A huge dermoid cyst with thrombocytosis

and preoperative intraperitoneal

rupture: An unusual presentation

Abstract
Benign cystic ovarian teratoma is the most common ovarian neoplasm accounting for 10-25% of ovarian tumors.They affect
women of all age and particularly women of reproductive age group.They may present with a variety of symptoms ranging
from being asymptomatic to pain abdomen, dysmenorrhea, pelvic pain, nausea, vomiting, fever, anorexia, loss of weight
and shortness of breath. The complications associated with benign cystic teratoma are torsion (16%), malignant
degeneration (2%), rupture (1-2%), and infection (1%). Its spontaneous or iatrogenic intraperitoneal rupture is associated
with chemical peritonitis. A dermoid cyst has been associated with thrombocytosis in 30% of the cases.

Hereby we present a case of huge ovarian dermoid cyst associated with thrombocytosis and spontaneous preoperative
rupture with chemical peritonitis.

INTRODUCTION
Dermoid cysts constitutes about 10-25% of all benign ovarian neoplasms and are the most
common germ cell tumors in women of reproductive age.[1,2] Spontaneous rupture, although
rare occurs in <1% of cases which requires immediate intervention. Further, rupture leads to
intraperitoneal spillage of its contents resulting in chemical peritonitis with protracted recovery
phase.[3] Though thrombocytosis has been reported in 30% of the cases of dermoid cysts in a
study[4] there has been no case report showing this association. Hence, we are presenting a rare
case of huge dermoid cyst with thrombocytosis and preoperative intraperitoneal rupture.

CASE REPORT
A 25years old nulliparous lady with a married life of 7 years presented with abdominal pain of
six months duration more since one month, abdominal distension noticed since one month,
oligomenorrhoea since one year (menses once in two to three months for one day with scanty
flow). Had significant weight loss (25 kilograms over last 6 months), anorexia, breathlessness and
easy fatigability.
On examination, patient was afebrile, comfortable in propped up position, had moderate pallor, preoperative weight
of 55 kilograms (weight along with huge ovarian mass) and BMI of 26 kg/meter. [2] On palpation mass arising from
pelvis corresponded to 36weeks gravid uterus size and clinically measured 34 × 28 cms. It had variable consistency
and restricted mobility in both vertical and horizontal plane. On per vaginal examination the mass was felt through
all the fornices with minimal tenderness. Rectal examination revealed that the rectal mucosa and parametrium was
free of nodularity or indurations.
Investigations
Haemoglobin-7.4g/dl, PCV-24.4%, WBC-8000/cu mm, platelet count-600,000/L, peripheral smear- dimorphic
anemia with thrombocytosis, urine routine and culture-normal, RFT and LFT, blood sugars were normal.
Tumor markers CA 125: 158.70U/ml, LDH - 137.79U/L. Abdominopelvic Ultrasound revealed a uterine
size of 7.3 × 3.8 × 4.4 cm, with endometrial thickness of 6 mm, a well defined cystic lesion of 24 ×
15 × 20 cm with diffusely or partially echogenic mass with posterior sound attenuation owing to
sebaceous material and hair seen within the cyst cavity (the tip of the iceberg sign). There was
no evidence of internal vascularity. The two ovaries could not be seen separately. Impression: A
large ovarian dermoid cyst.

CT Scan showed a well circumscribed rounded soft tissue density lesion in right adnexa measuring 28.4 × 12.5
× 14.9 cms. The lesion showed predominately cystic areas with interspersed fat within, a 4 mm nodular calcific
focus was noted in the anterior wall. There was evidence of mass effect in the form of displacement of uterus
and urinary bladder. Impression: Right sided dermoid cyst.

Management
Pre operatively two pint packed cells were transfused and anemia corrected. Simultaneously was
evaluated for thrombocytosis, bone marrow biopsy was advised but patient refused. During the
course of preoperative preparation she developed acute breathlessness and pain abdomen,
spontaneous rupture was suspected and was taken for emergency laparotomy. During surgery a
very thick peritoneal surface was noted which looked inflammed. On opening the parietal
peritoneum, a thick yellowish fluid of about 1.5 litres which had collected in the paracolic gutters
and subhepatic spaces was suctioned [Figure 1]. A left ovarian mass of 30 × 20 cm (weighing 10
kilograms) was noted [Figure 2] with thick yellowish fluid oozing from the ruptured site. This
huge ovarian mass was excised and sent for frozen section which revealed ulcerated dermoid
cyst [Figure 3]. Uterus, right ovary and appendix were normal. Omental biopsy and peritoneal
biopsy was taken. A thorough peritoneal lavage was given and abdomen closed.
Post operatively she developed fever and was treated symptomatically. Post operatively platelet count was
repeated and was as high as 800,000/ L probably due to reactionary thrombocytosis. Further, monitoring of
platelet count 2 weeks later revealed a drop to preoperative value. On 21st postoperative day, the patient reported
back to us with symptoms of vomiting and pain abdomen, was diagnosed to have subacute intestinal obstruction
which was treated conservatively. She recovered and went back after one week. On subsequent follow up in
outpatient department, platelet had dropped to 420,000/L suggesting that preoperative elevated platelet count
was due to reactionary thrombocytosis.

Histopathological examination
Mature cystic teratoma [Figure 4]
Omentum: Non specific inflammation
Peritoneum: Non specific inflammation

Tube: Inflammed and congested

DISCUSSION
Dermoid cyst or mature cystic teratomas is the most common benign germ cell tumor and the most common neoplasm
of the ovary.[5] Mature teratoma of the ovary comprises a cyst lined by an epidermis- like epithelium and contains a
variable admixture of elements of one or more of the three cell lines; meso, endo and ecto-dermal derivatives including
sebaceous secretions, hair, teeth, bone or fat.[6]

Katie Williams et al, have reported a maximum of 15 × 15 cms sized dermoid cyst in their case
report; however, the weight of ovarian dermoid has not been mentioned in any of the case reports.

The diagnosis of a mature cystic teratoma using CT imaging is straight forward because this
modality is more sensitive for fat.[7] Fat is reported in 93% of cases and teeth or other calcifications
in 50%.[8]
Despite the benign nature of the neoplasm’s they have generated considerable interest because of their unusual
presentation. Rupture or perforation of the cyst may give rise to peritonitis however spontaneous rupture of an
ovarian dermoid cyst is very rare (<1%) due to the thick capsule.[8] Peritonitis resulting from a chronically leaking
dermoid cyst is characterized by multiple small white peritoneal implants, diffuse or focal omental infiltration
and inflammatory masses involving the omentum and bowel and dense adhesions and variable ascites that
simulate carcinomatous or tuberculous peritonitis.[9] In our case there was chemical peritonitis induced by
chronic leakage of sebaceous material leading to omental, peritoneal and intestinal infiltration
mimicking malignancy.

Thrombocytosis (platelet count > 400,000/L) and raised CA 125 levels are more frequently associated with malignant
ovarian tumor than with benign ovarian tumor.[10] Thrombocytosis is present in 30% of dermoid cysts, 25% of serous
cystadenomas.[4] In our case thrombocytosis (platelet count = 600,000/L) and elevated CA-125 (158.70U/ ml)was
associated with a huge ovarian mass which was diagnosed to be a dermoid cyst radiologically and confirmed
histopathologically. As thrombocytosis is said to be present in both benign and malignant ovarian tumors,
thrombocytosis per se should not alter the management and should just be considered as a marker of tumor burden.

CONCLUSION

Since, benign ovarian tumors like dermoid cyst can present with thrombocytosis, elevated CA-
125 and mimic malignant ovarian tumor intra-operatively (like peritoneal, omental and
intestinal implants with adhesions), the role of frozen section has to be over emphasised to
decide upon conservative surgery particularly in nulliparous women.