Case Report

Ovarian Cystic Teratoma

Determined Phenotypic Response of Keratocytes and Uncommon Intracystic Floating Balls Appearance on Sonography and Computed Tomography
Jhanavi R. Rao, MBBS, Zarine Shah, MBBS, Vasudha Patwardhan, DMRD, Vijay Hanchate, MD, Hemangini Thakkar, MD, Ashwin Garg, DMRD

varian cystic tumors (dermoid cysts), derived from totipotent cells, are composed mainly of a cyst lined entirely or partly by epithelium resembling keratinized epidermis with sebaceous and sweat glands. The term dermoid emphasizes the preponderance of ectodermal tissue, with the elements derived from other germ layers being inevitably present.1,2 Sonography3,4 and computed tomography (CT)5,6 can easily facilitate diagnosis of these benign cystic fatty tumors. Generally, cystic teratomas are classified into 1 of 3 categories on the basis of their configuration and components. The first type shows layering of floating debris within a tumor6,7; the second type has nodular or palm treelike mural protrusions3,7; and the third type shows a fat-fluid level.3 We report a case of a dermoid cyst that had none of the classic sonographic features. Instead, multiple mobile fat balls were seen within the cyst, and no features of calcification, tooth, or bone were shown on sonography and CT. Also, the golden brown color of the hair in the dermoid was similar to that of the patients scalp hair. To our knowledge, that feature, showing the determined nature of keratocytes, has not been discussed before in the literature. We present unusual sonographic and CT features of a cystic ovarian teratoma with intracystic mobile spherical masses. The spherical fat balls, some of which were admixed with hair, caused the striking feature of multiple floating masses in the cyst.

Abbreviations CT, computed tomography

Case Report
A 60-year-old postmenopausal woman, gravida 2, para 2, living 2, was evaluated for heaviness and pain in the right iliac fossa of 6 months duration. She had mild fever with chills and burning micturition. There was no notable medical or surgical history. A radiograph of the abdomen was unremarkable. Sonography showed the presence of a large cystic mass in the right adnexa containing within it numerous floating, highly echogenic round masses (Fig. 1). The echogenicity of these masses characteristically corresponded to that of fat. Multiple linear hyperechoic structures (Fig. 2) were seen radiating from these masses, which correspond-

Received February 4, 2002, from the Department of Radiology, King Edward VII Memorial Hospital, Mumbai, India. Revision requested February 21, 2002. Revised manuscript accepted for publication February 28, 2002. We thank Vinita Salvi, MD, and residents of the Department of Gynecology and Obstetrics for providing the surgical findings. Address correspondence and reprint requests to Ashwin Garg, DMRD, Department of Radiology, King Edward VII Memorial Hospital, Parel, Mumbai 400012, India.

2002 by the American Institute of Ultrasound in Medicine J Ultrasound Med 21:687691, 2002 0278-4297/02/$3.50

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Figure 1. Transverse sonogram showing multiple mobile, spherical, echogenic structures floating in a cystic mass.

At laparotomy a large mass of 18 25 cm was seen. It was mildly congested and had twisted around its pedicle. The mass was easily dissected and removed along with the right ovary. In a cut section, the cystic mass was full of viscous, fatty fluid (Fig. 4). There were multiple yellowwhite, pultaceous, ball-like masses floating in the fluid, many of them containing golden brown hair (Fig. 5). No calcification or tooth element was found on gross examination. On retrospection, we found that the patient also had the same color hair on her head. Histologic examination showed that the cyst was lined by epithelium resembling keratinized epidermis with sebaceous and sweat glands. The histopathologic diagnosis was a benign cystic teratoma. The patients postoperative course was uneventful.

Discussion
ed to hair. Thus a mature cystic teratoma arising from the right ovary was considered as a preoperative diagnosis. Computed tomography, performed to determine the nature of the lesions and to evaluate the effects of this mass on adjacent structures, confirmed the sonographic findings. It showed an encapsulated, nonenhancing mass with homogenous lowattenuation internal architecture that measured 30 Hounsfield units. Multiple floating hyperdense fatty masses were seen within (Fig. 3). Serologic testing was done to rule out Echinococcus granulosis (considered unlikely); the results were negative.
Figure 2. Cystic mass with highly echogenic round structures and posterior shadowing. Multiple linear hyperechoic structures corresponding to hair are shown radiating from the spherical mass into surrounding fatty fluid.

Benign cystic teratomas, among the most common ovarian neoplasms (15%25%), are derived from the primitive germ cells of the embryonic gonad. They occur most often during active reproductive years, are rare before puberty, and are not infrequently seen in postmenopausal women. Although they contain well-differentiated derivatives of the 3 germ layers,1,2 ectoderm, mesoderm, and endoderm, ectodermal elements generally predominate; therefore they are also called dermoid cysts. The melanocytes, ectodermal derivatives, are distributed in the hair matrix and synthesize melanin, which is responsible for the color of hair. There are 2 types of cells: competent and determined. Cells that do not alter their phenotype in response to environmental influences are known as determined or committed cells, whereas other cells, which are environmentally responsive, are described as competent. In our patient, the golden brown hair in the dermoid cyst was similar to the hair on her scalp. This shows the determined feature of the melanocytes found in the dermoid cyst. Dermoid cysts tend to remain concealed unless they assume such a size as to produce a palpable abdominal mass or to cause pain as a result of torsion, the most common complication caused by the long pedicle they have. Some asymptomatic dermoids are detected incidentally on abdominal radiography, showing calcification or tooth. Other less common complications are rupture (1%) and malignant
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transformation (2%).8 In our case, the postmenopausal woman had pain secondary to torsion of the dermoid cyst. The radiologic diagnosis of cystic teratoma can be made readily on the basis of sonography, CT, or magnetic resonance imaging. Because an ovarian tumor may contain a large number of recognizable tissues, including matted hair, well-formed teeth, and semisolid sebaceous material, the variety and preponderance of internal contents presumably account for the spectrum of sonographic appearances. On sonography, a teratoma may appear as a predominantly cystic, solid, or complex mass.3,9 However, certain features are considered specific. These include an axial location, cephalad to the urinary bladder,10 an echogenic mural nodule (the dermoid plug or dermoid nipple),3 a fat-fluid or hair-fluid level,11 and distal acoustic shadowing produced by a highly echogenic mixture of matted hair and sebum, termed the tip of the iceberg sign.12 Another specific sign is dermoid mesh, i.e., multiple linear hyperechoic interfaces produced by the floating hair fibers within the cyst.13 However, our case did not have any of these classic features; instead, there were multiple round, floating, echogenic fat balls seen within the large anechoic cyst. Also, there was no calcification or toothlike structure shown on sonography and CT. On review of literature, we found only a small number of cases of cystic teratomas with multiple mobile spherical masses. These have been found in the ovary,14,15 retroperitoneum,16 and mediastinum.17 The composition of these masses was different in different locations: in the case of a cystic teratoma of the ovary, the nodules consisted of sebaceous debris with skin squames and hair15; and in a mature cystic teratoma of the mediastinum, mobile globules consisted of pastelike material, fat, and hair.17 In a retroperitoneal mature cystic teratoma, fat deposition was seen around hair tissue16; these spherical structures have been called intracystic fat balls.14,16 In our patient, spherical masses consisted of pastelike material and fat, and some were intermixed with hair. Other than cystic teratoma, intracystic multiple spherules also have been described in an epidermoid cyst in the floor of the mouth.18 According to Kawamoto et al,19 the appearance of multiple spherules floating within a pelvic cystic tumor has not been found in other tumors; therefore,
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Figure 3. Contrast-enhanced CT showing multiple round, fat-dense masses floating within the cyst.

this appearance is pathognomonic for a cystic teratoma. Computed tomography, with its unique ability to discriminate between tissues of different attenuations, can display with precision the internal architecture of the lesion and can show the presence of even a small amount of fat; therefore, CT is helpful in those instances in which plain radiography and sonography are nonspecific. The specific CT characteristics are those of a predominantly fatty mass with a dense dependent element (mixture of fat, hair,

Figure 4. Cut section of the specimen showing multiple mulberry-shaped, round, solid fatty masses floating in the fluid inside the thinly encapsulated dermoid cyst.

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In summary, unusual associated findings of a mature cystic teratoma may result in occasional diagnostic difficulty. Only a small number of cases of cystic teratomas with multiple mobile spherules or globules have been reported. This case further substantiates the idea that the sonographic and CT appearance of multiple floating masses in a cystic mass in the pelvis is pathognomonic for a cystic teratoma of the ovary.

References
1. Novak ER, Woodruff JD. Novaks Gynecologic and Obstetric Pathology With Clinical and Endocrine Relations. 8th ed. Philadelphia, PA: WB Saunders Co; 1979:476503. Scully RE. Germ cell tumors. In: Tumors of the Ovary and Maldeveloped Gonads. Washington, DC: Armed Forces Institute of Pathology; 1979:226 286. Hartmass WH (ed). Atlas of Tumor Pathology; Series 2, Fascicle 16. Quinn SF, Erickson SE, Black WC. Cystic ovarian teratomas: the sonographic appearance of the dermoid plug. Radiology 1985; 155:477478. Laing FC, Van Dalsem VF, Marks WM, Barton JL, Martinez DA. Dermoid cysts of the ovary: their ultrasound appearances. Obstet Gynecol 1981; 57: 99104. Freidman AC, Pyatt RS, Hartman DS, Downey EF Jr, Olson WB. CT of benign cystic teratomas. AJR Am J Roentgenol 1982; 138:659665. Skanne P, Heuber KH. Computed tomography of cystic ovarian teratomas with gravity-dependent layering. J Comput Assist Tomogr 1983; 7:837 841. Togashi K, Nishimura K, Itoh K, et al. Ovarian cystic teratoma: MR imaging. Radiology 1987; 162:669 673. Kurman RJ. Blausteins Pathology of the Female Genital Tract. 4th ed. New York, NY: Springer-Verlag; 1994. Sandler MA, Silver TM, Karo JJ. Gray scale ultrasonic feature of ovarian teratomas. Radiology 1979; 131:705709.

Figure 5. Specimen showing golden brown hair admixed with fatty masses.

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debris, and fluid) and globular foci of calcification (teeth, abortive tissue, or both) in a solid protuberance. Correlation with sonographic images has shown that in many cases, as in our case, the anechoic cystic component is pure sebum (which is liquid at body temperature) rather than fluid.20 The absence of multiple lesions interfacing within the sebum is the likely explanation for its anechoic appearance on sonography.4 On the contrary, a mixture of matted hair, soft tissue, and fat in the dermoid plug or floating masses is highly echogenic because of numerous tissue interfaces.21 Sonography in isolation or in combination with radiography has contributed considerably to the correct diagnosis; however, an echogenic dermoid may appear similar to bowel gas and may be overlooked. Similarly, echogenic fluid-filled masses may occasionally simulate solid lesions. Magnetic resonance imaging, with its better soft tissue contrast and multiplanar imaging, has an advantage over sonography and CT. To avoid radiation hazards, magnetic resonance imaging has become the procedure of choice for pelvic imaging.7 The cystic teratoma has the notable characteristic of fat (hyperintense on T1-weighted images) and water (hypointense on T1-weighted images and hyperintense on T2-weighted images). However, calcifications, bone, hair, and fibrous tissue, all frequently found in teratomas, are of low signal intensity.
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12. Guttman PH Jr. In search of the elusive benign cystic ovarian teratoma: application of the ultrasound tip of the iceberg sign. J Clin Ultrasound 1977; 5:403 406. 13. Malde HM, Kedar RP, Chadha D, Nayak S. Dermoid mesh: a sonographic sign of ovarian teratoma [letter]. AJR Am J Roentgenol 1992; 159:13491350. 14. Muramatsu Y, Moriyama N, Takayasu K, Nawano S, Yamada T. CT and MR imaging of cystic ovarian teratoma with intracystic fat balls. J Comput Assist Tomogr 1991; 15:528529. 15. Otigbah C, Thompson MO, Lowe DG, Setchell M. Mobile globules in benign cystic teratoma of the ovary. BJOG 2000; 107:135138. 16. Fujitoh H, Akiyosi S, Takoda S, Katsuki K, Okuda K. Hepatobiliary and pancreatic imaging: retroperitoneal mature cystic teratoma with a fat ball. J Gastroenterol Hepatol 1998; 13:540549. 17. Hession PR, Simpson W. Case report: mobile fatty globules in benign cystic teratoma of the mediastinum. Br J Radiol 1996; 69:186188. 18. Lohaus M, Hansmann J, Witzel A, Flechtenmacher C, Mende U, Reisser C. Ungewoehnlicher sonographischer Befund einer Epidermoidzyste. HNO 1999; 47:737740. 19. Kawamoto S, Sato K, Matsumoto H, et al. Multiple mobile spherules in mature cystic teratoma of the ovary. AJR Am J Roentgenol 2001; 176:14551457. 20. Seth S, Fishman EK, Buck JL, Hamper UM, Sanders RC. The variable sonographic appearances of ovarian teratomas: correlation with CT. AJR Am J Roentgenol 1988; 51:331334. 21. Fleischer AC, Cullinan JA, Kepple DM, Williams LL. Conventional and color Doppler transvaginal sonography of pelvic masses: a comparison of relative histologic specificities. J Ultrasound Med 1993; 12: 705712.

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