Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 40  |  Issue : 3  |  Page : 180-182

A huge dermoid cyst with thrombocytosis and preoperative intraperitoneal rupture: An unusual presentation


Department of Obstetrics and Gynecology, MVJ Medical College and Research Hospital, Karnataka, India

Date of Web Publication19-Oct-2013

Correspondence Address:
Ramya Shankar
No 34, 20th Main, 18th cross, Vijayanagar, Bangalore, Karnataka - 560 040
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.120063

Rights and Permissions
  Abstract 

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 2019 Aug 23];40:180-2. Available from: http://www.jscisociety.com/text.asp?2013/40/3/180/120063


  Introduction Top


Dermoid cysts constitutes about 10-25% of all benign ovarian neoplasms and are the most common germ cell tumors in women of reproductive age. [1],[2] 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. [3] Though thrombocytosis has been reported in 30% of the cases of dermoid cysts in a study [4] 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 Top


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. [2] 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.

Investigations

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.

Management

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.

Click here to view
Figure 2: Huge ovarian dermoid exteriorised

Click here to view
Figure 3: Site of rupture of ovarian dermoid

Click here to view


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.

Histopathological examination

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

Click here to view



  Discussion Top


Dermoid cyst or mature cystic teratomas is the most common benign germ cell tumor and the most common neoplasm of the ovary. [5] 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. [6]

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. [7] Fat is reported in 93% of cases and teeth or other calcifications in 50%. [8]

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. [8] 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. [9] 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. [10] Thrombocytosis is present in 30% of dermoid cysts, 25% of serous cystadenomas. [4] 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 Top


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.

 
  References Top

1.Fibus TF. Intraperitoneal rupture of a benign cystic ovarian teratoma: Findings at CT and MR imaging. AJR Am J Roentgenol 2000;174:261-2.  Back to cited text no. 1
    
2.Lipson SA, Hricak H. MR imaging of the femal pelvis. Radiol Clin North Am 1996;34:1157-82.  Back to cited text no. 2
    
3.Yang HS, Song TH, Bang HC, Park JH, Lee CH, Roh JW, et al. Persistant chemical peritonitis resulting from spontaneous rupture of an ovarian mature cytic teratoma. Korean J Obstet Gynecol 2011;54:726-30.  Back to cited text no. 3
    
4.Noh HT, Son SK. The clinical significance of Thrombocytosis in Patients presenting with a Pelvic Mass Korean J Gynaecol Oncol Colposc 1998;9:489-95.  Back to cited text no. 4
    
5.Hertzberg BS, Kliewer MA. Sonography of benign cystic teratoma of the ovary: Pitfalls in diagnosis Amer J Roentgenol 1996;167:1127-33.  Back to cited text no. 5
    
6.Outwater EK, Siegelman ES, Hunt JL. Ovaria teratomas: Tumor types and imaging characteristics. Radio Graphics 2001;21:475-90.  Back to cited text no. 6
    
7.Guerriero S, Mallarini G, Ajossa S, Risalvato A, Satta R, Mais V, et al. Transvaginal ultrasound and computed tomography combined with clinical parameters and CA-125 determinations in the differential diagnosis of persistent ovarian cysts in premenopausal women. Ultrasound Obstet Gynecol 1997;9:339-43.  Back to cited text no. 7
    
8.Buy JN, Ghossain MA, Moss AA, Bazzot M, Doucet M, Hugol D, et al. Cysticcxteratoma of the ovary: CT detection. Radiology 1989;171:697-701.  Back to cited text no. 8
    
9.Pantoja E, Noy MA, Axtmayer RW, Colon FE, Pelegrina I. Ovarian dermoids and their complications: Comprehensive historical review. Obstet Gynecol Surv 1975;30:1-20.  Back to cited text no. 9
    
10.Hakverdi AU, Yayla M, Gocmen A, Gul T, Erden AC, Demiroglu S. The clinical significance of preoperative serum CA-125 levels and thrombocytosis in patients with pelvic masses. Jinekoloji ve Obstetrik Dergisi 1995;9:205-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed3386    
    Printed46    
    Emailed0    
    PDF Downloaded188    
    Comments [Add]    

Recommend this journal