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Ovarian mucinous cystadenocarcinoma of low malignant potential associated with a mature cystic teratoma
GYNECOLOGIC
29, 250-254 (1988)
ONCOLOGY
Ovarian Mutinous Cystadenocarcinoma of Low Malignant Potential Associated with a Mature Cystic Teratoma’ VALERIE HUNTER,
Cpt., M.C.,” DANNY BARNHILL, Maj., M.C.,? DAVID JADWIN, Cpt., M.C.,S AND LIDA CROOKS, Maj., M.C.§
*Resident, Department of Obstetrics and Gynecology, MZhief, Gynecologic Oncology, Department of Obstetrics and Gynecology, $Resident, Department of Pathology, aStaff physician, Department of Pathology, Brooke Army Medical Center, Ft. Sam Houston, Texas 78234 Received May 28, 1986 A 54-year-old female underwent exploratory laparotomy for evaluation of a large abdominopelvic mass. She was found to have a 29-pound multicystic tumor arising from the right ovary. There were no other gross intraabdominal abnormalities. Histologic examination of the mass revealed a mutinous cystadenocarinoma of low malignant potential and a mature cystic teratoma. To our knowledge, this is the first case report of an ovarian epithelial adenocarcinoma of low malignant potential associated with a mature cystic teratoma. 0 1988 Academic
Prc\*.
Inc.
INTRODUCTION
Teratomas account for 15% of all ovarian neoplasms [I]. Approximately 95% of these tumors are mature cystic teratomas [I]. They usually occur in the second and third decades of life and are composed of mature tissue of ectodermal, mesodermal, and/or endodermal origan [I]. Ectodermal elements such as skin, hair, and sebaceous or sweat glands are the most common [I]. The mature cystic teratoma, or dermoid cyst, is a benign tumor which undergoes a malignant change in 1% of cases [2-51. The most common type of cancer found in a mature cystic teratoma is epithelial carcinoma which comprises 93% of cases [2,3]. Sarcomas make up 7% of the malignancies. Squamous cell carcinomas accounts for 83% of the epithelial tumors [2]. Granulosa cell tumors, carcinoid tumors, and malignant melanoma have also been reported in association with a mature cystic teratoma [2,4]. Treatment is individualized depending on the type of malignancy. While it is often clear that the malignancy arose directly from elements of the mature cystic teratoma, in some cases it is uncertain if the malignancy developed within the dermoid itself or in the ovary as a separate tumor. This report presents a patient with an ovarian mutinous cystadenocarcinoma of low malignant potential associated with a mature cystic teratoma. ’ The assertions and opinions contained herein are those of the authors and are not to be construed as official or as representing the views of the Department of Defense or the Department of the Army. 250 0090-8258188$1.50 Copyright All rights
0 IY88 by Academic Pre\\. Inc. of reproduction m any form reserved.
MATURE
CYSTIC
TERATOMA
251
CASE REPORT
The patient is a 54-year-old, para 4004, black female. Her last menstrual period was at age 42. She has had no hormonal replacement. The patient presented with a complaint of increasing abdominal girth for 2 months prior to admission. She denied any other signs or symptoms except for minimal initial weight loss associated with dieting. Her previous medical history is unremarkable. The abdominal distension was thought to be caused by a large cystic mass filling the entire abdominal cavity. The cervix was atrophic; however, the uterus and adnexae were not clearly palpable because of the abdominal distention. Barium enema, intravenous pyelogram, cystoscopy, proctoscopy, liver function tests, and hemogram were normal. Serum cY-fetoprotein, /?-hCG, and carcinoembryonic antigen were also normal. Abdominopelvic ultrasound revealed a large, multicystic mass filling the entire peritoneal cavity. Chest X-ray showed no specific abnormalities; however, the study was of poor quality because of upward displacement of the diaphragms due to the abdominal mass. At exploratory laparotomy, a 29-pound, cystic right ovarian mass measuring 35 x 30 x 2.5 cm was removed intact. Washings for cytologic evaluation were obtained from the pelvis, right and left paracolic gutters, and the right diaphragm. No other gross abnormalities were found on examination of the peritoneal cavity. The uterus and left ovary were removed. Biopsies of the omentum and right diaphragm were obtained. At this point in the procedure, the patient became hemodynamically unstable, and the abdomen was closed. Final histologic review of the surgical specimens revealed a mature cystic teratoma with a mutinous cystadenocarcinoma of low malignant potential with no evidence of spread beyond the right ovary (Fig. I). No additional therapy was recommended. Twelve months after discharge, the patient was fully functional, and her examination was normal. DISCUSSION
The portion of this patient’s tumor composed of epithelial adenocarcinoma of low malignant potential is characterized by multiple cysts with overgrowth of atypical mutinous epithelium. This mutinous epithelium is stratified into two or three layers. The proliferation of the epithelial cells is associated with papillary projections, and exfoliated clusters of these epithelial cells are prominent. The nuclei of the mutinous cells show mild to moderate atypism characterized by increased size, irregular contour, enlarged nucleoli, and hyperchromatisum (Fig. 2). The mature cystic teratoma is composed of keratinized squamous epithelium, sebaceous glands, neural tissue, and focal respiratory epithelium. All of these elements are mature (Fig. 3). Ovarian epithelial adenocarcinomas of low malignant potential are tumors which demonstrate specific histopathologic findings and clinical course intermediate between benign and clearly malignant tumors [6-91. They account for 15% of ovarian epithelial adenocarcinomas [6]. Fifty percent of epithelial tumors of low malignant potential are confined to the ovary at the time of diagnosis [6], and patients with these neoplasms have 95% 5-year survival [6,8]. While the question of adjuvant therapy for patients with an ovarian epithelial adenocarcinoma of
252
HUNTER ET AL.
FIG. I. Photomicrograph showing the ovarian tumor with elements of a mature cystic teratoma and mutinous cystadenocarcinoma of low malignant potential (X 30).
FIG. 2. Photomicrograph demonstrating the features of the mutinous cystadenocarcinoma of low malignant potential (X 75).
CASE
FIG. 3.
REPORTS
253
Photomicrogrdph showing the elements of the mature cystic teratoma (X 75)
low malignant potential is still debated, surgery alone appears to be adequate therapy for patients with Stage I disease (6.71. Although mature cystic teratomas most commonly occur in young women, those associated with a malignancy tend to be diagnosed in the sixth or seventh decades of life [3,10]. Older patients with a mature cystic teratoma should have careful histologic examination of the tumor to ensure that a concomitant malignancy is not overlooked. To our knowledge, this is the first case report of an ovarian mutinous cystadenocarcinoma of low malignant potential associated with a mature cystic teratoma. Although the staging procedure was not completed because of the patient’s intraoperative hemodynamic instability. there was no evidence of tumor spread beyond the ovary, and no additional therapy was recommended. REFERENCES I. DiSaia, P. J., and Creasman. W. T. Clinic~crlg:?“rco/ogic onc~ology. C. V. Mosby. St. Louis, MO (1984). 2. Climie. A. R. W., and Heath, L. P. Malignant degeneration of benign cystic teratomas of the ovary. Cancer 22, 824-832 (1968). 3. Krumerman, M. S., and Chung, A. Squamous carcinoma arising in benign cystic teratoma of the ovary, Cancer 39, 123771242 (1977). 4. Thompson, J. P., Dockerty, M. B., and Symmonds. R. E. Granulosa-cell carcinoma arising in a cystic teratoma of the ovary, Ohsret. Gynecol. 28(4). 549-552 (1966). 5. Seltzer. V., and Vogl, S. Stage II benign cystic teratoma with malignant squamous degeneration. N.Y. St. J. Med., May. 224-225 (1985). 6. Barnhill, D. R., Heller, P. B., Brzozowski, P., et ul. Epithelial ovarian carcinoma of low malignant potential, Obsrer. Gynecol. 65, 53-59 (1985).
254
HUNTER
ET AL.
7. Creasman, W. T., Park, R. C., Norris, H., et al. Stage I borderline ovarian tumors, Obsfet. Gynecol. 59, 93-95 (1982). 8. The Ovarian Tumor Panel of the Royal College of Obstetricians and Gynaecologists. Ovarian epithelial tumours of borderline malignancy: Pathologic features and current status, Brit. J. Ubsfet. Gynaecol. 90, 743-750 (1983). 9. Hart, W. R. Ovarian epithelial tumors of borderline malignancy (carcinomas of low malignant potential), Hum. Pathol. S(S), 541-549 (1977). 10. Pantoja, E., Rodriquez-Ibanez, I., Axtmayer, R. W., t-f al. Complications of dermoid tumors of the ovary, Ubstet. Gynecol. 45(l), 89-94 (1975).
29, 250-254 (1988)
ONCOLOGY
Ovarian Mutinous Cystadenocarcinoma of Low Malignant Potential Associated with a Mature Cystic Teratoma’ VALERIE HUNTER,
Cpt., M.C.,” DANNY BARNHILL, Maj., M.C.,? DAVID JADWIN, Cpt., M.C.,S AND LIDA CROOKS, Maj., M.C.§
*Resident, Department of Obstetrics and Gynecology, MZhief, Gynecologic Oncology, Department of Obstetrics and Gynecology, $Resident, Department of Pathology, aStaff physician, Department of Pathology, Brooke Army Medical Center, Ft. Sam Houston, Texas 78234 Received May 28, 1986 A 54-year-old female underwent exploratory laparotomy for evaluation of a large abdominopelvic mass. She was found to have a 29-pound multicystic tumor arising from the right ovary. There were no other gross intraabdominal abnormalities. Histologic examination of the mass revealed a mutinous cystadenocarinoma of low malignant potential and a mature cystic teratoma. To our knowledge, this is the first case report of an ovarian epithelial adenocarcinoma of low malignant potential associated with a mature cystic teratoma. 0 1988 Academic
Prc\*.
Inc.
INTRODUCTION
Teratomas account for 15% of all ovarian neoplasms [I]. Approximately 95% of these tumors are mature cystic teratomas [I]. They usually occur in the second and third decades of life and are composed of mature tissue of ectodermal, mesodermal, and/or endodermal origan [I]. Ectodermal elements such as skin, hair, and sebaceous or sweat glands are the most common [I]. The mature cystic teratoma, or dermoid cyst, is a benign tumor which undergoes a malignant change in 1% of cases [2-51. The most common type of cancer found in a mature cystic teratoma is epithelial carcinoma which comprises 93% of cases [2,3]. Sarcomas make up 7% of the malignancies. Squamous cell carcinomas accounts for 83% of the epithelial tumors [2]. Granulosa cell tumors, carcinoid tumors, and malignant melanoma have also been reported in association with a mature cystic teratoma [2,4]. Treatment is individualized depending on the type of malignancy. While it is often clear that the malignancy arose directly from elements of the mature cystic teratoma, in some cases it is uncertain if the malignancy developed within the dermoid itself or in the ovary as a separate tumor. This report presents a patient with an ovarian mutinous cystadenocarcinoma of low malignant potential associated with a mature cystic teratoma. ’ The assertions and opinions contained herein are those of the authors and are not to be construed as official or as representing the views of the Department of Defense or the Department of the Army. 250 0090-8258188$1.50 Copyright All rights
0 IY88 by Academic Pre\\. Inc. of reproduction m any form reserved.
MATURE
CYSTIC
TERATOMA
251
CASE REPORT
The patient is a 54-year-old, para 4004, black female. Her last menstrual period was at age 42. She has had no hormonal replacement. The patient presented with a complaint of increasing abdominal girth for 2 months prior to admission. She denied any other signs or symptoms except for minimal initial weight loss associated with dieting. Her previous medical history is unremarkable. The abdominal distension was thought to be caused by a large cystic mass filling the entire abdominal cavity. The cervix was atrophic; however, the uterus and adnexae were not clearly palpable because of the abdominal distention. Barium enema, intravenous pyelogram, cystoscopy, proctoscopy, liver function tests, and hemogram were normal. Serum cY-fetoprotein, /?-hCG, and carcinoembryonic antigen were also normal. Abdominopelvic ultrasound revealed a large, multicystic mass filling the entire peritoneal cavity. Chest X-ray showed no specific abnormalities; however, the study was of poor quality because of upward displacement of the diaphragms due to the abdominal mass. At exploratory laparotomy, a 29-pound, cystic right ovarian mass measuring 35 x 30 x 2.5 cm was removed intact. Washings for cytologic evaluation were obtained from the pelvis, right and left paracolic gutters, and the right diaphragm. No other gross abnormalities were found on examination of the peritoneal cavity. The uterus and left ovary were removed. Biopsies of the omentum and right diaphragm were obtained. At this point in the procedure, the patient became hemodynamically unstable, and the abdomen was closed. Final histologic review of the surgical specimens revealed a mature cystic teratoma with a mutinous cystadenocarcinoma of low malignant potential with no evidence of spread beyond the right ovary (Fig. I). No additional therapy was recommended. Twelve months after discharge, the patient was fully functional, and her examination was normal. DISCUSSION
The portion of this patient’s tumor composed of epithelial adenocarcinoma of low malignant potential is characterized by multiple cysts with overgrowth of atypical mutinous epithelium. This mutinous epithelium is stratified into two or three layers. The proliferation of the epithelial cells is associated with papillary projections, and exfoliated clusters of these epithelial cells are prominent. The nuclei of the mutinous cells show mild to moderate atypism characterized by increased size, irregular contour, enlarged nucleoli, and hyperchromatisum (Fig. 2). The mature cystic teratoma is composed of keratinized squamous epithelium, sebaceous glands, neural tissue, and focal respiratory epithelium. All of these elements are mature (Fig. 3). Ovarian epithelial adenocarcinomas of low malignant potential are tumors which demonstrate specific histopathologic findings and clinical course intermediate between benign and clearly malignant tumors [6-91. They account for 15% of ovarian epithelial adenocarcinomas [6]. Fifty percent of epithelial tumors of low malignant potential are confined to the ovary at the time of diagnosis [6], and patients with these neoplasms have 95% 5-year survival [6,8]. While the question of adjuvant therapy for patients with an ovarian epithelial adenocarcinoma of
252
HUNTER ET AL.
FIG. I. Photomicrograph showing the ovarian tumor with elements of a mature cystic teratoma and mutinous cystadenocarcinoma of low malignant potential (X 30).
FIG. 2. Photomicrograph demonstrating the features of the mutinous cystadenocarcinoma of low malignant potential (X 75).
CASE
FIG. 3.
REPORTS
253
Photomicrogrdph showing the elements of the mature cystic teratoma (X 75)
low malignant potential is still debated, surgery alone appears to be adequate therapy for patients with Stage I disease (6.71. Although mature cystic teratomas most commonly occur in young women, those associated with a malignancy tend to be diagnosed in the sixth or seventh decades of life [3,10]. Older patients with a mature cystic teratoma should have careful histologic examination of the tumor to ensure that a concomitant malignancy is not overlooked. To our knowledge, this is the first case report of an ovarian mutinous cystadenocarcinoma of low malignant potential associated with a mature cystic teratoma. Although the staging procedure was not completed because of the patient’s intraoperative hemodynamic instability. there was no evidence of tumor spread beyond the ovary, and no additional therapy was recommended. REFERENCES I. DiSaia, P. J., and Creasman. W. T. Clinic~crlg:?“rco/ogic onc~ology. C. V. Mosby. St. Louis, MO (1984). 2. Climie. A. R. W., and Heath, L. P. Malignant degeneration of benign cystic teratomas of the ovary. Cancer 22, 824-832 (1968). 3. Krumerman, M. S., and Chung, A. Squamous carcinoma arising in benign cystic teratoma of the ovary, Cancer 39, 123771242 (1977). 4. Thompson, J. P., Dockerty, M. B., and Symmonds. R. E. Granulosa-cell carcinoma arising in a cystic teratoma of the ovary, Ohsret. Gynecol. 28(4). 549-552 (1966). 5. Seltzer. V., and Vogl, S. Stage II benign cystic teratoma with malignant squamous degeneration. N.Y. St. J. Med., May. 224-225 (1985). 6. Barnhill, D. R., Heller, P. B., Brzozowski, P., et ul. Epithelial ovarian carcinoma of low malignant potential, Obsrer. Gynecol. 65, 53-59 (1985).
254
HUNTER
ET AL.
7. Creasman, W. T., Park, R. C., Norris, H., et al. Stage I borderline ovarian tumors, Obsfet. Gynecol. 59, 93-95 (1982). 8. The Ovarian Tumor Panel of the Royal College of Obstetricians and Gynaecologists. Ovarian epithelial tumours of borderline malignancy: Pathologic features and current status, Brit. J. Ubsfet. Gynaecol. 90, 743-750 (1983). 9. Hart, W. R. Ovarian epithelial tumors of borderline malignancy (carcinomas of low malignant potential), Hum. Pathol. S(S), 541-549 (1977). 10. Pantoja, E., Rodriquez-Ibanez, I., Axtmayer, R. W., t-f al. Complications of dermoid tumors of the ovary, Ubstet. Gynecol. 45(l), 89-94 (1975).