{"paper_id":"e619eada-3ee7-4afc-9310-38bcc7f1429d","body_text":"Case Report\nVolume 18 Issue 2- January 2020\nDOI: 10.19080/JGWH.2020.18.555982\nJ Gynecol Women’s Health\nCopyright © All rights are reserved by Balint O\nJ Gynecol Women’s Health 18(2): JGWH.MS.ID.555982 (2020) 001\nJournal of\nGynecology and Women’s Health\nISSN 2474-7602\nRare Association Between an Endometrioma and  \nA Mature Cystic Teratoma on the Same Ovary in \nA Postmenopausal Woman: A Case \nReport and Review of Literature\nBalint O*, Secoșan C, Pirtea L and Grigoraș D\nDepartment Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Victor Babeș’ Timisoara, Romania\nSubmission: January 11, 2020; Published: January 20, 2020\n*Corresponding author: Balint O, Department Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Victor Babeș’ Timisoara, Romania\nAbstract\nIn spite of their increased individual incidence, association of cystic teratomas and ovarian endometriomas on the same ovary is \nextremely rare. Moreover, both types of ovarian tumors are considered conditions affecting mostly premenopausal women. We present a case \nof a postmenopausal woman presenting with a symptomatic right ovarian mass. Ultrasound appearance consisted in a bilocular mass with a \ncomponent suggestive for an endometrioma and the other of a complex cyst with papillary projections. The histopathology report revealed the \nco-existence of an endometrioma with a mature cystic teratoma. Currently this is the only case report of this association of ovarian tumor types \nin a postmenopausal woman.\nKeywords: Endometrioma; Dermoid cyst; Mature teratoma\nCase Report\nFigure 1: (A) Ultrasound image of a bilocular ovarian mass \ncomposed of a lower cyst with “ground glass” content and \nan upper complex cyst with fluid and solid components. (B) \nPapillary projection originating from the upper cyst wall. (C) \nIntraoperative image of the ovarian mass.\nA 59 years old postmenopausal woman presented in our \nservice with a 3 months history of moderate non-colicky lower \nabdominal pain and recurrent minimal abnormal vaginal bleeding. \nThe patient had normal BMI and no significant medical or surgical \nhistory. At the admission, pelvic examination revealed minimal \nbleeding through the external cervical os, a normal sized uterus \nand a tender voluminous mass occupying the right iliac fossa. \nA transvaginal ultrasound showed an anteverted uterus with a \nnormal myometrial echotexture and an endometrial thickness of \n8mm. On the right side of the uterus a bilocular 8.9/7.6cm cystic \novarian mass was observed. The bilocular structure was composed \nof a lower cyst with a homogenous, hypoechoic “ground glass” \nlike content, highly suggestive for an endometrioma, separated \nby a thick septum from an upper cyst with heterogenous content, \nwith solid projections originating from the cyst wall (Figure 1). \nNo internal vascularization was noticed on colour Doppler. The \nleft ovary showed a normal appearance for a postmenopausal \nstatus. No other abnormal findings were observed. In order to \ninvestigate her abnormal uterine bleeding an endometrial biopsy \nwas obtained through D&C. The histopathology showed a complex \nendometrial hyperplasia with atypia. \n\n\nHow to cite this article: Balint O, Secoșan C, Pirtea L and Grigoraș D. Rare Association Between an Endometrioma and A Mature Cystic Teratoma on the \nSame Ovary in A Postmenopausal Woman: A Case Report and Review of Literature. J Gynecol Women’s Health. 2020: 18(2): 555982. \nDOI: 10.19080/JGWH.2020.18.555982\n002\nJournal of Gynecology and Women’s Health\nFor the surgical treatment, a laparoscopic approach was \nchosen. Intraoperative findings revealed a normally appearance \nuterus and left adnexa and a right voluminous ovarian mass with \nno extracystic vegetation. (Figure 1) A total hysterectomy with \nbilateral adnexectomy was performed. The uterus and left adnexa \nwere extracted from the abdomen through the vagina followed by \nthe intact ovarian mass placed in an endobag.\nPost-postoperative gross examination of the ovarian mass \nrevealed the bilocular structure seen by ultrasound. The dissection \nof the lower cyst showed a chocolate-like content confirming the \ndiagnosis of endometrioma suggested pre-operatively. The upper \ncyst was also dissected, and its content consisted in strands of \nhair and fatty tissue suggesting a diagnosis of mature teratoma \n(dermoid cyst). The histopathology examination confirmed the \novarian mass as being an association between an endometrioma \nand a mature cystic teratoma. No other pathological changes \nwere observed regarding the uterus besides the already known \nendometrial hyperplasia. The patient recovered well and was \ndischarged 48 hours later.\nDiscussion\nMature cystic teratomas and ovarian endometriomas \nrepresent common ovarian benign masses. Teratomas are the \nmost frequent germ cell tumors of the ovary with an incidence \nof 20% of all ovarian masses while endometriomas are present \nin 17-44% of women with endometriosis [1,2]. Also, both types \nof ovarian masses are considered conditions of premenopausal \nwomen with only few cases reported after menopause. In spite \nof their increased individual incidence, association of cystic \nteratomas and ovarian endometriomas on the same ovary is \nextremely rare. Our literature search identified 6 cases reported \nfrom 1960 until present (June 2019). The first case reported is an \nincidental finding in a 23 years old patient during surgery for a \novarian mass [3]. Later, Caruso and Pirelli describes a case of a 28 \nyears old woman with bilateral ovarian masses with a histology \nreport revealing separate endometrial and teratomatous lesions \non her left ovary [4]. In recent literature, four cases are reported. \nVan der Merwe presents the case of a 30 years old patient with \na voluminous compressive ovarian mass (43 x 23 x 20cm) of \nunknown origin at the time of surgery. Histologic examination \nshowed 3 types of lesion clearly separated, a mature cystic \nteratoma, a mucinous cystadenoma and areas of endometrial \nstroma. This case presents the largest mass reported, involving \nthis co-existence of pathologies and also the only one with the \nassociation of a third lesion [5]. The last three cases also report \nyoung women, ages 28 to 35 years old, with a unilateral ovarian \nmass with dimensions ranging between 6 and 8cm in largest \ndiameter. Two of the cases were diagnosed due to the appearance \nof a second condition, adnexal torsion and ectopic pregnancy (on \nthe contralateral side), respectively [6,7]. The third case was an \nincidental finding [8]. All 3 patients were treated by laparoscopic \napproach. \nOur case is currently the only reported case involving the \nco-existence of an endometrioma and a mature teratoma in \na postmenopausal woman. Postmenopausal endometriosis \nis a poorly studied subject in medical literature. In one of the \nlargest studies, 72 cases of postmenopausal endometriosis were \nidentified over a 12 years period. Among these patients, cystic \novarian endometriosis was the most frequent form representing \n79.2%. The median age was 58.5 years [9]. Although the exact \nmechanism that cause the appearance of endometriosis after \nmenopause is unknown, several theories have been described, \nmost accepted being the production of estrogen from non-ovarian \nsources like adrenal gland or adipose tissue or reactivation of \nold endometriotic lesion during hormone replacement therapies \n[10,11]. On the other hand, the incidence of mature cystic \nteratomas in postmenopausal woman is about 10% [12]. In \nthis group of women the natural evolution of mature teratomas \ninvolves slow growth but higher malignant transformation rates \nas opposed to premenopausal women [13,14].\nPre-operative diagnosis of postmenopausal ovarian masses \nrepresents a challenge due to the different presentation and \nsignificance of ovarian cysts. Transvaginal ultrasound remains \nthe most effective way of evaluating these patients. Is it important \nto be aware that some of the sonographic characteristics of \ndifferent type of ovarian cysts/masses change with age. The main \nsign of endometriotic cysts, represented by the “ground glass” \nechogenicity is present in only 62% of women over 45 years \nbut with a rate of papillary projections of 14% while in younger \nwomen, the “ground glass” echogenicity can be observed in 77% \nof case with only 3% presenting papillary projections [15]. \nSimilar with the last 3 cases, involving masses of under 8 cm \ndiameter, our case was treated by laparoscopic approach and \nthe mass was extracted using an endobag to prevent spillage. \nCurrent case highlights the importance of thorough evaluation of \npostmenopausal ovarian masses. The possibility of co-existence of \ndifferent ovarian lesions increases the challenge imposed by the \ndiscovery of an ovarian mass and must be take into consideration \neven in a menopausal woman. No diagnosis cannot be excluded \nbased on patient age.\nReferences\n1. Del Carpio-Orantes L (2013) Virosis emergentes en México. Revista \nMédica del Instituto Mexicano del Seguro Social 51(1): 8-11.\n2. Del Carpio-Orantes L (2016) Zika, a neurotropic virus? Revista médica \ndel Instituto Mexicano del Seguro Social 54(4): 540-543.\n3. Del Carpio-Orantes L (2018) Vías de transmisión del Zika, se puede \ntransmitir de persona a persona? Rev Med Inst Mex Seguro Soc 56(4): \n410-413.\n\n003\nJournal of Gynecology and Women’s Health\nHow to cite this article: Balint O, Secoșan C, Pirtea L and Grigoraș D. Rare Association Between an Endometrioma and A Mature Cystic Teratoma on the \nSame Ovary in A Postmenopausal Woman: A Case Report and Review of Literature. J Gynecol Women’s Health. 2020: 18(2): 555982. \nDOI: 10.19080/JGWH.2020.18.555982\nYour next submission with Juniper Publishers    \n      will reach you the below assets\n• Quality Editorial service\n• Swift Peer Review\n• Reprints availability\n• E-prints Service\n• Manuscript Podcast for convenient understanding\n• Global attainment for your research\n• Manuscript accessibility in different formats \n         ( Pdf, E-pub, Full Tsext, Audio) \n• Unceasing customer service\n                 Track the below URL for one-step submission \n  https://juniperpublishers.com/online-submission.php\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nDOI: 10.19080/JGWH.2020.18.555982\n4. Del Carpio-Orantes L, González Clemente MC (2018) Zika, enfermedad \nafebril? Rev Med Inst Mex Seguro Soc 56(3): 305-308.\n5. Del Carpio-Orantes L, María del Carmen González-Clemente, Teresa \nLamothe-Aguilar (2018) Zika and its vector mosquitoes in Mexico. \nJournal of Asia-Pacific Biodiversity 11(2): 317-319.\n6. Del Carpio-Orantes L (2019) Culex and Aedes Vexans, confirmed \nvectors of zika in Mexico. Med Int Méx 35(6): 931-933. \n7. Del Carpio-Orantes L (2018) Congenital Zika syndrome, time to \ncommunicate experiences. J Matern Fetal Neonatal Med 32(20): 3509-\n3510.\n8. Pan American Health Organization (2017) World Health Organization. \nZika suspected and confirmed cases reported by countries and \nterritories in the Americas Cumulative cases, 2015-2017.\n9. https://www.gob.mx/cms/uploads/attachment/file/522438/\nCuadro_Casos_ZIKA_y_Emb_sem_52_2019\n10. https://www.gob.mx/cms/uploads/attachment/file/454004/\nCuadro_Sx_Congenito_asociado_a_Zika_15042019 \n11.  Del Carpio-Orantes L, González Clemente MC (2018) Microcefalia y \narbovirus. Rev Med Inst Mex Seguro Soc 56(2): 186-188.","source_license":"CC0","license_restricted":false}