Presentation
Acute pelvic pain.
Patient Data
The uterus and endometrium are normal.
Right ovary normal with normal vascularity demonstrated.
The left ovary is markedly enlarged measuring 91 x 69 x 81 mm (264 ml) due to a large, multilocular mass with 2-3 avascular papillary projections measuring up to 25mm. This lesion has smooth internal septations which demonstrate minor vascularity (IOTA color score 2). No acoustic shadowing.
The left ovary was tender to ultrasound transducer pressure.
Small volume of free fluid in the pouch of Douglas and right adnexa.
Appearance is similar to previous ultrasound, however there are now low level echoes in the ovarian cyst locules suggestive of hemorrhage, and the vascularity previously seen in the solid components of the lesion is no longer evident. Given the acute representation with recurrent pain, torsion is strongly suspected.
Laparoscopy with detorsion and cystectomy was performed.
Histopathology report:
Sections show ovary with a cyst lined by a single layer of cuboidal epithelium with underlying fibrotic stroma. The cyst wall is thickened with extensive hemorrhage, edema, granulation tissue and chronic inflammation consistent with torsion. Focally within the cyst wall there are thyroidal follicular structures which contain eosinophilic material. These are lined by round bland nuclei with no features of papillary thyroid carcinoma. The follicular cells are positive with TTF-1, PAX8 and thyroglobulin. There are no features of a mature cystic teratoma. There is no evidence of malignancy. The background ovary shows multiple cystic follicles.
DIAGNOSIS:
Cystic struma ovarii with features of torsion.
Case Discussion
Risk stratification:
Based on the IOTA simple rules, this lesion has no "B" or "M" features and is therefore inconclusive.
ADNEX model: 55% risk of malignancy (borderline most likely)
Using O-RADS, this would be classified as ORADS 4 Intermediate risk of malignancy (10-50%): Multilocular cyst with solid component, any size, color score 1-2. Recommend management by a gynae-oncologist.
Discussion:
Struma ovarii in a 12 year old girl, presenting with recurrent ovarian torsion.
Ca 125, AFP and bHCG all within normal limits.
Struma ovarii is an uncommon subtype of an ovarian teratoma containing thyroid tissue. They are benign in 90-95% of cases.
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