Case 4.
24  (Continued)
FINDINGS: Predominately anechoic structure origi-
nating within the subcutaneous fat. Standoff tech-
nique allows for clear visibility of a neck extending
through the dermis to an opening in the skin
(Fig.  4.24.1). There is no identifiable flow within
the lesion (Fig.  4.24.2). Similar additional lesions
demonstrating varying degrees of internal debris
(Figs. 4.24.3 and 4.24.4).
DIAGNOSIS: Sebaceous cyst
DISCUSSION: Sebaceous cysts are of skin origin and
arise predominately in the hair-bearing areas of the
body. They frequently present in breast imaging as
a palpable mass in the axillary regions. Classically
these lesions are considered to lie entirely within the
skin (Fig. 4.24.3), but can also lie within the subcu-
taneous fat (Figs. 4.24.1 and 4.24.4). Lesions in the
subcutaneous fat often demonstrate a gland-shaped
216 AUNT MINNIE’S ATLAS AND IMAGING-SPECIFIC DIAGNOSIS
(c) 2015 Wolters Kluwer. All Rights Reserved.
neck coursing through the skin, as in this case. The
internal echogenicity of a sebaceous cyst will vary
according to the internal contents (42).
Epidermal inclusion cysts are considered in the
differential for cysts of skin origin and occur in a
similar anatomic distribution (43). What differen-
tiates an epidermal inclusion cyst is its distinctive
internal echogenicity with the classically described
onion-skin arising from the sloughing of keratin
layers into the cyst lumen (42).
Aunt Minnie’s Pearl
Sebaceous cyst is classically described as arising en-
tirely within the skin. However, it can also arise in the
subcutaneous tissues. In these cases the presence of a
demonstrable neck coursing through the skin can be
diagnostic.
 Case 4.25
HISTORY: A 22-year-old female presented with severe right lower quadrant pain, nausea, and vomiting

FIGURE 4.25.1 FIGURE 4.25.2

FIGURE 4.25.3

FINDINGS: Transvaginal scan, sagittal image
through the uterus (Fig. 4.25.1) shows normal endo-
metrial stripe without any intrauterine gestational
sac. There is significant amount of free fluid noted
posterior to the uterus. Figure  4.25.2 through the
right adnexa shows a large anechoic cystic mass
(O), which represents right ovary with corpus luteal
cyst. Anterior to that, there is an echogenic ring-like
structure (short arrows) that represents an extrauter-
ine gestational sac. A small yolk sac (long arrow) is
also present within the gestation sac. Figure 4.25.3
is a color Doppler US image through the right ad-
nexal region showing increased vascularity around
the gestational sac.
DIAGNOSIS: Right ectopic pregnancy
DISCUSSION: The incidence of ectopic pregnancy
has increased in recent years and is seen in 1%
to 2% of all pregnancies in United States (44–46). It
most commonly occurs in fallopian tubes (97%) but
can occur in cervix, ovary, cornua of the uterus or
even intra-abdominally. Among the tubal pregnan-
cies, ampulla is the most common site of implanta-
tion. If the patient’s beta-hCG is more than 1,500
to 2,000 mIU/mL and an intrauterine pregnancy is
not seen on a transvaginal scan, an ectopic preg-
nancy should be suspected (New9). Patients usually
present with lower abdominal pain. The risk fac-
tors include previous tubal surgery, previous ectopic
pregnancy, infertility treatment, and intrauterine
contraceptive device. On ultrasound, tubal preg-
nancy usually presents as a complex adnexal mass,

4 / ULTRASOUND 217

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