Cystic ovarian teratoma with intracystic fat balls

Abstract

Cystic teratomas can produce a wide spectrum of sonographic appearances, which depends on their major content 1 . Teratomas may be predominantly cystic, of complex mass, or even of solid appearance if the intracystic fat tissue, epithelial debris and hairs are conglomerated and produce hyperechogenic features filling the entire cyst 2 . Many specific ultrasonographic appearances of cystic teratoma have been reported including the tip of the iceberg sign, fat-fluid level, dermoid mesh and Rokitansky's protuberance (dermoid plug) 3 -6 . We present a case of another distinct ultrasonographic feature, namely multiple, discrete, uniform globules floating within the cyst. On examination of the gross specimen these globules were fat balls composed of cheese-like sebum material and hairs. This unique finding was discovered when a 33-year-old woman presented with abdominal distension and discomfort that she had experienced for 1 year. Physical examination showed that her abdomen was slightly distended with a midline, tense cystic mass of about 20 cm diameter in her lower abdomen. On pelvic examination, a large cystic mass of 20 cm diameter occupying most of the lower abdomen was noted. It had a smooth external wall and was slightly mobile but not tender. A normal-size uterus was palpated just posterior to this cyst. Transabdominal sonography revealed a large cystic mass of 20 cm diameter occupying the whole pelvic cavity extending up to the level of the umbilicus. This cyst had a striking ultrasound appearance with multiple, distinct, round, bright, echogenic, uniform globules of about 2 cm diameter floating in hypoechogenic fluid (Figure 1). A broad hyperechogenic area with multiple bright linear echoes and spots that were characteristic of cystic teratoma (dermoid plug) was also noted in the upper part of the cyst. Because the uterus and normal ovaries could not be depicted, transvaginal sonography was suggested but the patient refused the procedure. A preoperative ultrasonographic diagnosis of dermoid cyst was made. On exploratory laparotomy the week following ultrasound examination, a 16-cm unilocular left ovarian cyst was found. It contained serous fluid and numerous small, soft, cheese-like sebum balls of about 2 cm diameter with hairs in many of them (Figure 2). A broad, thick mass of cheese-like sebum tissue and hairs that represented a dermoid plug was also noted. The right ovary and the uterus were normal. Left salpingo-oophorectomy was performed

Ovarian cystic teratoma with a pathognomonic appearance of multiple floating balls: a case report and investigation of common characteristics of the cases in the literature

“…Furthermore, the histopathological diagnosis was mature cystic teratoma in all cases. Hence, we agree with the statement that the appearance of multiple floating balls on ultrasound is pathognomonic of mature cystic teratoma (7,10,15). In light of the literature, it is possible to suggest that even the existence of a single floating ball in an ovarian cystic mass is pathognomonic for ovarian teratoma (17,19,20).…”

“…We found 18 cases of ovarian cystic teratoma with multiple floating balls from 14 studies in the review of the literature (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). We investigated common features in these 18 cases from the literature and our present case, such as the age of the women, the size of the tumor, and the side of the body in which the tumor located.…”

Mature cystic teratoma of the ovary: a cutting edge overview on imaging features

“…The size of the balls varies up to 4 cm and these globules are usually found in large MCTs. These balls are hyperechoic because of cheese-like sebaceous material, keratin and hair, with keratin being the major component [31, 34]. In addition, these globules float within the cyst because their specific gravity is equal to or less than the cyst fluid at body temperature.…”

Multiple intracystic floating balls: an unusual but unique sonographic pattern of mature cystic teratoma

“…The great diversity in components of teratomas results in varied sonographic appearances. Certain features like tip-of-iceberg sign, fat-fluid level, dermoid mesh and rokitansky protuberance (dermoid plug) are specific to this entity and considered diagnostic 2. A sonographic appearance of multiple free-floating spherical balls in a cyst as seen in the presented case is rare2 and may present a diagnostic difficulty to the unwary.…”