Sex cord-stromal and steroid cell tumors of the ovary

MR diagnosis of steroid cell tumor of the ovary: value of chemical shift imaging

A 53-year-old asymptomatic woman was found to have a pelvic mass at medical examination. Magnetic resonance (MR) imaging revealed a 4-cm solid mass at the right adnexal region, which showed marked hyperintensity on T(2)-weighted imaging and marked enhancement on post-contrast T(1)-weighted imaging. Chemical-shift imaging showed slight but significant signal loss on out-of-phase images, which suggested the presence of intratumoral lipid. The resected specimen exhibited typical features of steroid cell tumor, and Oil Red O stain was positive for cytoplasmic lipid.

MRI, CT, and PET/CT for ovarian cancer detection and adnexal lesion characterization

OBJECTIVE

The purpose of this article is to describe the role of MR, CT, and PET/CT in the detection of ovarian cancer and the evaluation of adnexal lesions.

CONCLUSION

The goal of imaging in ovarian cancer detection is to expeditiously distinguish benign adnexal lesions from those requiring further pathologic evaluation for malignancy. For lesions indeterminate on ultrasound, MRI increases the specificity of imaging evaluation, thus decreasing benign resections. CT is useful in diagnosis and treatment planning of advanced cancer. Although (18)F-FDG-avid ovarian lesions in postmenopausal women are considered suspicious for malignancy, PET/CT is not recommended for primary cancer detection because of high false-positive rates.

Multi-detector CT features of benign adnexal lesions

RATIONALE AND OBJECTIVES

The purpose of our study was to evaluate the multidetector computed tomography (MDCT) features of benign adnexal lesions.

METHODS AND MATERIALS

We report the MDCT features of 68 histologically proven benign adnexal lesions. Pathologic diagnoses were nonneoplastic adnexal cysts (n = 16), endometriomas (n = 12), serous or mucinous cystadenomas (n = 15), fibromas or fibrothecomas (n = 7), teratomas (n = 6), and a variety of benign adnexal lesions (n = 12). The CT protocol included scanning of the abdomen after the intravenous administration of iodinated contrast material (portal phase) using a detector collimation of 16 x 0.75 mm and a pitch of 1.2.

RESULTS

Ovarian cysts had a characteristic CT appearance of a cystic lesion, with smooth, thin wall, and occasionally a few septa. Serous and mucinous cystadenomas were detected as multilocular cystic tumors containing serous fluid or liquids of higher than water CT density, respectively. Dilated fallopian tube was seen as an oblong, tubular, fluid-filled structure. MDCT was accurate to characterize mature cystic teratomas. Endometriomas had a variable CT appearance, including a unilocular or multilocular cystic mass, and a homogeneous hyperdense mass lesion. Fibrous tissue had a 50 HU CT density in patients with fibromas or fibrothecomas.

CONCLUSION

MDCT may provide accurate diagnostic information about the benign nature of adnexal lesions.

Radiologic Evaluation of Mesenchymal Tumors of the Female Genital Tract

Mesenchymal neoplasms of the female genital tract are a diverse group of tumors, of which the most common are smooth muscle tumors. There is a significant overlap in the imaging characteristics of benign and malignant tumors and final diagnosis often requires pathologic correlation. However, familiarity with typical radiologic features, common imaging pitfalls, and the utility of different imaging modalities can be valuable in the evaluation of mesenchymal tumors. This article highlights the imaging features of the most commonly encountered mesenchymal tumors in the female genital tract.

First case of juvenile granulosa cell tumor in an adult with Ollier disease

Ollier's disease (OD) is a rare disorder associated with the presence of multiple enchondromas. Granulosa cell tumors are rare sex cord-stromal ovarian tumors. This is the first report of a patient in her fourth decade with a combination of OD and juvenile granulosa cell tumor.A 36-year-old woman with OD developed an ovarian tumor. The tumor was found at a routine MRI scan. During surgery a stage IIc granulosa cell tumor was removed; pathologic examination showed a juvenile type. A review of literature showed 8 previous cases of (juvenile) granulosa cell tumor associated with OD.The coexistence of granulosa cell tumors in patients with OD is more frequent than expected by chance. We suggest that patients with OD should undergo regular gynecological investigation.

[MR Imaging of primary ovarian tumors with pathologic correlation]

Ovarian tumors are classified based on the cell of origin into epithelial tumors, germ cell tumors and sex cord-stromal tumors. This pictorial essay illustrates the MR imaging features of the main ovarian tumors with pathologic correlation. These key features are helpful to suggest a specific diagnosis or narrow the differential diagnosis, in order to optimize the surgical approach.

Secondary ovarian malignancies: frequency, origin, and characteristics

OBJECTIVE

To evaluate the frequency of metastatic tumors among malignant ovarian neoplasms, the site distribution of the primary malignancies that give rise to ovarian metastasis and the clinicopathologic features of metastatic tumors.

METHODS

We analyzed a total number of 116 patients diagnosed with metastasis to the ovary between 1985 and 2007 at the Radboud University Nijmegen Medical Centre. The medical records of the patients were reviewed for age at diagnosis, medical history, menopausal state, clinical manifestation, primary tumor, intraoperative findings, and prognosis. The pathology reports were reviewed for macroscopic appearances and histopathologic features.

RESULTS

Metastasis to the ovary accounted for 15% of all ovarian malignancies identified in the 22-year period at the Radboud University Nijmegen Medical Centre. The gastrointestinal tract was the most common primary site (39%), followed by breast (28%) and endometrium (20%). There were 22 metastases to the ovary that mimicked a primary ovarian tumor at first clinical presentation, of which the single greatest number of cases (36%) originated from a primary tumor of the large intestine. Ovarian cysts were present in 71% of patients, and most ovaries with metastatic disease were 10 cm in diameter or less. Bilateral ovarian involvement was present in 69% of the patients, including all patients with tumors of the stomach.

CONCLUSION

In case of an ovarian tumor, metastatic disease should always be considered to avoid pitfalls in diagnosis and therapy. The gastrointestinal tract is the most likely location of the primary tumor, followed by breast and endometrium.

Virilizing luteinized thecoma of the ovary in a 15-year-old female: a case report

BACKGROUND

Only 30% of luteinized thecomas are found in women under the age of 30, and they are typically benign. Only 11% of luteinized thecomas show clinical signs of androgen production. We present an unusual case of a 15-year-old female who presented with secondary amenorrhea and virilization and was subsequently diagnosed with a benign luteinized thecoma of the ovary. This is the youngest nonmalignant luteinized thecoma reported to date.

CASE

A 15-year-old Sri Lankan female presented with increasing hair growth, a hoarse voice, and secondary amenorrhea. On physical examination, there was marked hirsutism and clitoromegaly. Investigations found an elevated free testosterone level and an enlarged, homogenous left ovary with absent normal ovarian architecture. A laparotomy and unilateral salpingo-oophorectomy was performed. The final diagnosis was a luteinized ovarian thecoma, with no evidence of malignancy. Postoperatively, testosterone levels normalized and menstrual cycles resumed. Although laser treatment helped with her hirsutism, her other virilizing symptoms (deepening of voice, clitoromegaly) did not improve postoperatively.

CONCLUSION

This case of a virilizing ovarian luteinized thecoma emphasizes the need for timely evaluation, diagnosis, and treatment of patients presenting with symptoms of excess androgen secretion in order to avoid irreversible unwanted effects. Possible ovarian causes of excess androgen secretion should not be overlooked when considering possible causes of hyperandrogenism and secondary amenorrhea.

[Diagnostic imaging of menometrorrhagia]

Menometrorrhagia is a frequent cause of medical consulting. After a clinical examination showing the uterine origin of bleeding and that excludes a cervical or vulvo-vaginal origin, transvaginal sonography (TVS) represents the first-line technique examination. TVS allows to identify endometrial diseases (atrophy, polyps or diffuse hyperplasia), endometrial carcinoma, myometrial disorders (adenomyosis, leiomyoma or vascular abnormalities), and adnexal disorders. Color Doppler sonography and hysterosonography are useful complementary tools for ultrasound performance improvement. MR imaging should be performed if TVS is not contributive or is highly recommended for staging of uterine cancers. All these techniques provide useful information for optimal planning treatment.

Ovarian stromal hyperthecosis: sonographic features and histologic associations

OBJECTIVE

Ovarian stromal hyperthecosis (SH) has variable clinical importance but can cause hyperandrogenism, particularly in premenopausal women. Sonography is often used to evaluate the ovaries of women with hyperandrogenism, but there is little published regarding the sonographic appearance of SH. The primary purpose of this study was to describe the sonographic features of SH.

METHODS

A computerized search of our institution's pathology and imaging databases from 1996 through 2007 was performed to identify patients with histologically proven SH who had pelvic sonography before surgery. Sonograms and histologic findings were reviewed in each case.

RESULTS

Twenty ovaries with SH were identified, occurring in 14 patients with a mean age of 59.8 years (range, 36-83 years). The SH was bilateral in 6 patients, unilateral in 6, and of uncertain laterality in 2 with a unilateral oophorectomy. Sonographic findings were as follows: 5 normal, 1 with a hemorrhagic cyst (later resolved) and otherwise normal, 3 enlarged but otherwise normal, 1 with a solid mass due to the nodular form of SH, 1 with a solid mass due to a fibroma, 2 with polycystic ovaries, and 7 not seen. Six of the 14 patients (43%) also had an ovarian fibrothecoma.

CONCLUSIONS

Ovarian SH has variable sonographic features. Most commonly, the affected ovaries are either normal or slightly enlarged. A solid mass may infrequently be visible, and polycystic ovary syndrome changes may coexist with SH. A possible association of SH with fibrothecoma was also noted, which to our knowledge has not been previously reported.

Granulosa Cell Tumor of the Ovary: Tumor Review

Granulosa cell tumors of the ovary are rare neoplasms that originate from sex-cord stromal cells. The long natural history of granulosa cell tumors and their tendency to recur years after the initial diagnosis are the most prominent of their characteristics. The secretion of estradiol is the reason for signs at presentation such as vaginal bleeding and precocious puberty. Abdominal pain and hemoperitoneum, which occasionally can occur, are attributable to tumor rupture. The most common finding in pelvic examination is a tumor mass, which is subsequently confirmed with imaging techniques. Surgery is the mainstay of initial management for histological diagnosis, appropriate staging, and debulking. A more conservative unilateral salpingo-oophorectomy is indicated in patients with stage I disease and patients of reproductive age. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the appropriate surgical treatment for postmenopausal women and those with more advanced disease. The stage of disease is the most important prognostic factor associated with the risk of relapse. There are no clear conclusions regarding the role of postoperative chemotherapy or radiotherapy in stage I disease and in those with completely resected tumor. The use of adjuvant chemotherapy or radiotherapy has sometimes been associated with prolonged disease-free survival and possibly overall survival. Chemotherapy is the treatment of choice for patients with advanced, recurrent, or metastatic disease, and BEP (bleomycin, etoposide, and cisplatin) is the preferred regimen. Although the overall rate of response to treatment is high, the impact of treatment on disease-free or overall survival is unknown. Prolonged surveillance is mandatory because tumors tend to recur years after the initial diagnosis.

A case of Sertoli-Leydig cell tumour of the ovary with a multilocular cystic appearance on CT and MR imaging

We present a case of Sertoli-Leydig cell tumour of the ovary in a 14-year-old girl who presented with abdominal distension. Ultrasonography showed a multilocular cystic lesion filled with finely echogenic fluid. Contrast-enhanced CT demonstrated a huge multilocular cystic mass with thickened septa. At MR imaging, the capsule of the cyst was focally thickened, showing intermediate signal intensity on T2-W images. Although extensive cyst formation of Sertoli-Leydig cell tumour is rare, this tumour should be considered in the differential diagnosis of a multilocular cystic ovarian tumour in a young female.

Granulosa cell tumor of the ovary

Ovarian granulosa cell tumors (GCTs) are uncommon neoplasms that arise from the sex-cord stromal cells of the ovary. GCTs are characterized by long natural history and their tendency to recur years after the initial diagnosis. They present with symptoms and signs due to estradiol secretion, including vaginal bleeding and precocious puberty. Occasionally, tumor rupture causes abdominal pain and hemoperitoneum. GCT is usually associated with a mass on pelvic examination which is subsequently confirmed with imagine techniques. Surgery is the mainstay of initial management for histological diagnosis, appropriate staging and debulking surgery. In patients with stage I disease and those in reproductive age a more conservative unilateral salpingo-oophorectomy is indicated. In postmenopausal women and those with more advanced disease a total abdominal hysterectomy with bilateral salpingo-oophorectomy is the appropriate surgical treatment. The most important prognostic factor associated with a higher risk of relapse is the stage of disease. The role of post-operative chemo- or radiotherapy in stage I disease and those with completely resected tumor has not been defined. Nevertheless, the use of adjuvant chemotherapy or radiotherapy has sometimes been associated with prolonged disease-free survival and possibly overall survival. Chemotherapy should be considered for patients with advanced, recurrent or metastatic disease and the BEP (bleomycin, etoposide, cisplatin) is the currently preferable regimen. Although overall response rate (RR) is high, the impact on disease-free or overall survival is unknown. Due to their tendency to recur years after the initial diagnosis, prolonged surveillance is essential.

[Granulosa-cell tumor of the ovary: report of 16 cases]

OBJECTIVE

The aim of this work was to describe the epidemiological, pathological and clinical features of granulosa cell tumors and to study the different prognostic factors in order to determine an appropriate therapeutic attitude.

PATIENTS AND METHODS

We proceeded with a retrospective study of 16 cases of granulosa cell tumors of the ovary diagnosed over a period of 10 years (1994-2003). These cases included one case of juvenile type and 15 adult types.

RESULTS

Mean patient age was 46 years for the adult type (range 20-70 years) and 35 years for the juvenile type; 19% of the patients were nulliparous, 31% were menopausals. The predominant symptom was abdomino-pelvic pain with frequent hormonal manifestations. Mean tumor size was 10.5 cm with a solido-cystic aspect in 50% of cases. The treatment was surgical in all cases. Among the 16 patients, 14 (87.5%) were diagnosed at stage I and one (6.2%) at stage II. The juvenile tumor was at stage IV at time of diagnosis and only adjuvant chemotherapy was given. No relapse nor recurrence were noted for the adult type after a mean follow up of 2 years 2 months. For the juvenile form, locoregional recurrence with liver metastasis developed after 9 months.

CONCLUSION

Granulosa cell tumor of the ovary is an uncommon neoplasm. The adult form progresses slowly and often is diagnosed in an early stage of disease. Surgery is indicated. The juvenile forms are more exceptional and more aggressive. A prolonged post therapeutic follow-up is necessary because of the risk of recurrences, late and exceptional for the adult form but frequent and early for the juvenile form.

Recurrent ovarian granulosa cell tumors: clinical and imaging features

BACKGROUND

Granulosa cell tumor of the ovary differs from epithelial ovarian tumors in histologic appearance, clinical course and imaging findings. The purpose of this study was to evaluate clinical and imaging features of recurrent ovarian granulosa cell tumors.

METHODS

We performed retrospective evaluation of the medical, surgicopathologic records and CT or MR images of 11 patients with pathologically proven recurrent ovarian granulosa cell tumor.

RESULTS

The first recurrence of granulosa cell tumor was diagnosed at between 4 months and 18 years after the initial surgical resection of tumor (mean; 9.7 years). Six patients relapsed after 10 years after initial diagnosis. The recurrent tumors were located in the pelvic cavity alone in three patients, extrapelvic peritoneal cavity alone in two, both pelvic and extrapelvic peritoneal cavity in three, and paraaortic retroperitoneal space in three. The imaging appearances of recurrent masses were variable ranging from solid masses to completely cystic masses.

CONCLUSION

Recurrent granulosa cell tumor is characterized by late tumor recurrence manifested as a relatively small number of discrete peritoneal or retroperitoneal masses with variable imaging appearances from solid to cystic masses.

A Practical Approach to the Ultrasound Characterization of Adnexal Masses

Because pelvic ultrasound is commonly used to evaluate adnexal masses, it is important to understand the most useful sonographic features for predicting benign and malignant masses. Determining whether an adnexal mass is of ovarian or extraovarian origin is key in arriving at the most likely diagnosis. Most adnexal masses are benign, and each of the most common benign ovarian lesions has a typical sonographic appearance. Additionally, most malignant ovarian neoplasms have a solid component with detectable flow by Doppler ultrasound, allowing one to strongly suggest the diagnosis. We will review an approach to the ultrasound diagnosis of adnexal masses that progresses through a series of 4 questions to help lead one to the most likely diagnosis.

MR findings of ovarian tumors with hormonal activity, with emphasis on tumors other than sex cord-stromal tumors

Sex cord-stromal tumors including granulosa cell tumor, thecoma, Sertoli stromal cell tumor and steroid cell tumor are noted for their hormonal activity. However, there are many kinds of ovarian tumors other than sex cord-stromal tumors and tumor-like conditions with endocrine manifestations. Cross-sectional imaging, especially MR, can provide precise features of ovarian tumors and uterine morphological change even in a clinically latent excess of estrogen. In this article, we demonstrate typical imaging findings of ovarian tumors with hormonal activity. We also shortly explain the mechanism of the virilization and hyperestrogenism caused by ovarian tumors and tumor-like conditions.

Magnetic resonance imaging of adnexal masses

Adnexal masses are common in women of all ages. A range of physiological and benign ovarian conditions that develop in women, especially in the reproductive age, and adnexal malignancies can be evaluated with magnetic resonance imaging (MRI). Management of women with adnexal masses is frequently guided by imaging findings; therefore, precise characterization of adnexal pathology should be performed whenever possible. Magnetic resonance imaging is useful in characterization of adnexal masses that are not completely evaluated by ultrasound because it can provide additional information on soft tissue composition of adnexal masses based on specific tissue relaxation times and allows multiplanar imaging at large field of view to define the origin and extent of pelvic pathology. The patients most likely to benefit from MRI are pregnant women and those who are premenopausal and have masses that have complex features on ultrasound but do not have raised cancer antigen 125 tumor marker levels. The overlap in imaging appearance among different cell type malignancies makes it difficult to predict exact histology based on MRI appearance; however, MRI has a high accuracy in differentiating benign from malignant masses. Teratomas, endometriomas, simple and hemorrhagic cysts, fibromas, exophytic or extrauterine fibroids, and hydrosalpinges can be diagnosed with high confidence. In this article, the authors review the histopathologic background and MRI features of adnexal masses and discuss the role of MRI in the differentiation of benign from malignant adnexal pathologies.

Is It a Fibroid? Are You Sure?

Uterine fibroids are common benign lesions. Other common benign masses include renal cysts, renal angiomyolipomas, hepatic cysts, hepatic hemangiomas, thyroid cysts, adrenal incidentalomas, pulmonary granulomas and hamartomas, ovarian cysts, and dermoids. All these conditions, especially in asymptomatic patients, almost never have clinical significance. However, it is important to differentiate them from more sinister or even malignant lesions. In general, when a lesion is described as a fibroid, no further evaluation is performed. So if we say that a lesion is a fibroid, we have to be sure. Endometrial fibroids may mimic endometrial polyps or endometrial cancer. Subserous, especially pedunculated fibroids, may need further evaluation to differentiate them from ovarian pathology, colonic pathology, or even müllerian duct anomalies. Pelvic magnetic resonance imaging may be helpful in these cases.

Sertoli-stromal cell tumor of the right ovary: radiological-pathological correlation

A case of Sertoli-stromal cell tumor of the right ovary is reported. The patient was a 50-year-old perimenopausal woman with abdominal distention due to a large pelvic tumor. She had no signs of androgen excess. A large solid sponge-like tumor with multicystic areas throughout, in which there were some small hemorrhagic spots, was shown on magnetic resonance (MR) imaging. No endometrial thickening of the uterus was seen. Pathology examination revealed a Sertoli-stromal cell tumor with intermediate-to-poor differentiation. The edematous, watery, sponge-like appearance on the MR images correlated with the pathological findings.

Functioning ovarian tumors: direct and indirect findings at MR imaging

There are many kinds of ovarian tumors and tumorlike conditions that produce estrogen or androgen. Magnetic resonance imaging can demonstrate not only ovarian tumors but also an enlarged uterus with a thick endometrium, even in cases of a clinically latent excess of estrogen. These clinical and indirect imaging findings can aid in the differential diagnosis of ovarian tumors. Granulosa cell tumor and thecoma are well-known estrogen-producing tumors. In pediatric or postmenopausal patients, they manifest as precocious pseudopuberty or postmenopausal bleeding, respectively. Conversely, Sertoli-Leydig cell tumor is representative of hormone-producing tumors that cause virilization. However, there are other functioning ovarian tumors besides the sex cord-stromal tumors. It is well known that metastatic ovarian tumors often have androgen-producing stroma and that mucinous cystadenoma sometimes produces estrogens. Most other ovarian tumors can produce sexual hormones in their stroma. In addition, some endocrinologic abnormalities (eg, polycystic ovary syndrome) also cause virilization.

CT and MRI Findings of Sex Cord–Stromal Tumor of the Ovary

OBJECTIVE

The purpose of this article was to research the clinical and imaging features of sex cord-stromal tumors of the ovary to help in specific diagnosis of ovarian tumors. Sex cord-stromal tumors of the ovary are rare ovarian neoplasms, which arise from stromal cells and primitive sex cords in the ovary. The common types are granulosa cell tumors, fibrothecomas, sclerosing stromal tumors, and Sertoli-Leydig cell tumors. They account for most of the hormonally active ovarian tumors. They have characteristic imaging features in each type of the tumor.

CONCLUSION

Clinical and radiologic clues are helpful in differential diagnosis from the more common epithelial tumors; sex cord-stromal tumors primarily are treated surgically and have generally good prognosis.

Sclerosing stromal tumor of the ovary: MR-pathologic correlation in three cases

Sclerosing stromal tumor (SST) of the ovary is a very rare sex cord stromal tumor occurring in a younger age group than other types of stromal tumors and most commonly accompanied by menstrual irregularity. Several unique histologic features including pseudolobulation, sclerosis and prominent vascularity are clearly reflected at ultrasonography and MRI. We report the ultrasonographic and MR features of three cases of histologically confirmed SSTs, and relate them to the pathological findings.

Magnetic resonance imaging of benign adnexal disease

Magnetic resonance imaging (MRI) plays an important role in localizing and characterizing pelvic masses, particularly adnexal masses. The multiplanar capability of MRI helps to locate an abnormality outside the ovary and facilitate the exclusion of malignancy. Its superior soft-tissue contrast features help to diagnose specific benign masses, including teratoma, endometrioma, and ovarian fibroma. In addition, cystic ovarian neoplastic lesions can be further characterized as benign versus malignant, particularly after gadolinium administration. An approach to adnexal evaluation using MRI is discussed based on these features.

Juvenile granulosa cell tumor

Juvenile granulosa cell tumor (GCT) of the ovary is a rare neoplasm occurring in premenarchal girls and young women. Juvenile GCT that occurs in premenarchal girls usually produces sexual precocity as a consequence of estrogen secretion. Juvenile GCTs are more likely to grow to a relatively large size with a much smaller likelihood of peritoneal spread, unlike their counterpart, epithelial ovarian neoplasms. We report the radiology and pathology of a patient with juvenile GCT and review the literature of this rare tumor.

CT and MR imaging of ovarian tumors with emphasis on differential diagnosis

Ovarian tumors are classified on the basis of tumor origin as epithelial tumors (serous and mucinous tumors, endometrioid and clear cell carcinomas, Brenner tumor), germ cell tumors (mature and immature teratomas, dysgerminoma, endodermal sinus tumor, embryonal carcinoma), sex cord-stromal tumors (fibrothecoma; granulosa cell, sclerosing stromal, and Sertoli-Leydig cell tumors), and metastatic tumors. Epithelial tumors are primarily cystic and, when malignant, are associated with varying proportions of a solid component. Papillary projections are a distinctive feature of epithelial tumors. Profuse papillary projections are highly suggestive of borderline (low-malignant-potential) or malignant tumor. Ovarian teratomas demonstrate lipid material at computed tomography and magnetic resonance (MR) imaging. Malignant germ cell tumors manifest as a large, complex abdominal mass that contains both solid and cystic components. Tumor markers are helpful in diagnosis. The radiologic appearance of sex cord-stromal tumors varies from small solid masses to large multicystic masses. Granulosa cell tumors are usually large multicystic masses with solid components. Fibrothecoma, sclerosing stromal tumor, and Sertoli-Leydig cell tumors are usually solid masses. Fibromas have very low signal intensity on T2-weighted MR images. Certain radiologic findings predominate for each type of tumor. Knowledge of these key features of ovarian tumors provides the criteria for making a specific diagnosis or substantially narrowing the differential diagnosis.

Ovarian tumor with functioning stroma

The authors reported two cases with ovarian tumors with functioning stroma. One was an ovarian carcinoid with testosterone-producing stroma and another was an ovarian mucinous cystadenoma with elevated serum level of estrogen. They appeared as multilocular cystic masses with varying signal on MR. This imaging feature was mimicking both those of Sertoli-Leydig tumors with heterologous elements and granulosa cell tumors, which are well known as functioning tumors. It had been reported in pathological literatures that any type of ovarian tumors can show hormonal activity due to functional stroma, although, it is the first report in the radiological literatures.

Interface vessels on color/power Doppler US and MRI: a clue to differentiate subserosal uterine myomas from extrauterine tumors

PURPOSE

In subserosal myomas, vessels are often demonstrated between the masses and the uterus. This study was performed to assess the usefulness of demonstrating these vessels in differentiating subserosal myomas from extrauterine tumors on color or power Doppler US (CDUS/PDUS) and MRI.

METHOD

This retrospective study included 41 patients with subserosal myomas and 27 patients with solid extrauterine tumors. The incidence and shape of these vessels seen on CDUS/PDUS and MRI were compared in the myoma and extrauterine tumor groups.

RESULTS

The interface vessels were demonstrated in 39 of 41 subserosal myomas (18 on CDUS/PDUS, 14 on MRI, 7 on both), whereas they were seen in only 3 of 27 extrauterine tumors (1 on CDUS/PDUS, 2 on MRI). These three extrauterine tumors were ovarian malignancies that directly invaded the uterus. The shapes of these interface vessels were 7 intervening, 12 crossing, and 20 mixed in the myoma group, whereas they were mixed in all three extrauterine tumor groups. The sensitivity/specificity of this finding in differentiating subserosal myomas and extrauterine tumors was 100/92%, 91/91%, and 95/89%, respectively, with CDUS/PDUS, MRI, and either CDUS/PDUS or MRI.

CONCLUSION

Observation of the interface vessels between the uterus and juxtauterine masses seems to be a useful clue in differentiating subserosal myomas from extrauterine tumors.

MRI of gynaecological solid masses

Differential diagnosis of gynaecological masses is sometimes difficult, as there are so many histological types. However, magnetic resonance characteristics of some gynaecological tumours have been reported past several years. On the basis of the recent literature, we have made a decision tree for differential diagnosis of solid gynaecological tumours, in which there are some important divergences. Bilateral disease and invasive growth are malignant signs in most cases. Specific findings for different tumour types include: fibrovascular septa in dysgerminomas; preserving ovarian follicles in round cell tumours; pseudolobular patterns in young patients in sclerosing stromal tumours; and extremely hypointense masses on T2WI in Brenner tumours. Distinguishing between sex-cord stromal tumours, Brenner tumours and metastatic tumours may be hard, however, especially in middle age, because they all tend to show well-demarcated, hypointense masses on T2WI. Disproportionately clear zonal anatomy of the uterus, enlarged uterus and thickened endometrium, which are indirect findings of oestrogen-producing tumours, are useful diagnostic findings in children and postmenopausals.

Imaging evaluation of ovarian masses

Adnexal masses present a special diagnostic challenge, in part because benign adnexal masses greatly outnumber malignant ones. Determination of a degree of suspicion for malignancy is critical and is based largely on imaging appearance. Endovaginal ultrasonography (US) is the most practical modality for assessment of ovarian tumors because it is readily available and has a high negative predictive value. Morphologic analysis of adnexal masses is accurate for identifying masses as either low risk or high risk. The most important morphologic features are non-fatty solid (vascularized) tissue, thick septations, and papillary projections. Color Doppler US helps identify solid, vascularized components in a mass. Spectral Doppler waveform characteristics (eg, resistive index, pulsatility index) correlate well with malignancy but generally add little information to morphologic considerations. Computed tomography can help assess the extent of disease in patients before and after primary cytoreductive surgery. Magnetic resonance (MR) imaging is better reserved for problem solving when US findings are nondiagnostic or equivocal because, although it is more accurate for diagnosis, it is also more expensive. The signal intensity characteristics of ovarian masses make possible a systematic approach to diagnosis. Mature cystic teratomas, cysts, endometriomas, leiomyomas, fibromas, and other lesions can be accurately diagnosed on the basis of T1-weighted, T2-weighted, and fat-saturated T1-weighted MR imaging findings.