eMedicine Specialties > Oncology > Gynecologic Carcinomas

Teratoma, Cystic: Differential Diagnoses & Workup

Author: Chad A Hamilton, MD, Associate Program Director, NCC Fellowship in Gynecologic Oncology, Assistant Professor, Division of Gynecologic Oncology, Walter Reed Army Medical Center
Coauthor(s): Margarett C Ellison, MD, Consulting Staff, Kaiser Permanente, Los Angeles Medical Center
Contributor Information and Disclosures

Updated: Jan 23, 2009

Differential Diagnoses

Adnexal Tumors
Neurogenic Tumors of the Mediastinum
Benign Lesions of the Ovaries
Ovarian Cancer
Borderline Ovarian Cancer
Ovarian Cysts
Ectopic Pregnancy
Ovarian Dysgerminomas
Endometrial Carcinoma
Peritoneal Cancer
Endometriosis
Pilonidal Disease
Extragonadal Germ Cell Tumors
Rectal Prolapse
Germ Cell Tumors
Testicular Choriocarcinoma
Granulosa-Theca Cell Tumors
Testicular Seminoma
Hydrocele
Testicular Torsion
Lymphoma, Mediastinal
Testicular Trauma
Lymphomas, Endocrine, Mesenchymal, and Other Rare Tumors of the Mediastinum
Testicular Tumors: Nonseminomatous
Malignant Lesions of the Fallopian Tube and Broad Ligament
Thymic Tumors
Malignant Lesions of the Ovaries
Thymoma
Mediastinal Cysts

Other Problems to Be Considered

Sacrococcygeal teratomas should be differentiated from neural tube defects, specifically meningoceles or meningomyeloceles. Also included in the differential are epidermoid cysts, anal duct or pilonidal cysts, rectal abscesses, lymphangiomas, imperforate anus, and rectal prolapse.4,25

Ovarian cystic teratomas should be differentiated from other benign or malignant ovarian neoplasms, endometriomas, tuboovarian abscesses, pedunculated uterine fibroids, hydrosalpinxes, ectopic pregnancies, pelvic kidneys, and peritoneal cysts.32,6

Testicular teratomas should be differentiated from juvenile granulosa cell tumors, cystic dysplasia of the rete testes, testicular cystic lymphangioma, and simple testicular cysts.27

Mediastinal teratomas should be differentiated from other mediastinal masses, including neurogenic tumors (23%), thymomas (21%), lymphomas (13%), germ cell tumors (12%), enterogenous cysts (10%), pericardial cysts (7%), and other miscellaneous lesions (13%). Other less common mediastinal masses include primary carcinomas, mesenchymal tumors, endocrine tumors, giant lymph node hyperplasia, chondromas, and extramedullary hematopoiesis.33

Workup

Laboratory Studies

  • Elevated serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (HCG) levels may be indicative of malignancy, as these values are within reference ranges in most patients with benign teratomas.29

Imaging Studies

  • The workup for cystic teratomas is largely radiographic, and their appearance is similar despite varying locations.  
    • If the teratoma is recognized in utero, the fetus should undergo serial ultrasound surveillance for development of fetal hydrops. In the case of sacrococcygeal teratomas, an ultrasound examination may demonstrate cystic components and extension of the tumor into the pelvis or abdomen (see Image 3). Ultrasound may reveal mass displacement of the bladder and rectum, with compression of the ureters resulting in hydroureter or hydronephrosis.34,12
    • CT scanning of the abdomen and pelvis before surgical exploration can further delineate sacrococcygeal tumor from normal anatomic features.5
    • Similarly, ultrasonography with adjunctive CT scanning is useful in imaging suspected ovarian teratomas and may detect liver and retroperitoneal lymph node involvement in malignant cases. Ultrasonic findings ascribed to teratomas include shadowing echo densities, regionally bright echoes, hyperechoic lines and dots, and fluid-fluid levels.35  In a study by Mais et al, transvaginal ultrasonography had a sensitivity and specificity of 84.6% and 98.2%, respectively, for differentiating cystic teratoma from other ovarian masses.36  In another trial, Patel et al demonstrated a 98% positive predictive value and 85% sensitivity using ultrasound to diagnose and identify cystic teratomas.32
    • CT scan usually reveals the complex appearance of ovarian teratomas, with dividing septa, internal debris, fat attenuation (93%), and distinct calcification (56%).35
    • MRI can sufficiently differentiate lipid density from other fluid and blood and may be another useful adjunct for diagnosis of ovarian teratomas, with an accuracy of 99%.37
    • In the case of a suspected mediastinal teratoma, anterior-posterior and lateral chest radiographs provide important information as to size and location of the mass.38
    • CT scan and/or MRI may further clarify the diagnosis and also are invaluable in delineating the boundaries of mediastinal masses, potential vascular involvement, and respectability.38,39
    • Echocardiography can be used to delineate physiologic effects of mediastinal masses, such as tamponade or pulmonary stenosis, and may be used to guide needle biopsy.33

Procedures

  • Fine-needle aspiration or core biopsy can be used to differentiate benign from malignant mediastinal masses in 90% of cases.33

Histologic Findings

In cystic teratomas, the outside of the tumor wall is usually lined with native tissue. The cavity of the cyst is often lined with keratinized squamous epithelium and usually contains abundant sebaceous and sweat glands. Hair and other dermal appendages are usually present. Occasionally, the cyst wall is lined with bronchial or gastrointestinal epithelium. Foreign body giant cell reactions may be seen in various parts of the tumor and may, in the case of intraperitoneal teratomas, lead to formation of extensive adhesions if the tumor contents are spilled. Ectodermal tissue encountered may include brain, glia, neural tissue, retina, choroids, and ganglia. Mesodermal tissue is represented by bone, cartilage, smooth muscle, and fibrous tissue.38,40 One report describes a 7-cm ovarian teratoma containing a mandiblelike structure with 8 well-formed teeth.41

Staging

Sacrococcygeal teratomas are the only teratomas with a widely accepted staging or classification system. In a study of 405 patients treated by members of the Surgical Section of the American Academy of Pediatrics, Altman and associates report the following system:14

  • Type I tumors are predominantly external, attached to the coccyx, and may have a small presacral component (45.8%). No metastases were associated with this group.
  • Type II tumors have both an external mass and significant presacral pelvic extension (34%) and have a 6% metastases rate.
  • Type III tumors are visible externally, but the predominant mass is pelvic and intraabdominal (8.6%). A 20% rate of metastases was found in this group.
  • Type IV lesions are not visible externally but are entirely presacral (9.6%) and have an 8% metastases rate.

More on Teratoma, Cystic

Overview: Teratoma, Cystic
Differential Diagnoses & Workup: Teratoma, Cystic
Treatment & Medication: Teratoma, Cystic
Follow-up: Teratoma, Cystic
Multimedia: Teratoma, Cystic
References
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Further Reading

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Keywords

cystic teratoma, dermoid teratoma, dermoid cyst, ovarian cancer, ovarian cyst, ovarian malignancy, dermoid tumor, testicular cancer, testicular tumor, kyste dermoid, ovarian neoplasm, sacrococcygeal teratoma, dermoid, teratoma, dermoid cyst, mature cystic teratoma, monodermal

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Contributor Information and Disclosures

Author

Chad A Hamilton, MD, Associate Program Director, NCC Fellowship in Gynecologic Oncology, Assistant Professor, Division of Gynecologic Oncology, Walter Reed Army Medical Center
Chad A Hamilton, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, and Society of Gynecologist Oncologists
Disclosure: Nothing to disclose.

Coauthor(s)

Margarett C Ellison, MD, Consulting Staff, Kaiser Permanente, Los Angeles Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Lodovico Balducci, MD, Professor of Oncology and Medicine, University of South Florida College of Medicine; Division Chief, Senior Adult Oncology Program, H Lee Moffitt Cancer Center and Research Institute
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Benjamin Movsas, MD, Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center
Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, and American Society for Therapeutic Radiology and Oncology
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting; FibroGen Consulting fee Consulting

 
 
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