Intern 陳君豪 & 蔡佽學 Supervisor 2005/08/31 Intern Semina Intern 陳君豪 & 蔡佽學 Supervisor 2005/08/31

Information Name: 賴 x 璇 Sex: female Age: 7 y/o Admission Date: 94/07/11

Chief Complaint Intermittent abdominal pain for 1 year

Brief History - 1 year : Intermittent abdominal pain - 1 month: one abdominal mass - 2 days ago: abdominal pain became severe, appetite and activity decreased, constipation,

Brief History - GYN LMD : abdominal X-ray  one abdominal mass with calcification - 奇美 Hospital: one abdominal mass - Our ER: one firm, un-movable, 12x16 cm mass with tenderness

Birth History G2P2 C/S GA: Full-term BBW: 3183 gm DOIC (-) PROM (-)

Past History Feeding: on full diet Vaccination: on schedule Growth and Development: - BW: 26.1 Kg (50-75th%) - BL: 122.8 cm (75-90th%) Denied other major disease Denied hospitalization history

PE One 12x16 cm, firm, unmovable, well-defined margin, abdominal mass over anterior, middle abdomen Tenderness (+) Rebounding pain (-)

Lab Data Lymph 207.2 180 179 CRP ALK-P LDH 82.0% 363 4.19M 20.8K Seg Plt RBC WBC 11.0%

Imagine - Plain Film

Imagine - Abdominal CT

Imagine - Abdominal CT

Imagine - Abdominal CT

Pathology Mature cystic teratoma 11.7x10.2x7.5 cm in size 475g in weight

Discussion Teratoma of the Ovary

Teratoma Teratomas are tumors comprising more than a type one germ layer

Location of Teratoma Sacrococcygeal (57%) Gonad (29%) Mediastinal (7%) Retroperitoneal (4%) Cervical (3%) Intracranial (3%)

Teratoma of the Ovary Mature teratoma Immature teratoma Monodermal teratomas

Mature Teratoma 95% Second and third decades of life Ectodermal (skin, brain), mesodermal (muscle, fat), and endodermal (mucinous or ciliated epithelium)

Immature Teratoma Malignant teratoma, <1% First two decades of life Immature or embryonic tissues

Immature Teratoma Immature teratomas are typically larger (14–25 cm) than mature cystic teratomas (average, 7 cm) Prominent solid component Perforation of the capsule, which is not always well defined

Monodermal Teratomas Composed solely of one tissue type Thyroid tissue in struma ovarii Neuroectodermal tissue in carcinoid tumor

Epidemiology Mature cystic teratomas account for 10-20% of all ovarian neoplasms Most common ovarian neoplasm in patients younger than 20 years 8-15% bilateral 1-2% showed malignant degeneration

Clinical Symptom Incidental findings on physical examination, during radiographic studies, or during abdominal surgery Asymptomatic mature cystic teratoma of the ovaries have been reported at rates of 6-65% in various series.

Clinical Symptom Abdominal pain (47.6%), Abdominal mass or swelling (15.4%) Abnormal uterine bleeding (15.1%) Bladder symptoms, gastrointestinal disturbances, and back pain are less frequent Abdominal pain ranges from slight to moderate. Torsion and acute rupture commonly are severe pain

Lab Elevated serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (HCG) levels may be indicative of malignancy Within reference ranges in most patients with benign teratomas.

Imaging Studies - X-Ray Soft tissue mass containing calcification (such as teeth)

Imaging Studies - US Cystic components Echogenic mass Acoustic shadow

Imaging Studies - CT Cystic tumor with fat and calcification Bullseye sign

Imaging Studies - MRI Differentiate lipid density from other fluid and blood

Complications Torsion: 3.2-16% Rupture: 1-4%, - leading to shock or hemorrhage Infection: 1%, - Coliform bacteria Autoimmune hemolytic anemia Malignant degeneration - 1-2%, squamous, adenocarcinoma

Treatment Mature cystic teratomas of the ovaries should be removed by simple cystectomy rather than salpingo-oophorectomy

Staging Stage 1 only in the ovary (or both ovaries) Stage 2 spread into the fallopian tube, uterus, or elsewhere in the pelvis Stage 3 spread to the lymph nodes or to the peritoneum Stage 4 spread to distance organ

Thanks for your attention !!