- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
Struma ovarii is a specialized or monodermal teratoma predominantly composed of mature thyroid tissue . Thyroid tissue must comprise more than 50 percent of the overall tissue to be classified as a struma ovarii. Struma ovarii accounts for approximately 5 percent of all ovarian teratomas [2-4]. Depending on the histologic features, struma ovarii can be classified as benign or malignant . The clinical presentation, diagnosis, and management of struma ovarii will be reviewed here. Ovarian teratomas are reviewed in detail elsewhere. (See "Ovarian germ cell tumors: Pathology, clinical manifestations, and diagnosis", section on 'Teratomas'.)
Women with struma ovarii usually present with pain and/or a pelvic mass and less frequently with ascites. Clinical and biochemical features of hyperthyroidism are uncommon in women with struma ovarii, occurring in less than 5 to 8 percent of cases [3,5-8]. The clinical manifestations of struma ovarii are based upon single case reports and small case series [2-5,9,10].
General findings — Struma ovarii is most common between the ages of 40 and 60 years. In case series of 20 to 30 patients with histologically confirmed struma ovarii, abdominal pain was present in 20 to 42 percent and a palpable lower abdominal mass in 23 to 58 percent [4,8]. In one series, no definite symptoms were present in 14 patients (41.2 percent), in whom the presence of an ovarian tumor was incidentally noted on ultrasonography performed for other reasons . Ascites was present in 12 to 17 percent of patients. CA-125 was elevated in 4 of 13 women in whom it was measured (one of three who were found to have malignant struma ovarii).
Hyperthyroidism — Clinical and biochemical features of hyperthyroidism are uncommon in women with struma ovarii. In hyperthyroid patients, the serum thyroid-stimulating hormone (TSH) is low and free thyroxine (T4) and/or triiodothyronine (T3) are elevated. The thyroid gland typically is not enlarged, but serum thyroglobulin is elevated. Radioiodine uptake is low or absent in the thyroid gland, but present in the pelvis. Rarely, women with struma ovarii and hyperthyroidism also have a goiter . There are at least two possible explanations for this association:
●The coexistence of Graves' disease and struma ovarii, which has been reported rarely in the literature [11,12]. Serum thyroid-stimulating immunoglobulins (thyrotropin-receptor antibodies [TRAb]) would be expected to stimulate function of thyroid tissue in the ovary as well as in the neck.
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- Wolff EF, Hughes M, Merino MJ, et al. Expression of benign and malignant thyroid tissue in ovarian teratomas and the importance of multimodal management as illustrated by a BRAF-positive follicular variant of papillary thyroid cancer. Thyroid 2010; 20:981.
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- CLINICAL MANIFESTATIONS
- General findings
- Struma ovarii
- Malignant struma ovarii
- DIFFERENTIAL DIAGNOSIS
- Pelvic mass
- Benign struma ovarii
- Malignant struma ovarii
- - Low risk of recurrence and no metastatic disease
- - High risk of recurrence or metastatic disease
- - Equivocal risk
- SUMMARY AND RECOMMENDATIONS