In a 25-year-old woman with a mature ovarian teratoma, what is the recommended management—surgical excision versus observation—and appropriate follow-up?

Management of Mature Ovarian Teratoma in a 25-Year-Old Woman

For a 25-year-old woman with a mature ovarian teratoma (dermoid cyst), surgical excision via fertility-sparing cystectomy is the definitive treatment, with no adjuvant therapy required and routine surveillance thereafter. 1, 2

Surgical Management

Fertility-sparing surgery is the standard of care for reproductive-age women with mature teratomas:

• Perform laparoscopic ovarian cystectomy as the gold standard approach, preserving the ovary whenever possible 2
• Unilateral salpingo-oophorectomy with preservation of the contralateral ovary and uterus is appropriate if cystectomy is not feasible 1, 3
• Comprehensive surgical staging (omentectomy, peritoneal biopsies, washings) is not necessary for mature teratomas, as these are benign tumors 1
• Routine contralateral ovarian biopsy is unnecessary when the opposite ovary appears macroscopically normal 1

The key distinction here is that mature teratomas are benign tumors requiring only complete excision, unlike immature teratomas which are malignant and require staging 4, 5.

No Adjuvant Therapy Required

Mature teratomas do not require any postoperative chemotherapy or additional treatment after complete surgical excision 1:

• Stage IA grade 1 mature teratomas have excellent prognosis with surgery alone 1
• Approximately two-thirds of germ cell tumors are stage I, and low-risk stage I cases require no adjuvant treatment 1
• The 5-year survival rate exceeds 85% for appropriately treated germ cell tumors, with mature teratomas having essentially 100% cure rates 1

Surveillance Strategy

Follow-up should focus on detecting the rare complications of mature teratomas:

• Clinical examination and pelvic ultrasound at routine gynecologic intervals 1, 2
• Tumor markers (AFP, β-hCG, LDH) are typically normal in mature teratomas and need not be routinely monitored unless there was concern for mixed elements 1, 2
• No intensive surveillance protocol is required, as mature teratomas are benign 1, 5

Critical Pitfalls to Avoid

Always obtain expert pathology review to confirm the diagnosis is truly a mature teratoma and exclude immature or malignant elements 3:

• Malignant transformation occurs in only 1-2% of mature teratomas, most commonly squamous cell carcinoma in women >45 years old 2, 5
• Any immature neural tissue (neurotubules, rosettes) changes the diagnosis to immature teratoma, requiring chemotherapy 4
• Mixed germ cell tumors containing yolk sac or embryonal elements require platinum-based chemotherapy 1, 3

In women <15 years or >45 years with large solid components on imaging, consider laparotomy rather than laparoscopy due to higher malignancy risk 6:

• Laparoscopic spillage of malignant contents can worsen prognosis 6
• Preoperative imaging with MRI showing characteristic fatty and calciferous content is pathognomonic for benign dermoid cysts 1, 2, 7

Bilateral involvement occurs in approximately 10-15% of cases—always examine the contralateral ovary intraoperatively 5:

• If bilateral mature teratomas are present, bilateral cystectomy preserving ovarian tissue is preferred over bilateral oophorectomy in young women 5