Tofan Widya Utami received Doctoral degree from the University of Indonesia, Jakarta-Indonesia. She is currently a senior lecturer and researcher at the same university. Being gynecologic oncologist at the university hospital, her research interests include clinical and biomedical research of gynecologic cancer.
Abbreviations
MT Mature teratoma
FIGO International Federation of Gynecology and Obstetrics
CT-SCAN Computed tomography scan
MRI Magnetic resonance imaging
ECOG Eastern Cooperative Oncology Group
CP Carboplatin and paclitaxel
BEP Bleomycin, etoposide, and platinum
FOLFOX Folinic acid, 5-fluorouracil, and oxaliplatin
Short Commentary
Mature teratoma (MT) is a cystic or solid tumor consisting of adult tissues with resembling epidermis tissues and its appendages on the border. It is the most common type of benign ovarian mass (58% of all benign ovarian tumors and 27–44% of all ovarian tumors) with malignant transformation rates varying from 1 to 6.6% [1, 2]. The aim of this study was to provide a description of the malignant transformations of MTs at a single university hospital in Jakarta, Indonesia, within 5-year interval (January 2015–December 2018) at a single university hospital in Jakarta, Indonesia.
High frequency of malignant transformation MTs was observed (13 over 84MTs, 15.48%). The median age of the patients was 36.5 years (range 26–63) younger than most of the studies shown in Table 1. Patients who were originally from our hospital had a good performance score (ECOG 1) at the time of admission and before an operation. On the contrary, referred patients from other hospitals came with poorer conditions (ECOG 3) and with advanced stage of the disease preoperatively. All patients came with presenting symptoms of an abdominal palpable mass, ranging from 3 to 28 cm (mean 15 cm considerably higher than other studies). Eight over 13 patients were staged as advanced ovarian carcinoma (FIGO IIA 1 patient, IIIC 6 patients, and IVB 1 patient). Five patients presented with stage IA. Chemotherapy was assigned to some advanced ovarian cancer, 1/8 had BEP regimen, 3/8 had CP, and there was only one patient who completed the full course.
The histopathology reported some different transformation; squamous cell carcinoma being the common type (4/13 patients), followed by the mucinous type and thyroid type. Pseudomyxoma condition was also reported in 2 patients. Figure 1 shows the MT features and the malignant transformation in one patient (case no. 8). The figure shows the alteration of squamous malignancy among the benign features. Two out of three mucinous carcinoma transformation were complicated with pseudomyxoma. Figure 2 shows various types of malignant transformation within our institution.
The early stage was established by full staging in 4 out of 6 cases, although it remains debatable whether full staging was always necessary in these cases. Fertility sparing surgery has been reported to have no difference in long-term oncological outcome from radical surgery for stages I and II who hope to have fertility preservation. This study showed that patients with malignant transformation of MT also presented at later stages like other ovarian cancer. Only 5/13 patients had tumor limited to the ovary. Adjuvant therapy in early and/or completely resected cases is highly controversial as most of the histopathology types are relatively chemoresistant [2, 3]. The most common malignant transition, squamous carcinoma, has a very good prognosis if limited to the ovary and operated without a spill. Therefore, it does not need adjuvant treatment, although this was given in the one case in the series. All 4 patients with stage IA and IIA diseases that were treated only with surgery have no evidence of disease until now. In advanced cases, adjuvant chemotherapy is most probably palliative both in completely and in incompletely resected cases. Also, the 2 cases for advanced disease which were reported died of disease. The choice of chemotherapy regimen was either TC or BEP. Other study reported that combination chemotherapy of folinic acid, 5-fluorouracil, and oxaliplatin (FOLFOX) could benefit patients with mucinous adenocarcinoma [4].
Nine publications were systematically reviewed to provide a comprehensive assessment of the prevalence and characteristics of the malignant transformations of MTs (Table 1) [5]. Besides having a high prevalence of malignant transformations on mature teratomas, this study indicated a younger age and similar increasing risk on large ovarian tumors. Even though the squamous cell carcinoma was the main type of transformation, the mucinous type was also high and presented with systemic complications such as pseudomyxoma peritonei with poor prognosis.
Authors Contributions All authors have read and approved the manuscript. TWU interpreted the data regarding the malignant transformation of the mature teratoma and writing the manuscript; HMARP performed the data collection, co-author the manuscript, and corresponding author; TH performed the histological examination and pointed out the importance of the histological results.
Funding None. All the research and writing was self-funded from the authors.
Conflict of interest No conflict of interest.
Ethics Approval Ethics approval was obtained from the Ethics committee of the Faculty of Medicine, University of Indonesia (attached ethical approval letter); No. KET-498/UN2.F1/ETIK/PPM.00.02/2019 and Protocol Number: 19–05-0531.
Availability of Data and Material Data and materials were available in the Case Report Form of Dr. Cipto Mangunkusumo Hospital.
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2. Duffy S, Day EK, Bryson G, Millan D, Lindsay R. Malignant tumours arising within mature cystic teratomas of the ovary: prevalence and clinical outcomes. Eur J Obstet Gynecol Reprod Biol. 2018;221:198–9. https ://doi.org/10.1016/j.ejogr b.2017.12.022.
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4. Yoshikawa N, Teshigawara T, Ikeda Y, Nishino K. Fertilitysparing surgery of malignant transformation arising from mature cystic teratoma of the ovary. Oncotarget. 2018;9(44):27564–73.
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