OT are usually detected in young women; the patients' median age at diagnosis is 35 and 27 years in the case of mature cystic teratoma and immature teratoma, respectively [3] [6].

Abdominal pain is the single most important symptom of OT. Women may also experience abnormal uterine bleedings. Occasionally, OT exerts local mass effects that interfere with bladder and intestinal function. Torsion, rupture, and infection of OT are rare events, but dreaded complications causing a rapid deterioration of a patient's general condition [7]. Of note, about one in six patients are asymptomatic. Here, OT is incidental finding diagnosed during a routine physical and gynecological examination.

• Abdominal Lymphadenopathy

  Total-body 18F-FDG PET/CT studies helped to differentiate benign from malignant ovarian teratoma, as well as abdominal lymphadenopathy, subsequently confirmed by histopathology. [ncbi.nlm.nih.gov]

• Lymphadenopathy

  Total-body 18F-FDG PET/CT studies helped to differentiate benign from malignant ovarian teratoma, as well as abdominal lymphadenopathy, subsequently confirmed by histopathology. [ncbi.nlm.nih.gov]

  Massive para-aortic, periceliac and bilateral iliac lymphadenopathy was seen. Ascites with floating bowel loops were also noted. CT Scan abdomen [Figure - 3] [Figure - 4] further confirmed the above findings. [ijri.org]

• Euthyroid

  We report this case of Hashimoto's thyroiditis in a clinically euthyroid patient who tested positive for antithyroid peroxidase antibodies in spite of normal thyroid hormone profile. [ncbi.nlm.nih.gov]

• Cushingoid

  Cushingoid appearance, may inform a focused investigation. [ncbi.nlm.nih.gov]

• Abdominal Tenderness

  The clinical course consisted of progressive abdominal tenderness after a 1600-m run and 12 subsequent sit-ups. [ncbi.nlm.nih.gov]

• Insomnia

  She presented with recurrent seizure attacks with muscle weakness, psychosis, dyskinesia, autonomic failure and insomnia. [ncbi.nlm.nih.gov]

  Within a few days to two weeks, this progresses to psychiatric and cognitive symptoms that include everything from anxiety and insomnia to hallucinations, delusions, mania, memory deficits, delirium, language difficulties to frank mutism. [hormonesmatter.com]

• Behavior Problem

  Postoperatively, the patient's menstrual cycles became regular and her behavioral problems resolved. Her testosterone levels fell precipitously as well. [ncbi.nlm.nih.gov]

• Hyperactivity

  The perioperative management and complications of anti-NMDAR encephalitis, including hypoventilation, paroxysmal sympathetic hyperactivity (PSH) and epilepsy, are challenging for ansthesiologists. [ncbi.nlm.nih.gov]

• Cerebellar Sign

  Only after other cerebellar signs developed was it possible to diagnose a paraneoplastic syndrome. [neurologyindia.com]

• Generalized Seizure

  A 21-year-old woman developed psychiatric symptoms, progressive unresponsiveness, generalized seizures, severe dyskinesia, marked fluctuation of blood pressure, and hypersalivation after a flu-like episode. [ncbi.nlm.nih.gov]

Workup comprises diagnostic imaging to confirm the presence of an ovarian mass and to assess whether metastases have developed in other parts of the reproductive system, lymph nodes, or distant organs:

• Ultrasonography yields reliable results regarding the presence of ovarian tumors and allows for the detection of metastases in other organs and lymph nodes. The ultrasonographic image of OT typically comprises hypo- and hyperechogenic areas, which correspond to heterogeneous tissues, calcified and fluid-filled spaces, and septa. This technique is readily available, cost-effective, and highly specific [8].
• Availability and costs argue against the employment of computed tomography and magnetic resonance imaging. They are, however, of major importance for tumor staging in the case of malignant OT. Additionally, these techniques may be helpful to clarify uncertain diagnoses [9], owing to a higher sensitivity (60-94% for ultrasonography, 93-98% for computed tomography, [8]).

In order to distinguish between benign and malignant OT, measurements of serum α-1-fetoprotein, β-human chorionic gonadotropin and cancer antigen 125 (CA 125) should be performed. Enhanced concentrations of either marker are indicative of malignancy [10] [11].

Ovarian teratoma (OT) is a germ cell tumor to be encountered in the female gonads. OT are rather common and account for up to 20% of ovarian neoplasms [1]. There are distinct types of OT [2]:

• Mature cystic teratoma is the most common type of OT. Tumor cells are well differentiated and derive from at least two of the three germ cell layers. A mature cystic teratoma typically consists of an outer layer of squamous epithelium enclosing fat, muscle, hair follicles, skin glands and liquid, sebaceous material. Therefore, this benign neoplasm is also referred to as a dermoid cyst. A considerable share of patients presents with bilateral tumors [3] [4]. Of note, mature cystic teratomas have occasionally been reported to undergo malignant transformation [5].
• Immature teratomas are similarly composed of tumor cells deriving from at least two germ cell layers. However, these cells are poorly differentiated and this type of OT is generally associated with higher tumor grades. Fortunately, less than 1% of OT are immature teratomas.
• Monodermal teratoma differs from the afore-described variants in that it contains degenerated cells of either ectodermal, mesodermal or endodermal origin only. Struma ovarii and ovarian carcinoid tumor fall into this category and primarily contain thyroid and neuroectodermal tissue, respectively. Other types of monodermal teratoma have been described.

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2. Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumor types and imaging characteristics. Radiographics. 2001;21(2):475-490.
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5. Rojas CP, Ganjei-Azar P, Garcia-Buitrago MT. Unexpected Malignant Diagnosis in Colonic Biopsies: Malignant Transformation of Ovarian Mature Teratomas-Two Case Reports and Review of the Literature. Case Rep Pathol. 2015;2015:905462.
6. Jorge S, Jones NL, Chen L, et al. Characteristics, treatment and outcomes of women with immature ovarian teratoma, 1998-2012. Gynecol Oncol. 2016;142(2):261-266.
7. Park SB, Kim JK, Kim KR, Cho KS. Imaging findings of complications and unusual manifestations of ovarian teratomas. Radiographics. 2008;28(4):969-983.
8. Saba L, Guerriero S, Sulcis R, Virgilio B, Melis G, Mallarini G. Mature and immature ovarian teratomas: CT, US and MR imaging characteristics. Eur J Radiol. 2009;72(3):454-463.
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10. Panteli C, Curry J, Kiely E, et al. Ovarian germ cell tumours: a 17-year study in a single unit. Eur J Pediatr Surg. 2009;19(2):96-100.
11. Taskinen S, Fagerholm R, Lohi J, Taskinen M. Pediatric ovarian neoplastic tumors: incidence, age at presentation, tumor markers and outcome. Acta Obstet Gynecol Scand. 2015;94(4):425-429.