Volume 12, No 3 International Journal of Radiation Research, July 2014

Ultrasonography of immature teratomas:

11 case reports

Z.Y. Shen1*, B. Hu2, G.L. Xia1, K. Shen1

1Department of Radiology, Nantong Tumor Hospital, No. 30, North Tongyang Road, Nantong, Jiangsu, China

226361
2Department of Ultrasound in Medicine, Shanghai Institute of Ultrasound in Medicine, Shanghai Jiaotong

University Af iliated Sixth People’s Hospital, Shanghai, China 200233

ABSTRACT

Background: Ovarian immature teratoma is a very rare type of tumor
associated with a high relapse rate and mortality. Correspondingly, early
► Original article diagnosis is important for effec ve treatment. The goal of this study was to
retrospec vely analyze the ultrasound characteris cs of 11 cases of immature
teratomas. Materials and Methods: Between January 2002 and December
2010, 11 pa ents were diagnosed with pathologically confirmed immature
teratomas. Pa ents enrolled in this study underwent a transabdominal
* Corresponding author:
ultrasound examina on prior to surgery. Tumor size, shape, internal echo,
Dr. Zhi‐Yong Shen,
calcifica on, cys c degenera on, and blood flow for each immature teratoma
Fax: +86 513 86571201
were analyzed. Levels of alpha fetal protein (αFP) were also evaluated.
E‐mail: [email protected]
Results: The average tumor size was 8 cm (range, 4–13). Echo pa erns
obtained included mixed echo (n = 7), solid echo (n = 2), and cys c echo (n =
Received: June 2013
2). Coarse calcifica ons were detected in five cases, while blood flow signal
Accepted: Sept. 2013
was detected in one case, and ascites were detected in three cases. Only one
case had elevated levels of αFP. Conclusion: Ultrasound imaging of immature
Int. J. Radiat. Res., July 2014;
teratomas detected large tumors that were predominantly involved mixed‐
12(3): 203-209
echo masses, cys c degenera on, and coarse calcifica on on the cavity wall.
In some cases, blood flow signal was detected in the mass and ascites were
present in the abdominal cavity.

Keywords: Immature teratoma , ultrasound, calcification, alpha-fetal protein.

INTRODUCTION duced by Norris et al. (2), and was later modified

by Gonzales-Crussi (3). At the time of
Teratomas are common germ cell tumors that presentation, the symptoms most frequently
occur in females, and arise from totipotent
reported were lower abdominal or pelvic pain,
primitive germ cells. Teratomas are composed of and an increase in abdominal girth.
tissues derived from two or three germ cell
Mature teratomas and immature teratomas
layers (1), and are classified as mature teratomas have different treatment guidelines and
prognoses. For example, mature teratomas are
if they contain differentiated tissues, or
immature teratomas if they contain immature typically macroscopically resectable, while
tissues. In the latter case, immature teratomas immature teratomas are treated with salpingo-
can contain varying amounts of neuroectoder- oophorectomy, omentectomy, aortic lymph node
mal or blastemal tissues, and thus, are classified dissection, appendectomy, and biopsy of the
according to the amount of immature tissue remaining ovary. In contrast with mature
present. This grading system was irst intro- teratomas, immature teratomas are prone to
Shen et al. / Ultrasonography of immature teratoma

recurrence and peritoneal implants (4) and a reviewing sonograms and diagnosing ovarian
rapid onset of death has been associated with masses.
implants, even with grade I implants (5). There- Tumor size, shape, internal echo, presence of
fore, an accurate diagnosis prior to surgery is of calci ication, and cystic degeneration were
signi icant importance in order to identify the detected for each immature teratoma using
most effective treatment options and to establish two-dimensional ultrasonography. The blood
an accurate prognosis. Currently, ultrasonogra- low associated with each tumor was also
phy is the most commonly used diagnostic analyzed using color low imaging. The
method for ovarian masses. Therefore, the aim of parameters of any blood signals obtained were
this study was to analyze the sonographic further characterized by resistance index (RI)
features of patients with immature teratomas. and pulse index (PI) values, which were
recorded using pulse wave Doppler technology.
Levels of FP in human serum or plasma
MATERIALS AND METHODS samples were detected using enzyme-linked
immunosorbent assays (ELISAs).


Patients
Between January 2002 and December 2010, RESULTS
11 patients were diagnosed with immature

teratomas and all the tumors were pathologically
The clinical data and ultrasound
con irmed. The average patient age was 32 years
characteristics of the 11 patients retrospectively
(range, 12–62), and initial discomfort reported
analyzed in this study are listed in table 1.
by patients was commonly associated with an
Representative ultrasonography images are also
unusual pelvic mass, abdominal distension, or
provided in igures 1-4.
abdominal pain and discomfort. Parents or
Ovarian cysts or solid masses were detected
guardians of these patients provided written
during exploratory surgery. Although most
informed consent prior to being enrolled in this
tumors were maintained within a complete
retrospective study. This study was approved by
capsule, some tumors did not exhibit clear
the ethics committee of our institution. Clinical
boundaries due to intestinal adhesions, while
data, laboratory tests, imaging data, surgical
other tumors were associated with ascites.
notes, treatments, and results were obtained
Additional observations of the tumors detected
from each patient’s medical records.
included: the presence of capsule hair, a
grease-like substance, and the presence of some
Methods rough, partially gray papillary nodules. The
The initial diagnosis for all patients included a capsule wall thickness also varied from 0.1–0.5
complete medical history, a physical examina- cm, and internal calci ications were observed. All
tion, complete blood count, routine blood histopathologic samples were evaluated by an
chemistry results, and serum levels of tumor experienced pathologist.
markers, including alpha fetal protein (αFP). For 10/11 patients, their levels of αFP were
found to be within the normal range (i.e., < 25
Ultrasonography of pelvic masses was
obtained using a Philips/ATL HDI 5000 ng/ml), while the remaining patient had an αFP
(Universal Diagnostic Solutions, Oceanside, CA, level of 127 ng/ml. According to the
classification system previously established for
USA) and PHILIPS IU22 (Philips Medical
teratomas, 7/11 (63.6%) cases in this series
Systems, Bothell, WA, USA). At the time of
imaging, patients had a full bladder and were were classified as grade I, 2/11 (18.2%) cases
were classified as grade II, and 2/11 (18.2%)
maintained in a supine position in order to
optimize imaging of the adnexal mass. Image cases were classified as grade III. Six tumors
analysis was performed by two independent (cases 1, 2, 5–8) were correctly diagnosed
individuals with more than ten years experience pre-operatively, while the remaining ive cases
Int. J. Radiat. Res., Vol. 12 No. 3, July 2014 204
 Shen et al. / Ultrasonography of immature teratoma

were misdiagnosed as mature teratomas. Based Compared with mature teratomas, immature
on ultrasound imaging, mixed echo was detected teratomas are larger, less well-de ined, have a
in seven cases, coarse calci ication was detected prominent solid component, and are associated
in ive cases, ascites were detected in three
with foci of hemorrhage (7,8). In a previous study
cases, and af luent blood signal was detected in that evaluated immature teratomas using
one case. In the latter case, the RI and PI values magnetic resonance (MR) imaging (9), all lesions
of the blood signal detected were 0.43 and 0.65, that were detected appeared to be fat-containing
respectively. tumors with solid components consisting of

numerous cysts of various sizes. The solid
tissues exhibited a wide variety of signal
DISCUSSION intensities on T2-weighted images. However, in
most cases, ultrasound is the irst method
employed for imaging examinations. The
Ovarian immature teratomas are a type of
malignant germ cell tumor that represents less characteristics of immature ovarian teratomas
than one percent of all ovarian malignant tumors detected by ultrasound are reported less, in
diagnosed. For treatment, imaging studies are contrast to that of mature cystic teratomas,
critical. For example, computed tomography which are predominantly characterized by a well
(CT) can reveal a contrast-enhanced mass -de ined ovarian tumor with a typical fat– luid
consisting of both solid and cystic elements, as level and a round mass with a tuft of matted hair
well as scattered point-shaped calci ications (6). (6,10).

Table 1. Ultrasonography features and AFP results for the pa ents examined.
PaƟent Sonography Tumor AFP
Case no. Pathology Results; Ultrasongraphy characterisƟcs
age (yr) result dimensions (cm3) (ng/ml)
1 28 CM 11 × 8 × 9 13 grade II; coarse calcifica on with acous c shadow
2 24 SM and CM 9×9×7 19 grade III with SCC; blood flow signal within the mass, RI 0.43, PI0.65
3 22 Mixed* 9×6×9 11 grade I; heterogeneous
4 17 CM 4×3×3 12 grade I; coarse calcifica on
5 58 Mixed 9×9×8 15 grade I; ascites
6 56 Mixed 12 × 11 × 12 127 grade I; coarse calcifica on, ascites
7 24 Mixed 8×7×9 18 grade I; coarse calcifica on with acous c shadow, ascites
8 62 Mixed 5×4×5 21 grade III; coarse calcifica on
9 12 Mixed 4×4×5 19 grade I; no specialty
10 23 SM 8×7×8 11 grade II; heterogeneous
11 35 SM 5×3×5 21 Grade I; no specialty
*Mixed: Exhibited a prominent solid component with cys c elements; SM: solid mass; CM, cys c mass; IT, immature teratoma; RI: resistance index;
PI: pulse index; SCC, squamous cell carcinoma.

Figure 1. Ultrasonography (A) and pathological (B) analysis of a pelvic mass detected in a 24‐year‐old pa ent.
A pa ent experiencing abdominal distension underwent an ultrasound that detected a mixed mass with a diameter of 8 cm
associated with coarse calcifica on in the thick tumor wall (magnifica on 200x).

205 Int. J. Radiat. Res., Vol. 12 No. 3, July 2014

Shen et al. / Ultrasonography of immature teratoma

Figure 2. An ultrasound of a 17‐year‐old pa ent experiencing abdominal distension. A) A cyst with a heterogeneous internal echo
and a diameter of 3.5 cm was detected (the white arrow indicates coarse calcifica on). B) Gross pathologic specimen of the
tumor. C) Dissected specimen of the tumor; hair, necro c hemorrhagic degenera on and coarse calcifica on (the blue arrow)
were also observed. D) Immature neural ssue detected by hematoxylin/eosin staining (magnifica on, 100×).

Figure 3. A) An ultrasound of a 28‐year‐old pa ent with a pelvic mass. Coarse calcifica ons adhered to the wall of a cyst (arrow)
with a diameter of nine cm were detected. B) Immature neural ssue detected by hematoxylin/eosin staining (magnifica on,
200×).

Figure 4. Diagnosis of a 24‐year‐old pa ent with a pelvic mass.

A) A solid mass with a diameter of 9 cm was detected by
ultrasound. B) Color flow imaging iden fied a strong flow signal
in the mass, while pulsed Doppled detected a flow signal with a
RI value of 0.43 and a PI value of 0.65. C) A grade III immature
teratoma with squamous cell carcinoma (magnifica on 200x).

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 Shen et al. / Ultrasonography of immature teratoma

In the present study, the 11 cases of immature another study of immature teratomas that used
teratomas analyzed by ultrasonography were MR imaging (9).
characterized by both the histologic subtype and Typically, an af luent blood low signal is not
the tumor components detected in mature teratomas using ultrasound.
involved.
However, malignant teratomas can manifest a
Correspondingly, a mixed echo (n = 7) was
detected for most of the immature teratomas blood low signal when carcinomas are present.
evaluated, indicating the presence of multiple Abnormal blood low can also be detected in
stage I ovarian carcinomas by ultrasound (12). For
cystic and solid areas. Gross pathologic
tumor-induced vessels that are often dilated and
examination con irmed the presence of
heterogeneous masses near the uterus and saccular, they can also contain tumor cells within
bladder, and these contained cystic, fatty, and their endothelial lining (13). As a result, tumor
calcified elements. Therefore, we report that microvasculature differs from that of normal
tissue (13). Tumors can contain giant capillaries
immature teratomas contain a mixture of
and arteriovenous shunts without intervening
calcific, fatty, and fluid densities and are
capillaries. As a result of these differences in
associated with a greater number of solid
elements than mature teratomas. tissue vasculature, an af luent blood low signal
The cystic aspect of immature teratomas can can be detected within some malignant terato-
also represent regions of internal necrosis or mas. In this series, only one tumor had af luent
hemorrhage , while small foci of fat can also
(11) blood low detected, and this is hypothesized to
be associated with immature teratomas. In the be due to the onset of necrosis of other tumors.
latter case, these foci of fat can represent rapidly The other important ultrasound characteris-
growing tumors that frequently undergo a
tics observed in this study was coarse
perforation of the tumor capsule containing calci ication (n = 5). The pathologic equivalent of
them, thereby disrupting a well-de ined tumor coarse calci ication detected on ultrasound is the
mass (12). Three of the eleven cases also had
presence of bone or teeth, and if present, these
ascites in the abdominal cavity, indicating that tend to be located within so-called Rolitansky
nodules (14,15). Coarse calci ication can also
the peritoneal area was in iltrated. In
combination, these results are consistent with contain immature elements such as

Table 2. Ultrasonography differences in the detec on of mature versus immature teratomas.

Mature cysƟc teratomas Immature teratomas
Incidence rate One of the most frequent ovarian tumors in Represent < 1% of ovarian teratomas and typically affect
female pa ents of reproduc ve age younger pa ents (< 20 y of age) (10)
Size Average, 7 cm Typically larger (14–25 cm)(25)
Border Well‐defined Not always well‐defined, frequently exhibit perfora on of
the capsule (26)
Gray scale ultra‐ Involve a cys c lesion with a densely echogenic Appear solid, have a prominent solid component with cys c
sound tubercle (e.g., a Rokitansky nodule) projec ng elements(27),
into the cyst lumen (10). Alterna vely can be a or have a large, irregularly shaped solid component contain‐
diffusely or par ally echogenic mass with the ing coarse calcifica ons (1)
echogenic area usually demonstra ng sound
a enua on owing to sebaceous material and
hair within the cyst cavity (28). Mul ple thin,
echogenic bands are caused by hair in the cyst
cavity (6).
Calcifica on localized to the mural nodule (1) Calcifica on typically sca ered throughout the tumor (6)

Fat intermixed with hair strands are echogenic Small foci of fat within the solid component can be difficult
and o en a enuate the sound beam to recognize (6)
Color Doppler flow Seldom associated with intratumoral blood Significant intratumoral blood flow detected (29)
imaging flow
RI > 0.6; PI > 1 (29) RI < 0.4; PI < 0.6 (29)

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Shen et al. / Ultrasonography of immature teratoma

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