Objective
The objective of the study was to evaluate the clinical characteristics of ovarian teratoma by age.
Study Design
This was a retrospective study. Five hundred eighty medical records were reviewed from patients who underwent operative removal of ovarian teratomas at Samsung Medical Center between January 1996 and February 2010.
Results
The proportion of asymptomatic patients increased significantly after 20 years of age ( P = .0006). Ovarian torsion was noted in 26 patients (4.9%), without an age-specific difference ( P = .5019; range, 0.0–8.2%). Tumor size was different according to age group ( P < .0001), with larger tumor size in younger patients (<20 years old) relative to older patients. Immature teratoma revealed a higher incidence of symptomatic tumors on the first visit and significantly larger tumor size ( P = .0004) compared with mature teratoma.
Conclusion
Patients with ovarian teratoma have different clinical manifestations by age. It could help us understand clinical characteristics of the disease.
Mature teratoma, or dermoid cyst, is the most common ovarian tumor, accounting for 10-20% of all ovarian tumors. The disease is known to occur in patients at any age, but the peak incidence is reported in reproductive age. Although most adult cases were asymptomatic and incidentally detected on routine pelvic examination or pelvic imaging studies, the adnexal mass identified in children and adolescents showed different clinical manifestations, such as abdominal pain and distention. Nevertheless, previous studies focused only on young age groups, even though teratoma can be encountered at any age. Therefore, it is necessary to collect clinical information from all age groups with ovarian teratoma and analyze age-specific clinical characteristics of the disease.
There have been some studies regarding the clinical characteristics of ovarian teratoma, such as symptoms, size, operation method, malignant transformation, and tumor marker. However, age-focused analysis has been rarely reported, and most of the patient groups were restricted to childhood and adolescent periods. Therefore, we extended the age range and analyzed the age-specific clinical characteristics of 580 Korean female patients who underwent surgery because of ovarian teratoma.
Materials and Methods
The Samsung Medical Center Institutional Review Board approved this study, and it was determined to be exempt from informed medical consent requirements, because it was a retrospective review of the medical records.
The initial 4 presenting signs and symptoms of the patients were incidental finding, abdominal distension, palpable mass, and abdominal pain. The incidental finding category included patients diagnosed by routine gynecologic examination or diagnosed by symptoms not associated with tumor, such as vaginal discharge or menstrual irregularity.
Patient age was categorized into 6 groups. Groups 1-6 represented patients under the age of 10 years (n = 9), 10-19 years old (n = 58), 20-29 (n = 217), 30-39 (n = 143), 40-49 (n = 87), and 50 years and older (n = 66), respectively.
Tumor size was determined by review of the operative records, pathologic descriptions, and preoperative imaging studies, such as ultrasonography, computed tomography, and magnetic resonance imaging. Malignant tumors included any type of pathologically confirmed malignancy of the ovary, including immature teratoma, combined malignancy, and malignant transformation. The term combined malignancy means any malignant tumor, such as adenocarcinoma or borderline malignancy combined with mature teratoma, and malignant transformation means any type of malignancy, such as granulosa cell tumor or squamous cell carcinoma arising in ovarian teratoma.
Blood samples were obtained preoperatively and measured using radioimmunoassay for CA19-9 and CA125. The cutoff values for CA19-9 and CA125 were 35 U/mL. All patients underwent pelvic ultrasonography, and additional imaging studies were performed in some cases with suspicion of malignancy.
Statistical analysis was conducted for age-specific differences of initial symptoms, torsion rate, tumor size, serum tumor markers, and the incidence of malignant tumors. The Cochran-Armitage and Kruskal-Wallis tests were used where appropriate. Comparison between benign and malignant tumors was also conducted using the Fisher’s exact and Wilcoxon 2-sample tests. For malignant tumors, only those defined as immature teratoma were included, because combined malignancy and malignant transformation contain mature teratoma components.
Results
Clinical features of 580 patients operated for ovarian teratoma at Samsung Medical Center between January 1996 and February 2010 were reviewed.
Patient ages ranged from 5 to 85 years, with a mean (±SD) of 32.7 ± 12.6 years. In terms of initial symptoms, 29% of all patients revealed symptoms (168 of 580), with lower abdominal pain as the most frequent symptom for presentation in 59.5% (100 of 168) of all symptomatic patients. In age under 10 years and 10 to 19 years old, most patients were diagnosed because of symptoms such as abdominal pain and palpable mass (88.9% and 72.4%, respectively). However, the majority of patients at age 20 years and older presented without symptoms. The proportions of incidental findings were 71.4%, 86.4%, 78.6%, and 87.5% aged 20-29, 30-39, 40-49, and 50 years and older, respectively, which showed an abrupt increase in asymptomatic patients at age 20 years and older ( P = .0006).
Torsion was noted in 26 patients (4.9%), and the mean (±SD) size of tumors with torsion was 9.4 ± 2.9 cm (range, 5.1–17.0 cm). Torsion rate revealed no significant age-specific difference ( P = .5019). Tumor size ranged from 1.7 to 36.0 cm in diameter, with a mean (±SD) of 7.8 ± 4.5 cm, with a significant difference according to age group ( P < .0001). In particular, tumor size was much larger in patients age under 10 years and 10-19 years old (>10 cm) than in patients 20 years of age and older (≤8 cm).
Serum CA19-9 and CA125 levels also showed no significant age-specific differences by the Kruskal-Wallis test ( P = .0954 and P = .0901, respectively; Table 1 ). The mean serum CA19-9 level was 169.6 ± 560.7 U/mL, with 42.2% of patients above the normal range (<35 U/mL). The mean serum CA125 level was 25.4 ± 74.2 U/mL, with 12.1% of patients above the normal range (<35 U/mL). Serum CA19-9 levels showed a correlation with tumor size, bilaterality, and presence of symptoms ( P < .0001, P = .0002, and P = .0150, respectively). Bilateral tumors were detected in 15.1% of patients ( Table 1 ).
| Age | Group 1 | Group 2 | Group 3 | Group 4 | Group 5 | Group 6 a |
|---|---|---|---|---|---|---|
| Number of patients | 6 | 49 | 202 | 140 | 84 | 64 |
| Initial symptom, n (%) | ||||||
| Incidental | 1 (16.7) | 16 (32.7) | 144 (71.4) | 121 (86.4) | 66 (78.6) | 56 (87.5) |
| Abdominal distension | 0 (0.0) | 12 (24.4) | 11 (5.4) | 0 (0.0) | 1 (1.2) | 1 (1.6) |
| Palpable mass | 2 (33.3) | 5 (10.2) | 8 (3.9) | 2 (1.4) | 3 (3.6) | 0 (0.0) |
| Abdominal pain | 3 (50.0) | 16 (32.7) | 39 (19.3) | 17 (12.2) | 14 (16.6) | 7 (10.9) |
| Torsion, n (%) b | 0 (0.0) | 4 (8.2) | 13 (6.4) | 5 (3.6) | 3 (3.5) | 1 (1.6) |
| Tumor size, cm (mean ± SD) c | 10.1 ± 1.5 | 11.6 ± 6.2 | 8.0 ± 4.0 | 6.7±3.1 | 6.1 ± 3.3 | 6.4 ± 3.0 |
| Serum CA19-9 level (mean ± SD) d | 32.3 ± 33.4 | 82.1 ± 146.0 | 243.4 ± 771.7 | 137.7 ± 330.8 | 87.0 ± 252.2 | 151.8 ± 614.6 |
| Serum CA125 level (mean ± SD) e | 14.8 ± 5.4 | 20.6 ± 13.5 | 25.6 ± 50.0 | 22.5 ± 26.4 | 20.7 ± 31.9 | 10.9 ± 8.4 |
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