Presentation
Acute abdominal pain and rigidity.
Patient Data
Two masses composed of fat and fluid with a calcific focus (likely tooth) are seen with in the pelvis There is surrounding fat stranding. A chain of fat density material is seen extending from the right mass along the right iliac vessels. Liquid fat density material is also seen throughout the abdomen forming fat fluid levels best seen anterior to the left lobe of the live liver and anterior to the spleen.
Fluid filled abdominal cavity with enhancing peritoneum (right side greater than left). No definite free air identified. Large bowel is fluid filled. The liver, spleen, adrenal glands, kidneys and pancreas are unremarkable. Lung bases and bones are unremarkable.
Extensive free fluid is seen throughout the abdomen (blue * ) with smooth thickening and enhancement of the peritoneum (red * ). In the pelvis two rounded heterogenous masses are present (orange dotted lines) posterior to the uterus (U) and bladder (B). They have components with density of fluid, fat (both solid and liquid) soft tissue and even a calcified structure which has a very 'molar' shape (green arrow). In the upper abdomen liquid fat-density material can be seen floating anteriorly with a fluid / fat level (yellow arrows).
This patient went on to have surgical resection of the larger lesions which was confirmed to have ruptured.
Histology
MACROSCOPIC DESCRIPTION: A solid nodule 40mm in diameter with a fatty cut surface and hair tufts attached to its outer surface. Sectioning reveals bony tissue embedded within the fat (?tooth).
MICROSCOPIC DESCRIPTION: Sections show a mature cystic teratoma which predominantly consists of adnexal structures and skin. However there is a small amount of mature glial tissue present. No immature elements are seen.
FINAL DIAGNOSIS: Mature cystic teratoma with majority of elements in keeping with a dermoid cyst. Focal mature glial tissue. No immature elements.
Case Discussion
This case demonstrates the typical appearances of a ruptured dermoid cyst, with fat density sebacious material layering in upper abdomen.
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