What is the recommended treatment for a dermoid cyst?

Treatment of Dermoid Cysts

Dermoid cysts can be safely managed with either surgical excision or annual ultrasound surveillance, with the treatment choice depending primarily on cyst size, patient symptoms, and risk of malignancy. 1

Diagnosis and Classification

Dermoid cysts (mature cystic teratomas) are:

• The most common ovarian tumors, accounting for up to 20% of all ovarian tumors 1
• Typically benign with only 1-2% risk of malignant transformation, usually in postmenopausal women 1
• Characterized by specific ultrasound features including:
  • Hyperechoic components with acoustic shadowing
  • Hyperechoic lines and dots (representing hair)
  • Fluid-fluid levels with floating liquid fat 1

Management Algorithm

For Premenopausal Women:

1. For dermoid cysts <10 cm:

   • Option 1: Annual ultrasound surveillance if asymptomatic 1
   • Option 2: Surgical excision, preferably via laparoscopy 2, 3
   • An optional initial follow-up at 8-12 weeks may be helpful to confirm diagnosis 1

2. For dermoid cysts >10 cm:

   • Surgical excision is recommended due to increased risk of complications 1
   • Laparoscopic approach is preferred when feasible 2, 4

3. For symptomatic dermoid cysts (regardless of size):

   • Surgical excision is recommended 2
   • Symptoms may include pain, pressure, or torsion 5

For Postmenopausal Women:

1. For dermoid cysts <10 cm:

   • Annual ultrasound surveillance may be considered 1
   • Surgical excision should be strongly considered due to higher risk of malignant transformation 1

2. For dermoid cysts >10 cm:

   • Surgical excision is recommended 1

Special Considerations:

• If changing morphology or developing vascular component is observed:
  • Premenopausal: Referral to ultrasound specialist or MRI 1
  • Postmenopausal: Direct referral for MRI 1

Surgical Approach

When surgical excision is indicated:

• Laparoscopic approach is preferred due to:

  • Significantly less blood loss (58.6 ml vs 103.8 ml) 2
  • Shorter hospital stay (3.2 days vs 6.3 days) 2
  • Less post-surgical pain 2
  • Fewer post-surgical complications 2
  • Lower costs 2

• Conservative treatment (cystectomy) is possible in over 80% of cases, preserving ovarian function 3

• Techniques to prevent chemical peritonitis:

  • Use of endoscopic impermeable sack for intact cyst removal 3
  • Content aspiration for cysts >10 cm 4

Follow-up Recommendations

• For surgically treated patients: Routine gynecological follow-up
• For patients under surveillance: Annual ultrasound 1
• If malignant transformation is found (rare), management follows ovarian cancer protocols 1

Potential Complications

• Rupture: May cause chemical peritonitis requiring antibiotics 5
• Torsion: Requires emergency surgery 5
• Malignant transformation: Most common in postmenopausal women, typically to squamous cell carcinoma (>80% of malignant cases) 1

Important Caveats

• CT imaging combined with elevated inflammatory markers (CRP) and tumor markers (CA125, CA19-9, SCC) may help differentiate cyst rupture from torsion 5
• Dermoid cysts in locations other than ovaries (e.g., nasal, facial) may require different surgical approaches and preoperative imaging to rule out intracranial connections 6
• The risk of missing malignant degeneration with ultrasound surveillance is quite low 1