Predictive factors for recurrence of ovarian mature cystic teratomas after surgical excision

doi:10.1016/j.ejogrb.2013.09.004

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 171, Issue 2, December 2013, Pages 325-328

https://doi.org/10.1016/j.ejogrb.2013.09.004 Get rights and content

Abstract

Objective

To study the recurrence rate and predictive factors for recurrence after surgical excision of ovarian mature cystic teratomas (MCT).

Study design

Retrospective study of 382 patients who underwent surgical excision of MCT and whose post-surgical follow-up data were available over six months. Patients who underwent concomitant oophorectomy or had a history of oophorectomy were excluded. Medical records were reviewed for evidence of recurrence. The Cox-hazard model was used for the estimation of predictive factors for recurrence. Categorical data were compared using the Chi-square and Fisher's exact tests.

Results

There were 16 recurrences within a mean follow-up period of 43.0 months, with a recurrence rate of 4.2%. Young age (<30 years old, Y) (hazard ratio (HR) 2.98; 95% confidence interval (CI) 1.04–8.62, P = 0.043), large cyst (≥8 cm in diameter, L) (HR 2.75; 95% CI 1.03–7.37, P = 0.044), and bilaterality (B) (HR 2.88; 95% CI 1.07–7.76, P = 0.036) were shown to be significant predictive factors. When a patient had all these three factors, the recurrence rate was 21.0%, otherwise 3.4% (P < 0.01). Patients with Y + L, Y + B, and B + L also showed significantly higher recurrence rate (21.4%, 15.9%, and 11.4%, respectively).

Conclusion

The long-term recurrence rate after surgical excision of MCT in this study is 4.2%. A patient with young age (<30 years old) or large cyst (≥8 cm in diameter) or bilateral cysts is at high risk of recurrence, which is even higher when a patient has more than one of these factors.

Introduction

Mature cystic teratomas (MCT), also called dermoid cysts, are the most common ovarian neoplasms, accounting for 30% of benign tumors [1]. They typically affect women of reproductive age, making conservative ovarian surgery, i.e. excision of the MCT, the first-line management.

A few reports have shown the rate of post-surgical recurrence of MCT. It appears to be around 3–4% according to Anteby et al. (3/91 cases, 3.3%), Lakkis et al. (4/118, 3.4%), and Chapron et al. (2/48, 4.1%), although the backgrounds vary, including both oophorectomy and excision of the MCT [2], [3], [4]. These figures imply the importance of post-surgical check-up and early detection of the recurrence. Predictive factors, if any, would therefore be clinically very useful since MCT is a relatively frequent disease.

The risk factors, however, are poorly known at the moment. Anteby et al. suggested that the risk of developing a subsequent MCT was higher in patients with bilateral or multiple MCT because two out of three cases with recurrence had bilateral or multiple MCT at the initial surgery [2]. Laberge et al. compared 95 laparoscopy- and 150 laparotomy-treated cases, and found a 7.6% recurrence at two years in the laparoscopy group and 0% in the laparotomy group, suggesting laparoscopic treatment as a risk factor [5]. These two papers were the only existing reports in the English literature providing us some information about the patients with high risk of recurrence. The evidence level of the former one [2] is very low, however, because in the analysis of risk factors they looked at only three patients with recurrence without any controls. The latter study [5] provides only information on the surgical procedure. To provide appropriate information on the risk of recurrence for patients undergoing excision of MCT, the existing evidence was insufficient. We therefore investigated the predictive factors for recurrence of MCT after surgical excision in a larger number of cases.

Section snippets

Materials and methods

We analyzed the recurrence of MCT retrospectively, reviewing the hospital charts of all patients who underwent surgery for MCT in the University of Tokyo Hospital between January 1991 and December 2010. The diagnosis of MCT was confirmed by a surgical pathology report. Patients who underwent oophorectomy or those who had a history of oophorectomy were excluded from the present study. Among 605 patients who met this criterion, those without follow-up data over six months after surgery were

Results

Table 1 shows the patients’ characteristics. Among 382 patients, 161 (42%) were young and 107 (28%) had a large cyst. Eighty-seven patients (23%) had bilateral, 152 (40%) had right-sided and 143 (37%) had left-sided MCTs. Multiple MCTs were detected in 108 patients (28%). Multiple MCTs included two types: (type 1) one unilocular cyst in each ovary, and (type 2) more than one multilocular cyst in either or both ovaries. Seventy-nine patients had type 1 and 29 patients had type 2 multiple MCTs.

Comment

In this series of 382 patients who underwent surgical excision of MCT, the recurrence rate was 4.2%, a similar rate to previous smaller series [2], [3], [4]. Young age, large cyst, and bilaterality were significant risk factors for recurrence. Any combination of these three factors showed a clear relationship with recurrence. This study analyzes predictive factors for post-surgical recurrence of MCT with a larger series of cases than any previous study.

Multiplicity showed a marginal effect on

Conflict of interest statement

The authors report no conflict of interest.

Funding

None.

Acknowledgement

We thank Dr. Hiroshi Ohtsu of Department of Clinical Trial Data Management, Graduate School of Medicine, University of Tokyo, for his statistical advice.

References (9)

W.F. Peterson et al.
Benign cystic teratomas of the ovary; a clinico-statistical study of 1007 cases with a review of the literature
Am J Obstet Gynecol
(1955)
P.Y. Laberge et al.
Short-term morbidity and long-term recurrence rate of ovarian dermoid cysts treated by laparoscopy versus laparotomy
J Obstet Gynaecol Can
(2006)
D. Luxman et al.
Laparoscopic conservative removal of ovarian dermoid cysts
J Am Assoc Gynecol Laparosc
(1996)
G. Morgante et al.
Surgical treatment of ovarian dermoid cysts
Eur J Obstet Gynecol Reprod Biol
(1998)

There are more references available in the full text version of this article.

Cited by (34)

Oocyte accumulation for fertility preservation in women with benign ovarian tumours with a history of previous surgery, multiple or large cysts
2021, Reproductive BioMedicine Online
Citation Excerpt :
Nevertheless, the size of the tumour can be a limiting factor, as large tumours are more likely to result in oophorectomy (Roman et al., 2010; Borghese et al., 2013; Dunselman et al., 2014; Legendre et al., 2014). In addition, all these tumours, especially endometriomas (Guo, 2009), are at high risk of recurrence with consequent repeat surgeries (Ben-Ami et al., 2010; Harada et al., 2013; Rogers et al., 2014), increasing the risk of ovarian reserve damage and further fertility impairments. It is now well established that anti-Müllerian hormone (AMH) is the most reliable indicator for ovarian follicular content (Dewailly et al., 2014).
What are ovarian stimulation cycle outcomes and acceptance rates of an oocyte accumulation programme in young women with benign ovarian tumour (BOT)?
Retrospective cohort study conducted at the Academic Assisted Reproductive Technology and Fertility Preservation Centre, Lille University Hospital, between January 2016 and December 2019. The number of metaphase II oocytes per cycle and per patient after accumulation were evaluated. Two groups were identified for the analysis: endometrioma (‘endometrioma’) and dermoid, mucinous or serous cyst (‘other cysts’).
A total of 113 fertility-preservation cycles were analysed in 70 women aged 27.9 ± 4.8 years. Almost all women had undergone previous ovarian surgery before fertility preservation (89%). Mean anti-Müllerian hormone levels before ovarian stimulation was 12.5 ± 8.7 pmol/l. A total of 6.4 ± 3.4 oocytes were retrieved, and 4.3 ± 3.4 metaphase II (MII) oocytes were vitrified per cycle. All agreed to the oocyte accumulation programme and all underwent at least one cycle. To date, 36 (51%) patients achieved two or three fertility- preservation cycles. After accumulation, 7.0 ± 5.23 MII oocytes were vitrified per patient. No difference was found in ovarian response and oocyte cohort between the ‘endometrioma’ and ‘other cysts’ groups. Questionnaires completed after oocyte retrieval revealed abdominal bloating and pelvic pain in most patients, with no difference according to the type of cyst. No serious adverse events occurred.
Oocyte accumulation should be systematically offered to young women with BOT irrespective of histological type, as it seems to be well-tolerated. Long-term follow-up is needed to assess the efficiency of oocyte accumulation to optimize the chances of subsequent pregnancies.
Incidentally Found Dermoid with All Forms of Mature Teeth
2021, Journal of Minimally Invasive Gynecology
Asymptomatic giant teratoma in a pregnant woman. Unilateral laparotomic adnexectomy in the second trimester of pregnancy, and full-term eutocic delivery. Literature review
2020, Clinica e Investigacion en Ginecologia y Obstetricia
Los embarazos cursan simultáneamente con una masa anexial de forma inusual; y cuando lo hacen, son en su mayoría de manera asintomática. En casi el 25% identificaremos un teratoma quístico maduro. Tanto el diagnóstico, como el seguimiento y tratamiento de dichas tumoraciones pueden dificultarse en esta etapa y la valoración de los pros y contras para optar por un tratamiento quirúrgico durante la gestación suponen un dilema importante. Entre las características a valorar está el tamaño de la tumoración. Cuando dichas masas son mayores de 10 cm, a pesar de tener características ecográficas benignas, pueden estar enmascarando una neoplasia en uno de cada 10 casos; lo que haría considerar el tratamiento quirúrgico durante la gestación; y en estas ocasiones se opta con frecuencia por realizar un abordaje laparotómico para evitar, en la medida de lo posible, la rotura de dichas tumoraciones gigantes.
Presentamos el caso de una paciente gestante asintomática a la que se le diagnostica un quiste anexial gigante. Tras su estudio, se realiza una laparotomía exploradora en semana 16 de embarazo completando la anexectomía unilateral, con el diagnóstico definitivo de un teratoma quístico maduro. La recuperación posterior y la finalización a término de una gestación normoevolutiva se completa con éxito. Se hace una revisión del diagnóstico, seguimiento y abordaje quirúrgico de las masas anexiales encontradas durante la gestación.
It is rare for pregnancies to occur simultaneously with an adnexal mass, and when they do, they are mostly asymptomatic. In almost 25%, it is identified as a mature cystic teratoma. Both the diagnosis, monitoring, and treatment of these diseases can be difficult at this stage, and the assessment of the pros and cons for surgical treatment during pregnancy, which can lead to controversy, is a major problem. Among the characteristics to be assessed is the size of the tumour. When these masses are larger than 10 cm, despite having benign ultrasound characteristics, they may be masking a neoplasm in 1 out of 10 cases. In which case, surgical treatment would be considered during the pregnancy and a laparoscopy approach is often carried out to avoid, as far as possible, the rupture of these giant tumour masses.
The case is presented of an asymptomatic pregnant patient who is diagnosed with an adnexal giant cyst. After the work-up study, an exploratory laparotomy was performed in the 16th week of pregnancy, with a unilateral adnexectomy being performed, with the definitive diagnosis of a mature cystic teratoma. The subsequent recovery and the conclusion to full-term using standardised management was completed successfully. A review is presented on the diagnosis, follow-up and surgical approach of adnexal masses during pregnancy.
Intraoperative Rupture of Ovarian Dermoid Cysts in the Pediatric and Adolescent Population: Should This Change Your Surgical Management?
2017, Journal of Pediatric and Adolescent Gynecology
Citation Excerpt :
Laparotomies were performed more commonly in cases of bilateral and larger cysts and were associated with larger EBL. These results mirror previously stated reasons that providers might choose to perform laparotomy over laparoscopy in cases of large or multiple adnexal cysts.9,11,12,20 This study also confirmed multiple other findings of previous studies: cyst rupture is more likely to occur in the laparoscopic cases especially with cysts greater than 5 cm, and ODCs can be asymptomatic with incidentally found adnexal cysts on imaging or present with nonspecific symptoms such as vague abdominal pain.2,3,5,33
(1) To determine the incidence of chemical peritonitis after cystectomy for ovarian dermoid cysts with intraoperative cyst rupture in the pediatric and adolescent population; and (2) to examine the intraoperative and postoperative outcomes of cystectomies performed for ovarian dermoid cysts using laparoscopy and laparotomy, especially those with intraoperative cyst rupture.
A retrospective cohort study of female patients who underwent ovarian cystectomy with proven ovarian dermoid pathology between July 2007 and July 2015.
Texas Children's Hospital, Houston, Texas.
One hundred forty-four patients between the ages of 1 and 21 years who underwent an ovarian cystectomy with proven benign ovarian dermoid histology on the basis of pathology reports.
Occurrence of spill of cyst contents, chemical peritonitis, postoperative complications, and hospital readmissions.
One hundred forty-four female patients underwent cystectomy (38 laparotomy and 106 laparoscopy) resulting in benign ovarian dermoid histology. Their mean age was 12.4 ± 4.1 years (range, 1-21), mean cyst size was 9.2 ± 6.4 cm (range, 1-30 cm), no patients had elevated tumor markers, 42 (29.1%) presented with torsion, 73 (50.7%) had cyst fluid spill, and there were no cases of chemical peritonitis. Few significant differences were found between cases performed via laparoscopy and laparotomy and those with and without intraoperative cyst rupture resulting in spill of contents. Laparotomy cases were found to have larger mean cyst size (P < .001), estimated blood loss (P = .003), and presence of bilateral cysts (P = .017) compared with laparoscopic cases. Cyst fluid spill occurred in more laparoscopic cases ([67/106] 63.2% vs [6/38] 15.8%; P < .001), and risk increased with cyst size greater than 5 cm (P < .001). In the laparoscopy group, cyst size greater than 5 cm was more likely to present with torsion (P < .001). There was no significant difference in the repeat cystectomy rate between the laparoscopy and laparotomy groups even with cyst rupture (P = .394). Only 5 cases presented to the emergency room postoperatively and 2 were admitted postoperatively for umbilical port site dehiscence and pyelonephritis.
Laparoscopic cystectomy of ovarian dermoid cysts is associated with greater intraoperative cyst rupture. However, cyst rupture is rarely associated with complications, therefore minimally invasive surgical management of ovarian dermoid cysts is a reasonable surgical approach.
Repeated pregnancy with concomitant presence of ovarian teratoma: A case report and literature review
2017, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
Therefore, trauma-related disseminated tumor growth was not favored. Harada et al. [12] suggested that young age (<30 years), large cyst size (diameter, >8 cm), and bilateral occurrence were predictive factors for recurrence, with the risk of recurrence being especially high in the presence of more than one of these factors. Our patient got two of the three predictive factors for recurrence: 17-years-old with left ovarian teratoma of 9 cm in diameter initially.
Benign mature teratoma during pregnancy is common, mostly discovered incidentally by antenatal sonography. However, repeated pregnancy coincident with ovarian mature teratoma is rarely reported. The cases of teratoma with rapid growing characteristics are even more unique.
A 17-year-old woman was pregnant at 6 weeks of gestation with a left ovarian teratoma. She underwent artificial abortion followed by surgical removal of the teratoma. However, eleven years after the surgery, a right ovarian teratoma was found incidentally by antepartum sonography at 21 weeks of gestation. The right ovarian teratoma developed uneventfully, with rapid growth during pregnancy. Abdominal delivery at term was accomplished without any complication.
Younger patients and patients with bilateral or large size dermoid cysts should be followed up closely. Further studies are needed for better understanding of its natural clinical course and the mechanism of progression. The treatment options should be made individually, weighing the risks of torsion, rupture, or obstruction of labor versus the potential for unnecessary surgical risk to mother and fetus.
Systematic proposal of fertility preservation by mature oocyte cryopreservation for recurrent benign ovarian tumors
2017, Gynecologie Obstetrique Fertilite et Senologie
Étudier prospectivement la réponse ovarienne à la stimulation et la cohorte ovocytaire éligible à la vitrification chez de jeunes patientes porteuses de volumineuses tumeurs ovariennes bénignes à haut potentiel de récidive dont le traitement chirurgical expose au risque d’altération de la réserve folliculaire ovarienne.
Les critères d’éligibilité étaient : âge entre 18 et 36 ans, présence d’au moins une volumineuse tumeur ovarienne bénigne (≥ 5 cm) à haut risque de récidive. Les patientes ont bénéficié d’une stimulation ovarienne contrôlée au moins 3 mois après leur chirurgie et après évaluation de leur réserve (AMH et comptage folliculaire). Les ovocytes en métaphase II étaient congelés par vitrification.
Vingt-quatre patientes de 25 ± 5 ans en moyenne et présentant des kystes dermoïdes, mucineux ou endométriosiques ont été incluses entre janvier 2015 et juillet 2016. Toutes avaient un antécédent chirurgical ovarien. Le taux moyen d’AMH était de 15,3 pmol/L. Les nombres moyens d’ovocytes totaux recueillis par patiente et d’ovocytes en métaphase II étaient respectivement de 7 ± 5 et 4,4 ± 4. Parmi les patientes, 38 % ont faiblement répondu à la stimulation ; 86 % des patientes avaient un nombre d’ovocytes M II inférieur ou égal à huit. Sept patientes ont souhaité bénéficier d’un second recueil ovocytaire à des fins d’accumulation ovocytaire.
Cette étude démontre la faisabilité et la bonne adhésion des patientes à la proposition systématique de préservation par congélation d’ovocytes. Du fait des chirurgies antérieures et d’une moindre réserve ovarienne de base, l’incidence des mauvaises réponses ovariennes est élevée dans cette série avec, en conséquence, un nombre d’ovocytes éligibles à la vitrification par cycle relativement bas. Une stratégie d’accumulation ovocytaire pour augmenter les chances ultérieures de grossesse est préconisée.
To investigate prospectively the pattern of the follicular growth and to characterize the COH outcome in terms of oocyte number and maturity in patients with voluminous recurrent benign ovarian tumors with a high surgical risk of significant reduction of the ovarian follicular content.
The inclusion criteria were: age between 18 and 36, presence of at least one benign ovarian tumor (≥ 5 cm) with high risk of recurrence. The fertility preservation cycle was performed at least 3 months after the cyst surgery. The controlled ovarian stimulation was performed after the ovarian reserve was assessed (AMH measurement and sonographic antral follicle count). Triggering was performed by hCG when at least 3 follicles reached 18 mm of diameter. Metaphase II oocytes were cryopreserved by the vitrification technique.
Twenty-four women with dermoid, endometrioma or seromucinous cysts were included from January 2015 to July 2016. All of them had previous ovarian surgery. Mean AMH levels were 15.3 pmol/L. The mean number of total oocytes retrieved was 7 ± 5. The mean number of metaphase II oocytes was 4.4 ± 4. The incidence of low ovarian response was 38%. Among the patients, 86% had less than 8 metaphase II oocytes vitrified. Seven patients asked for a second cycle in order to have more oocytes.
We demonstrated the feasibility of the systematic proposal of fertility preservation by oocyte cryopreservation in this group of young patients with recurrent ovarian benign tumors. Taking into account history of previous surgery and high incidence of low ovarian reserve, the ovarian response under stimulation was frequently poor with, as consequence, low retrieved oocyte number per cycle. An oocyte accumulation strategy is then proposed to enhance further pregnancy chances.

View all citing articles on Scopus

View full text

Predictive factors for recurrence of ovarian mature cystic teratomas after surgical excision

Abstract

Objective

Study design

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Comment

Conflict of interest statement

Funding

Acknowledgement

Am J Obstet Gynecol

J Obstet Gynaecol Can

J Am Assoc Gynecol Laparosc

Eur J Obstet Gynecol Reprod Biol