Growing Teratoma Syndrome of the Ovary Showing Three Patterns of Metastasis: A Case Report
A 14-year-old girl presented to a local hospital in June 2006 with abdominal fullness. Physical examination was normal except for abdominal discomfort. Computed tomography (CT) scans revealed a 15-cm mass and a small amount of ascites, but no sign of lymph node enlargement (fig. ). Serum tumor markers were slightly elevated: CA19-9 = 113.8 U/ml, CA125 = 60 U/ml, SCC = 2.5 ng/ml, and α-fetoprotein (AFP) = 297.4 IU/ml. Serum human chorionic gonadotropin (HCG) was negative. Liver and renal function tests, electrolytes, and a complete blood count were all normal. The initial laparotomy revealed that the left ovary was larger than the size of a child's head and had already ruptured with slightly bloody fluid in the pelvic cavity. Left salpingo-oophorectomy and omentectomy were performed. The cytologic examination of ascites detected malignant cells. Histological examination revealed the tumor to be a mixed germ cell tumor which included a grade 3 immature teratoma (75%), mature teratoma (10%), embryonal carcinoma (10%), and yolk sac tumor (5%) (fig. ). The patient was therefore diagnosed with a left ovarian mixed germ cell tumor, clinical stage 1c [pT1c(2) NxMx].\nShe underwent 6 cycles of chemotherapy postoperatively with cisplatin, etoposide, and bleomycin (BEP). The tumor markers normalized 1 month after the operation. Five years after the completion of chemotherapy, routine CT scans revealed dissemination in the pelvic region, para-aortic lymph node metastasis, and lung metastasis (fig. ). However, the interval since the last examination had been 18 months based on the patient's wishes. No tumor marker was elevated.\nThe patient was admitted to Nagoya University Hospital for resection of the three types of metastatic mass. Secondary laparotomy showed a 3-cm dissemination on the mesentery of the sigmoid colon and two 1-cm disseminations on the posterior uterus. We removed the three disseminated lesions. Next, we removed an 8-cm metastatic tumor in the para-aortic lymph node. One month after the secondary laparotomy, video-assisted thoracoscopic surgery was performed for a right lung metastasis. Pathologic analysis of the resected specimens revealed that all metastatic tumors were mature teratomas (fig. ). The patient is now undergoing regular follow-up and remains disease free 11 months after the second surgery.