Dermoid cyst of the ovary

Dermoid cyst of the ovary is a benign germ cell tumor.

The very definition - germinohema explains the origin of the cyst, since germinis is an embryo, in the medical sense - an embryonic layer, a leaf. Dermoid cysts are often classified as true tumors, since the neoplasm is formed due to cell mitosis, unlike cysts that form as a result of fluid accumulation or stagnation.

According to statistics, a dermoid ovarian cyst is diagnosed in 20% of patients with various types of cysts. A dermoid develops from three germ layers - external, middle and internal (ectoderm, mesoderm and endoderm). A cyst can be determined regardless of age, but most often it forms in early childhood, develops very slowly and can manifest clinically when it increases during hormonal changes - puberty, pregnancy, menopause. Dermoid neoplasms are most often localized in one ovary, are considered benign ovarian tumors (BOT), but from 1.5 to 2% can become malignant into squamous cell carcinoma.

According to the international classifier, the disease is defined as follows:

ICD-10-0. M9084/0 – Dermoid cyst.

Causes of Dermoid Ovarian Cyst

The etiology and exact causes of the ovarian dermoid cyst are still being studied today, there are several versions, united by one generally accepted theoretical and practical basis - a violation of embryogenesis. The explanation that the dermoid forms as a result of hormonal changes is considered incorrect, rather the hormonal system provokes the acceleration of cyst growth, but is not its original cause.

Indeed, a dermoid cyst may not manifest itself clinically for decades, and is not visible on ultrasound if it is very small. During pregnancy, menopause or puberty, a dermoid is detected more often, as it begins to grow. However, the cyst has not been found to be related to the menstrual cycle, it does not affect it at all, so hormonal causes of a dermoid ovarian cyst should not be considered true.

The main version that can explain the formation of dermoids is a violation of tissue differentiation during embryogenesis. As a result, a small dense tumor with a stalk is formed. The cyst is localized in the ovary on one side, closer to the uterus (in front), has a heterogeneous, complex consistency, consisting of the following elements:

• Ectoderm – skin scales, neuroglia (neural tissue) – ganglia, glia, neurocytes.
• Mesoderm – elements of bone, muscle, cartilage, fat, fibrous tissue.
• Endoderm – tissue elements of the salivary glands, thyroid gland, bronchial and gastrointestinal epithelium.

The walls of the cyst capsule are thin, but since they are formed from connective tissue, they are strong and elastic. The dermoid always has a long stalk, is mobile and is not fused with the surrounding skin.

Summarizing the causes of ovarian dermoid cysts, they can be described as follows:

The etiology of dermoids is of embryonic nature, when elements of the germ layers (usually mesenchymal) remain in the ovarian tissue of the ovary. Under the influence of hormonal, less often traumatic factors, a dermoid cyst can increase in size and manifest itself clinically.

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Dermoid cyst of the ovary and pregnancy

A dermoid ovarian cyst and pregnancy may not interfere with each other if the neoplasm does not increase, does not suppurate, and does not cause complications in the form of torsion of the cyst stalk. The cyst itself does not affect the gestation of the fetus at all and cannot have a pathological effect on either the mother's body or the development of the embryo. However, the growing uterus provokes natural dystopia - displacement of internal nearby organs, respectively, the dermoid cyst can be infringed, its stalk can be compressed and twisted. The consequence of this condition is necrosis of the cyst or its rupture. It is for this reason that the best way to avoid surgery during pregnancy is considered to be preventive diagnostics six months before conception. During a comprehensive examination, the cyst, if any, is detected, removed, and such treatment does not interfere with further fertilization of the woman. In the case where a dermoid cyst and pregnancy are already “neighbors,” a small neoplasm is observed; if it begins to increase in size, it is operated on laparoscopically no earlier than the 16th week, so as not to disrupt the gestation process and preserve the fetus.

The symptoms of a dermoid formation in a pregnant woman are not specific, the cyst often develops asymptomatically and does not manifest itself with painful sensations. The clinic of "acute abdomen" can only be the case if the dermoid began to actively grow, increase, and its stalk twisted.

A cyst is most often diagnosed during an examination when registering for pregnancy. Palpation reveals a painless, mobile, dense tumor, the size and condition of which are determined using ultrasound.

It should be emphasized once again that a small dermoid cyst (up to 3 cm) does not affect pregnancy, just as pregnancy may not have a provoking effect on the cyst. However, the dermoid should be removed, since there is a risk of its malignancy, it is not high - only 1.5-2%, but it is better to neutralize it. Dermoid cysts are most often operated during or after cesarean section. The prognosis for the treatment of dermoids uncomplicated by inflammation, suppuration or torsion is favorable.

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Symptoms of Dermoid Ovarian Cyst

A dermoid cyst develops slowly but constantly, its symptoms are not much different from those of other benign formations, and may be as follows:

• The first sensations of aching, transient pain may appear if the cyst has grown to 5 centimeters.

Large cysts – from 10 to 15 centimeters – manifest themselves in this way:

• Pulling pain in the lower abdomen.
• A feeling of pressure and distension in the abdomen.
• A large cyst in asthenic women can cause a visual increase in the abdomen.
• As a result of pressure on the bladder, urination becomes more frequent.
• Pressure on the intestines causes bowel movements disorders – diarrhea or constipation.
• An inflamed cyst is accompanied by an increase in body temperature and severe pain in the lower abdomen.
• Torsion of the cyst stalk provokes the classic clinical picture of “acute abdomen”, pelvic peritonitis – unbearable pain radiating down to the leg, fever, nausea, tachycardia, drop in blood pressure, cyanosis.

Thus, the symptoms of a dermoid ovarian cyst depend on the size of the tumor and its location, but most often the dermoid does not cause complaints and does not affect the woman’s health, especially if the size is less than 5 centimeters.

Dermoid cyst of the left ovary

The ovaries are a paired organ of the small pelvis and, like all other paired structures, they are asymmetrical and cannot be of the same size in principle, this is due to human anatomy. It should be recognized that the true cause of asymmetry and the difference in the sizes of the ovaries has not yet been studied much, but most likely it is associated with a genetic factor and different blood vessel supply (vascularization).

Statistics show that a dermoid cyst of the left ovary is much less common than in the right one, apparently, this is due to the asymmetrical location of the organ, which is formed at the stage of antenatal ontogenesis. The uneven position of the ovaries is present at all stages of their intrauterine development, with the right ovary prevailing over the left, both in the functional sense and in the anatomical (size) sense.

In addition, the vascularization (blood supply) of the left and right ovaries differs from each other: the artery of the left ovary is diverted into the left renal vein, and the ovarian branch of the right ovary is diverted into the inferior vena cava. Thus, the left ovary develops somewhat more slowly, and the separation of germ layers into it is possible to a lesser extent than into the right ovary. It is also necessary to take into account that during puberty, in puberty and later, with regular menstrual cycles, the left ovary ovulates less often and less intensely, respectively, the hormonal factor that could provoke tumor growth affects it little. A left-sided benign tumor can form in utero and not manifest itself during life with any signs.

A dermoid cyst of the left ovary is diagnosed at any age - from youth to menopause, most often it is small in size - up to 3-4 centimeters and very rarely grows to 5 centimeters. Such a dermoid is treated in the same way as a cyst of the right ovary - only by surgery. Surgery is mandatory, since there is a risk of the left-sided cyst developing into squamous cell carcinoma.

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Dermoid cyst of the right ovary

Dermoid cyst of the right ovary is diagnosed twice as often as dermoid of the left ovary. The reasons for this phenomenon are poorly understood; etiologically, right-sided cysts can be explained by the peculiarities of embryogenesis.

In practical gynecology, especially in surgery, there are facts, not yet confirmed by scientific developments and substantiated theories, that indicate that the right ovary of a woman is more susceptible to various tumor formations and other pathologies. Anatomically, the right and left ovaries are not much different from each other, but they are located laterally asymmetrically and often have different parameters - sizes. In addition, the right ovary is more intensively supplied with blood, due to the fact that a direct path is laid to it: artery-aorta. Another possible reason for the fact that the dermoid cyst of the right ovary is more common is its more active ovulatory activity. According to statistics, the distribution of ovulation between the ovaries is as follows:

• Right ovary - 68%.
• Left ovary – 20%.
• The remaining percentages include ovulation evenly distributed between the ovaries.

It is believed that a dermoid cyst can develop for a very long time and grows slowly, literally a millimeter per year. It may not bother a woman for decades until a certain trigger stage, usually a hormonal change, less often a traumatic event. Obviously, the right ovary, each time performing the function of ovulation, is subject to microtrauma of a functional nature, therefore, it is more vulnerable and susceptible to hormonal influence. Perhaps this is one of the reasons why a dermoid cyst of the right ovary leads in the diagnostic list of all germ cell cysts.

Treatment of a right dermoid cyst involves surgical intervention if the neoplasm is large; if the pedicle is twisted, an emergency operation is indicated. If the dermoid is detected during a routine examination or when registering for pregnancy, is small (up to 3 centimeters) and does not bother the woman for six months, it is subject to observation. At the first favorable opportunity (after childbirth), it is better to remove the dermoid cyst to avoid complications - an increase in the formation, twisting of the pedicle or malignancy (development into a malignant process).

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Diagnosis of ovarian dermoid cyst

Ovarian cysts, especially dermoid ones, are most often diagnosed during routine gynecological examinations, when registering for pregnancy or due to painful symptoms presented by a woman. However, dermoids are asymptomatic, so their detection in 80% is secondary.

The first stage of diagnostics of ovarian dermoid cysts consists of examination and bimanual examination. As a rule, the examination method is vaginal-abdominal, less often recto-abdominal manual examination. A mature dermoid tumor (teratoma) is felt on palpation as an oval, mobile, rather elastic formation, which is localized on the side of the uterus or in front of it. Palpation of the dermoid does not cause painful sensations to the woman, except for discomfort associated with the examination, there are no other unpleasant phenomena. Confirmation of the detected tumor requires more accurate methods, such as ultrasound or puncture. Ultrasound examination is a highly informative method, the procedure involves the use of a transabdominal or transvaginal sensor. Ultrasound shows the parameters of the dermoid, the thickness of its capsule, the consistency of the cavity (composition), the presence of calcifications, in addition, with the help of ultrasound it is possible to determine how intensively the blood supply to the cyst is. If the ultrasound results do not satisfy the gynecologist, the woman may be prescribed a computed tomography (CT) scan or MRI.

In case of complicated process – inflammation, suppuration, large tumor, combined cysts, diagnostics of ovarian dermoid cyst involves puncture from the vaginal vault, including laparoscopic method. In case of suspicion of oncoprocess, however, and in standard examination also, blood test for SA – tumor markers is prescribed. Thus, malignancy of cyst is confirmed or excluded, in addition, differentiation of dermoid from other neoplasms of germinogenic nature is carried out.

Diagnosis of dermoid cyst (mature teratoma) of the ovary:

• Collection of anamnesis, including hereditary.
• Gynecological examination complex – examination, palpation.
• A rectovaginal examination is possible, excluding or confirming pressure on nearby organs or tumor growth.
• Ultrasound examination, usually transvaginal.
• If necessary, puncture and cytology of the obtained material.
• If necessary, Doppler ultrasound to differentiate between benign and malignant tumor development.
• Identification of possible tumor markers – CA-125, CA-72.4, CA-19.9.
• Computerized tomography or magnetic resonance imaging.
• A radiographic contrast study of the stomach may be prescribed.
• Cystoscopy and urography are possible.

It should be noted that an important object of study is the dermoid tubercle, which is the first indicator of possible malignancy of the process. It is examined histologically by puncturing, laparoscopy.

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Dermoid ovarian cyst on ultrasound

Ultrasound echography is still one of the most informative and safe methods of examination in obstetric and gynecological practice. The procedure is based on the principle of echolocation, when the sensor emits an ultrasonic wave, which in turn is reflected from the dense structure of the organ, and returns to the sensor again. As a result, an accurate image of the desired section appears on the screen. Since ultrasound mainly works in the mode of wave reception, not radiation, the method is absolutely safe for the body, including for pregnant women who have indications for examination.

Dermoid cyst of the ovary is determined quite accurately on ultrasound, most often the method involves examination using a transvaginal sensor. Previously, the method of examination through the anterior wall of the peritoneum was widely used, and for this it is necessary that the bladder is as full as possible. This caused a lot of inconvenience and created obstacles that are absent in the transvaginal method.

Dermoid ovarian cyst on ultrasound is differentiated from other types of cysts, teratomas and is defined as a visible neoplasm with thickened walls from 7 to 14-15 millimeters with echo-positive inclusions from 1 to 5 mm. Ultrasound should be performed repeatedly to track the dynamics of cyst changes. Mature dermoid teratomas have clear contours when scanning, but each study can provide new information about the contents of the cyst when various hyperechoic elements are visualized. Occasionally, ultrasound determines a tumor with very dense, almost homogeneous contents with rare linear inclusions. It should be recognized that it is the internal structure of the cyst that creates certain difficulties in diagnosis, because it can include only mesenchymal tissues, but can also consist of endo and ectoderm.

Ultrasound scanning of dermoids often requires clarification using MRI or CT due to the polymorphism of the cyst contents.

Sonographic signs of ovarian dermoid:

• Based on localization, a dermoid cyst is defined on ultrasound as unilateral; bilateral cysts are very rare, occurring in only 5-6% of women examined.
• The size of a dermoid can vary from 0.2-0.4 to 12-15 centimeters.

It should be noted that small dermoids are poorly screened and 5-7% of women with cysts up to 2 centimeters require additional research methods.

Ultrasound examination of a dermoid formation is performed in the following ways:

• Using an abdominal sensor with a full bladder.
• A transvaginal probe is a more informative method.

Using a rectal probe if the results of a previous transabdominal or transvaginal ultrasound are unclear, if a virgin is being examined, and also in case of occlusion or stenosis of the vaginal opening in elderly people (often after gynecological operations).

It should also be noted that a dermoid containing mesodermal elements (bones, dental elements) is the only germ cell cyst that can also be identified by abdominal radiography.

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Treatment of ovarian dermoid cyst

The only reliable way to neutralize and remove a mature teratoma (dermoid) is surgery. Treatment of a dermoid ovarian cyst with medications, reflexology, and physiotherapy procedures cannot be effective due to the structure of the cyst contents. Unlike other types of neoplasms, cysts filled with fluid, exudate, dermoids are not able to dissolve, because they contain bone, fibrous, fatty, and hair elements inside.

The method of surgical intervention is directly related to the following factors:

• Patient's age.
• Cyst size.
• Localization of the neoplasm.
• The degree of neglect of the process.
• The condition of the cyst is inflammation and suppuration.
• Torsion of the cyst stalk (emergency surgery).
• The nature of a dermoid cyst is benign or malignant neoplasm.

The standard parameters for selecting the operation method are as follows:

• Young women of reproductive age are recommended to undergo cystectomy (removal of the tumor within healthy tissue) or resection of the ovary at the site of cyst formation.
• Women in the climacteric period are prescribed an oophorectomy - removal of either one ovary affected by a cyst, or less often both. It is also possible to remove the ovary and fallopian tube - adnexectomy.
• If the dermoid stalk is twisted, the operation is performed on an emergency basis.

Most often, surgical intervention is performed laparoscopically, what will be used - laparoscopy or laparotomy, the doctor decides based on the woman's health. In the postoperative period, treatment of a dermoid ovarian cyst may include therapy with hormonal system support agents, it is also necessary to take into account that normal conception is possible only six months after surgery.

Treatment of dermoid in pregnant women is carried out somewhat differently:

• A small formation that is not prone to rapid enlargement or suppuration should be monitored throughout pregnancy.
• A rapidly enlarging cyst is subject to surgical removal, but not earlier than the 16th week of pregnancy.
• All dermoids, even small ones, should be removed after childbirth to eliminate the risk of their malignancy.
• A suppurating cyst, accompanied by torsion of the stalk, is removed at any stage of pregnancy, since it is a matter of preserving the life of the mother.

Removal of ovarian dermoid cyst

Surgical removal of a dermoid cyst of the ovary is considered the gold standard for the treatment of benign ovarian tumors (BNTs) of germ cell origin, and this method is especially relevant for mature teratomas (dermoids).

When removing a cyst, surgeons try to minimize traumatic damage to organs and preserve reproductive function (fertility). Modern surgery has a lot of instrumental, hardware technologies for performing such operations, thus reducing the inpatient treatment period, and scars and marks practically disappear over time.

Dermoids removal can be variable, so cysts from 0.5 to 5 centimeters in size, uncomplicated formations, are operated using laparoscopy. As a rule, three small incisions are made, through which a video camera and surgical instruments are passed. The operation lasts no more than an hour, literally in 3-5 days the woman can leave the hospital and continue treatment on an outpatient basis.

There are several types of operations, the choice of which depends on the size of the cyst, the age of the woman, and concomitant diseases.

Removal of a dermoid ovarian cyst can be done in the following ways:

1. Cystectomy. This is the removal of the cyst - its capsule and contents within the boundaries of healthy tissue. The ovary remains intact, it is not operated on. As a rule, cystectomy is performed for small dermoids, when the formation has not grown into the ovarian tissue of the ovary. A small surgical incision heals after 203 months, after six months the scar is almost invisible, and the ovaries do not change their functionality.
2. Resection (wedge-shaped) of a part of the ovary, when the dermoid is removed together with the damaged tissue area. Such an operation is indicated for a dermoid of more than 5-7 centimeters, and an absolute indication is torsion of the pedicle. Over time, the function of the operated ovary is restored, during the rehabilitation period the follicular reserve comes from the healthy ovary (compensation).
3. Removal of a dermoid cyst of the ovary together with the ovary is an ovariectomy. This method can be chosen in case of rupture, necrosis of the cyst, torsion of the stalk, suppuration.

Women of reproductive age who wish to become pregnant in the future most often undergo laparoscopy or wedge resection. Patients who have given birth with a high risk of cyst malignancy, women of menopausal age are recommended to undergo complete removal of the affected ovary.

Emergency operations are performed in the case of an “acute abdomen”, which is typical for torsion and suppuration of a cyst.

Consequences of removal of ovarian dermoid cyst

Like any other operation, removal of a dermoid ovarian cyst can have a variety of consequences. It is impossible to say for sure that laparoscopy or ovariectomy are absolutely safe and do not provoke consequences.

The most important task in treating a woman with a cyst is to minimize the risk of developing cancer, as well as maintaining fertility and normal functioning of the hormonal system.

Young patients of childbearing age are more likely to fear the consequences of the operation, as they want to bear and give birth to a baby. In fact, the removal of a dermoid that is not complicated by suppuration and other types of inflammation is not a contraindication to pregnancy. After six months, or better yet, a year, it is possible to conceive a healthy fetus and have a completely successful birth, even if one of the ovaries has been removed. Of course, pregnancy is impossible if both ovaries are removed, as well as after chemotherapy after treatment of squamous cell carcinoma, which can develop from a dermoid in 1.5-2% of cases.

Typical, although rare, consequences of ovarian dermoid cyst removal:

• Recurrence of cyst development with incomplete or partial removal of the cyst capsule.
• Infertility, including persistent. If resection or oophorectomy was performed on one ovary, it recovered, but the woman cannot conceive, the cause should be sought in other, clinically similar diseases of the pelvic organs, hormonal system, thyroid gland, and so on.
• Endometriosis.
• A disruption in the functioning of the hormonal system, which ideally should recover within a year – either on its own or with the help of hormone replacement therapy.

It should be noted that maintaining fertility depends on the volume of healthy ovarian tissue remaining. If more than half of the tissue is preserved, conception is possible after 6 months, until which time the ovary restores its lost functions. If resection was performed on two ovaries, in which 50% of healthy tissue also remained, pregnancy is possible after a year, provided that all medical recommendations are followed. Only 10-13% of patients lose fertility as a result of surgical treatment of a dermoid cyst.

Removal of a dermoid ovarian cyst, the consequences of which are usually not alarming, is a mandatory measure that reduces the risk of the dermoid developing into cancer.

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Laparoscopy of ovarian dermoid cyst

The gold standard for choosing surgical treatment for mature teratomas, as well as other benign ovarian tumors, is laparoscopy of the ovarian dermoid cyst.

Previously, such cysts were treated with adnexectomy, hysterectomy (removal with appendages). Currently, surgeons strive to minimize complications and use low-trauma, organ-preserving methods, which include a safe and effective method - laparoscopy. This reduces the possibility of developing adhesions by 2 times, the healing process of surgical incisions lasts no more than 2 months (usually 4 weeks), in addition, the laparoscopic method allows you to preserve the reproductive function of a woman and has one of the main advantages for patients - it does not provoke cosmetic defects of the peritoneum skin.

Also, the ability to control the removal process using a surgical video camera ensures the identification of pathological tissue, thus ensuring that healthy ovarian structures remain intact.

In older women, in menopause and later periods, laparoscopy of ovarian dermoid cysts reduces the risk of thromboembolism, which previously occurred quite often during abdominal surgeries.

According to statistics, 92-95% of all operations on dermoid cysts are performed using laparoscopy, which speaks not so much about the demand and popularity of the method, but about its effectiveness and safety.

Laparoscopy is performed using a special device - a laparoscope, minimal punctures are made in the peritoneum to perform all the necessary manipulations through them. The operation is controlled by a miniature video camera, which allows the doctor to see the state of the internal cavity, organs, and control the instrument. The tumor is enucleated, the capsule is removed, and coagulation of the ovarian tissue incisions is performed at the same time, so there is practically no bleeding. Sutures can be applied to the ovary only in the case of a huge cyst - from 10 to 15 centimeters. In addition to the fact that the dermoid is removed during the operation, a revision of the condition of the second ovary is also mandatory. After removing the cyst or excising part of the ovary, the surgeon flushes the abdominal cavity to neutralize the risk of peritonitis or inflammation. In addition, sanitation is needed to completely extract the contents of the cyst - hair follicles, fatty dendrite, which can get into the peritoneum during the enucleation of the cyst. Sanitation is performed using an aspirator (irrigator), the remaining contents of the dermoid are removed in the same way as its main structure. In the future, only control of hemostatic indicators of small surgical punctures (wounds) is required. The extracted material must be examined histologically.

Recovery after laparoscopy of the ovarian dermoid cyst does not take much time. Literally a day after the operation, a woman can move, get up, the main rehabilitation lasts no more than 2 weeks, and after 1.5-2 months you can even start sports training, but in a gentle version.