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A retroperitoneal dermoid cyst which causes mechanical jaundice
European Journal of Radiology Extra 55 (2005) 61–63
A retroperitoneal dermoid cyst which causes mechanical jaundice Baki Koseoglu a , Murat Ulusoy a , Tamer Karsidag b,∗ b
a Department of Radiology, Haseki State Hospital, 34300 Aksaray, Istanbul, Turkey Department of General Surgery, Haseki State Hospital, 34300 Aksaray, Istanbul, Turkey
Received 10 November 2004; received in revised form 19 May 2005; accepted 20 May 2005
Abstract Dermoid cysts are embryonal neoplasms arising from three germ cell layer (ectoderm, mesoderm and endoderm). Their radiological features are characteristic. Dermoid cysts are principally encountered in the gonads, but rarely in sequestered primitive cell rests elsewhere. Abdominal dermoid cysts may be localized in the stomach, liver or retroperitoneum. In this study a retroperitoneal dermoid cyst which causes mechanic jaundice is being presented. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Dermoid cyst; Jaundice; Retroperitoneum
1. Introduction Dermoid cysts are embryonal neoplasms arising from totipotent cells and composed of three germ layer (ectoderm, mesoderm and endoderm). They are one of the most characteristic tumor as radiological [1]. In this study, we presented a retroperitoneally localized dermoid cyst causing obstructive jaundice.
2. Case report A 23-year-old male patient was examined for signs and symptoms of obstructive jaundice. Ultrasonografic (US) findings: a heterogeneous mass, 10 cm × 11 cm × 13 cm in diameter, extending from retroperitoneal area to the right subhepatic area, displacing the gallbladder laterally and pancreas anteriorly was recorded. It compressed both inferior vena cava and hilum of the liver superiorly. Because it displaced the common bile duct medially and cranially, it caused dilatation of the common bile duct and intrahepatic bile ducts. ∗ Corresponding author at: Gazi Berkay cad. No: 13/9, 80200 Sisli, Istanbul, Turkey. Tel.: +90 532 366 9522; fax: +90 212 296 6092. E-mail address: [email protected] (T. Karsidag).
1571-4675/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2005.05.007
The mass contained a hyperechoic area showing posterior acoustic attenuation. This heterogeneous mass was covered by thick wall (Fig. 1a and b). Color-Doppler examination showed no obvious vascularization. Abdominal Computed Tomography (CT) following oral and IV contrast material injection showed a hypodens area (−138 HU) corresponding to fat tissue, a milimetric hyperdensity (+175 HU) corresponding to calcification and hypodens areas (+12 HU) corresponding to viscous fluid (Fig. 2). Besides relations to neighboring organs and vessels, compression and displacement of intestinal segments were obviously demonstrated. Fast Spin Echo (FSE) T1 and T2 weighted with fat suppression Magnetic Resonance Images depicted the fat component of this mass by signal loss (Fig. 3a and b). All radiological modalities showed that the lesion was a dermoid cyst. The patient was operated and the lesion was noticed to be retroperitoneally origin and proved the truth of the neighborhoods which was shown radiologically. The macroscopic examination was also suggesting dermoid cyst. Histopathological examination showed mature stratified keratinized squamous epithelium, hair shofts, ecrine, apocrine and sebaceous glands; all together making the diagnosis of mature cystic teratoma (dermoid cyst) obviously (Fig. 4).
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B. Koseoglu et al. / European Journal of Radiology Extra 55 (2005) 61–63
Fig. 1. (a and b) US images of lesion with widening of intrahepatic biliary ducts secondary to lesion.
Fig. 3. (a and b) MR images of lesion.
Fig. 4. Histopathologic slices of lesion. Fig. 2. CT image of lesion following contrast matrial.
B. Koseoglu et al. / European Journal of Radiology Extra 55 (2005) 61–63
63
3. Discussion
References
Abdominal dermoid cysts may be localized in the stomach, liver or retroperitoneal area. Sacrococcigeal region is a frequent site of involvement. These are mostly benign lesions but may undergo malignant transformation as age increases. Although the incidence of malignancy is low (less than 1%), patients with dermoid cysts are frequently operated due to torsion, infection or rupture secondary to enlargement of these cysts. Even though most cases are diagnoses before the age of 6 months, rarely dermoid cyst remain undiagnosed until adulthood [2,3]. Dermoid cyst are diagnosed with high accuracy via modalities like US, CT and MRI. The ultrasonografic iceberg sign, CT scan showing fat density, chemical shift artifact on MRI and signal-void images following fat suppression are all typical for dermoid cysts [4–6]. This retroperitoneally localized dermoid cyst was identified at the age 23 years and presented itself with mechanical (obstructive) jaundice. We could notice other retroperitoneally localized dermoid cysts in the literature, but not one being the cause of obstructive jaundice [7–10]. Bogovac et al. [11] has described a case of teratoma causing obstructive jaundice but the origin of the lesion was not mentioned clearly. As a result, we would like to emphasize that dermoid cysts may be localized in different sites of the body and present themselves with different signs and symptoms. They can be easily diagnosed radiologically.
[1] Haaga John R, Lanzieri Charles F. Computed Tomography and Magnetic Resonance Imaging Of the Whole Body, vol. 2. 3rd ed. Philadelphia, PA, United States: Elsevier Moslay Co.; 1994. p. 1316. [2] Davidson AJ, Hartman DS, Goldman SM. Mature teratoma of the retroperitoneum: radiologic, pathologic and clinical correlation. Radiology 1989;172:421–5. [3] David Sutton. Textbook of Radiology and Medical Imaging, vol. 2, 5th ed; 1992. p.1074. [4] Guttman Jr PH. In search of the elusive benign cyctic ovarian teratoma: application of the ultrasound tip of the iceberg sign. J Clin Ulltrasound 1977;5:403–6. [5] Occhipinti KA, Frankel SD, Hricak H. Ovary computed tomography and magnetic resonance imaging. Radiol Clin North Am 1993;31:1115. [6] Outwtater EK, Dunton CJ. Imaging of the ovary and adnexia: clinical issues and applications of MR imaging. Radiology 1993;194: 1–18. [7] Turi Z, Orley J, Szigetvari I, Doszpod J. Sonographic diagnosis of a retroperitoneal dermoid cyst in a young girl. Ultrasound Obstetr Gynecol 1998;12(5):367–8. [8] Bellin MF, Duron JJ, Curet P, Dion-Voirin E, Grellet J. Primary retroperitoneal teratoma in the adult: correlation of MRI features with CT ant pathology. Magn Reson Imaging 1991;9(2): 263–6. [9] Weinstein BJ, Lenkey JL, Williams S. Ultrasound and CT demonstration of a benign cystic teratoma arising from the retroperitoneum. AJR Am J Roentgenol 1979;133(5):936–8. [10] Patrzyk W. Retroperitoneal dermoid cyst as a cause of renal colic. Pol Przegl Chir 1975;47(2A):309–12 (Polish). [11] Bogavac M, Celanovic M, Dordevic M, Guduric B, Mudric V, Vukadinov J. A case report on the obstructive syndrome (icterus) caused by a teratoma. Med Pregl 1986;39(11/12):573–4. SerboCroatian (Roman).
A retroperitoneal dermoid cyst which causes mechanical jaundice Baki Koseoglu a , Murat Ulusoy a , Tamer Karsidag b,∗ b
a Department of Radiology, Haseki State Hospital, 34300 Aksaray, Istanbul, Turkey Department of General Surgery, Haseki State Hospital, 34300 Aksaray, Istanbul, Turkey
Received 10 November 2004; received in revised form 19 May 2005; accepted 20 May 2005
Abstract Dermoid cysts are embryonal neoplasms arising from three germ cell layer (ectoderm, mesoderm and endoderm). Their radiological features are characteristic. Dermoid cysts are principally encountered in the gonads, but rarely in sequestered primitive cell rests elsewhere. Abdominal dermoid cysts may be localized in the stomach, liver or retroperitoneum. In this study a retroperitoneal dermoid cyst which causes mechanic jaundice is being presented. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Dermoid cyst; Jaundice; Retroperitoneum
1. Introduction Dermoid cysts are embryonal neoplasms arising from totipotent cells and composed of three germ layer (ectoderm, mesoderm and endoderm). They are one of the most characteristic tumor as radiological [1]. In this study, we presented a retroperitoneally localized dermoid cyst causing obstructive jaundice.
2. Case report A 23-year-old male patient was examined for signs and symptoms of obstructive jaundice. Ultrasonografic (US) findings: a heterogeneous mass, 10 cm × 11 cm × 13 cm in diameter, extending from retroperitoneal area to the right subhepatic area, displacing the gallbladder laterally and pancreas anteriorly was recorded. It compressed both inferior vena cava and hilum of the liver superiorly. Because it displaced the common bile duct medially and cranially, it caused dilatation of the common bile duct and intrahepatic bile ducts. ∗ Corresponding author at: Gazi Berkay cad. No: 13/9, 80200 Sisli, Istanbul, Turkey. Tel.: +90 532 366 9522; fax: +90 212 296 6092. E-mail address: [email protected] (T. Karsidag).
1571-4675/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2005.05.007
The mass contained a hyperechoic area showing posterior acoustic attenuation. This heterogeneous mass was covered by thick wall (Fig. 1a and b). Color-Doppler examination showed no obvious vascularization. Abdominal Computed Tomography (CT) following oral and IV contrast material injection showed a hypodens area (−138 HU) corresponding to fat tissue, a milimetric hyperdensity (+175 HU) corresponding to calcification and hypodens areas (+12 HU) corresponding to viscous fluid (Fig. 2). Besides relations to neighboring organs and vessels, compression and displacement of intestinal segments were obviously demonstrated. Fast Spin Echo (FSE) T1 and T2 weighted with fat suppression Magnetic Resonance Images depicted the fat component of this mass by signal loss (Fig. 3a and b). All radiological modalities showed that the lesion was a dermoid cyst. The patient was operated and the lesion was noticed to be retroperitoneally origin and proved the truth of the neighborhoods which was shown radiologically. The macroscopic examination was also suggesting dermoid cyst. Histopathological examination showed mature stratified keratinized squamous epithelium, hair shofts, ecrine, apocrine and sebaceous glands; all together making the diagnosis of mature cystic teratoma (dermoid cyst) obviously (Fig. 4).
62
B. Koseoglu et al. / European Journal of Radiology Extra 55 (2005) 61–63
Fig. 1. (a and b) US images of lesion with widening of intrahepatic biliary ducts secondary to lesion.
Fig. 3. (a and b) MR images of lesion.
Fig. 4. Histopathologic slices of lesion. Fig. 2. CT image of lesion following contrast matrial.
B. Koseoglu et al. / European Journal of Radiology Extra 55 (2005) 61–63
63
3. Discussion
References
Abdominal dermoid cysts may be localized in the stomach, liver or retroperitoneal area. Sacrococcigeal region is a frequent site of involvement. These are mostly benign lesions but may undergo malignant transformation as age increases. Although the incidence of malignancy is low (less than 1%), patients with dermoid cysts are frequently operated due to torsion, infection or rupture secondary to enlargement of these cysts. Even though most cases are diagnoses before the age of 6 months, rarely dermoid cyst remain undiagnosed until adulthood [2,3]. Dermoid cyst are diagnosed with high accuracy via modalities like US, CT and MRI. The ultrasonografic iceberg sign, CT scan showing fat density, chemical shift artifact on MRI and signal-void images following fat suppression are all typical for dermoid cysts [4–6]. This retroperitoneally localized dermoid cyst was identified at the age 23 years and presented itself with mechanical (obstructive) jaundice. We could notice other retroperitoneally localized dermoid cysts in the literature, but not one being the cause of obstructive jaundice [7–10]. Bogovac et al. [11] has described a case of teratoma causing obstructive jaundice but the origin of the lesion was not mentioned clearly. As a result, we would like to emphasize that dermoid cysts may be localized in different sites of the body and present themselves with different signs and symptoms. They can be easily diagnosed radiologically.
[1] Haaga John R, Lanzieri Charles F. Computed Tomography and Magnetic Resonance Imaging Of the Whole Body, vol. 2. 3rd ed. Philadelphia, PA, United States: Elsevier Moslay Co.; 1994. p. 1316. [2] Davidson AJ, Hartman DS, Goldman SM. Mature teratoma of the retroperitoneum: radiologic, pathologic and clinical correlation. Radiology 1989;172:421–5. [3] David Sutton. Textbook of Radiology and Medical Imaging, vol. 2, 5th ed; 1992. p.1074. [4] Guttman Jr PH. In search of the elusive benign cyctic ovarian teratoma: application of the ultrasound tip of the iceberg sign. J Clin Ulltrasound 1977;5:403–6. [5] Occhipinti KA, Frankel SD, Hricak H. Ovary computed tomography and magnetic resonance imaging. Radiol Clin North Am 1993;31:1115. [6] Outwtater EK, Dunton CJ. Imaging of the ovary and adnexia: clinical issues and applications of MR imaging. Radiology 1993;194: 1–18. [7] Turi Z, Orley J, Szigetvari I, Doszpod J. Sonographic diagnosis of a retroperitoneal dermoid cyst in a young girl. Ultrasound Obstetr Gynecol 1998;12(5):367–8. [8] Bellin MF, Duron JJ, Curet P, Dion-Voirin E, Grellet J. Primary retroperitoneal teratoma in the adult: correlation of MRI features with CT ant pathology. Magn Reson Imaging 1991;9(2): 263–6. [9] Weinstein BJ, Lenkey JL, Williams S. Ultrasound and CT demonstration of a benign cystic teratoma arising from the retroperitoneum. AJR Am J Roentgenol 1979;133(5):936–8. [10] Patrzyk W. Retroperitoneal dermoid cyst as a cause of renal colic. Pol Przegl Chir 1975;47(2A):309–12 (Polish). [11] Bogavac M, Celanovic M, Dordevic M, Guduric B, Mudric V, Vukadinov J. A case report on the obstructive syndrome (icterus) caused by a teratoma. Med Pregl 1986;39(11/12):573–4. SerboCroatian (Roman).