Teeth, and hair, and sebum, oh my! A case of bilateral large ovarian teratomas

Abstract

Background: An ovarian teratoma can be classified as either mature (benign) or immature (malignant). Mature teratomas contain hair follicles, adipose tissue, glial tissue, and perinerval nervous tissue. They can reach massive sizes. Immature teratomas are fortunately rarer and generally don’t contain mature tissue. Abdominal pain is the most common presentation of teratomas in general. Approximately 10-15% of ovarian teratomas present bilaterally.

Case Presentation: A 45-year-old nulligravida woman presented to the clinic with a chief complaint of abdominal pain and pressure as well as dyspareunia. She also noted a 4-month history of abnormal, heavier periods. Past medical history was unremarkable. Social history was significant for a 30-pack-year smoking history, binge drinking, and methamphetamine use. Family history was notable for ovarian cancer in her mother. Ultrasound showed an enlarged uterus (13.2x7.9x8.6 cm) with a thickened endometrium (2.66 cm). The left ovary was enlarged (9.7x9.4x6.5 cm), and the right ovary was even larger than the left (11.5x7.8x11.3 cm). Tumor markers were within normal range. The patient underwent a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The uterus, right ovary, and left ovary were too large to be evacuated through the vagina, as is standard protocol, so they were cut in pieces. Fragmentation of each ovary yielded un-pigmented hair, over one dozen teeth, and large amounts of sebaceous fluid. The patient had an uneventful post-op recovery, and she admitted to resolution of her previous pain at two-week follow-up.

Discussion: The patient’s mother had died of ovarian cancer at the age of 71. The type of ovarian cancer was unknown to the patient. The patient’s teratomas were found to be benign. Approximately 1% of mature teratomas do undergo malignant transformation. This could possibly have happened if the patient had delayed surgery. However, whether this is what happened to her mother is unlikely, as the prevalence of familial ovarian teratomas is thought to be extremely rare. Finally, it is unknown whether the patient’s social history could have increased the chances of her teratoma undergoing malignant transformation. Some suggest that exposure to a carcinogenic environment could cause such a transformation.