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Malignant transformation of ovarian teratoma

Case contributed by Doaa Faris Jabaz
Diagnosis probable

Presentation

Right upper quadrant abdominal pain.

Patient Data

Age: 80 years
Gender: Female

A large pelvic abdominal multilocular mass lesion was seen measuring about 18.5 x 10.5 x 10 cm along its maximum axial, craniocaudal, and AP dimensions respectively. it originates from the left adnexa, intimately related/displaces the uterine body into the right, and crosses the midline just below the umbilical level, most locules are of fluid density, however fat level presents in the central locule with few septal tiny calcifications, thick (>5 mm) enhancing vascular septa are seen with most tumoral vessels originating from the left uterine artery.

Clear fat in its vicinity except for mild stranding/fluid noted posteriorly and track along the retroperitoneal tissue planes may suggest micro-perforations, no torsion or solid mural enhancing nodule, and no ascites. The mass gently displaces the bowel loops, with no tethering or pressure effect causing an obstruction. No apparent peritoneal deposit.

Bilateral pelvic side wall and retroperitoneal (paraaortic, aortocaval, periportal) LAP, the nodes are enhancing, round with lost hilum, most are >10 mm, the largest one seen at the right para-iliac region measures 45 x 30 mm compressing/deforming the right external iliac vein, no thrombosis albeit wall invasion can’t be excluded, no inguinal LAP.

Unremarkable uterus and right ovary

Liver: at least four masses of partially ill-defined/ confluent borders were seen, they show moderate, heterogenous enhancement with necrotic/cystic areas, no intrahepatic biliary tree dilatation, no portal or hepatic vein thrombosis, incidental finding of replaced right hepatic artery arising from the SMA

Lung bases: about ten randomly distributed nodules were seen bilaterally concerning for metastases, right-sided pleural-based wedge-shaped consolidation with internal lucencies.

Multiple calcified gallstones. Right-sided moderate hydronephrosis due to ureteric stones.

Case Discussion

The CT findings are most compatible with malignant transformation of an ovarian teratoma originating from the left ovary with pelvic and retroperitoneal lymphadenopathy, distant liver, and lung metastasis. Proposed radiologic FIGO stage / IVb. Histologic confirmation was not possible since the patient prefered not to undergo further workup.

Malignant transformation of an ovarian cystic teratoma is uncommon and occurs in postmenopausal females, unlike benign cystic teratomas, which usually occur in reproductive age.

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