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Malignant struma ovarii

Leila Yassa, Peter Sadow and Ellen Marqusee*

S U M M A RY THE CASE
A 25-year-old woman presented to her gyne-
Background A 25-year-old woman presented to her gynecologist with
cologist with pelvic pain. Physical examination
pelvic pain. Pelvic ultrasonography showed a 9 cm left ovarian mass. The
revealed a left-sided pelvic mass. Transvaginal
patient underwent left oophorectomy, omental biopsy, and lymph node
ultrasonography showed a 9 cm diameter, thick-
sampling. The ovarian mass proved to be a struma ovarii with numerous
microscopic foci of papillary thyroid carcinoma. The patient had no
walled, septated cystic left ovarian mass with
symptoms of hyperthyroidism, and her thyroid function and serum solid components that did not have the typical
thyroglobulin levels were normal. appearance of a dermoid cyst. The patient had
no history of thyroid dysfunction. Her past medical
Investigations Investigations included a pelvic ultrasound scan,
history included gastroesophageal reflux disease,
histological examination of the ovarian mass and omental nodules, and
asthma and polycystic ovarian syndrome. She did
lymph node sampling.
not smoke cigarettes, but used marijuana approxi-
Diagnosis Malignant struma ovarii. mately three times per week. She had been taking
Management The patient was referred to an endocrinology clinic for further albuterol, as needed, for asthma. She had no family
investigations. Serum levels of TSH, thyroglobulin and thyroglobulin history of ovarian or endocrine tumors.
antibodies were measured. In addition, the patient underwent thyroid The patient underwent a laparotomy, which
ultrasonography, which showed a 1 cm nodule that proved benign on biopsy. revealed a large, left ovarian mass, adherent to
She was treated with thyroxine to reduce TSH secretion. Follow-up pelvic the sigmoid colon and uterus, and a nodular
ultrasonography 1 year later showed no evidence of recurrent disease, and her omentum. The ovarian mass was separated from
serum thyroglobulin levels remained normal. the colon and uterus and then resected. The
Keywords malignant struma ovarii, ovarian teratoma, radioactive iodine, omentum was biopsied and multiple lymph nodes
struma ovarii, thyroid carcinoma were excised. On pathological examination, the
ovarian mass proved to be a 10 cm struma ovarii
consisting predominantly of normal thyroid tissue
with multiple foci of papillary thyroid micro­
carcinoma (Figure 1); the largest focus of carci-
noma was 9 mm in the largest dimension. The
omental nodules (the largest nodule measured
2.5 cm) had the histologic characteristics of benign
strumosis (Figure 2; indicating the diagnosis of a
mature teratoma), consisting entirely of benign
thyroid tissue with no evidence of carcinoma. No
neoplastic cells were found on examination of the
excised lymph nodes and the peritoneal washings.
L Yassa is an Assistant in Medicine at Newton Wellesley Hospital, Wellesley The patient was referred to an endocrinology
and at Massachusetts General Hospital, Boston, MA, P Sadow is an Assistant clinic for further management.
Pathologist at Massachusetts General Hospital and E Marqusee is an Physical examination of the patient revealed
Associate Physician at Brigham and Women’s Hospital, Boston, MA, USA. no abnormalities. Her serum TSH concentration
was 2.1 mIU/l (reference range: 0.5–5.0 mIU/l)
Correspondence
*Thyroid Division, Brigham and Women’s Hospital, 77 Avenue Louis Pasteur, Boston,
and her serum thyroglobulin concentration was
MA 02115, USA 28.5 µg/l (reference range: 2.0–35.0 µg/l); serum
emarqusee@partners.org thyroglobulin antibodies were not detected.
Ultrasonography of the thyroid revealed
Received 15 February 2008 Accepted 12 May 2008 Published online 17 June 2008
www.nature.com/clinicalpractice
a 1 cm nodule in the left lobe; fine-needle
doi:10.1038/ncpendmet0887 aspiration revealed a benign thyroid nodule.

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Figure 1 Microscopic focus of papillary thyroid carcinoma, follicular variant,
within benign, unremarkable spindled ovarian stroma (hematoxylin and eosin
[H & E] staining; magnification ×400). Of note, lesional cells show extensive
grooving and occasional intracytoplasmic pseudoinclusions.
Figure 2 Benign thyroid tissue (strumosis) present as nodular, circumscribed
foci within the omentum (hematoxylin and eosin [H & E] staining; magnification
×100). Follicular cells show rounded, dark nuclei without grooves, membrane
irregularities, clearing or pseudoinclusions, with a lack of invasive borders.
CT of the abdomen and pelvis and transvaginal
ultra­sonography, performed 6 months after
surgery, showed no recurrence in the surgical
bed, no evidence of metastatic disease, and a
normal-appearing right ovary.
470 nature clinical practice ENDOCRINOLOGY & METABOLISM
The patient was treated with thyroxine to
reduce TSH secretion, but did not take this treat-
ment regularly. After 1 year her TSH and thyro-
globulin concentrations were normal (1.4 mIU/l
and 43 µg/l, respectively). At that time, repeat
thyroid ultrasonography showed no change
in the thyroid nodule, pelvic ultrasonography
showed a normal remaining right ovary with
no masses, and CT of her abdomen and pelvis
showed no masses.
DISCUSSION OF DIAGNOSIS
Twenty percent of ovarian tumors are teratomas,
and up to 20% of teratomas contain thyroid
tissue. Struma ovarii, defined as containing
50% or more thyroid tissue, is less common,
accounting for approximately 5% of all ovarian
teratomas. Most patients with struma ovarii
present with a pelvic mass, and pelvic ultra­
sonography characteristically shows a hetero­
geneous, solid mass, occasionally with ascites. The
patient commonly undergoes surgery, because an
ovarian malignancy is suspected. Intraoperative
frozen section often only reveals a teratoma,
and the diagnosis of struma ovarii is usually
made postoperatively. Benign thyroid tissue can
also be found in small foci on the peritoneal
surface, and this finding is termed strumosis.
Clinical and biochemical hyperthyroidism is
unusual, occurring in less than 5% of cases.
Histologic features of thyroid carcinoma
are found in 5–37% of struma ovarii (referred
to as malignant struma ovarii). The nuclear
features of papillary carcinoma are usually
used as the criteria for diagnosis of malignant
struma ovarii, and most cases reported are
papillary carcinoma.1–3 Some cases initially
reported as follicular carcinoma might in fact
represent a follicular variant of papillary carci-
noma.4 Immunohistochemical staining with
HBME-1 (Hector Battifora mesothelial [cell] 1)
and galectin-3, often positive in papillary
thyroid carcinoma, can also help confirm the
diagnosis.5,6 BRAF (v-raf murine sarcoma viral
oncogene homolog B1) mutations, common in
papillary thyroid carcinoma, were present in two-
thirds of malignant struma ovarii with papillary
features.7 RET proto-oncogene re­arrangements
(RET/PTC) were seen in 7 of 10 malignant
struma ovarii with histologic features of follicular
variant papillary thyroid carcinoma.8 One case of
benign struma ovarii was, however, also found
to have a RET proto-oncogene re­arrangement.9
Although rare, thyroid carcinoma, metastatic to
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the ovary, has been reported and should not be Table 1 Frequency, sites and detection of disease recurrence in patients with
confused with malignant struma ovarii. In the malignant struma ovarii.
case of thyroid metastasis, the ovarian mass has Disease recurrence Number of casesa
no ter­atomatous features.10
No recurrence reported 42
The behavior of malignant struma ovarii is
based on summaries of single case reports and Recurrence reported 14
small case series.11–13 The mean age at diag- Site of recurrenceb
nosis of malignant struma ovarii in one series Adjacent pelvic structuresc 9
of 24 patients was 43 years.11 In a summary of
Lung 4
39 patients with malignant struma ovarii, 9
Bone 2
(23%) had metastases.12 The predominant
sites of metastasis were adjacent pelvic struc- Contralateral ovary 1
tures, including the contralateral ovary, but Liver 1
some patients had distant metastases, including Brain 1
metastases to the lungs, bone, liver, and brain;
Lymph nodes 2
however, in other small series the rates of meta­
stasis were lower.2 Because systematic reviews of Skin 1
thyroidectomy specimens in patients with malig- Method of detection of recurrence
nant struma ovarii have not been performed, the Patient presenting with symptoms 10
percentage of patients with coexisting primary Iodine scanning 1
thyroid carcinoma is unknown. Recurrence rates
Incidental finding on pathological examination after 2
after initial surgical treatment vary, but were as unrelated surgery
high as 35% in one summary of 24 case reports,
Not reported 1
with a median time to recurrence of 4 years.11
aTotal number of cases reported = 56. bSome patients had recurrence at multiple sites.
Of note, all recurrences in this series occurred cPeritoneum, omentum, fallopian tubes and mesenteric surfaces of the spleen and diaphragm.
in patients who had no additional surgical or
radioiodine treatment after their initial pelvic
surgery. In our own review of 56 cases reported
in the literature since 1966, sites of recurrence with greater sensitivity. In addition, after near-
included adjacent pelvic structures, lung, liver, total thyroidectomy, radioactive iodine can then
bone, lymph nodes, skin and brain2,4,11–16 be used for the treatment of recurrent disease.14
(Table 1). Treatment with thyroxine was not A few patients with metastatic malignant struma
documented consistently enough to determine ovarii have been treated with external beam radia­
its impact on recurrence rates. tion and chemotherapy; however, on the basis of
the similarities between malignant struma ovarii
TREATMENT AND MANAGEMENT and thyroid carcinoma, we think radio­active
Currently, no consensus exists on the surgical and iodine should be first-line therapy for treatment
postoperative treatment of patients with malig- of recurrent disease.
nant struma ovarii. Because ovarian malignancy A risk stratification of malignant struma
is often suspected preoperatively, initial pelvic ovarii similar to that used in thyroid carcinoma
surgery may include a total abdominal hysterec- can help determine the most appropriate post­
tomy and bilateral salpingo-oophorectomy with operative treatment. Patients with thyroid carci-
omentectomy, peritoneal washings and lymph noma confined to the struma ovarii, measuring
node sampling. To preserve fertility, however, less than 2 cm, with no worrisome histologic
a unilateral oophorectomy or strumectomy is features, can be considered low risk. Conversely,
often performed.11 After the initial surgery, once patients with larger thyroid carcinomas, disease
the malignant struma ovarii is discovered, treat- outside the struma ovarii, or more aggressive
ment options include further pelvic surgery, with histologic features should be considered high
total abdominal hysterectomy and oophorec- risk. The case patient was young and wished to
tomy (Box 1). Some authors advocate near-total preserve fertility. Her malignant struma consisted
thyroidec­tomy followed by radioactive iodine of multiple microscopic foci of classic papillary
ablation.11 In a manner analogous to treatment of carcinoma. Pelvic imaging studies showed no
patients with thyroid carcinoma, monitoring evidence of additional tumor and there was
of serum thyroglobulin can then be performed no evidence of carcinoma in her thyroid gland.

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Competing interests Box 1 Treatment options for malignant struma
The authors declared no
competing interests. ovarii.
Pelvic surgery
■ Cystectomy
■ Unilateral oophorectomy
■ Total hysterectomy and bilateral salpingo-
oophorectomy
■ Total hysterectomy, bilateral salpingo-
oophorectomy with omentectomy and lymph
node sampling
Adjuvant treatment
■ None
■ Thyroxine, to reduce TSH secretion
■ Near-total thyroidectomy with radioactive
iodine ablation
In addition, the presence of ter­atomatous
features in her ovarian mass argued against a
diagnosis of metastases from a papillary thyroid
carcinoma. Given these findings, we recom-
mended only thyroxine therapy, to reduce TSH
secretion, periodic measurements of serum
thyroglobulin and periodic pelvic imaging. In
view of her low-risk disease, we recommended
a target serum TSH between 0.1 and 0.5 mIU/l.
It is our opinion that the goal for serum TSH
suppression in patients with malignant struma
ovarii should be similar to that for patients with
thyroid carcinoma. Although serum thyro­globulin
is unlikely to become undetectable in patients
without thyroidectomy on thyroxine therapy,
any rise in thyroglobulin above baseline should
prompt further evaluation for recurrent disease.
Near-total thyroidectomy followed by radio­
iodine to detect and potentially treat recurrent
disease should be considered at that time.
CONCLUSIONS
In summary, for younger patients with malig-
nant struma ovarii who wish to preserve fertility,
oophorectomy may be the most appropriate
surgery if pelvic imaging and surgical explora-
tion do not reveal extra-ovarian disease. For
those patients with low risk of persistent or
472 nature clinical practice ENDOCRINOLOGY & METABOLISM
recurrent thyroid carcinoma, we recommend
thyroxine therapy, pelvic imaging and periodic
measurements of serum thyroglobulin. For those
patients with a higher risk of recurrence based
on the pathology of the carcinoma, near-total
thyroidectomy with radioactive iodine ablation
is indicated.
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