Abstract Background Teratomas are the commonest germ cell tumours and are most frequently found in the testes and ovary. Extragonadal teratomas are rare and mainly occur in midline structures. Uterine teratomas are extremely rare with only a few previous case reports, usually involving mature teratomas of the uterine cervix. Case Presentation We report an 82-year-old lady presenting with post-menopausal bleeding. Initial investigations revealed a benign teratoma of the uterus which was removed. Her symptoms persisted and a recurrent, now malignant, teratoma of the uterine corpus was resected at hysterectomy. Six months after surgery she relapsed with para-aortic lymphadenopathy and was treated with a taxane, etoposide and cisplatin-containing chemotherapy regimen followed by retroperitoneal lymph node dissection. Conclusion In this report we discuss the aetiology, diagnosis and management of uterine teratomas, and review previous case studies.</p

A Papadia

CW Newton 3rd

D Linder

Daniel Poulter

DM Patterson

IA McNeish

Iain Lindsay

J Wang

Kyriakos Papanikolaou

M Akai

Michael Seckl

Mohammed Ameen

NK Panesar

O Takahashi

Peter Townsend

Rebecca Gray

S Iwanaga

SC Lim

Simon Butler-Manuel

SP Tyagi

Thomas Newsom-Davis

Timothy Christmas

V Gomez-Lobo

Y Ansah-Boateng

English

PubMed

Newsom-Davis, Thomas

Springer

Case report: Malignant teratoma of the uterine corpus

Thomas  Newsom-Davis

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Abstract Background Teratomas are the commonest germ cell tumours and are most frequently found in the testes and ovary. Extragonadal teratomas are rare and mainly occur in midline structures. Uterine teratomas are extremely rare with only a few previous case reports, usually involving mature teratomas of the uterine cervix. Case Presentation We report an 82-year-old lady presenting with post-menopausal bleeding. Initial investigations revealed a benign teratoma of the uterus which was removed. Her symptoms persisted and a recurrent, now malignant, teratoma of the uterine corpus was resected at hysterectomy. Six months after surgery she relapsed with para-aortic lymphadenopathy and was treated with a taxane, etoposide and cisplatin-containing chemotherapy regimen followed by retroperitoneal lymph node dissection. Conclusion In this report we discuss the aetiology, diagnosis and management of uterine teratomas, and review previous case studies.</p

Christmas Timothy

Butler-Manuel Simon

Papanikolaou Kyriakos

Lindsay Iain

Ameen Mohammed

Gray Rebecca

Poulter Daniel

Newsom-Davis Thomas

Townsend Peter

Seckl Michael

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BMC Cancer

BioMed CentralBMC Cancer
ssOpen AcceCase report
Case report: Malignant teratoma of the uterine corpus
Thomas Newsom-Davis†1, Daniel Poulter†2, Rebecca Gray†3, 
Mohammed Ameen4, Iain Lindsay5, Kyriakos Papanikolaou2, Simon Butler-
Manuel2, Timothy Christmas6, Peter Townsend2 and Michael Seckl*1
Address: 1Department of Medical Oncology, Imperial College School of Medicine, Charing Cross Hospital, Fulham Palace Road, London, UK, 
2Department of Obstetrics and Gynaecology, East Surrey Hospital, Redhill, Surrey, UK, 3Department of Medicine, East Surrey Hospital, Redhill, 
Surrey, UK, 4Derpartment of Histopathology, East Surrey Hospital, Redhill, Surrey, UK, 5Department of Histopathology, Imperial College School 
of Medicine, Charing Cross Hospital, Fulham Palace Road, London, UK and 6Department of Urological Surgery, Imperial College School of 
Medicine, Charing Cross Hospital, Fulham Palace Road, London, UK
Email: Thomas Newsom-Davis - t.ndavis04@imperial.ac.uk; Daniel Poulter - drdanielpoulter@doctors.org.uk; 
Rebecca Gray - beckygray@doctors.org.uk; Mohammed Ameen - mohammed.ameen@sash.nhs.uk; Iain Lindsay - iain.lindsay@imperial.nhs.uk; 
Kyriakos Papanikolaou - kyrpap@doctors.org.uk; Simon Butler-Manuel - simon.butler-manuel@sash.nhs.uk; 
Timothy Christmas - tim.christmas@rmh.nhs.uk; Peter Townsend - peter.townsend@sash.nhs.uk; Michael Seckl* - m.seckl@imperial.ac.uk
* Corresponding author    †Equal contributors
Abstract
Background: Teratomas are the commonest germ cell tumours and are most frequently found in
the testes and ovary. Extragonadal teratomas are rare and mainly occur in midline structures.
Uterine teratomas are extremely rare with only a few previous case reports, usually involving
mature teratomas of the uterine cervix.
Case Presentation: We report an 82-year-old lady presenting with post-menopausal bleeding.
Initial investigations revealed a benign teratoma of the uterus which was removed. Her symptoms
persisted and a recurrent, now malignant, teratoma of the uterine corpus was resected at
hysterectomy. Six months after surgery she relapsed with para-aortic lymphadenopathy and was
treated with a taxane, etoposide and cisplatin-containing chemotherapy regimen followed by
retroperitoneal lymph node dissection.
Conclusion: In this report we discuss the aetiology, diagnosis and management of uterine
teratomas, and review previous case studies.
Background
Teratomas (from the Greek teraton for monster) are the
most common germ cell tumours (GCTs) and are com-
posed of two or more germ layers (ectoderm, mesoderm
or endoderm), derived from a pluripotential malignant
precursor cell. Mature teratomas consist of adult-type dif-
ferentiated components such as cartilage and glandular
epithelium. Immature teratomas contain tissue with par-
tial somatic differentiation similar to that in foetal tissue.
Teratomas with malignant transformation demonstrate
aggressive neoplastic growth of one or more of the histo-
logical components.
In adults, teratomas most commonly arise in the testes or
more rarely the ovaries, with the peak age of presentation
between 20 and 40 years [1]. However extragonadal ter-
atomas can occur and are found in any mid-line structure
including the thyroid, retroperitoneum, mediastinum,
Published: 18 June 2009
BMC Cancer 2009, 9:195 doi:10.1186/1471-2407-9-195
Received: 8 January 2009
Accepted: 18 June 2009
This article is available from: http://www.biomedcentral.com/1471-2407/9/195
© 2009 Newsom-Davis et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
BMC Cancer 2009, 9:195 http://www.biomedcentral.com/1471-2407/9/195pericardium and brain (typically the pituitary and/or pin-
eal gland). Very rarely, teratomas are found in other solid
(e.g. breast, parotid gland, liver) and hollow (e.g.
oesophagus, stomach, bladder, uterine cervix) organs.
Here, we report a case of uterine teratoma, which is a very
rare presentation of this tumour.
Case presentation
An 82-year-old lady was referred to gynaecology outpa-
tients in June 2007 with a one month history of post men-
opausal bleeding. Her past gynaecological history
included a negative hysteroscopy in 1998, and previous
use of hormone replacement therapy. She had previously
given birth to two children. The patient was fit and well,
with no significant past medical history apart from hyper-
tension for which she took bendroflumethiazide and
atenolol.
Physical examination revealed a bulky uterus with no
adnexal masses. A pipelle biopsy demonstrated only tiny
fragments of blood clot. A subsequent transvaginal ultra-
sound scan showed a large endometrial mass with calcifi-
cation (Figure 1A). The ovaries appeared normal. She
underwent a hysteroscopy in July 2007 when a 6 cm uter-
ine fibrotic polyp, which filled the uterine cavity, was
removed.
Microscopy demonstrated polypoid tissue with a variably
cellular and fibrotic stroma, focal adipose and possible
chondroid metaplasia, but no malignant features. The
glands showed focal mucinous and keratinising sqau-
mous epithelial metaplasia. There was focal nuclear aty-
pia, focal mitotic activity and occasional cribriform gland
fusion. These features were in keeping with either atypical
complex hyperplasia within an endometrial polyp associ-
ated with metaplastic changes, or a polypoid uterine ter-
atoma.
Immunohistochemistry showed positive staining of the
small crowded epithelium for the epithelial marker cytok-
eratin (CK)-7 and the thyroid and lung marker TTFI. There
was positive staining of the chondroid area for S100 pro-
tein, focal staining of dilated gland epithelium and stro-
mal cells for oestrogen receptor and progesterone
receptor, and staining of stromal cells for smooth muscle
α-actin (SMA). Thyroglobulin, desmin, CK20 and CDX2
staining was negative. A diagnosis of benign teratoma
with thyroid gland and cartilaginous elements was there-
fore made.
Following hysteroscopy, the bleeding continued. A repeat
ultrasound scan revealed that the teratoma had grown
back almost completely filling the uterine cavity. A mag-
netic resonance imaging (MRI) scan in November 2007
showed the tumour filling and distending the endome-
trial cavity and extending down into the cervix (Figure 1B–
C). There was evidence of posterior wall myometrial inva-
sion but there was no lymphadenopathy and the ovaries
appeared normal. Tumour markers including alpha-feto-
protein (AFP), carcinoembryonic antigen (CEA) and
Ca19-9 were within normal limits. Serum Ca125 was
slightly elevated at 42 U/ml (normal range 0–35 units
(U)/ml) and lactate dehydrogenase (LDH) raised at 372
IU/L (normal range 125–250 U/ml).
The patient proceeded to a total abdominal hysterectomy
and bilateral salpingo-oophorectmy in December 2007.
At operation, the uterus was found to contain a haemor-
rhagic polypoid tumour (110 × 80 × 70 mm) arising from
the posterior aspect of the endometrial cavity (Figure 1D–
E). Uterine size was equivalent to that of a 12-week gesta-
tion uterus.
Microscopically the tumour was a teratoma containing
mature and immature elements with mixed malignant
transformation (Figure 2). The tissue types found
included squamous and glandular epithelium, thyroid
parenchyma, smooth muscle, connective and adipose tis-
sue. In addition there were areas of immature bone, inva-
sive adenocarcinoma, and papillary thyroid carcinoma.
There was extensive lymphovascular invasion and deep
myometrial, but not serosal, involvement. The omentum,
cervix, fallopian tubes and ovaries were free of tumour.
Immunohistochemistry showed that the malignant epi-
thelial components were positive for CK-7 and TTF-1, but
negative for CK20 and thyroglobulin. One area of the
tumour stained positive for desmin but not for SMA, S100
Radiological and surgical specimen appearances of uterine teratomaFigure 1
Radiological and surgical specimen appearances of 
uterine teratoma.Page 2 of 4
(page number not for citation purposes)
BMC Cancer 2009, 9:195 http://www.biomedcentral.com/1471-2407/9/195or CD10, suggesting that this is likely to be a small focus
of myogenic sarcoma.
The histopathological conclusion was of a poorly differ-
entiated adenocarcinoma and a focal myogenic sarcoma
arising in a polypoid uterine teratoma with mature and
immature elements. A post-operative computer tomogra-
phy (CT) scan of the thorax, abdomen and pelvis found
no evidence of distant disease giving an overall Interna-
tional Federation of Gynaecology and Obstetrics (FIGO)
disease stage 1C.
The patient recovered well from surgery and was referred
for oncological follow up. Given her age and performance
status a surveillance approach was taken with regular clin-
ical examinations, serial tumour markers and routine CT
scans. Initially in remission, six months post-operatively
para-aortic lymphadenopathy was detected on CT
although she remained asymptomatic with an Eastern
Cooperative Oncology Group (ECOG) performance sta-
tus of 0. In view of her age and wishes for a treatment with
acceptable toxicity, the patient was commenced on an ini-
tial dose of cisplatin (20 mg/m2) and etoposide (100 mg/
m2). This was well tolerated so one week later treatment
was continued with a fortnightly alternating regimen of
paclitaxel (135 mg/m2) and etoposide (150 mg/m2), fol-
lowed by paciltaxel (135 mg/m2) and cisplatin (60 mg/
m2). This treatment was chosen based on our experience
of its effectiveness and tolerability in the treatment of
relapsed germ cell tumours and gestational trophoblastic
disease [2,3].
After three cycles of chemotherapy there was a reduction in
the size of the para-aortic mass, but an increase in the cystic
component suggesting possible differentiation towards a
mature teratoma. Consequently she underwent a retro-
peritoneal lymph node dissection in October 2008. Histol-
ogy from this confirmed the presence of metastatic ter-
atoma. Unfortunately she had a turbulent post-operative
course and, although she recovered well enough to return
home a month later, she sadly died shortly thereafter.
Conclusion
Extra-gonadal GCTs represent 1%–2% of all germ cell
tumours [4]. Their histological features are analogous to
those of gonadal GCTs but they occur in locations other than
the gonads. Extra-gonadal GCTs usually arise from midline
structures, the commonest sites being the retroperitoneum
and mediastinum. Teratomas arising from the uterus are
extremely rare: Since the first description of a uterine ter-
atoma by Mann in 1929 there have been just a handful of
case reports [5]. The majority of these are mature teratomas
and there are only three previous reports in the literature of
immature teratomas arising from the uterus [6-8]. All previ-
ous reports have been in women of reproductive age and to
our knowledge this is the first report of a teratoma in a post-
menopausal lady. In addition this is the first report of a
malignant GCT arising from a benign teratoma. A malignant
teratoma arising from a dermoid in any location in the body
is in itself a rare phenomenon, estimated to occur in only
0.5% of cases.
Teratomas of the uterus should be differentiated from
other tumours that can present with more than one germ
layer, such as a mixed Müllerian tumour, and from perfo-
rated ovarian teratomas. The differential diagnosis of
mature teratoma also includes neuroectodermal tumours.
There are two hypotheses regarding the origin of uterine
teratomas. The blastomere theory proposes that they arise
from residual pluripotent embryonic cells left behind fol-
lowing a missed abortion or undelivered papyraceous
twin. Foetal tissue could also be inadvertently implanted
into the uterine wall during instrumentation [9,10]. This
has been largely discredited however as teratoma cells
have a 46,XX karyotype meaning that they are derived
solely from the host and have completed meiosis [11].
Furthermore, in this case, the patient was post-menopau-
sal, had a normal hysteroscopy in 1998, and there was no
Histopathological appearances of malignant teratoma of the uterusFigure 2
Histopathological appearances of malignant ter-
atoma of the uterus.Page 3 of 4
(page number not for citation purposes)
BMC Cancer 2009, 9:195 http://www.biomedcentral.com/1471-2407/9/195lymphoid proliferation within the teratoma. A more likely
aetiology, therefore, is the parthenogenic theory which
suggests that uterine teratomas arise from primordial cells
that have been misplaced during ontogeny instead of
migrating, as planned, from the yolk sac endoderm to the
gonadal ridge [12]. The propensity of these tumours to
arise in midline structures is explained by the passage of
primordial cells in the midline.
Uterine teratomas usually present with abnormal per vag-
inal (p.v.) bleeding, p.v. discharge or pelvic pain.
Although most ovarian germ cell tumours are diagnosed
pre-operatively by ultrasound examination, in none of the
previous reports of uterine teratomas was a correct pre-
operative diagnosis made. Most were misdiagnosed as
uterine or cervical polyps. This reflects the variable sono-
graphic appearances of uterine teratomas which fre-
quently lack the characteristic dense echogenic tubercle
(Rokitansky nodule) projecting into a cystic lumen, the
diffusely echogenic mass representing the presence of hair
or sebaceous elements, and multiple thin, echogenic
bands of hair within the cavity [12]. MRI and CT have
been reported to show a cystic tumour with adipose tissue
in the case of mature teratomas and a solid tumour with
small foci of calcification with immature teratomas [13].
Teratomas of the uterine corpus have been treated by tumour
resection or total abdominal hysterectomy, with or without
pelvic and/or para-aortic lymphadenectomy [4]. Those of
the uterine cervix can also be managed by conization. The
role of adjuvant chemotherapy for completely resected uter-
ine teratomas is not clear. Using ovarian GCTs as an exam-
ple, some institutions advocate the use of adjuvant BEP
(bleomycin, etoposide, cisplatin) chemotherapy whereas
others prefer to take a surveillance approach [14]. Given the
lack of experience in managing uterine teratoma patients,
either can be justified. Where there is concern regarding the
patient's performance status or age, as is the situation in this
case, an expectant approach is not unreasonable with close
clinical surveillance, regular cross-sectional imaging and
monitoring of serum tumour markers (AFP, HCG, Ca125
and LDH). Due to the small number of reported cases, the
prognosis of uterine teratomas is uncertain.
Although rare, uterine teratomas should be considered in
the differential diagnosis of any intrauterine mass, even in
the absence of typical radiological features.
Abbreviations
AFP: Alpha-fetoprotein; CEA: Carcinoembryonic antigen;
CK: Cytokeratin; CT: Computerised tomography; ECOG:
Eastern Cooperative Oncology Group; FIGO: Interna-
tional Federation of Obstetrics and Gynaecology; GCT:
Germ cell tumour; LDH: Lactate dehydrogenase; MRI:
Magnetic resonance imaging; p.v.: Per vagina
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
TND, RG and DP are the main authors. KP, SBM, TC, MS
and PT were all involved in patient management and pro-
vided critical review of the manuscript. IL and MA pro-
vided images/figures.
Consent
Written consent was obtained from the patient for publi-
cation of their details.
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Pre-publication history
The pre-publication history for this paper can be accessed
here:
http://www.biomedcentral.com/1471-2407/9/195/pre
pubPage 4 of 4
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3rd, Abell MR: Iatrogenic fetal implants. Obstet Gynecol

DR: Coexistent immature teratoma of the uterus and endometrial adenocarcinoma complicated by gliomatosis peritonei. Gynecol Oncol

F: Parthenogenic origin of benign ovarian teratomas.

FA: Foetal remnants in the uterus and their relation to other uterine heterotopia. Histopathology

GJ: A review of the close surveillance policy for stage I female germ cell tumors of the ovary and other sites.

Immature teratoma of the uterine fundus. Kurume Med J

Kiyokawa T: A case of struma uteri.

Lim JY: Mature teratoma of the uterine cervix with lymphoid hyperplasia. Pathol Int

Newlands ES, Seckl MJ: Paclitaxel-containing high-dose chemotherapy for relapsed or refractory testicular germ cell tumours.

PC: Nonpuerperal uterine inversion associated with an immature teratoma of the uterus in an adolescent. Obstet Gynecol

Ragni N: Mature cystic teratoma of the uterus presenting as an endometrial polyp. Ultrasound Obstet Gynecol

Seckl MJ: Salvage chemotherapy of relapsed or high-risk gestational trophoblastic neoplasia (GTN) with paclitaxel/ cisplatin alternating with paclitaxel/etoposide (TP/TE). Ann Oncol

Tanaka T: Mature cystic teratoma of the uterine corpus. Acta Obstet Gynecol Scand

Uterine cervical teratoma with divergent neuroepithelial differentiation and development of an oligodendroglioma: report of a case and review of the literature. Ann Diagn Pathol

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Case report: Malignant teratoma of the uterine corpus

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