A 37-year-old woman comes to the emergency department due to sudden-onset nausea and severe right lower quadrant pain. The pain developed an hour ago after exercise and has become increasingly severe. The patient has no chronic medical conditions and has had no prior surgeries. She does not use contraception, and her last menstrual period was 3 weeks ago. Blood pressure is 136/94 mm Hg and pulse is 104/min. The abdomen is tender to palpation over the right lower quadrant. Pelvic ultrasound shows a right ovarian mass with no blood flow to the ovary. The specimen obtained from diagnostic laparoscopy and right oophorectomy is shown in the image below: Which of the following is the most likely diagnosis?

Question

A 37-year-old woman comes to the emergency department due to sudden-onset nausea and severe right lower quadrant pain.  The pain developed an hour ago after exercise and has become increasingly severe.  The patient has no chronic medical conditions and has had no prior surgeries.  She does not use contraception, and her last menstrual period was 3 weeks ago.  Blood pressure is 136/94 mm Hg and pulse is 104/min.  The abdomen is tender to palpation over the right lower quadrant.  Pelvic ultrasound shows a right ovarian mass with no blood flow to the ovary.  The specimen obtained from diagnostic laparoscopy and right oophorectomy is shown in the image below:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3923_ee72_9249_233131bff0b5_MD0001_00 This patient with sudden, severe right lower quadrant pain and absent blood flow to the ovary has ovarian torsion due to a mature cystic teratoma (ie, dermoid cyst). Dermoid cysts are benign germ cell tumors typically diagnosed in women age 10-30. Patients with a mature teratoma are often asymptomatic and diagnosed incidentally (eg, pelvic examination, ultrasound). However, the increase in ovarian bulk can predispose to ovarian torsion (rotation of the adnexa around the infundibulopelvic ligament); affected patients typically develop sudden, unilateral pelvic pain after physical activity (eg, exercise). Teratomas have a gross appearance consistent with all 3 germ cell layers (ectoderm, mesoderm, endoderm). These pluripotent germ cells reside in the ovary and later differentiate into nonovarian tissue, including skin, hair, sebaceous glands (ectoderm); muscle, cartilage, fat (mesoderm); and thyroid or gastrointestinal tissue (endoderm). The typical teratoma is a unilateral, multicystic mass containing yellow sebaceous fluid, solid components (eg, teeth, cartilage), and hair. (Choice A) An ectopic pregnancy can implant on the ovary and cause nausea, abdominal pain, and an ovarian mass. However, gross pathology typically reveals products of conception (eg, embryo, chorionic villi). (Choice B) Endometriomas are cystic masses of ectopic endometrial tissue and old blood that typically have a homogenous, chocolate cyst appearance. (Choice D) Mucinous cystadenomas are benign, surface epithelial ovarian masses that appear as thin-walled loculations of mucinous fluid; there is no associated hair. (Choice E) Ovarian fibromas are sex cord tumors and have smooth capsules with homogenously dense tissue composed of fibroblastic cells. (Choice F) Yolk sac tumors are malignant germ cell tumors with gray-yellow, necrotic, and hemorrhagic areas on a gross specimen; there is no associated hair. Educational objective: Mature cystic teratomas (ie, dermoid cysts) are derived from all 3 germ cell layers; therefore, the typical gross appearance is a multicystic mass containing yellow sebaceous fluid, solid components (eg, teeth, cartilage), and hair. Although often asymptomatic, affected patients are at increased risk of ovarian torsion. __________ References: Bilateral dermoid ovarian torsion in a young woman: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/29880039)

A 37-Year-Old Woman Comes to the Emergency Department Due to Sudden-Onset