What is the recommended treatment approach for a patient with an ovarian teratoma?

Treatment of Ovarian Teratoma

For mature teratomas (dermoid cysts), surgical excision via laparoscopic cystectomy with ovarian preservation is the treatment of choice in reproductive-age women, while stage IA grade 1 immature teratomas require only surgery without adjuvant chemotherapy after adequate staging. 1

Mature Teratomas (Dermoid Cysts)

Surgical Approach

• Laparoscopic cystectomy is the gold standard, preserving the ovary whenever possible in women of reproductive age 2, 3
• For cysts <4-6 cm, observation is a reasonable option, though surgery is justified for larger lesions 3
• The surgical technique involves placing the resected cyst in an EndoCatch bag, aspirating contents, and removing through the smallest incision possible to minimize spillage risk 2
• Unilateral salpingo-oophorectomy with preservation of the contralateral ovary and uterus is adequate for fertility preservation 1

Age-Specific Considerations

• Premenopausal women: Conservative surgery (cystectomy) is preferred to preserve fertility 1, 3
• Postmenopausal women: Bilateral salpingo-oophorectomy with hysterectomy may be performed, though the approach should be individualized 1

Key Surgical Principles

• Avoid tumor rupture during surgery by using careful laparoscopic technique 1
• The cyst should ideally be removed intact to prevent chemical peritonitis, though spillage in 11-13% of cases does not typically cause peritonitis or fever 2
• Full staging procedures (omentectomy, peritoneal biopsies, lymph node dissection) are NOT necessary for mature teratomas 1

Immature Teratomas

Stage IA Grade 1

• Surgery alone is sufficient—no adjuvant chemotherapy required after adequate surgical staging 1
• Adequate staging includes peritoneal washings, infracolic omentectomy, and biopsies of diaphragmatic peritoneum, paracolic gutters, and pelvic peritoneum 1

Stage IA Grades 2-3 and Stage IB-IC

• Adjuvant chemotherapy is recommended, though active surveillance is an option for select cases 1
• Some data suggest all grades of immature teratoma can be managed with close surveillance after fertility-sparing surgery, reserving chemotherapy for documented recurrence 1
• BEP regimen (bleomycin, etoposide, cisplatin) is the standard chemotherapy: 3 cycles of 5-day BEP for completely resected disease 1

Advanced Stage Disease

• Fertility-sparing surgery should be considered even in advanced stages due to high chemosensitivity 1
• Debulking surgery aims to remove gross tumor without extensive procedures that delay chemotherapy 1
• 4 cycles of BEP (omitting bleomycin after cycle 3 to reduce lung toxicity risk) for macroscopic residual disease 1

Critical Staging Components

What IS Required

• Unilateral salpingo-oophorectomy (fertility-sparing) 1
• Peritoneal washings or ascites cytology 1
• Infracolic omentectomy 1
• Biopsies of diaphragmatic peritoneum, paracolic gutters, and pelvic peritoneum 1

What is NOT Required

• Systematic biopsy of normal-appearing contralateral ovary is unnecessary 1
• Routine lymph node dissection is NOT mandatory—only perform if nodes appear abnormal 1
• Retroperitoneal evaluation is not required for germ cell tumors 1

Common Pitfalls to Avoid

• Do not perform radical surgery or extensive lymphadenectomy in young patients with apparent early-stage disease—the efficacy of salvage chemotherapy makes aggressive initial surgery unnecessary 1
• Do not use fine needle aspiration for solid or mixed ovarian masses—this is absolutely contraindicated 4, 5
• Do not delay surgery for large mature teratomas due to risk of torsion (16% of cases), rupture (1-4%), or rare malignant transformation (1-2%) 6
• Laparoscopic staging is viable for immature teratomas not diagnosed on frozen section, and can detect occult disease 7

Surveillance Strategy for Conservative Management

For patients managed with surveillance (stage IA grade 1 immature teratoma or small mature teratomas):

• Regular clinical examination 1
• Tumor markers (AFP, β-hCG, LDH) monitoring 1
• Abdominopelvic imaging including transvaginal ultrasound at regular intervals 1
• Follow-up extends over 10 years with gradually increasing intervals between appointments 1
• Most relapses occur within 12-18 months, typically in peritoneal cavity or retroperitoneal lymph nodes 1