Berteloot, Patrick

De Beule, Julie

Petré, Carine

Vanhoenacker, Filip

Verheyen, Luc

English

Ghent University Academic Bibliography

Case 12917 Rupture of an ovarian teratomaDe Beule Julie, Petré Carine MD , Verheyen Luc MD , Berteloot Patrick MD , Vanhoenacker Filip1 2 3MD PhD1 Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen, Belgium1 Department of Surgery, AZ Sint-Maarten, Duffel-Mechelen, Belgium2 Department of Gynaecology AZ Sint-Maarten, Duffel-Mechelen, Belgium3University Hospital Antwerp , Department of Radiology, University Hospital Antwerp;Wilrijkstraat, 10 2650 Antwerp, Belgium; University of Gent, Belgium.Email:filip.vanhoenacker@telenet.be University Hospital Antwerp  Uroradiology & Genital Male Imaging Section: 2015, Aug. 2 Published: 68 year(s), femalePatient:Clinical HistoryA 68-year-old female psychiatric patient was admitted to the emergency department because ofvomiting and diarrhea for about two days. Clinical examination revealed marked abdominaldistention, bubbling sounds by auscultation and diffuse tenderness of the abdomen. For furtherwork-up an abdominal CT was performed.Imaging FindingsContrast-enhanced (CE) CT showed a large mass in the pelvis containing fluid, fat and a tooth (Fig1). A rim of fat was seen at the outer upper border of the mass, surrounded by intra-abdominal fluid(Fig 1a and Fig 1c). Perisplenic and perihepatic intra-abdominal fluid as well as subdiaphragmaticareas of low density mimicking intraperitoneal air were seen at the upper abdomen (Fig 2a and Fig1c). Changing the window setting from parenchymal to pulmonary window revealed that thedensity of these subdiaphragmatic foci were different from pulmonary air and similar to fat on theHounsfield scale (Fig 2b).DiscussionOvarian teratoma's account for about 20% of the ovarian neoplasms in adults [1, 2]. Mature cysticteratoma is the most common subtype containing sebaceous secretions, hair and teeth [1, 2].Histologically this subtype consists of a cyst with an epidermal-like epithelial lining withintralesional components of endoderm, ectoderm and mesoderm [2]. The immature subtypecontains also these three components but additional embryogenic tissue is always found in thissubtype with malignant biological behaviour [1]. Mature cystic teratoma's grow slowly at a rate of1, 8 mm each year and remain usually asymptomatic and therefore they present often as anincidental finding on imaging done for other reasons [1, 3, 4]. On ultrasound, a Rokitansky nodulecontaining hair, teeth and fat can cause an acoustic shadowing which is pathognomonic for matureteratoma's [1]. The tip of the ice berg sign" can provoke acoustic shadowing caused by a collectionof hair floating on top of the sebum [1]. On CT one should look for the typical three components:fat, fluid and teeth [1]. Complications such as infection, torsion or rupture are relatively rare [2, 5].The most common complication is torsion (5-15%) of the ovarian pedicle, sometimes associatedwith small bowel obstruction in case of adherence of the bowel to the cyst wall [1, 3, 4].Obstruction due to mass effect of large lesions has also been reported [4]. Infection (1, 2 %) is a farless frequent complication [2]. Rupture (0, 7-3, 8%) of a mature teratoma is also unusual becausethe capsule of the lesion is often thick whereas in the immature variant this complication is morecommon [1, 3, 4]. Although torsion, infection, trauma, prolonged pressure caused by pregnancy ormalignant transformation are considered as potential etiologies, often the precise cause of rupture isnot obvious like in our case [3]. An intraperitoneal fat-fluid level on CT can be diagnostic for aruptured teratoma [3]. Leakage of sebaceous liquid can cause chemical peritonitis with possiblesecondary bowel obstruction [1, 2, 3]. In our case, the intra-operative view revealed indeedchemical peritonitis due to a ruptured ovarian teratoma (Fig 3). On imaging, it is important todifferentiate between free intraperitoneal air caused by gastrointestinal perforation and teratomarupture with spilling of intra-abdominal fat, which may cause chemical peritonitis. Therefore,meticulous and adjusted window setting is mandatory to avoid misinterpretation of fat-fluid levelsas free subdiafragmatic air.Final Diagnosisrupture of a teratoma with signs of chemical peritonitisDifferential Diagnosis Listfree intraperitoneal air due to a gastro-intestinal perforation, rupture of a teratoma with chemicalperitonitis, peritonitis carcinomatosa, infectious peritonitisFiguresFigure 1 CE CT of the pelvisContrast-enhanced CT of the pelvis showed a large mass lesion within the pelvis. There wasintra-lesional fat (double white asterisks) and fluid (single white asterisk). The white arrowsmark a peripheral fatty rim. © F. Vanhoenacker Phd, MD, Department of Radiology, AZ Sint Maarten Hospital Duffel, Belgium 2015. Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Contrast agent-intravenous;  Special Focus: Cysts; A slightly higher axial level: Besides intralesional fat (double white asterisks) and fluid(single white asterisk) , a radio-opaque structure in this heterogeneous mass corresponding toa tooth (white arrows) was seen. © F. Vanhoenacker Phd, MD, Department of Radiology, AZ Sint Maarten Hospital Duffel, Belgium 2015. Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Contrast agent-intravenous;  Special Focus: Cysts; The peripheral fatty rim, also partially located outside of the intrapelvic mass (red arrows)was better shown. Perihepatic free fluid and low density areas mimicking free abdominal air(white arrows) were seen (parenchymal window). © F. Vanhoenacker Phd, MD, Department of Radiology, AZ Sint Maarten Hospital Duffel, Belgium 2015. Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Contrast agent-intravenous;  Special Focus: Cysts; Figure 2 Axial CE CT upper abdomen: parenchymal window - pulmonary windowParenchymal window: There was free abdominal fluid around liver and spleen as well asareas of low density simulating free air (white arrows). © F. Vanhoenacker Phd, MD, Department of Radiology, AZ Sint Maarten Hospital Duffel, Belgium 2015. Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Contrast agent-intravenous;  Special Focus: Cysts; The areas of low density (black arrows) have a different density than that of the stomach andthe air within the lung. The density of these areas are similar to the density of retroperitonealfat. © F. Vanhoenacker Phd, MD, Department of Radiology, AZ Sint Maarten Hospital Duffel, Belgium 2015. Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Contrast agent-intravenous;  Special Focus: Cysts; Figure 3 Intraoperative viewThe exploratory laparotomy revealed a ruptured teratoma with intra-lesional hair and diffusewhite-green sebaceous fluid throughout the abdomen. © T. Spiessens MD, Department of abdominal surgery, AZ Sint Maarten Hospital Duffel, Belgium 2015. Area of Interest: Abdomen;  Imaging Technique: Experimental;  Procedure: Diagnostic procedure;  Special Focus: Cysts; References[1] Choudhary S, Fasih N, Mc Innes M, Merginean C (2009) Imaging of ovarian teratomas:appearances and complications J Med Imaging Radiat Oncol 53:480-8[2] Nader R, Thubert T, Deffieux X, de Laveaucoupet J, Ssi YK, et al (2014) Delivery inducedintraperitoneal rupture of a cystic ovarian teratoma and associated chronic chemical peritonitis CaseRep Radiol. 2014:189409[3] Tejima K, Enomoto R, Arano T, Miwa J, Matsubara Y, et al. (2013) A case of chemicalperitonitis and pleuritis caused by spontaneous rupture of a benign cystic ovarian teratoma thatimproved without surgical intervention Clin J Gastroenterol 6:274-80[4] Al-Harfoushi R, Abdulaziz el-H, Andrabi SI, Patterson B, Whiteside M (2011) Ovarian teratomapresenting as small bowel obstruction in an elderly lady-A case report Int J Surg Case Rep. 2:6-8[5] Khanna S, Srivastava V, Saroj S, Mishra Sp, Gupta SK (2012) An unusual presentation ofovarian teratoma: a case report Case Rep Emerg Med 2012:845198CitationDe Beule Julie, Petré Carine MD , Verheyen Luc MD , Berteloot Patrick MD , Vanhoenacker Filip1 2 3MD PhD1 Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen, Belgium1 Department of Surgery, AZ Sint-Maarten, Duffel-Mechelen, Belgium2 Department of Gynaecology AZ Sint-Maarten, Duffel-Mechelen, Belgium3University Hospital Antwerp , Department of Radiology, University Hospital Antwerp;Wilrijkstraat, 10 2650 Antwerp, Belgium; University of Gent, Belgium.Email:filip.vanhoenacker@telenet.be (2015, Aug. 2)  Rupture of an ovarian teratoma {Online}URL: http://www.eurorad.org/case.php?id=12917

Rupture of an ovarian teratoma

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Rupture of an ovarian teratoma

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