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DERMOID CYSTS OF THE OVARY PRESENTING AS A CAUSE OF ACUTE ABDOMINAL PAIN IN CHILDHOOD

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DERMOID

CYSTS

OF

THE

OVARY

PRESENTING

AS A CAUSE

OF

ACUTE

ABDOMINAL

PAIN

IN CHILDHOOD

By Cohn C. Ferguson, M.D., F.R.C.S.(C), and Thomas K. Goodhand, M.D.

Departments of Surgery of the Children’s Hospital and of the Uniccr.sitq of \Ia;iitoba

CASE

REPORTS

(Accepted November 24, 1958; submitted November 3.)

ADDRESS: (C.C.F.) Department of Surgery, University of Manitoba, Winnipeg, Canada.

S

YMPTOMS referable to denmoid cysts

of the ovary are relatively uncommon

before the age of puberty. When they do

occur, however, tile diagnosis may be

straightforward on the symptoms produced may mimic other intra-abdominal disease.

This report is concerned with five benign

ovarian denmoids removed from four girls

at the Winnipeg Children’s Hospital since

1954.

INCIDENCE

Gross1 has reported seven benign denmoid

ovarian cysts in cilildnen treated at the

Boston Children’s Hospital during a period

of 20 years. Butt2 reported 14 benign

tera-tomas in young girls at the Hospital for

Sick Children in Toronto. From three other

reported senies,35 he collected a total of 82

cases. In a 28-year period at the Mayo

Clinic, Costin and Kennedy6 found only

10 cases of tenatoma (including dermoids)

in girls less than 15 years of age. Schultz

estimates the incidence of all ovarian

tu-mors in girls less than 15 years of age to be

about 1% of all tumors occurring in children

of both sexes in this age group. Benign

tenatomas therefore approximate 0.35% of

all tumors in this age group.

PATHOLOGY

Denmoid cysts of the ovary are usually

composed of tissues arising from ectoderm,

such as skin, hair, sebaceous glands and

teeth. They are in reality adult tenatomas,

and are given the designation “dermoid

cysts” because of this predominance of

dermal structures. If adequate sections are

studied, as Cappehl8 has indicated,

nepre-sentative derivatives of all three germ layers

will he evident. The tumors may be

mahig-nant at the outset or Illalignancy can

de-velop in a previously benign lesion. While

this latter change is more common in adults,

it can occur in childhood, as reported in a

9-year-old girl by Puhr#{176}(quoted by

Peter-son’#{176}).

Case

1

HISTORY AND PHYSICAL FINDINGS: C.\V., a

43-vear-old girl, had stiffened from repeated episodes of left lower al)dominah pain

associ-ated with nausea and, on occasion, vomiting

for a period of 18 months. On several occa-sions either appendicitis or infection of the un-nan’ tract had been susl)ected, i)ut it ‘as not until the pelvic mass was felt on rectal exami-nation that the true nature of the condition was established.

ROENTGENOGRAPHIC FINDINGS :

Roentgeno-grams revealed a soft tissue mass situated he-tween bladder and rectum, but no calcification was apparent.

OPERATIVE FINDINGS: Laparotomv was

per-formed on November 12, 1957, and a cyst measuring 6 cm in greatest diameter was found involving the entire left ovar’. The right

ovary was normal and therefore a left oophor-etomy was performed.

PATHOLOGIC FINDINGS: Sections showed the

cyst wall to be lined by stratified squamous epithelium and containing dermal appendage

such as sebaceous glands, sveat glands, and

hair follicles. Well-defined ghial tissue was also

present. Although no entodermal structures were seen in these sections, they- might be present in other areas. There was no evidence

of mahignanc- . The anatomic diagnosis was

adult teratoma of ovary (dermoid c’st).

Case 2

HISTORY AND PHYSICAL FINDINGS: AT., a

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-ARTICLES 949

November, 1957, the l)atient developed severe ai)(lolflinal pain accompanied by’ vomiting, and fever of 40#{176}C.The abdomen became distended ail a hard tender pelvic mass could be felt P’ rectum. A diagnosis of ruptured appendi-citis with l)el\’ic abscess ‘as made and the chikl

‘as tredted conservativel . Although the gen-eral status improved, the pelvic mass remained hard and fixed. On December 17, 1957, 4 weeks after the onset of the illness, the child vas a(llllitted to the Children’s Hospital.

ROENTGENOGRAPHIC FINDINGS : Roentgeno-grams of the lower abdomen revealed a dell-sit measuring 1.7 Clii long and 1 eni wide ill the mid-pelvis (Fig. 1). A diagnosis of ovarian dermoid was made.

OPERATIVE FINDINGS: At laparotomv, a firm

a(lherellt IT1LSS was found ill the l)elvis vhich 011 dissection ‘as found to i)e a tViSte(l and infarcted c’st of the left ovar’ measuring

6 cm ill greatest diameter. The night ovary

‘as normal, and a left salpingo-oophorectomv

was performed.

PATHOLOGIC FINDINGS : M kroscopic sections siio prti11s of cyst vall lined b 5tlIllOU5 e1)itheliurn vith hair follicles and sei)aceous glan(IS. ihere was heniorrhagic infarction of

the wall with deposition of hemosidenin in some areas. Small fragments of cartilage were included. There was no evidence of mahig-nancy. The anatomic diagnosis was adult tera-toma of ovary.

Case 3

HISTORY AND PHYSICAL FINDINGS: J.I., an

8-year-old girl, had acute loven abdominal P#{176}#{176}with vomiting of :3 days duration. At the time of admission to the hospital on November

2:3, 1954, the temperature was 38#{176}Cand the leukocvte count was 15,100/mm1. The lower al)domen was tender vith muscle guarding and a mid-line pelvic mass was palpated on rectal exaniination. A clinical diagnosis of acute a

pendicitis ‘as made.

ROENTGENOGRAPHIC FINDINGS : Roentgeno-grams of the abdomen revealed an irregular

calcified or ossified density 2 cm in diameten Opposite the right side of the distal portion of the sacrum (Fig. 2).

OPERATIVE FINDINGS: At lapanotomv, a

gall-grenous mass 8.5 by 5 cm in size, involving the left ovar, was found. A left salpingo-oophorec-tom’ was performed.

(3)

950 DERMOID CYSTS OF THE OVARY

showed an ovarian cyst containing

subcutane-Ous fat, squamous epithehium, sebaceous glands

and hair follicles. There was considerable

hem-orrhage into the mass. There was no evidence

of malignant neoplasia. The anatomic diagnosis

was adult teratoma (dermoid cyst) of ovary, strangulated.

Case 4

HISTORY, PHYSICAL AND ROENTGENOGRAPHIC

FINDINGS: G.G., a 13-year-old girl, complained

of low back pain of 2 months’ duration.

Clini-cal examination revealed no abnormality’, but

roentgenograms showed two calcified or

ossi-fled densities in the pelvis. A diagnosis of

bi-lateral ovarian dermoids was made and

opera-tiOll advised.

OPERATIVE FINDINGS: Laparotomy was

per-formed on December 30, 1957. A cyst,

measur-ing approximately 4.5 cm in diameter, was found arising from each ovary. Bilateral ovar-ian cvstectomies were performed. Fortunately’, it was possible to leave both Fallopian tubes and a considerable amount of normal ovarian tissue on both sides.

PATHOLOGIC FINDINGS: Microscopic sections

showed a varied histologic appearance. One

cst was partially lined by’ skin containing se-baceous glands, hair follicles, and sweat glands.

The wall contained an inclusion of cerebehlar

cortex complete with Purkinje cells. Sections

of the other cyst contained epithehium resem-bling that of the respiratory tract and small fragments of hyaline cartilage. There was no

evidence of malignancy’. The anatomic

diagno-sis was adult teratomas of ovaries.

CONCLUSIONS AND SUMMARY

Benign dermoid ovarian cysts

uncom-monly cause symptoms in young girls. It

is estimated that they constitute 0.35% of

all tumors occurring in children of both

sexes less than 15 years of age.

Symptoms produced by the cysts may

mimic other intna-abdominah disease, and

in three of the four cases reported in this

series the girls were initially considered to

have either acute appendicitis or infection

of the urinary tract. All three had a pelvic

mass palpable per rectum. The fourth girl

was found to have bilateral calcified

densi-ties in the ovaries when examined

roent-In three of the four children, calcified

or ossified material in the pelvis was seen

in roentgenograms of the lower abdomen,

and this finding was considered by the

radiologist to be indicative of ovarian

den-moid cyst.

In two patients the cysts and associated

Fallopian tubes had undergone torsion with

infarction, and salpingo-oophorectomies

were performed. In one girl, a simple

oophonectomy was carried out, and, in the

fourth child with bilateral dermoids, a

bi-lateral ovarian cystectomy with

preserva-tion of tubes and as much ovarian tissue

as possible was performed.

All four girls have subsequently made

satisfactory progress.

Acknowledgment

The authors are indebted to Drs. R. Lyons

and

J.

T. Farn for permission to include their

cases in this report.

REFERENCES

1. Gross, R. E. : The Surgery of Infancy

and Childhood. Philadelphia, Saunders,

1953, p. 497.

2. Butt,

J.

A. : Ovarian tumors in children.

Am.

J.

Obst. & Gvnec., 69:8:33, 1955. 3. Witzberger, C. M., and Agerty, H. A.:

Ovarian tumors in infancy and

child-hood, with report of case and review of

literature. Arch. Pediat., 54:339, 1937.

4. Dargeon, H. W. : Ovarian tumors in

child-hood. PEDIATRICS, 3:773, 1949.

5. Ladd, W. E., and Gross, R. E. : Abdominal

Surgery in Infancy and Childhood. Philadelphia, Saunders, 1941, p. 388.

6. Costin, M. E., Jr., and Kennedy, R. L.

J.:

Ovarian tumors in infants and in

chil-dren. Am.

J.

Dis. Child., 76:127, 1948.

7. Schultz, 0. T. : Tumors of infancy and

childhood, in Abt, I. A. : Pediatrics,

Vol. 8. Philadelphia, Saunders, 1926,

p. 707.

8. Cappell, D. F. : In Muirs’ Textbook of Patholog’, 6th Ed. London, Arnold,

1951, p. 973.

9. Puhr, L. : Seltenes Karzinomatoses

Den-moid des Ovarium. Zentralbl. Gvn#{228}k.,

59:659, 1935.

-10. Peterson, W. F. : Malignant degeneration

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1959;23;948

Pediatrics

Colin C. Ferguson and Thomas K. Goodhand

ABDOMINAL PAIN IN CHILDHOOD

DERMOID CYSTS OF THE OVARY PRESENTING AS A CAUSE OF ACUTE

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1959;23;948

Pediatrics

Colin C. Ferguson and Thomas K. Goodhand

ABDOMINAL PAIN IN CHILDHOOD

DERMOID CYSTS OF THE OVARY PRESENTING AS A CAUSE OF ACUTE

http://pediatrics.aappublications.org/content/23/5/948

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