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Endometrioma With Calcification Simulating a Dermoid whereas only 6% of nonendometriomas did so. Their data indicate that a mass with low-level internal echoes, hyperechoic wall foci, and no neoplastic features is 32 times more likely to be an endometrioma than another adnexal mass. Generally endometriomas are not thought to contain fluid-fluid levels. However, endometriomas contain blood of different ages, which sometimes can appear as a fluid-fluid level on imaging studies. The observation missed on the initial sonographic examination was that the dependent layer in the fluid-fluid level was echogenic, which was due to the presence of echogenic blood. If this echogenic layer was fat, it would have been in the supernatant location; that is, the mass would show supernatant hyperechoic and dependent hypoechoic layers. However, this mass showed supernatant hypoechoic and dependent hyperechoic layers, which have been observed in endometriomas. 6 Certain sonographic features (focal acoustic impedance, regional bright echoes, and hyperechoic lines and dots) are predictive of cystic teratomas. 7 Although the hyperechoic shadowing focus is very predictive of a teratoma, not all hyperechoic shadowing areas are due to calcifications. Furthermore, although a calcification can certainly occur in a teratoma, a calcification by itself is not pathognomonic of a teratoma. A teratoma can contain a nonshadowing echogenic focus or a shadowing calcification. The positive predictive value for individual sonographic features associated with dermoid masses is 80% for a shadowing echogenic focus and 20% for a fluidfluid level. 6 On sonography, the dermoid plugs are seen as an echogenic mass, often associated with distal acoustic shadowing. 8 Although hyperechoic foci are described in the wall of the endometriomas, a discrete shadowing focus similar to that seen in a dermoid cyst has not been reported in the literature. Histopathologic findings of the resected endometrioma revealed extensive fresh and old blood with hemosiderin-laden macrophages. A large, marblelike calcification was identified. The most commonly promulgated hypothesis is that calcification of degenerated hyalinized cells leads to the eventual formation of psammoma bodies in any organ. 9 In most situations, the concentration of calcium and phosphate in the extracellular fluid cannot initiate hydroxyapatite crystal formation, but once a crystal nidus is formed, it can sustain development of large calcified masses. The nidus within an endometrioma can originate from degenerating cells, from ruptured cell membrane material, or from calcium-rich intracellular organelles. All these possibilities are plausible. Necrosis appears to be one of the common denominators for calcification and psammoma body formation. In endometriosis, there is some necrosis of the cells as the hormonally active glandular tissue is subjected to the menstrual cycle. 10,11 Fine-needle aspiration cytologic examination of endometriomas is well documented. Aspirates of endometriomas are generally moderately cellular, containing endometrial stroma and glandular components. The ovarian tumors associated with psammoma bodies include adenofibromas, cystadenocarcinomas, and papillary adenocarcinomas. Psammoma bodies in an epithelial tumor are not diagnostic of a malignancy. 12 Psammoma bodies are seen in both benign and malignant lesions. In conclusion, although a focal calcification is pathognomonic of a dermoid, it may be occasionally seen in endometriomas. Awareness of this finding will include endometrioma in the differential diagnosis of a cystic adnexal mass containing a calcification. Also, the fluid-fluid level seen in the adnexal mass on sonography is strongly suggestive but not pathognomonic of dermoids and may be seen in endometriomas and other cystic tumors. These lesions can then be further characterized with MRI, which has the capability of differentiating blood products from fat, thus allowing a definitive diagnosis. References 1. Mais V, Guerriero S, Ajossa S, Angiolucci M, Paoletti AM, Melis GB. The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma. Fertil Steril 1993; 60:776–780. 2. Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA. Endometriomas: diagnostic performance of US. Radiology 1999; 210:739–745. 3. Fried AM, Rhodes RA, Morehouse IR. Endometrioma: analysis and sonographic classification of 51 documented cases. South Med J 1993; 86:297–301. 4. Jain KA. Prospective evaluation of adnexal masses with endovaginal gray-scale and duplex and color Doppler US: correlation with pathologic findings. Radiology 1994; 191:63–67. 5. Volpi E, De Grandis T, Zuccaro G, La Vista A, Sismondi P. Role of transvaginal sonography in the detection of endometriomas. J Clin Ultrasound 1995; 23:163–167. 1240 J Ultrasound Med 2006; 25:1237–1241
Jain 6. Kim HC, Kim SH, Lee HJ, Shin SJ, Hwang SI, Choi YH. Fluidfluid levels in ovarian teratomas. Abdom Imaging 2002; 27:100–105. 7. Patel MD, Feldstein VA, Lipson SD, Chen DC, Filly RA. Cystic teratomas of the ovary: diagnostic value of sonography. AJR Am J Roentgenol 1998; 171:1061–1065. 8. Sheth S, Fishman EK, Buck JL, Hamper UM, Sanders RC. The variable sonographic appearances of ovarian teratomas: correlation with CT. AJR Am J Roentgenol 1988; 151:331–334. 9. Johannessen JV, Sobrinho-Simoes M. The origin and significance of thyroid psammoma bodies. Lab Invest 1980; 43: 287–296. 10. Minkowitz G. Psammoma bodies in endometriosis: clinical, cytological, and physiopathological implications. Diagn Cytopathol 1996; 14:331–333. 11. Anderson HC. Mechanisms of pathologic calcification. Rheum Dis Clin North Am 1988; 14:303–319. 12. Kern SB. Prevalence of psammoma bodies on Papanicolaoustained cervicovaginal smears. Acta Cytol 1991; 35:81–88. J Ultrasound Med 2006; 25:1237–1241 1241
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