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Ultrasound Obstet Gynecol 2003; 22: 102–103
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.181

Picture of the Month

Cystic ovarian teratoma with intracystic fat balls

S. JANTARASAENGARAM, S. SIRICHAROENTHAI and K. VAIROJANAVONG

Ultrasound Unit, Department of Obstetrics and Gynecology, Rajavithi Hospital, Bangkok, Thailand

Cystic teratomas can produce a wide spectrum of sono- hairs in many of them (Figure 2). A broad, thick mass of
graphic appearances, which depends on their major cheese-like sebum tissue and hairs that represented a der-
content1 . Teratomas may be predominantly cystic, of moid plug was also noted. The right ovary and the uterus
complex mass, or even of solid appearance if the intracys- were normal. Left salpingo-oophorectomy was performed
tic fat tissue, epithelial debris and hairs are conglomerated
and produce hyperechogenic features filling the entire
cyst2 . Many specific ultrasonographic appearances of cys-
tic teratoma have been reported including the tip of the
iceberg sign, fat–fluid level, dermoid mesh and Roki-
tansky’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. Phys-
ical 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 exami-
nation, a large cystic mass of 20 cm diameter occupying
most of the lower abdomen was noted. It had a smooth Figure 1 Transverse scan of the cyst showing multiple, uniform,
external wall and was slightly mobile but not tender. echogenic balls floating in the hypoechogenic fluid.
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 cav-
ity extending up to the level of the umbilicus. This cyst
had a striking ultrasound appearance with multiple, dis-
tinct, 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 ter-
atoma (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 ultra-
sound examination, a 16-cm unilocular left ovarian cyst
was found. It contained serous fluid and numerous small, Figure 2 Gross specimen of the left ovarian cyst showing multiple,
soft, cheese-like sebum balls of about 2 cm diameter with uniform fat balls in serous fluid. Many of the fat balls contain hairs.

Correspondence to: Dr S. Jantarasaengaram, Department of Obstetrics and Gynecology, Rajavithi Hospital, 2 Phyathai Road, Rajathevee
District, Bangkok 10400, Thailand (e-mail: surasakjan@yahoo.com)

Copyright  2003 ISUOG. Published by John Wiley & Sons, Ltd. PICTURE OF THE MONTH

Picture of the Month
without any complication. The postoperative period was
uneventful and the pathological report identified the cyst
as a mature teratoma of the ovary.
A review of the literature revealed that the presence
of intracystic fat balls within a cystic ovarian teratoma
was first reported by Muramatsu et al.7 in 1991 with
computed tomography (CT) scan imaging. Five years
later, Hession and Simpson8 reported the same CT scan
finding of cystic teratoma in the mediastinum. In 2000,
Otigbah et al.9 reported ultrasound imaging of mobile
globules in a cystic teratoma of the ovary. The most
recent two reports of Kawamoto et al.10 and Rao et al.11
found the same ultrasonographic appearance in 2001 and
2002, respectively. All reported patients with a teratoma
in the ovary presented with abdominal distension and/or
a large mass (15–20 cm diameter) as in the present case.
The fat globules in all these reports have been described as
being 1.5–2 cm in diameter and composed of cheese-like
sebum and hairs. The fat globules must have a specific
gravity equal to or less than that of the fluid inside the
cyst at body temperature so that they float within the cyst.
Globule formation may be from tiny, floating tissue nuclei
that accumulate cell debris, sebum and hairs around them
or from floating pluripotent cells that act as a core and
then differentiate into outer fat tissue and hairs. In all
the reported cases, fat globules have occurred in rather
large cysts so the fat balls might require sufficient space
for their formation. Whether globule formation occurs in
both benign and malignant cysts is not known, but all
cases reported to date have been benign.
In summary, multiple intracystic fat balls are a rare
morphological feature of cystic teratoma.
Copyright  2003 ISUOG. Published by John Wiley & Sons, Ltd.
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103
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