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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 3  |  Issue : 3  |  Page : 62-66

Mature cystic ovarian teratoma invading the bladder: A rare case report


1 Department of Urology, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
2 Department of First Clinical Medical College, Graduate School of Shanxi Medical University, Taiyuan, Shanxi, China

Date of Submission24-Jul-2018
Date of Acceptance16-Sep-2018
Date of Web Publication28-Sep-2018

Correspondence Address:
Dr. Weibing Shuang
Department of Urology, First Hospital of Shanxi Medical University, No. 85, JieFang South Road, Yingze District, Taiyuan 030001, Shanxi
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_10_18

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  Abstract 


Mature cystic teratomas (MCTs) are the most common type of ovarian germ-cell tumor, rarely showing bladder invasion. We present a case of a premenopausal 47-year-old female who suffered from increased frequency to urinate followed by lower abdominal pain for 3 years. To the best of our knowledge, we present the first case of mature cystic ovarian teratoma invading the bladder, associated with lower abdominal pain after urination. Open partial cystectomy and lesion side accessory resection were done, which seemed effective in managing MCT that invades bladder.

Keywords: Frequent urination, lower abdominal pain after urination, mature cystic ovarian teratoma, premenopausal, urinary bladder


How to cite this article:
Guo H, Yin K, Wang Y, Tong X, Yang H, Xia M, Shuang W. Mature cystic ovarian teratoma invading the bladder: A rare case report. Transl Surg 2018;3:62-6

How to cite this URL:
Guo H, Yin K, Wang Y, Tong X, Yang H, Xia M, Shuang W. Mature cystic ovarian teratoma invading the bladder: A rare case report. Transl Surg [serial online] 2018 [cited 2018 Dec 19];3:62-6. Available from: http://www.translsurg.com/text.asp?2018/3/3/62/242490




  Introduction Top


Mature cystic teratomas (MCTs) of the ovary are the most common type of benign germ-cell tumor, composed of mature histologic structures of ectodermal, mesodermal, and endodermal origins.[1] It accounts for approximately 10%–25% of all ovarian tumors, bilateral in 10%–15% of cases,[2] which occurs predominantly in women in their second and third decades of life but rarely occurs in the postmenopausal age group.[3] One of the most common locations is the ovary, and rarely, it may occur in the urinary bladder.[4] MCTs are mostly asymptomatic, incidentally found during clinical examinations, radiographic studies, or during abdominal operations performed for other indications.[3] When it invades the bladder, symptoms may include irritative lower urinary tract symptoms, urinary retention, and pilimiction.[4],[5],[6],[7] With imaging studies, it can be easily diagnosed clinically; however, the confirmed diagnosis depends on histopathology. Due to its small chance of malignancy, surgical resection is a good option with good prognosis.[8]


  Case Report Top


A 47-year-old premenopausal woman presented with a 3-year history of intermittent irritative lower urinary tract symptoms as follows: increased frequency to urinate and lower abdominal pain after urination, which got worse in the last 6 months. She did not complain of urgency, hematuria, or low back pain. There was no relevant family history of ovarian or bladder malignancies. No significant findings were seen on physical examination, apart from three incision scars over the lower part of the left abdomen, correlating with a surgical history of laparoscopic appendectomy due to acute exacerbation of chronic appendicitis 4 years ago. By reviewing the previous case files, we noticed that the surgeon had probed the left ovary because of abnormal ultrasonographic features (those considered to be teratoma), considered as an ovarian cyst, and recommended regular follow-up. Urinalysis showed urinary tract infection with  Escherichia More Details coli, revealed by urinary culture. Other routine laboratory investigations were within normal limits. Ultrasound (US) indicated a solid low echo occupancy in the left side of the anterior wall of the bladder, 1.7 cm × 1.5 cm in size, and point strong echo can be seen on the surface of the neoplasm [Figure 1]. The occupancy was further evaluated with contrast-enhanced US (CEUS) using Sulfur hexafluoride microbubbles, which suggested bladder cancer. Computed tomography (CT) scanning reflected that the low-density strip-shaped shadow, with ring calcification and small nodular calcification inside, existed on the left side of the pelvic cavity, and the border with the left accessory and the left side of the bladder wall was less clear; enhanced scanning three-phase CT value was 29 HU in arterial phase, 31 HU in venous phase, 31 HU during the elimination period, and all of which contributed to consider it as a benign lesion [Figure 2]. Spiral CT three-dimensional (3D) imaging showed the left neoplasm invaded the left side of the bladder [Figure 3]. Cystoscopy revealed that a mass of approximately 1.5 cm in size was covered by a white material with hairs seen, and did not move along with the water flow [Figure 4]. Biopsy was taken, and the histopathology of which demonstrated squamous epithelium and keratosis on the surface.
Figure 1: Urinary ultrasound indicated that a solid low echo occupancy existed in the left anterior sidewall of the bladder, 1.7 cm × 1.5 cm in size, and point strong echo can be seen on the surface of the neoplasm

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Figure 2: The maximum diameter of the tumor outside of the bladder on the horizontal axis at three stages (a: arterial phase, b: venous phase, and c: elimination period). The maximum diameter of the tumor inside of the bladder on the horizontal axis at three stages (d: arterial phase, e: venous phase, and f: elimination period)

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Figure 3: Spiral computed tomography three-dimensional imaging showed that the left neoplasm invaded the left side of the bladder:

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Figure 4: Cystoscopy revealed that a mass of approximately 1.5 cm in size was covered by white material (a) with hairs seen (b)

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To relieve the symptoms, the patient underwent an open partial cystectomy and left accessory resection with general anesthesia. During the surgery, we observed that the left anterior sidewall of the bladder and peritoneal adhesions and local boundaries were unclear. After opening the bladder, the tumor was seen at the left side of the bladder, with a size of about 1.7 cm × 1.5 cm × 1.5 cm, externally invaded, cystic, and with few hairs [Figure 5]. When the tumor was pulled, the surrounding parts moved together [Figure 5]. After the consultation with gynecologist and general surgeon, the tumor was determined to have risen from the left accessory and was subsequently removed together with the left accessory. The mass was approximately 1.7 cm × 1.5 cm × 1.5 cm and was stuck into the bladder and left accessory [Figure 6]. Cut open at its maximum diameter; the mass was revealed to be cystic [Figure 6]. The postsurgical histopathology showed all kinds of mature tissue of the left ovary from all the three germ layers (ectoderm: skin and nerve; mesoderm: muscle, fat, bone, and cartilage; and endodermal: mucinous or ciliated epithelium gastrointestinal, bronchial, and thyroid tissue), and thus diagnosed as MCT [Figure 7]; the oviduct was confirmed to be under chronic inflammation.
Figure 5: The tumor was seen at the left side of the bladder with a size of about 1.7 cm × 1.5 cm × 1.5 Cm, externally invaded, cystic, and few hairs (a). On pulling the tumor, the surrounding parts moved together (b)

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Figure 6: The mass was approximately 1.7 cm × 1.5 cm × 1.5 cm, and it sticked into the bladder and left accessory (a). Cut open at its maximum diameter; the mass revealed to be cystic (b)

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Figure 7: Histopathology after surgery showed all kinds of mature tissue of the left ovary, from all the three germ layers (ectoderm: skin and nerve; mesoderm: muscle, fat, bone, and cartilage; and endodermal: mucinous or ciliated epithelium gastrointestinal, bronchial, and thyroid tissue) (a-i)

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At 3 months, after the surgery, the patient's general condition is fine, with an obvious improvement in her quality of life. The study was approved by the Ethics Committee of First Hospital of Shanxi Medical University (No. 2018.K006). And the patient signed an informed consent form.


  Discussion Top


MCTs of ovary are the most common type of benign germ-cell tumor. Most of them are often asymptomatic, complications reported include ovarian torsion (16%), rupture (1%–4%), malignant transformation (1%–2%), infection (1%), invasion into adjacent viscera, and autoimmune hemolytic anemia (<1%).[9] When it invades the bladder, symptoms may include irritative lower urinary tract symptoms, urinary retention, and pilimiction.[4],[5],[6],[7] In this case, frequent urination and lower abdominal pain after urination were observed. We supposed the reason of the patient's frequent urination was that the tumor stimulated the bladder mucus inducing the filling feel of the bladder. Moreover, the reason of the patient's abdominal pain after urination was that the tumor pulled the nerve of abdominal organs and tissues after the bladder emptying and shrinking. In this case, the reason of ovarian teratoma invasion of the bladder could be as follows: (1) ovary probing during laparoscopic appendectomy may have damaged the bladder, and then the tumor herniated into the bladder; (2) intrauterine device and special sexual behavior could hurt the filled bladder, and subsequently, the tumor broke into the bladder; and (3) most likely, the neoplasm grew into the bladder naturally. Infections did not work in the process because the peritoneal cavity was not seen obvious adhesions during the surgery.

MCTs could mimic distal ureteric stone or badder cancer.[10],[11] Most MCTs can be diagnosed by US. However, there are numerous pitfalls in US diagnostic modality because of the fact that these tumors may have a variety of appearances.[12] Therefore, US did not confirm the relation of the bladder and the left accessory in this case. CEUS could be a reliable tool in the evaluation of patients with bladder tumors, which is an effective, inexpensive, and noninvasive method.[13] However, it has low specificity and accuracy in the diagnosis of MCTs. By contrast, being highly sensitive to detect fat, CT imaging can easily diagnose MCTs when observed for fat attenuation within a cyst, with or without calcification of the wall.[14] Fat is not fortified enhanced scanning. The case we present here is consistent with the features of MCTs on CT imaging. Spiral CT 3D imaging played an important role in making a surgical plan.[15] On T1-weighted and T2-weighted images at magnetic resonance imaging (MRI), the cystic spaces demonstrate both high and low signal intensity. Fat-suppressing sequences in MRI can identify fat components in lesions. Besides, MR can better aid in differential diagnosis with other types of ovarian teratomas.[16]

Open partial cystectomy and lesion side accessory resection are effective in the management of MCT that invades the bladder.[4],[9],[10],[11] The patient's symptoms here have completely disappeared after surgery.


  Conclusion Top


To the best of our knowledge, we present the first case of mature cystic ovarian teratoma invading the bladder, with the reporting complaint of lower abdominal pain after urination, which may help in concluding its source. CEUS showed low specificity and accuracy in the diagnosis of MCT. CT played an important role in diagnosing MCT because of its high sensitivity. Spiral CT 3D imaging was beneficial to make a surgical plan. Open partial cystectomy was an effective treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Comerci JT Jr., Licciardi F, Bergh PA, Gregori C, Breen JL. Mature cystic teratoma: A clinicopathologic evaluation of 517 cases and review of the literature. Obstet Gynecol 1994;84 (1):22-8.  Back to cited text no. 3
    
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Naqvi KZ, Abdullah A, Jabeen M, Iqbal F, Edhi M. Ovarian dermoid causing pilimiction. J Coll Physicians Surg Pak 2015;25 (1):71-2.  Back to cited text no. 4
    
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Tandon A, Gulleria K, Gupta S, Goel S, Bhargava SK, Vaid NB. Mature ovarian dermoid cyst invading the urinary bladder. Ultrasound Obstet Gynecol 2010;35 (6):751-3.  Back to cited text no. 5
    
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Bhuiyan ZH, Akhter N, Islam MF, Khan SA, Tawhid MH. Pilimiction. Mymensingh Med J 2008;17 (2 Suppl):S107-10.  Back to cited text no. 7
    
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Goudeli C, Varytimiadi A, Koufopoulos N, Syrios J, Terzakis E. An ovarian mature cystic teratoma evolving in squamous cell carcinoma: A case report and review of the literature. Gynecol Oncol Rep 2017;19:27-30.  Back to cited text no. 8
    
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Sardesai S, Raghoji V, Dabade R, Shaikh H. Benign cytic teratoma of ovary perforating into the urinary bladder: A rare case. J Obstet Gynaecol India 2012;62 (Suppl 1):54-5.  Back to cited text no. 9
    
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Omar M, El-Gharabawy M, Samir A, El Sherif E, Monga M. Mature cystitic teratoma of the bladder masquerading as a distal ureteral stone. Urol Case Rep 2017;13:94-6.  Back to cited text no. 10
    
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Chuang HY, Chen YT, Mac TL, Chen YC, Chen HS, Wang WS, Tsai EM. Urothelial carcinoma arising from an ovarian mature cystic teratoma. Taiwan J Obstet Gynecol 2015;54 (4):442-4.  Back to cited text no. 11
    
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Hertzberg BS, Kliewer MA. Sonography of benign cystic teratoma of the ovary: Pitfalls in diagnosis. Am J Roentgenol 1996;167 (5):1127-33.  Back to cited text no. 12
    
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Gupta VG, Kumar S, Singh SK, Lal A, Kakkar N. Contrast enhanced ultrasound in urothelial carcinoma of urinary bladder: An underutilized staging and grading modality. Cent European J Urol 2016;69 (4):360-5.  Back to cited text no. 13
    
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Lai PF, Hsieh SC, Chien JC, Fang CL, Chan WP, Yu C. Malignant transformation of an ovarian mature cystic teratoma: Computed tomography findings. Arch Gynecol Obstet 2005;271 (4):355-7.  Back to cited text no. 14
    
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Benz RM, Garcia MA, Amsler F. Initial evaluation of image performance of a 3-D x-ray system: Phantom-based comparison of 3-D tomography with conventional computed tomography. J Med Imaging (Bellingham) 2018;5 (1):015502.  Back to cited text no. 15
    
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Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: Tumor types and imaging characteristics. Radiographics 2001;21 (2):475-90.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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