What is the recommended treatment for a dermoid cyst?

Treatment of Dermoid Cysts

The recommended treatment for dermoid cysts is either surgical excision or annual ultrasound surveillance, with the choice primarily depending on cyst size, patient symptoms, and risk factors. 1

Diagnostic Evaluation

• Ultrasound imaging is the preferred initial diagnostic modality with high accuracy (95% correct characterization rate) 1
• Characteristic ultrasound features include:
  • Hyperechoic components with acoustic shadowing (calcified material, teeth, bone)
  • Hyperechoic lines and dots (coiled hair)
  • Fluid-fluid levels with floating liquid fat
  • Floating echogenic spherical structures (pathognomonic but less common) 1

Management Algorithm

Surveillance Approach

• Annual ultrasound surveillance is appropriate for:
  • Dermoid cysts <10 cm in size
  • Asymptomatic patients
  • Patients wishing to preserve fertility 1
• Sonographically diagnosed dermoids can be safely followed with yearly ultrasound with very low risk of missing malignant degeneration 2

Surgical Approach

• Surgical excision is recommended for:
  • Dermoid cysts >10 cm (due to increased risk of complications)
  • Symptomatic cysts (regardless of size)
  • Cysts with concerning features on imaging
  • Cysts with changing morphology or developing vascular components 1

Surgical Options

• Laparoscopic approach is preferred when feasible:
  • Less blood loss (58.64±30.17 ml vs 103.84±38.45 ml with laparotomy) 3
  • Shorter hospital stay (3.18±0.39 days vs 6.32±1.09 days) 3
  • Less post-surgical pain 3
  • Faster recovery 3
• Vaginal approach with laparoscopic assistance can be considered:
  • Advantages in operating time and post-operative outcomes 4
  • Lower rates of intraperitoneal spillage of dermoid tissue 4

Important Considerations

Risk of Cyst Rupture

• Laparoscopic cystectomy has higher rates of intraoperative cyst rupture (63.2% vs 15.8% with laparotomy) 5
• Risk increases with cyst size >5 cm 5
• Despite higher rupture rates, complications from rupture are rare 5
• To minimize risk of chemical peritonitis:
  • Use of endoscopic impermeable sack for extraction 6
  • Thorough peritoneal lavage if spillage occurs

Risk of Malignancy

• Dermoid cysts are typically benign with only 1-2% risk of malignant transformation 1
• Malignant transformation is most common in postmenopausal women 1
• The risk of missing malignant degeneration with ultrasound surveillance is quite low 2

Fertility Considerations

• For patients desiring future fertility, ovarian cystectomy with preservation of normal ovarian tissue is preferred over oophorectomy 6
• Conservative treatment (cystectomy) can be performed in over 80% of cases 6
• Risk of recurrence after conservative treatment is approximately 4% 6

Special Considerations for Non-Ovarian Dermoid Cysts

For dermoid cysts in other locations (e.g., nasal, facial):

• Imaging is crucial before surgery to rule out intracranial connections 7
• Complete surgical excision is typically recommended to prevent local complications such as inflammation, infection, and bone resorption 7
• The surgical approach depends on size, location, and extension of the cyst 7