Cystic Teratoma

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Practice Essentials

Teratomas are germ cell tumors commonly composed of multiple cell types derived from one or more of the 3 germ layers. Teratomas range from benign, well-differentiated (mature) cystic lesions to those that are solid and malignant (immature). Additionally, teratomas may be monodermal and highly specialized. This article focuses on mature cystic teratomas, commonly referred to as dermoid cysts. See the images below.



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Mature cystic teratoma of the ovary exhibiting multiple tissue types.



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Mature cystic teratoma of the ovary with hair, sebaceous material, and thyroid tissue.

Malignant transformation occurs in 1–3% of mature cystic teratomas (MCTs), usually in postmenopausal women. Transformation to squamous cell carcinoma occurs most commonly (75%), followed by transformation to adenocarcinoma and carcinoid tumors.[1]

Sacrococcygeal teratomas may be diagnosed antenatally during routine ultrasounds, fetal anomaly scans, or when the mother presents with clinical symptoms such as size greater than dates or polyhydramnios.[2]  Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications. Testicular teratomas most often present as a painless scrotal mass, except in the case of torsion. Mediastinal teratomas are often asymptomatic.

The treatment of mature teratomas is largely surgical. Patients should be informed of the risks of surgery and of the various surgical options, as discussed in Surgical Care.

For patient education information, see An Overview of Dermoid Cysts.

Background

Inconsistent nomenclature often confuses discussions of various subtypes of teratomas. The word is derived from the Greek teras, meaning monster, which Virchow coined in the first edition of his book on tumors, published in 1863.[3]

In 1831, Leblanc coined the term dermoid cyst in the veterinary literature when he removed a lesion that resembled skin at the base of a horse's skull, which he called a “kyste dermoid.”[4] Both dermoid and teratoma, terms now more than a century old, remain in general use and often are used interchangeably, with various preferences among subspecialties. The earliest implications were that elements similar to skin and its appendages comprised dermoids, while teratomas had no such limits. Dermoids now are recognized as often being trigerminal and containing practically any type of tissue.

For those who continue to make a distinction, dermoids are tumors that maintain rather orderly arrangements, with well-differentiated ectodermal and mesodermal tissues surrounding endodermal components. Teratomas, specifically solid teratomas, are essentially devoid of organization; thus, the presence of some degree of organization, a high degree of cellular differentiation, and cystic structure differentiates dermoids from teratomas.[3]

Pathophysiology

Teratomas are made up of a variety of parenchymal cell types representing more than 1 germ layer and often all 3. Arising from totipotential cells, these tumors typically are midline or paraxial.[5]

The most common location is sacrococcygeal (57%). Because they arise from totipotential cells, teratomas are encountered commonly in the gonads (29%). By far the most common gonadal location is the ovary, although they also occur somewhat less frequently in the testes. Cystic teratomas occasionally occur in sequestered midline embryonic cell rests and can be mediastinal (7%), retroperitoneal (4%), cervical (3%), and intracranial (3%).[6]

Cells differentiate along various germ lines, essentially recapitulating any tissue of the body. Examples include hair, teeth, fat, skin, muscle, and endocrine tissue.

The parthenogenic theory, which suggests an origin from the primordial germ cells, is now the most widely accepted. This theory is bolstered by the anatomic distribution of the tumors along lines of migration of the primordial germ cells from the yolk sac to the primitive gonads.[5, 7]  Additional support came from Linder and associates' studies of mature cystic teratomas of the ovaries. They used sophisticated cytogenetic techniques to demonstrate that these tumors are of germ cell origin and arise from a single germ cell after the first meiotic division.[8]

Epidemiology

Frequency

Sacrococcygeal teratomas (SCT) are the most common tumors in newborns, occurring in 1 per 20,000-40,000 births.[5, 9] A population-based (rather than tertiary referral center) estimate from the United Kingdom found a birth prevalence of 1 per 27,000 live births.[10]  A retrospective study of newborns diagnosed with SCT in southern Sweden from 2000 to 2013 found an overall incidence of approximately 1 per 14,000 live births, with overall mortality of 11%.[11]

Mature cystic teratomas account for 10-20% of all ovarian neoplasms. They are the most common ovarian germ cell tumor and also the most common ovarian neoplasm in patients younger than 20 years. They are bilateral in 8-14% of cases.[4, 3, 12, 13]

The incidence of all testicular tumors in men is 2.1-2.5 cases per 100,000 population. Germ cell tumors represent 95% of testicular tumors after puberty, but pure benign teratomas of the testis are rare, accounting for only 3-5% of germ cell tumors. The incidence of all testicular tumors in prepubertal boys is 0.5-2 per 100,000, with mature teratomas accounting for 14-27% of these tumors. It is the second most common germ cell tumor in this population.[14, 15]

Benign teratomas of the mediastinum are rare, representing 8% of all tumors of this region.[16]

Sex

Sacrococcygeal teratomas are much more common in females than in males, occurring in a female-to-male ratio of approximately 3-4:1. Most sources report no sex predilection for mediastinal teratomas. Others document a marked male or marked female predominance. Excluding testicular teratomas, 75-80% of teratomas occur in girls.[6]

Age

The presenting location of teratomas correlates with age. In infancy and early childhood, the most frequent location is extragonadal, whereas teratomas presenting after childhood more commonly are located in the gonads.[17]

An increasing number of patients with sacrococcygeal teratomas are diagnosed antenatally. In the series by Gabra et al, this proportion increased from 11% before 1988 to 53% from 1988-2001. Patients presenting later tend to have less obvious external tumors; symptoms of bladder or bowel dysfunction often lead to diagnosis.[18]

Cystic teratomas of the ovary can occur in persons of any age, although they are diagnosed most frequently during the reproductive years. The peak incidence in most series is at age 20-40 years.[19]

Testicular teratomas may occur at any age but are more common in infants and children. In adults, pure testicular teratomas are rare, constituting 2-3% of germ cell tumors.[20]

Mediastinal teratomas can be found in persons of any age but occur most commonly in adults aged 20-40 years.[16, 21]

Prognosis

Mature cystic teratomas can result in significant morbidity. Potential complications vary depending on the site of occurrence.

Sacrococcygeal teratoma

Sacrococcygeal teratomas are commonly diagnosed prenatally, and complications may occur in utero or during or after birth. The outcome after prenatal diagnosis is significantly worse than that in older postnatal surgical series, with survival rates ranging from 54-77%.[2, 22, 23]

Potential complications in utero include polyhydramnios and tumor hemorrhage, which can lead to anemia and nonimmune hydrops fetalis. If significant arteriovenous shunting occurs within the tumor, hydrops may result from high-output cardiac failure. Development of hydrops is an ominous sign. If it develops after 30 weeks' gestation, the mortality rate is 25%. If it is recognized, delivery is recommended as soon as lung maturity is documented. Development of hydrops before 30 weeks' gestation has an abysmal prognosis, with a 93% mortality rate.[22, 24]  Makin et al reported that antenatal intervention for the treatment of fetal hydrops did not improve outcomes with neonatal deaths in 6 of 7 cases (86%).[2]  Hydrops and prematurity are the two main factors that contribute to mortality.

Postpartum morbidity associated with sacrococcygeal teratomas is attributable to associated congenital anomalies, mass effects of the tumor, recurrence, and intraoperative and postoperative complications. Ten to twenty-four percent of sacrococcygeal teratomas are associated with other congenital anomalies, primarily defects of the hindgut and cloacal region, which exceeds the baseline rate of 2.5% expected in the general population.[25, 18, 5]

In one larger series that included 57 cases of benign teratomas over a 40-year period from a single institution, 5 recurrences were documented. Only one of the patients who experienced recurrence did not undergo a coccygectomy, and one patient who was thought to have a benign tumor with immature elements was found to have embryonal carcinoma after the third excision. In this same series, 3 patients had postoperative wound infections and one patient had postoperative pneumonia. The overall survival was 95% and morbidity or mortality rates were consistent over the 40-year period of the study.[9]

In a more recent series, all 26 patients diagnosed with benign teratomas survived. Seven of 20 patients with long-term follow-up developed neuropathic bladder or bowel disturbances.[18]  

Partridge and colleagues studied a series of 45 patients, noting anorectal complications in 29% and urologic complications in 33%. These were associated with both prenatal obstructive findings and therapeutic interventions, as well as Altman classification, perineal reconstruction, and tumor recurrence.[26]  A longitudinal cross-sectional follow-up study found that sequelae developing in childhood tended to improve with time, while functional symptoms reported in adulthood were common in the general population and not significantly increased over a control group.[27]

In a Dutch study of 47 adults who had been treated for SCT during infancy between 1970 to 1993, urinary incontinence was present in 30% and had a greater reported negative impact than unintentional defecation. Ten patients (21%) reported constipation; a tumor diameter of >10 cm and Altman type I or type II SCT were associated with constipation during adulthood.[28]

Ovarian teratoma

Complications of ovarian teratomas include the following:

Torsion is by far the most significant cause of morbidity, occurring in –3-11% of cases. Several series have demonstrated that increasing tumor size correlates with increased risk of torsion.[4, 29]

Rupture of a cystic teratoma is rare and may be spontaneous or associated with torsion. Most series report a rate of less than 1%,[4, 3]  though Ahan et al reported a rate of 2.5% in their report of 501 patients.[19]  Rupture may occur suddenly, leading to shock or hemorrhage with acute chemical peritonitis. Chronic leakage also may occur, with resultant granulomatous peritonitis. Prognosis after rupture is usually favorable, but the rupture often results in formation of dense adhesions.

Infection is uncommon and occurs in less than 1-2% of cases. Coliform bacteria are the organisms most commonly implicated.[19, 29]

Encephalitis associated with antibodies against the N-methyl D-aspartate receptor (NMDAR) has been linked to tumors, especially ovarian mature teratomas. In a series of 400 cases, 335 of them in women, 165  patients (49%) had tumors and all but six were ovarian teratomas. The syndrome is characterized by a viral-like prodrome followed by a multistage progression of symptoms that includes psychosis, memory deficits, seizures, language disintegration, decreased consciousness, dyskinesias, and autonomic instability. Substantial recovery is usually seen with tumor resection and immunotherapy.[30]

Autoimmune hemolytic anemia has been associated with mature cystic teratomas in rare cases. In these reports, removal of the tumor resulted in complete resolution of symptoms. Theories behind the pathogenetic mechanism include (1) tumor substances that are antigenically different from the host and produce an antibody response within the host that cross reacts with native red blood cells, (2) antibody production by the tumor directed against host red blood cells, and (3) coating of the red blood cells by tumor substance that changes red blood cell antigenicity. In this context, radiologic imaging of the pelvis may be indicated in cases of refractory hemolytic anemia.[31, 32]

In its pure form, mature cystic teratoma of the ovary is always benign, but in approximately 0.2-2% of cases, it may undergo malignant transformation into one of its elements, the majority of which are squamous cell carcinomas. The prognosis for patients with malignant degeneration is generally poor but dependent on stage and degenerated cell type.[4, 33]

Testicular teratoma

Testicular teratomas occur in children and adults, but their incidence and natural history contrast sharply. Pure teratomas comprise 38% of germ cell tumors in infants and children but only 3% after puberty. In children, they behave as a benign tumor, whereas in adults and adolescents they are known to metastasize.[20, 34]  With no documented cases of metastasis, morbidity from prepubertal testicular teratomas is largely limited to surgical or postoperative complications.

During and after puberty, all teratomas are regarded as malignant because even mature teratomas (composed of entirely mature histologic elements) can metastasize to retroperitoneal lymph nodes or to other systems. Reported rates of metastasis vary from 29-76%. Morbidity is associated with growth of the tumor, which may invade or obstruct local structures and become unresectable. Approximately 20% of patients relapse during surveillance.[20]

Mediastinal teratoma

Mature teratomas of the mediastinum, the most common mediastinal germ cell tumor, are benign lesions. They do not have the metastatic potential observed in testicular teratoma and are cured by surgical resection alone. Because of their anatomic location, intraoperative and postoperative complications are the only significant source of morbidity, as other intrathoracic structures are often intimately involved with the tumor.[35]

History and Physical Examination

Sacrococcygeal teratoma 

Sacrococcygeal teratomas may be diagnosed antenatally during routine ultrasounds, fetal anomaly scans, or when the mother presents with clinical symptoms such as size greater than dates or polyhydramnios.[2]  Those not diagnosed antenatally present in 2 patterns. The most common pattern is in neonates, who present with a large, predominantly benign tumor protruding from the sacral area that is noted prenatally or at the time of delivery. Less commonly, the newborn may exhibit only asymmetry of the buttocks or present at 1 month to 4 years of age with a presacral tumor that may extend into the pelvis. Symptoms of bladder or bowel dysfunction may be present. The latter group is at a significantly higher risk for malignancy.[18]

Ovarian teratoma

Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications. Asymptomatic mature cystic teratomas of the ovaries have been reported at rates of 6-65% in various series. When symptoms are present, they may include abdominal pain, mass or swelling, and abnormal uterine bleeding. Bladder symptoms, gastrointestinal disturbances, and back pain are less frequent. When abdominal pain is present, it usually is constant and ranges from slight to moderate in intensity. Torsion and acute rupture commonly are associated with severe pain. Hormonal production is thought to account for cases of abnormal uterine bleeding, but histologic examination has not provided evidence to support this theory.[19, 4, 3, 36]  See the image below.



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A 12-cm mature cystic teratoma of the ovary prior to excision.

Testicular teratomas

Testicular teratomas most often present as a painless scrotal mass, except in the case of torsion. In most cases, the masses are firm or hard, nontender, and do not transilluminate. Testicular pain and scrotal swelling are occasionally reported with teratomas, but this is nonspecific and simply indicates torsion until proven otherwise. Hydrocele is frequently associated with teratoma in childhood. On examination, the testis is diffusely enlarged, rather than nodular, although a discreet nodule in the upper or lower pole sometimes can be appreciated.[37, 38]

Mediastinal teratomas

Mediastinal teratomas are often asymptomatic. When symptoms are present, they relate to mechanical effects and include chest pain, cough, dyspnea, or symptoms related to recurrent pneumonitis. Many patients present with respiratory findings, and the pathognomonic finding of trichoptysis (cough productive of hair or sebaceous material) may result if a communication develops between the mass and the tracheobronchial tree. Other serious presentations are superior vena cava syndrome or lipoid pneumonia. Mediastinal teratomas are occasionally discovered incidentally on chest radiographsa.[39, 6, 16, 21]

Laboratory Studies

Elevated serum alpha-fetoprotein (AFP) and beta human chorionic gonadotropin (HCG) levels may be indicative of malignancy, as these values are within reference ranges in most patients with benign teratomas.[39]  

Tumor markers, such as squamous cell carcinoma (SCC) antigen, are useful for identifying the presence of SCC arising from mature cystic teratoma (MCT), but no set cut-off level has been established. Choi et al reported elevated SCC antigen levels ranging from 1.5 ng/mL in International Federation of Gynecology and Obstetrics (FIGO) stage Ia tumors to 11.3 ng/mL in stage IIIc in four patients with confirmed SCC arising from MCT.[42]  

 

Imaging Studies

The workup for cystic teratomas is largely radiographic, and their appearance is similar despite varying locations.

If the teratoma is recognized in utero, the fetus should undergo serial ultrasound surveillance for development of fetal hydrops. Amniotic fluid volume and placental thickness should be evaluated as early markers for hydrops. Tumor growth rate and vascular flow through solid portions may help assess fetal risks. In the case of sacrococcygeal teratomas, an ultrasound examination may demonstrate extension of the tumor into the pelvis or abdomen and possible displacement of the bladder and rectum, with compression of the ureters resulting in hydroureter or hydronephrosis.[43, 23]

Fetal magnetic resonance imaging (MRI) likely provides the most accurate assessment of anatomical extent and impact, with excellent resolution regardless fetal orientation, maternal obesity, oligohydramnios, or shadowing from the bony pelvis, which may limit ultrasound visualization.[24] Computed tomography (CT) scanning of the abdomen and pelvis before surgical exploration can further delineate sacrococcygeal tumor from normal anatomic features.[9]

Ultrasonography with adjunctive CT scanning is useful in imaging suspected ovarian teratomas and may detect liver and retroperitoneal lymph node involvement in malignant cases. Ultrasonic findings ascribed to teratomas include the following[44]  :

In a study by Mais et al, transvaginal ultrasonography had a sensitivity and specificity of 84.6% and 98.2%, respectively, for differentiating cystic teratoma from other ovarian masses.[45] In another trial, Patel et al demonstrated a 98% positive predictive value and 85% sensitivity using ultrasound to diagnose and identify cystic teratomas.[40]

CT scan usually reveals the complex appearance of ovarian teratomas, with dividing septa, internal debris, fat attenuation (93%), and distinct calcification (56%).[44]

MRI can sufficiently differentiate lipid density from other fluid and blood and may be another useful adjunct for diagnosis of ovarian teratomas, with an accuracy of 99%.[46]

When a testicular mass is detected on prenatal ultrasound or postnatally as a palpable nodule or as volumetric increase in the scrotum, ultrasound may be the most useful adjunct test. Testicular teratomas have a varied ultrasound appearance, which may include solid and cystic elements, septations, calcifications, and rare vascularity. Despite this, evaluation before surgical treatment may aid in decisions regarding testis-sparing enucleation or excision.[47]

In the case of a suspected mediastinal teratoma, anterior-posterior and lateral chest radiographs provide important information as to size and location of the mass.[48]

CT scan and/or MRI may further clarify the diagnosis and also are invaluable in delineating the boundaries of mediastinal masses, potential vascular involvement, and respectability.[48, 49]

Echocardiography can be used to delineate physiologic effects of mediastinal masses, such as tamponade or pulmonary stenosis, and may be used to guide needle biopsy.[41]

Procedures

Fine-needle aspiration or core biopsy can be used to differentiate benign from malignant mediastinal masses in 90% of cases.[41]

Histologic Findings

In cystic teratomas, the outside of the tumor wall is usually lined with native tissue. The cavity of the cyst is often lined with keratinized squamous epithelium and usually contains abundant sebaceous and sweat glands. Hair and other dermal appendages are usually present. Occasionally, the cyst wall is lined with bronchial or gastrointestinal epithelium. Foreign body giant cell reactions may be seen in various parts of the tumor and may, in the case of intraperitoneal teratomas, lead to formation of extensive adhesions if the tumor contents are spilled.

Ectodermal tissue encountered may include brain, glia, neural tissue, retina, choroids, and ganglia. Mesodermal tissue is represented by bone, cartilage, smooth muscle, and fibrous tissue.[48, 50] One report describes a 7-cm ovarian teratoma containing a mandiblelike structure with 8 well-formed teeth.[51]

Staging

Sacrococcygeal teratomas are the only teratomas with a widely accepted staging or classification system. In a study of 405 patients treated by members of the Surgical Section of the American Academy of Pediatrics, Altman and associates report the following system:[25]

Surgical Care

Sacrococcygeal teratoma 

Sacrococcygeal teratomas diagnosed prenatally should be monitored closely. In high-risk (large, solid, vascular) sacrococcygeal teratoma, in utero surgery may be an option in carefully selected cases. In the presence of developing hydrops, other minimally invasive antenatal procedures such as fetoscopic laser ablation, radiofrequency ablation, interstitial laser ablation, or vascular coiling may be options to interrupt the vascular flow to the tumor. In selected high-risk fetuses, early delivery and ex utero surgery may be an option.[52, 53]

In fetuses with larger tumors, cesarean delivery should be considered to prevent dystocia or tumor rupture. Because of the poor prognosis associated with development of hydrops prior to 30 weeks' gestation, these fetuses may benefit from in utero surgery. In most cases, sacrococcygeal teratomas should be resected electively in the first week of life, since long delays may be associated with a higher rate of malignancy.[54]

Complete excision should be done through a chevron-shaped buttock incision, with careful attention to the preservation of the muscles of the rectal sphincter. The coccyx always should be resected with the tumor, as failure to do so results in a 35-40% recurrence rate. Hemorrhage from the middle sacral vessels and hypogastric arteries is the most common complication.[6]

Ovarian teratoma

Mature cystic teratomas of the ovaries may be removed by simple cystectomy rather than salpingo-oophorectomy. See the image below.



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A 12-cm mature cystic teratoma of the ovary prior to excision.

Although malignant degeneration is quite rare, the cyst should be removed in its entirety, and if immature elements are found, the patient should undergo a standard staging procedure.

Guidelines issued by the Royal College of Obstetricians and Gynecologists (RCOG) in the United Kingdom recommend that when surgery is indicated, a laparoscopic approach be generally considered to be the gold standard for the management of all benign ovarian masses. In addition, laparoscopic bilateral salpingo-oophorectomy is recommended for removal of postmenopausal cystic teratomas at low risk of malignancy.[55]

The patient should be counseled appropriately about the risks and benefits of laparoscopy and laparotomy. Ample literature supports laparoscopy as an acceptable alternative approach in resection. Benefits include reductions in postoperative pain, blood loss, hospital stay, and total cost. Risks include prolonged operative time, increased operating room costs, and potential need for a prompt second staging procedure if an unexpected malignancy is revealed.

Some studies have found an increased intraoperative spillage rate with laparoscopy, while others have not. Spillage is associated with increased risk of chemical peritonitis (estimated incidence of 0.2%) and increased risk of adhesion formation. The risks of recurrence (4%), as well as malignant degeneration (0.2-2%), should be discussed.[56, 57, 58, 59, 60]

Testicular teratomas

Testicular teratomas traditionally have been treated by simple or radical orchiectomy. More recently, conservative excision by enucleation also has been recommended for prepubertal teratomas of the testis.[20, 61]  Several studies have failed to demonstrate negative sequelae for prepubertal testicular teratomas, so testis-sparing procedures are appropriate.[62, 63] Patients should be counseled regarding the following risks[38, 34] :

The risk of malignancy increases with maturation of the testes, and this is a significant concern in children at or near puberty. In this group, areas of normal surrounding testicular tissue should be excised and sent for frozen section. If frozen section reveals areas of maturity, proceeding to orchiectomy is recommended. Enucleation or partial orchiectomy for teratoma in pubertal or adult males is not recommended.[34]

Mediastinal teratomas

Mature teratomas of the mediastinum should be completely surgically resected. The tumor may be adherent to surrounding structures, necessitating resection of the pericardium, pleura, or lung. When complete resection is achieved, it results in excellent long-term cure rates with little chance of recurrence. When complete resection is impossible, partial resection often leads to symptom relief, frequently without relapse.[48, 41]

What are cystic teratomas?How are cystic teratomas differentiated from dermoids?What is the pathophysiology of cystic teratomas?What is the prevalence of cystic teratomas?What are the sexual predilections of cystic teratomas?Which age groups have the highest prevalence of cystic teratomas?Which factor affects the potential complications of cystic teratomas?What is the prognosis of sacrococcygeal teratomas?What are the potential complications of ovarian teratoma?What is the prognosis of ovarian teratoma?What is the prognosis of testicular teratoma?What is the prognosis of mediastinal teratoma?How are sacrococcygeal teratomas diagnosed?What are the signs and symptoms of ovarian teratomas?What are the signs and symptoms of testicular teratomas?What are the signs and symptoms of mediastinal teratomas?Which conditions are included in the differential diagnoses of sacrococcygeal teratomas?Which conditions are included in the differential diagnoses of ovarian cystic teratomas?Which conditions are included in the differential diagnoses of testicular teratomas?Which conditions are included in the differential diagnoses of mediastinal teratomasWhat are the differential diagnoses for Cystic Teratoma?Which lab findings suggest malignancy in cystic teratomas?What is a tumor marker for mature cystic teratoma (MCT)?What is the role of imaging studies in the workup of cystic teratoma?What is the role of biopsy in the workup of cystic teratoma?Which histologic findings are characteristic of cystic teratoma?How are sacrococcygeal teratomas staged?How are sacrococcygeal teratomas treated?How are ovarian teratomas treated?How are testicular teratomas treated?How are mediastinal teratomas treated?

Author

Chad A Hamilton, MD, Chief, Gynecologic Oncology Service, Walter Reed National Military Medical Center; Program Director, NCC Fellowship in Gynecologic Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

Margarett C Ellison, MD, Consulting Staff, Kaiser Permanente, Los Angeles Medical Center

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Benjamin Movsas, MD,

Disclosure: Nothing to disclose.

Chief Editor

Yukio Sonoda, MD, Associate Professor, Weill Cornell Medical College; Associate Attending Surgeon, Gynecology Service, Department of Surgery, Memorial Hospital for Cancer and Allied Diseases; Associate Member, Memorial Sloan-Kettering Cancer Center

Disclosure: Nothing to disclose.

Additional Contributors

Lodovico Balducci, MD, Professor, Oncology Fellowship Director, Department of Internal Medicine, Division of Adult Oncology, H Lee Moffitt Cancer Center and Research Institute, University of South Florida Morsani College of Medicine

Disclosure: Nothing to disclose.

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Mature cystic teratoma of the ovary exhibiting multiple tissue types.

Mature cystic teratoma of the ovary with hair, sebaceous material, and thyroid tissue.

A 12-cm mature cystic teratoma of the ovary prior to excision.

A 12-cm mature cystic teratoma of the ovary prior to excision.

Mature cystic teratoma of the ovary exhibiting multiple tissue types.

Mature cystic teratoma of the ovary with hair, sebaceous material, and thyroid tissue.

Large teratomatous epignathus diagnosed by prenatal ultrasound.

A 12-cm mature cystic teratoma of the ovary prior to excision.