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LETTERS TO EDITOR
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 143-145

Huge mixed germ cell tumor of the ovary clinically mimicking pregnancy in an adolescent girl: A case report


1 Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India
2 MBBS Graduate, IGMCRI, Puducherry, India
3 Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India

Date of Submission14-Sep-2020
Date of Decision15-Nov-2020
Date of Acceptance02-Mar-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
Thirunavukkarasu Arun Babu
Associate Professor of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_287_20

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How to cite this article:
Babu TA, Balakrishnan P, Sharmila V. Huge mixed germ cell tumor of the ovary clinically mimicking pregnancy in an adolescent girl: A case report. Cancer Res Stat Treat 2021;4:143-5

How to cite this URL:
Babu TA, Balakrishnan P, Sharmila V. Huge mixed germ cell tumor of the ovary clinically mimicking pregnancy in an adolescent girl: A case report. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Apr 22];4:143-5. Available from: https://www.crstonline.com/text.asp?2021/4/1/143/312075



Malignant germ cell tumors comprise 5% of all ovarian neoplasms and are derived from the primordial germ cells of the embryonic gonad.[1] Mixed germ cell tumors (MGCTs) with dysgerminoma in combination with yolk sac tumors are a common occurrence.[2],[3] However, MGCTs of the ovary are rare tumors in adolescent girls with poor prognosis. Here, we report a case of a huge MGCT with mature teratoma and yolk sac components in a 16-year-old girl mimicking a term-size gravid uterus in the initial visit.

A 16-year-old, nulliparous girl presented with complaints of secondary amenorrhea and abdominal distension that was diffuse, progressive, and painless for the past 5 months. She had attained menarche 4 years ago, and since then her menstrual cycles had been regular. On examination, the vitals were stable, and there was no pallor or pedal edema. An abdominal examination revealed a uniformly distended and tense abdomen with a palpable intra-abdominal mass similar in size to a 32-week fetus. Fluid thrill was negative. Speculum and vaginal examinations were normal, and a bimanual examination showed a normal anteverted uterus with a left adnexal mass. The urine pregnancy test was negative. Ultrasound examination showed a huge left ovarian mass with solid and cystic areas. Magnetic resonance imaging showed a left ovarian mass of size 45 cm × 35 cm × 10 cm with solid and cystic areas extending up to the diaphragm and displacing the bowel loops [Figure 1]. The right ovary and the uterus were normal. The serum alpha-fetoprotein level was elevated. An exploratory laparotomy and a left salpingo-ovariotomy were performed in view of the germ cell tumor of the left ovary. Gross examination revealed a mass of size 45 cm × 35 cm × 10 cm weighing 5500 g, with a capsular breach and gray-tan solid nodular and cystic areas [Figure 2]. A histopathological examination revealed a yolk sac tumor comprising Schiller Duval bodies and tumor cells in polyvesicular sheets and papillary pattern in combination with mature cystic teratoma component with skin epithelium, adnexal structures, and respiratory epithelium [Figure 3]a and [Figure 3]b. Based on the age of the patient, elevated serum alpha-fetoprotein level, and histological features, a diagnosis of MGCT with yolk sac tumor and mature teratoma was made. The patient's serum alpha-fetoprotein level decreased gradually after surgery. She regained her menstrual cycles 1 month after the surgery. Postsurgery, the patient received 3 cycles of adjuvant chemotherapy and is doing well without any evidence of recurrence or metastasis at the end of 6 months of follow-up. A timeline of the events of our index case is depicted in [Table 1].
Figure 1: Magnetic resonance imaging of the abdomen showed a huge solid and cystic mass occupying the whole abdomen pushing the diaphragm

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Figure 2: A gross photograph of the excised mass of size 45 cm × 35 cm × 10 cm with solid grey-tan nodular areas and focal cystic areas

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Figure 3: (a) Microphotograph showing a yolk sac tumor with Schiller Duval bodies (Hematoxylin and eosin stain, ×40); (b) Microphotograph showing a mature cystic teratoma made of skin, adnexal structures, and respiratory epithelium (Hematoxylin and eosin stain, ×400)

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Table 1: Timeline of presentation, diagnosis, and management of index case, a 16-year-old girl with huge mixed germ cell tumor of the ovary clinically mimicking pregnancy

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An MGCT attaining such a huge size in a short duration and mimicking a near term-size gravid uterus is very rare and has never been reported in the literature. Granulosa tumor of the ovary is the most common ovarian tumor causing amenorrhea in patients. Yolk sac tumors presenting with secondary amenorrhea as in our case are very rare.[4]

The usual clinical presentation of MGCTs comprising yolk sac component and mature teratoma includes abdominal distension, palpable abdominal mass, and abdominal pain. Patients with metastatic foci of yolk sac tumors often present with shortness of breath and chest pain. Endocrine manifestations such as irregular menstrual bleeding occurring because of estrogen release in embryonal carcinoma are usually not seen.

Elevated serum alpha-fetoprotein level is a clue to suspect yolk sac tumors preoperatively, as was done in our case. Tumor markers such as beta human chorionic gonadotropin and lactate dehydrogenase are elevated in choriocarcinoma and dysgerminoma. Pure yolk sac tumors with a small proportion of mature teratoma component are common. Our patient had MGCT with equal proportions of yolk sac tumor and benign mature cystic teratoma. The presence of both benign and malignant components in an ovarian tumor is extremely rare.[5] The clinicopathological profile and treatment outcomes of MGCT of the ovary in adolescent patients reported in the literature are summarized in [Table 2].
Table 2: Clinical characteristics of other cases of mixed germ cell tumor of the ovary in adolescent girls reported in the literature

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In conclusion, a pelvic mass in young girls is of great concern because of the possibility of malignancy and effect on the fertility, and early diagnosis can help in providing fertility-sparing treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent from the patient's parents. In the form, the patient's parents have given their consent for her images and other clinical information to be reported in the journal. The patient's parents understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goyal LD, Kaur B, Badyal RK. Malignant mixed germ cell tumors of the ovary: A series of rare cases. J Reprod Infertil 2019;20:231-6.  Back to cited text no. 1
    
2.
Rana S, Gill MK, Kalhan S, Satarkar RN, Sangwaiya A, Singh P. Immature teratoma with embryonal carcinoma; A rare malignant mixed germ cell tumor in a 13-year-old girl. Iran J Pathol 2016;11:66-70.  Back to cited text no. 2
    
3.
Pagaro PM, Gore CR, Patil T, Chandanwale S. Mixed germ cell tumors: Report of two cases. Med J DY Patil Univ 2013;6:298-301.  Back to cited text no. 3
  [Full text]  
4.
Caserta D, Ralli E, Bordi G, Moscarini M. An unusual clinical presentation of a pure yolk sac tumor of the ovary: Case report. Eur J Gynaecol Oncol 2013;34:577-9.  Back to cited text no. 4
    
5.
Goyal LD, Kaur S, Kawatra K. Malignant mixed germ cell tumour of ovary—An unusual combination and review of literature. J Ovarian Res 2014;7:91.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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