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 cystsof 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
I:I(. I ( j )J r I ft ( . I‘ it ‘ t f I i 1 i ;i ( 1(1(H ,( (l(1IIt II t
#{149}
r#{149} 1 tI 1 1t i t:j
#{149} ( /)/)i i i#{149}iJit. (: #{149}. R()( 1t( )F. I t )(k i\\ tI tl iFfll 1(t-((1( li( ( I(1 II K t‘ ) tIt(111 I (1tH IU
-I U . .\t L )t H )t 1IV I\\ I1 iI ti I i i F( 1 ( 1 ( IFt t( I( I
(- t 1 tI - I -It tr\ \ t I 1 ( I
I-’it.- . Il( )H#{149}(I-. ( t ( - R -i I - t( )ItI (1 tI -I\
I 1 I t--I I I(’ (1i it1( I tI - 1#{149}(1 1 t( 1
\ LF\
-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.
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 theircases 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