What are the management options for dermoid cysts?

Management of Dermoid Cysts

Dermoid cysts should be managed based on size, location, patient age, and menopausal status, with surgical excision recommended for most cases to prevent complications and malignant transformation.

Diagnosis and Classification

• Dermoid cysts (mature teratomas) are benign congenital tumors classified as choristomas, accounting for approximately 20% of all ovarian tumors 1
• They typically present with characteristic imaging features including fatty and calciferous content, hair, teeth, and cartilage that may be pathognomonic on MRI 1
• Diagnosis is primarily made through imaging studies (ultrasound, MRI, CT) with ultrasound showing hyperechoic components with acoustic shadowing, hyperechoic lines and dots, fluid-fluid levels, and occasionally floating echogenic spherical structures 1

Management Algorithm Based on Location

Ovarian Dermoid Cysts

Premenopausal Patients:

• For cysts <10 cm:
  • Optional initial follow-up at 8-12 weeks to confirm diagnosis 1
  • If not surgically removed, annual ultrasound surveillance should be considered 1
  • Most patients are typically under gynecologist care 1

Postmenopausal Patients:

• For cysts <10 cm with confident diagnosis:
  • Annual ultrasound follow-up if not surgically excised 1
  • Higher vigilance required due to increased risk of malignant transformation 1
  • If changing morphology or developing vascular components are observed, direct referral for MRI is recommended 1

Surgical Indications (Any Age):

• Cysts >10 cm in size 1
• Changing morphology or developing vascular components 1
• Symptoms (pain, pressure, torsion) 1
• Risk of malignant transformation (especially in postmenopausal women) 1

Orbital Dermoid Cysts

• Complete surgical excision is the mainstay of treatment 2
• Superficial orbital dermoid cysts are more common and easier to identify than deep cysts 2
• Imaging plays a major role in management of deep orbital tumors 2

Frontotemporal Dermoid Cysts

• For cysts <2 cm: Direct excisional approach without preoperative CT 3
• For cysts >2 cm: Preoperative CT evaluation to determine exact location 3
  • If invading temporal fossa: Hemicoronal approach for excision 3
  • If not crossing lateral orbital rim: Direct excisional approach 3

Surgical Approaches

Ovarian Dermoid Cysts

• Conservative approach: Fertility-sparing surgery is recommended for premenopausal women 1
• Laparoscopic options:
  • Intraperitoneal cystectomy (78.6% of cases) 4
  • Use of endoscopic impermeable sack to extract intact cyst prevents chemical peritonitis 4
  • Ovariectomy (14.3% of cases) or transparietal cystectomy (7.1% of cases) in select situations 4
• Standard approach: For postmenopausal women, hysterectomy and bilateral salpingo-oophorectomy may be considered 1
• For advanced cases: Debulking surgery without compromising fertility is advised as chemotherapy is effective for residual disease 1

Cutaneous/Superficial Dermoid Cysts

• Complete surgical excision is the treatment of choice to avoid complications 5
• Endoscopic excision techniques may be considered for cosmetically sensitive areas:
  • Allows for small, occult incisions 6
  • Provides better visualization and magnified view of dissected areas 6
  • Avoids visible facial scarring in young patients 6

Follow-up Recommendations

• Recurrence risk after conservative treatment is approximately 4% 4
• For ovarian dermoid cysts, annual ultrasound surveillance is recommended if not surgically removed 1
• If changing morphology or developing vascular components are observed, further imaging with MRI is indicated 1
• The optimal duration or interval for surveillance has not been established 1

Special Considerations

• In cases of dermoid cysts with malignant transformation (1-2% of cases, typically in postmenopausal women), more aggressive surgical management is required 1
• Squamous cell carcinoma is the most common type of malignancy arising from dermoid cysts (>80% of cases) 1
• If malignant transformation is confined to the ovary, prognosis is excellent with adnexectomy alone 1
• For malignant transformation extending beyond the ovary, platinum-based chemotherapy regimens may be considered, though prognosis is poor 1