A 27-year-old woman underwent laparoscopic right ovarian cystectomy for a 7.4 cm mature cystic teratoma. The bisected gross specimen is shown. The structure marked **B** on the cyst wall is the site from which hair, tooth, and bone elements characteristically arise. This structure is known as the:

Question

Accepted Answer

D. Rokitansky protuberance (dermoid nipple). ## Why Rokitansky protuberance (dermoid nipple) is right

The Rokitansky protuberance (also called dermoid nipple) is the characteristic mural nodule found in mature cystic teratomas from which organized tissue elements—hair, teeth, bone, and other differentiated structures—arise. This is a pathognomonic feature of mature teratomas and is formed by a localized proliferation of pluripotent germ cells that differentiate into tissues from all three germ layers. On imaging, it appears as a hyperechoic mural nodule with acoustic shadowing (from calcified tooth/bone), and histologically it contains the most organized and mature tissue elements. The clinical anchor is that the Rokitansky protuberance is the anatomical site of origin of the hair and tooth elements visible in the gross specimen. (Berek and Novak's Gynecology, 16th Edition, Chapter on Ovarian Neoplasms)

## Why each distractor is wrong

- **Germinal epithelium nodule**: The germinal epithelium (ovarian surface epithelium) is the source of epithelial ovarian cancers and does not give rise to hair, teeth, or bone. It is not a characteristic feature of teratomas.
- **Thecal cell proliferation**: Thecal cells are stromal cells involved in steroid hormone production and are not associated with the formation of organized tissue elements like hair and teeth in teratomas.
- **Granulosa cell tumor focus**: Granulosa cells form granulosa cell tumors (a type of sex cord–stromal tumor), not teratomas. They do not produce hair, teeth, or bone elements.

**High-Yield:** The Rokitansky protuberance is the diagnostic hallmark of mature cystic teratoma—a solid mural nodule from which all organized tissue elements (hair, teeth, bone) arise and where malignant transformation (if it occurs) most commonly begins.

[cite: Berek and Novak's Gynecology, 16th Edition, Chapter on Ovarian Neoplasms]

Answer

A. Germinal epithelium nodule

Answer

B. Thecal cell proliferation

Answer

C. Granulosa cell tumor focus

A 27-year-old woman underwent laparoscopic right ovarian cystectomy for a 7.4 cm mature cystic teratoma. The bisected gross specimen is shown. The structure marked B on the cyst wall is the site from which hair, tooth, and bone elements characteristically arise. This structure is known as the:

Explanation

Why Rokitansky protuberance (dermoid nipple) is right

Why each distractor is wrong

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