Downloaded from www.ajronline.org by 36.76.24.237 on 09/09/17 from IP address 36.76.24.237. Copyright ARRS.

For personal use only; all rights reserved

Pictorial Essay
Atypical CT and MRI Manifestations of Mature
Ovarian Cystic Teratomas
Sung Eun Rha1, Jae Young Byun1, Seung Eun Jung2, Hyo Lim Kim1, Soon Nam Oh1, Hyun Kim3, Heejeong Lee4, Byung Kee Kim4, Jae Mun Lee2

M ature cystic teratoma is a com-

monly encountered ovarian tumor,
constituting 20% of all ovarian tu-
mors in adults and 50% of all ovarian tumors
in children [1]. Mature cystic teratomas are
composed of well-differentiated derivations of
the three germ cell layers (ectoderm, meso-
derm, and endoderm). In most cases, they are
easily diagnosed on imaging studies because
of their characteristic intratumoral fat compo-
nent. Although typical imaging findings of ma-
ture cystic teratomas are well known to

A B
Fig. 1.33-year-old woman with mature cystic teratoma without fat in cystic cavity.
A, Axial T1-weighted gradient-echo image (TR/TE, 470/14) shows homogeneous low-signal-intensity mass with focal high signal intensity (arrow) along right-sided anterior wall of mass.
B, Axial gadolinium-enhanced fat-saturated T1-weighted image (736/14) shows signal suppression (arrow), suggesting presence of small fat component in cyst wall. Fat-
saturated MRI or gradient-echo technique with both in-phase and opposed-phase imaging is useful to detect small amount of fatty tissue on MR images.

Received November 11, 2003; accepted after revision February 13, 2004.
1
Department of Radiology, Kangnam St. Marys Hospital, College of Medicine, The Catholic University of Korea, 505, Banpo-Dong, Seocho-Ku, Seoul 137-040, South Korea. Address
correspondence to J. Y. Byun (jybyun@catholic.ac.kr).
2
Department of Radiology, St. Marys Hospital, The Catholic University of Korea, 62 Yeouido-dong, Youngdungpo-gu, Seoul 150-713, South Korea.
3
Department of Radiology, Daejeon St. Marys Hospital, The Catholic University of Korea, 520-2 Daeheung-dong, Choong-gu, Daejeon 301-723, South Korea.
4
Department of Pathology, Kangnam St. Marys Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-040, South Korea.
AJR 2004;183:743750 0361803X/04/1833743 American Roentgen Ray Society

AJR:183, September 2004 743

 Rha et al.

Fig. 2.23-year-old woman having atypical mature cystic teratoma with purely
cystic component. Axial contrast-enhanced CT scan shows large homogeneous
fluid-attenuated mass with focal high calcification (arrowhead) along wall. No de-
tectable fat component is present within cystic mass. In these cases, differentia-
tion from other epithelial ovarian neoplasms may be difficult.
Downloaded from www.ajronline.org by 36.76.24.237 on 09/09/17 from IP address 36.76.24.237. Copyright ARRS. For personal use only; all rights reserved

Fig. 3.35-year-old woman with atypical mature cystic teratoma without fat component.
A, Axial T1-weighted spin-echo image (TR/TE, 700/17) shows large well-defined
low-signal-intensity mass with subtle different signal-intensity lesion (arrow-
heads) in mass.
B, Axial T2-weighted fast spin-echo image (TR/effective TE, 3,200/90) shows mass
with homogeneous high signal intensity.
C, Gadolinium-enhanced T1-weighted spin-echo image (TR/TE, 500/17) shows no
significant contrast enhancement in mass (arrowheads). Pathologically, internal
content of mass was cheeselike sebaceous material with less fatty tissue in cyst
than in usual cystic teratomas.

B C

744 AJR:183, September 2004

 CT and MRI of Ovarian Cystic Teratomas

Fig. 4.28-year-old woman with mature cystic teratoma composed of pure fat
component. Contrast-enhanced CT scan shows well-defined mass of fat attenua-
tion (T) in pelvic cavity. Note absence of detectable calcification or matted tuft of
hair in mass. These tumors may mimic other uncommon lipid-containing pelvic tu-
mors. In addition, small-sized teratoma with mainly fatty component and floating
debris may be missed on imaging studies or mistaken for gas-filled bowel loops, es-
pecially with improper setting of image contrast.
Downloaded from www.ajronline.org by 36.76.24.237 on 09/09/17 from IP address 36.76.24.237. Copyright ARRS. For personal use only; all rights reserved

radiologists, various atypical imaging features
can be particularly misleading. This article il-
lustrates atypical imaging manifestations of
mature ovarian cystic teratomas depending on
their tumor components and the presence of
combined complications on CT and MRI.
Atypical Imaging Manifestations of
Mature Cystic Teratomas Depending on
Tumor Components
Mature Cystic Teratomas Without Fat in the Cystic Cavity
A minor percentage of mature cystic terato-
mas have only a small amount of fat or no visi-
ble fat on imaging studies. In one series [2],
15% of mature cystic teratomas did not show
fatty tissue in the cystic cavity. Approximately
half had only a small fat component in the cys-
tic wall (Fig. 1) or in the Rokitansky nodule. In
the remainder, fatty tissue was not identified in
the lumen or the cystic wall, and the aqueous
fluid filled the entire cyst (Figs. 2 and 3).
Mature Cystic Teratomas with a Pure Fatty
Component in the Cyst
Rarely, mature cystic teratomas have a pure
fat component on imaging without any other
component (Fig. 4). These tumors may mimic
other uncommon lipid-containing pelvic tumors
such as pedunculated lipomatous uterine tumor,
benign pelvic lipoma, and liposarcoma [3].
Combination Tumors and Collision Tumors Containing
Mature Cystic Teratomas
A combination tumor is defined as a tu-
mor in which the intermixed varying histo-
logic components result from a common
stem cell; a mixed germ cell tumor is a typi-
cal example. Mixed germ cell tumors contain
more than one germ cell component; virtu-
ally any combination of cell types can occur
among embryonal carcinomas, dysgermino-
mas, teratomas, and yolk sac tumors (endo-
dermal sinus tumor) [1]. The imaging
findings of mixed germ cell tumors are vari-
able and reflect the diversity of this group of
tumors. When a predominantly solid and het-

A B

Fig. 5.Mixed germ cell tumors (mature cystic teratoma and yolk sac tumor) in 19-year-old woman with elevated -fetoprotein level of 1,383 ng/mL (normal range, 020
ng/mL) and cancer antigen-125 level of 330 IU/mL (normal range, 035 IU/mL).
A, Axial contrast-enhanced CT scan shows large cystic mass containing focal fat component (arrowheads), dense calcifications, and several solid enhancing nodules (arrows).
B, Photograph of surgical specimen shows multiseptate cystic mass filled with hair and sebum (mature cystic teratoma component) and several solid nodular masses (yolk
sac tumor component, arrows). Elevated serum -fetoprotein and human chorionic gonadotropin levels can help establish diagnosis.

AJR:183, September 2004 745

 Rha et al.

erogeneous ovarian tumor contains fatty ar-
eas or calcifications suggestive of a mature
cystic teratoma or when a mature cystic ter-
atoma contains an enhancing solid portion, a
diagnosis of a mixed germ cell tumor should
be considered (Fig. 5).
Collision tumor is defined as a tumor with
Downloaded from www.ajronline.org by 36.76.24.237 on 09/09/17 from IP address 36.76.24.237. Copyright ARRS. For personal use only; all rights reserved
nous tumor show a typical multiloculated
cystic mass with an internal locule filled with
pure fat (Figs. 6 and 7).
Atypical Imaging Manifestations of
Mature Cystic Teratomas Depending on
Torsion
Torsion is the most common complication
associated with mature cystic teratomas. The
rate of torsion was reported at 3.216% [5].
Torsion of the ovarian pedicle produces circu-
latory stasis that is initially venous but be-
comes arterial. If the torsion is complete,

two adjacent but histologically distinct tumors
without histologic admixture at the interface.
Collision tumors involving ovaries are rare, but
the most common type of ovarian collision tu-
mor is composed of a mature cystic teratoma
and a mucinous cystadenoma or cystadeno-
carcinoma [4]. Imaging studies of a collision
tumor composed of a teratoma and a muci-
Combined Complications
Mature cystic teratomas have an unusually
high complication rate compared with other
ovarian tumors and are prone to torsion, rupture,
and infection (often with Salmonella organ-
isms). Malignant transformation is another rare
complication. The complicated teratomas show
atypical but characteristic imaging findings.
gangrenous and hemorrhagic infarction re-
sults. If the torsion is partial and intermittent
with spontaneous untwisting, symptoms may
subside, only to return within hours, days, or
weeks [6].
A torsed teratoma may show atypical im-
aging findings such as smooth eccentric wall
thickening of the mass (Fig. 8), peritumoral

A B

Fig. 6.36-year-old woman with collision tumor (mature cystic teratoma and muci-
nous cystadenoma).
A, Axial T1-weighted gradient-echo image (TR/TE, 370/14) shows large multilocular
cystic mass with heterogeneous signal intensity in locules. One locule (arrow-
heads) has very high signal intensity.
B, On axial T2-weighted turbo spin-echo image (3,200/99), mass shows high signal
intensity. Central locule (arrowheads) also shows high signal intensity.
C, Gadolinium-enhanced fat-saturated axial T1-weighted gradient-echo image
(560/14) shows saturation of high-signal-intensity foci (arrowheads) in mass; find-
ing indicates fat. Surgery revealed collision tumor of right ovary composed of ma-
ture cystic teratoma and mucinous cystadenoma.
C

746 AJR:183, September 2004

 CT and MRI of Ovarian Cystic Teratomas
Downloaded from www.ajronline.org by 36.76.24.237 on 09/09/17 from IP address 36.76.24.237. Copyright ARRS. For personal use only; all rights reserved

Fig. 7.33-year-old woman with collision tumor (mature cystic teratoma and
borderline mucinous tumor). Axial contrast-enhanced CT scan shows large
multiloculated cystic mass of left ovary with several locules filled with fat (ar-
rows). Pathologically, collision tumor composed of benign cystic teratoma and
borderline mucinous tumor was confirmed. Mature cystic teratomas are
sometimes incorporated into wall of mucinous cystadenoma.
Fig. 8.Torsion of left ovarian mature cystic teratoma with hemorrhagic infarction in 10-
year-old girl with 24-hr history of lower abdomen pain. Contrast-enhanced CT scan shows
eccentric smooth wall thickening of mass (arrows) containing fat and teeth. Surgery re-
vealed left ovarian cystic teratoma with torsion of 720 and hemorrhagic infarction.

Fig. 9.Torsion of left ovarian cystic teratoma in 27-year-old woman with 2-day his-
tory of lower abdomen pain.
A, Axial gadolinium-enhanced T1-weighted turbo spin-echo image (TR/TE, 500/10)
shows ovoid pelvic mass (M) with internal high-signal-intensity fat component.
Note amorphous masslike structure (arrows) connecting mass and uterus (U); find-
ing is suggestive of twisted pedicle.
B, Sagittal fat-saturated T2-weighted turbo spin-echo image (2,100/80) shows mul-
tifocal suppression of high signal intensity (arrowheads) in tumor, suggesting char-
acteristic multiple fat balls in mature cystic teratoma.

A B

AJR:183, September 2004 747

 Rha et al.
Downloaded from www.ajronline.org by 36.76.24.237 on 09/09/17 from IP address 36.76.24.237. Copyright ARRS. For personal use only; all rights reserved

A B

Fig. 10.Torsion of right ovarian cystic teratoma in 47-year-old woman with 7-day history of gradually increasing lower abdomen pain.
A, Contrast-enhanced CT scan shows large well-defined low-attenuation mass (M) with focal fat component (arrow) in right side of lower abdomen.
B, Contrast-enhanced CT scan obtained caudad to A shows amorphous masslike structure (arrows) connecting mass and uterus (not shown); finding is suggestive of
twisted vascular pedicle. Surgery revealed torsed right ovarian teratoma with hemorrhagic infarction.

infiltration seen as ill-defined linear or retic-
ular shadows in the peritumoral spaces,
hemorrhage within the mass, ascites or hemo-
peritoneum, and a thickened fallopian tube on
CT or MRI. A thickened fallopian tube is the
most specific imaging finding for adnexal tor-
sion and manifests as an amorphous or tubu-
lar masslike structure or has a targetlike
appearance between the torsed teratoma and
the uterus or a beaklike protrusion extending
from the uterus and partially covering the
ovarian teratoma [6] (Figs. 9 and 10).
Rupture
There is a low rate of spontaneous rupture
of mature cystic teratomas (1.23.8%) [4].
Both acute and chronic clinical presentations
are seen in intraperitoneal rupture. Acute
peritonitis is caused by the sudden rupture of
the tumor contents, usually in association
with torsion, trauma, infection, or labor (Fig.
11). Chronic granulomatous peritonitis re-
sults from a chronically leaking cystic ter-
atoma and is the more common presentation.
On imaging, detection of discontinuity of
the wall of the tumor is diagnostic for rup-
tured teratoma (Figs. 11 and 12). Chronic

A B

Fig. 11.39-year-old woman with acute traumatic rupture of mature cystic teratoma.
A, Contrast-enhanced CT scan shows large inhomogeneous low-attenuation right ovarian mass (R) with toothlike calcification in anterior wall at right side of abdomen;
finding represents right ovarian cystic teratoma. Note also well-defined mass (L) with focal fat (arrow) in left side of abdomen; finding suggests left ovarian teratoma.
B, Contrast-enhanced CT scan obtained cephalad to A shows focal disruption of medial wall of mass (arrowheads) with spillage of internal contents. Patient had acute
lower abdomen pain after blunt abdominal trauma. Surgery confirmed ruptured right ovarian teratoma with hemorrhage.

748 AJR:183, September 2004

 CT and MRI of Ovarian Cystic Teratomas
Downloaded from www.ajronline.org by 36.76.24.237 on 09/09/17 from IP address 36.76.24.237. Copyright ARRS. For personal use only; all rights reserved

A B

Fig. 12.75-year-old woman with chronic granulomatous peritonitis resulting from chronically leaking mature cystic teratoma.
A, Contrast-enhanced CT scan shows ill-defined hazy infiltration in omentum and mesentery, mimicking peritoneal carcinomatosis.
B, Contrast-enhanced CT scan obtained caudad to A shows large cystic mass with eccentric dense calcification and fluid collection (F) in pelvic cavity. Note focal disruption of
wall (arrow), suggesting rupture site of mature cystic teratoma. Surgery confirmed chronic granulomatous peritonitis resulting from rupture of mature cystic teratoma.

granulomatous peritonitis shows the unusual
imaging findings of ascites, hazy omental in-
filtration, and an inflammatory mass involv-
ing the omentum and bowel, mimicking
those imaging findings of carcinomatous or
tuberculous peritonitis [7] (Fig. 12).
Malignancy Associated with Mature Cystic Teratomas
Malignancy associated with mature cystic
teratoma is rare and complicates 12% of re-
ported cases. It may occur either by malig-
nant transformation of one of the preexisting
benign elements or may represent a malig-
nant lesion coexistent with a benign teratoma
[5] (Fig. 13).
Malignant transformation usually occurs in
postmenopausal women, in contrast to mature
cystic teratoma, which is detected in women of
reproductive age. In 85% of these cases, the ma-

Fig. 13.78-year-old woman with mature cystic teratoma engulfed by uterine endome-
trial stromal sarcoma. Contrast-enhanced CT scan shows large lobulated low-attenua-
tion mass in midpelvic cavity, containing focal fat attenuation and rim calcifications
(arrows) in posterior part. Surgery revealed large necrotic uterine sarcoma (high-grade
endometrial stromal sarcoma) engulfing preexisting left ovarian mature cystic teratoma
(arrows).
Fig. 14.52-year-old woman with mature cystic teratoma with malignant transforma-
tion. Contrast-enhanced CT scan shows well-defined ovarian tumor with typical fat
fluid level, round mass of matted tuft of hair (arrowheads), and enhancing lobulated
soft-tissue component (arrow) in anterior wall. Results of histopathologic examina-
tion confirmed squamous cell carcinoma arising in mature cystic teratoma.

AJR:183, September 2004 749


lignant elements are composed of squamous
cell carcinoma arising from the squamous lin-
ing of the cyst wall [5]. The Rokitansky protu-
berance is a common site of malignant
transformation and should be sectioned appro-
priately during pathologic analysis.
On CT and MRI, ovarian teratoma with ma-
Downloaded from www.ajronline.org by 36.76.24.237 on 09/09/17 from IP address 36.76.24.237. Copyright ARRS. For personal use only; all rights reserved
lignant transformation appears as a fat-contain-
ing tumor with an enhancing, irregularly
marginated solid component (Fig. 14). The
solid component tends to be relatively large and
to show extensive transmural extension and di-
rect invasion of neighboring pelvic organs. The
contrast enhancement of the Rokitansky protu-
berance should raise the possibility of malig-
nant transformation [8]. The imaging findings
of malignant transformation may be similar to
those of mixed germ cell tumors. Elevated se-
rum -fetoprotein and human chorionic gona-
dotropin levels and younger age can help in the
diagnosis of mixed germ cell tumors.
750
Rha et al.
Conclusion
Imaging findings of mature cystic terato-
mas can be atypical depending on the tumor
components and the presence of combined
complications. Understanding the atypical
imaging manifestations of mature cystic
teratomas permits a more specific and accu-
rate diagnosis.
Acknowledgment
We thank Bonnie Hami, Department of
Radiology, University Hospitals Health Sys-
tem, Cleveland, OH, for editorial assistance
in preparing the manuscript.
References
1. Prat J. Female reproductive system. In: Damjanov
I, Linder J, eds. Andersons pathology, 10th ed.
St. Louis, MO: Mosby, 1996:22312309
2. Yamashita Y, Hatanaka Y, Torashima M, Takahashi
M, Miyazaki K, Okamura H. Mature cystic terato-
mas of the ovary without fat in the cystic cavity:
MR features in 12 cases. AJR 1994;163:613616
3. Dodd GD 3rd, Budzik RF Jr. Lipomatous tumors
of the pelvis in women: spectrum of imaging
findings. AJR 1990;155:317322
4. Kim SH, Kim YJ, Park BK, Cho JY, Kim BH, Byun
JY. Collision tumors of the ovary associated with
teratoma: clues to the correct preoperative diagno-
sis. J Comput Assist Tomogr 1999;23:929933
5. Comerci JT Jr, Licciardi F, Bergh PA, Gregori C,
Breen JL. Mature cystic teratoma: a clinicopatho-
logic evaluation of 517 cases and review of the
literature. Obstet Gynecol 1994;84:2228
6. Rha SE, Byun JY, Jung SE, et al. CT and MR im-
aging features of adnexal torsion. RadioGraphics
2002;22:283294
7. Fibus TF. Intraperitoneal rupture of a benign cys-
tic ovarian teratoma: findings at CT and MR im-
aging. AJR 2000;174:261262
8. Kido A, Togashi K, Konishi I, et al. Dermoid
cysts of the ovary with malignant transformation:
MR appearance. AJR 1999;172:445449
AJR:183, September 2004