Endometrioma With Calcification Simulating a Dermoid - Journal of ...

Endometrioma With Calcification Simulating a Dermoid
Pelvic sonography depicted a normal uterus
and normal left ovary. In the right adnexa, there
was a 4 × 3 × 3.5-cm mass, which showed
enhanced through-transmission, and a fluidfluid
level consisting of echogenic fluid layering
with hypoechoic fluid. This was thought to be a
fat-fluid level (Figure 1A). It also showed an 11-
mm discrete calcification (Figure 1B). The mass
was surrounded by normal-appearing ovarian
parenchyma. These findings were thought to be
diagnostic of a cystic teratoma. Magnetic resonance
imaging was recommended for confirmation
of the sonographic diagnosis because MRI is
recommended to characterize complex masses
for definitive diagnosis at our institution.
Magnetic resonance imaging showed a normal
uterus and normal left ovary containing physiologic
follicles. There was a 4 × 3 × 3.5-cm mass in
the right ovary. This mass showed high signal
intensity on conventional and fat-suppressed
T1-weighted images (Figure 2, A and B). High signal
intensity was also seen on fat-suppressed T2-
weighted images (Figure 2C). Bright signal
intensity not suppressed by fat is indicative of
blood products. Normal ovarian parenchyma
was seen surrounding the mass on fat-suppressed
T2-weighted images (Figure 2C). The calcification
within the mass that was well
visualized on sonography (Figure 1B), was seen
as a focus with low signal intensity on all the MRI
sequences (Figure 2, A–D). A fluid-fluid level was
seen in the mass, with partial shading indicative
of old blood, on T2-weighted images (Figure 2, C
and D). This fluid-fluid level did not show fat signal
intensity on MRI and was determined to be
related to old and new blood products. On MRI,
this was not thought to be fat-fluid level. Thus,
with analysis of the signal intensities on all the
sequences, the mass was thought to be an
endometrioma containing an unusual feature of
a discrete calcification.
The patient then had a laparoscopic removal of
the mass. Histopathologic findings of the resected
endometrioma revealed extensive fresh and
old blood with hemosiderin-laden macrophages.
The calcification was located in the fluid portion
of the mass. There was no solid component in
this cystic mass at histopathologic examination.
A marblelike calcification fell out when the mass
was cut open after removal.
Discussion
Although endometriomas can have variable
sonographic appearances, certain sonographic
criteria are useful in making a definitive diagnosis.
Most experts 1,3–5 have agreed on one common
sonographic feature of diffuse dispersion of
low-level echoes within a cystic mass. Patel et al 2
addressed a set of features that would increase or
decrease the likelihood ratio for the diagnosis of
an endometrioma. Their findings confirm that
Figure 1. A, Transverse transabdominal sonogram shows a fluid-fluid level (arrow) in a cystic mass and solid ovarian tissue of normal ovarian parenchyma
(arrowheads). B, Coronal endovaginal sonogram shows a cystic mass filled with diffuse low-level internal echoes and a 1.1-cm calcification (calipers).
A
B
1238 J Ultrasound Med 2006; 25:1237–1241