian mass was excised and sent for frozen section which revealed ulcerated dermoid cyst [Figure 3]. Uterus, right ovary and appendix were normal. Omental biopsy and peritoneal biopsy was taken. A thorough peritoneal lavage was given and abdomen closed.
|Figure 1: Pultaceous material draining out on opening parietal peritoneum.|
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Post operatively she developed fever and was treated symptomatically. Post operatively platelet count was repeated and was as high as 800,000/ μL probably due to reactionary thrombocytosis. Further, monitoring of platelet count 2 weeks later revealed a drop to preoperative value. On 21 st postoperative day, the patient reported back to us with symptoms of vomiting and pain abdomen, was diagnosed to have subacute intestinal obstruction which was treated conservatively. She recovered and went back after one week. On subsequent follow up in outpatient department, platelet had dropped to 420,000/μL suggesting that preoperative elevated platelet count was due to reactionary thrombocytosis.
Mature cystic teratoma [Figure 4]
Omentum: Non specific inflammation
Peritoneum: Non specific inflammation
Tube: Inflammed and congested
|Figure 4: Histopathology of the specimen, (A) Sebaceous glands (B) Ectodermal tissue|
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| Discussion|| |
Dermoid cyst or mature cystic teratomas is the most common benign germ cell tumor and the most common neoplasm of the ovary.  Mature teratoma of the ovary comprises a cyst lined by an epidermis- like epithelium and contains a variable admixture of elements of one or more of the three cell lines; meso, endo and ecto-dermal derivatives including sebaceous secretions, hair, teeth, bone or fat. 
Katie Williams et al, have reported a maximum of 15 × 15 cms sized dermoid cyst in their case report; however, the weight of ovarian dermoid has not been mentioned in any of the case reports.
The diagnosis of a mature cystic teratoma using CT imaging is straight forward because this modality is more sensitive for fat.  Fat is reported in 93% of cases and teeth or other calcifications in 50%. 
Despite the benign nature of the neoplasm's they have generated considerable interest because of their unusual presentation. Rupture or perforation of the cyst may give rise to peritonitis however spontaneous rupture of an ovarian dermoid cyst is very rare (<1%) due to the thick capsule.  Peritonitis resulting from a chronically leaking dermoid cyst is characterized by multiple small white peritoneal implants, diffuse or focal omental infiltration and inflammatory masses involving the omentum and bowel and dense adhesions and variable ascites that simulate carcinomatous or tuberculous peritonitis.  In our case there was chemical peritonitis induced by chronic leakage of sebaceous material leading to omental, peritoneal and intestinal infiltration mimicking malignancy.
Thrombocytosis (platelet count > 400,000/μL) and raised CA 125 levels are more frequently associated with malignant ovarian tumor than with benign ovarian tumor.  Thrombocytosis is present in 30% of dermoid cysts, 25% of serous cystadenomas.  In our case thrombocytosis (platelet count = 600,000/μL) and elevated CA-125 (158.70U/ml)was associated with a huge ovarian mass which was diagnosed to be a dermoid cyst radiologically and confirmed histopathologically. As thrombocytosis is said to be present in both benign and malignant ovarian tumors, thrombocytosis per se should not alter the management and should just be considered as a marker of tumor burden.
| Conclusion|| |
Since, benign ovarian tumors like dermoid cyst can present with thrombocytosis, elevated CA-125 and mimic malignant ovarian tumor intra-operatively (like peritoneal, omental and intestinal implants with adhesions), the role of frozen section has to be over emphasised to decide upon conservative surgery particularly in nulliparous women.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]