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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 1  |  Page : 39-41

A rare case of bilateral multiple ovarian dermoids with uterine fibroid and ectopic kidney


Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Science, Wardha, Maharashtra, India

Date of Web Publication21-May-2019

Correspondence Address:
Dr. Suvarna Satish Deshpande
Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Science, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_79_18

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  Abstract 


Ovarian dermoid cysts are made up of solid, cystic, and fat tissue arising from two of the three germ layers. The incidence of they being bilateral is rare and accounts for 10%–15%. A 42-year-old female came with chief complaints of increased bleeding during menses and pain in the abdomen. Ultrasonography revealed echogenic lesion with heterogeneous echotexture in both the ovaries with internal echogenic strands within which was s/o bilateral dermoid cyst. The patient had a left ectopic renal kidney on contrast-enhanced computed tomography of the abdomen; there was well–defined, rounded, mixed-density mass lesion seen in the pelvis showing fat density, areas of calcification (Rokitansky protuberance), soft tissue, and fluid components. After postoperative and histopathological correlation, it was found to be bilateral dermoid.

Keywords: Bilateral, contrast-enhanced computed tomography, dermoid, ectopic kidney, ultrasonography


How to cite this article:
Deshpande SS, Phatak SV. A rare case of bilateral multiple ovarian dermoids with uterine fibroid and ectopic kidney. J Datta Meghe Inst Med Sci Univ 2019;14:39-41

How to cite this URL:
Deshpande SS, Phatak SV. A rare case of bilateral multiple ovarian dermoids with uterine fibroid and ectopic kidney. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2019 Dec 14];14:39-41. Available from: http://www.journaldmims.com/text.asp?2019/14/1/39/258660




  Introduction Top


Dermoid cysts are cystic lesions which are well-differentiated derivatives of two of the three germ layers that is ectoderm, endoderm, and mesoderm.[1] The wall of teratomas consists of hair follicle, skin glands, muscle, and other tissues with the presence of an elevation called as Rokitansky nodule. Hair strands present arise from this nodule.[2]

Mature teratomas (dermoid cyst) comprise 10%–20% of all the neoplasms of the ovary. Most of the mature teratomas are benign, but 0.1%–0.2% may undergo carcinomatous changes. Predominantly, they occur as unilateral dermoids, but 10%–15% of cases can be seen as bilateral dermoids.[3]

Majority of the mature teratomas are asymptomatic and accidently diagnosed on a pelvic examination. Some of them which are symptomatic may present with pain in the abdomen.[4] Complication of a dermoid cyst can be torsion, rupture of the cyst resulting into chemical peritonitis.[5]


  Case Report Top


A 42-year-old female came with chief complains of heavy bleeding during menses and pain in the abdomen for 2–3 months. The patient underwent tubal ligation surgery 10 years back. There was no significant family history. On per abdominal examination, a mass was felt on deep palpation on the left side, which was nontender. On per vaginal examination, the uterus was bulky and a mass was felt in the left fornix which was separately palpable. The patient was found to be anemic with peripheral blood smear revealing microcytic hypochromic red blood cell with few teardrop cells. On transabdominal sonography, there was evidence of bulky uterus of size 13.1 cm × 7.7 cm × 5.4 cm with posterior myometrial fibroid (3.6 cm × 3.3 cm) [Figure 1]. Right ovary measured 8.8 cm × 6.4 cm with echogenic lesion and few hair strands within [Figure 2], left ovary measured 9.1 cm × 6.8 cm [Figure 3] showed heterogeneous echotexture with no evidence of vascularity on Doppler s/o bilateral ovarian dermoid cyst. The left kidney was seen in pelvic cavity s/o ectopic kidney [Figure 4]. On contrast-enhanced computed tomography (CT) of the abdomen, there was well–defined, rounded, mixed-density mass lesion seen in the pelvis showing fat density (−15 HU units), areas of calcification (Rokitansky protuberance) (1209 HU units), soft tissue, and fluid components [Figure 5]. The left kidney was seen in the pelvis in the midline with the malrotated pelvicalyceal system. The patient underwent hysterectomy with bilateral oophorectomy. Postoperative event was uneventful. On histopathological examination, report revealed the specimen to be bilateral dermoid [Figure 6].
Figure 1: Ultrasonography image shows bulky uterus with posterior myometrial fibroid

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Figure 2: Ultrasonography image of the right ovary shows echogenic lesion with few hair strands within

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Figure 3: Ultrasonography image of the left ovary shows heterogeneous echotexture with no vascularity on Doppler

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Figure 4: Ultrasonography image of the left ectopic kidney seen in the pelvic cavity

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Figure 5: Axial section on contrast-enhanced computed tomography shows a well-defined, rounded, mixed-density mass lesion seen arising in bilateral ovaries which is showing fat density of - 15 HU units, areas of calcification of 1209 HU units, soft tissue, and fluid components

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Figure 6: Intraoperative image showing bilaterally enlarged ovaries

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  Discussion Top


Among the ovarian neoplasms, about 32% are cystic teratomas, and among them, 15% are bilateral. These mature cystic teratomas (MCTs) called as dermoid cyst are common in the age of reproduction. They do not cause symptoms till they reach a considerable age.[6] Ovarian teratomas arise from multiple cell type which consists of one or more than one of all the three layers. A lining of mature teratomas consists of squamous epithelium with cornifying materials, hair, sebaceous glands, sweat glands, hair follicles, and fat tissue. Lower abdominal pain is the most common symptom in cystic teratomas with torsion being the most common complication. Fluid, fat, and solid tissue are generally the contents of a dermoid cyst because of which we can see peculiar sonographic features. Dermoid plug, an echogenic mass within the cyst made up of hair, teeth, or fat, is the most common finding. Dermoid mesh, multiple small hyperechoic lines and dots within the cyst, gives a picture of mesh. These hyperechogenic foci present in the cystic fluid are small hair. A hyperechoic area is considered as the tip of ice berg, which is only visualized. This is the result of a mass which comprises of matted hair and sebum casting an echogenic shadow. “Fat–fluid level” or “hair–fluid level” or “fluid–fluid” level is due to layering of serous fluid and sebum at two different levels. Thus, ultrasonography (USG) becomes an easy, noninvasive, cost-effective modality due the peculiar features of the dermoid cyst in detection of the same.[7] Contrast-enhanced CT is very helpful and has a sensitivity of 93%–98% in the detection of MCT. Intratumoral fat in MCT can be a round floating mass which is seen in the interface between two liquid components intermingled with hair or a component in the cyst wall or Rokitansky nodule. On the CT image, a Rokitansky nodule looks like a rounded structure protruding into the cystic lumen or mural thickening which is a bridge across the cyst or sometimes only a tooth. The Rokitansky nodule is significant because it tells about malignant transformation. Contrast enhancement of a Rokitansky nodule raises the possibility of malignant transformation, which does not always indicate malignancy. Curvilinear or globular calcification in the Rokitansky protuberance, in the wall of the MCT or in/near the septa, is indicative of tooth present. The presence of multiple bilateral MCTs recurrence – especially in high-risk patients – should be taken into consideration by close follow-up and regular ultrasound examination.[8]


  Conclusion Top


This case report highlights the uniqueness of dermoids being present in bilateral ovaries in a patient of uterine fibroid and ectopic kidney. Thus, these bilateral dermoids can be detected early by USG and CT underlining the importance of an accurate preoperative diagnostic imaging. Being asymptomatic, early diagnosis of dermoid is necessary so as to restrict its malignant transformation which improves its prognosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shah J, Shah R, Raychaudhuri C. Radiological evaluation of ovarian dermoid.  Back to cited text no. 1
    
2.
Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: Tumor types and imaging characteristics. Radiographics 2001;21:475-90.  Back to cited text no. 2
    
3.
Srikanth S, Anandam G. Bilateral dermoid cyst of ovary. Med J Dr DY Patil Univ 2014;7:492.  Back to cited text no. 3
    
4.
O'Neill KE, Cooper AR. The approach to ovarian dermoids in adolescents and young women. J Pediatr Adolesc Gynecol 2011;24:176-80.  Back to cited text no. 4
    
5.
Nezhat CR, Kalyoncu S, Nezhat CH, Johnson E, Berlanda N, Nezhat F, et al. Laparoscopic management of ovarian dermoid cysts: Ten years' experience. JSLS 1999;3:179-84.  Back to cited text no. 5
    
6.
Fayez I, Khreisat B, Athamneh T, Omoosh R, Daibes MA. Multiple bilateral ovarian mature cystic teratomas with ovarian torsion: A Case report. Oman Med J 2018;33:163-6.  Back to cited text no. 6
    
7.
Kite L, Uppal T. Ultrasound of ovarian dermoids – Sonographic findings of a dermoid cyst in a 41-year-old woman with an elevated serum hCG. Australas J Ultrasound Med 2011;14:19-21.  Back to cited text no. 7
    
8.
Rha SE, Byun JY, Jung SE, Kim HL, Oh SN, Kim H, et al. Atypical CT and MRI manifestations of mature ovarian cystic teratomas. AJR Am J Roentgenol 2004;183:743-50.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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