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

[Ovarian Sertoli-Leydig tumor: A tricky tumor]

We report the case of a 15 years old teenage girl presenting with a primary amenorrhea and hypervirilisation symptoms. The clinical assessement found a 16cm wide heterogenous ovarian mass testosteronemia and alpha-foeto protein levels were increased. On gross exam the tumor was solid and cystic, multilocular containing serous and mucinous liquids. Microscopically, there was a sertoli cells rich solid area in which the cells had a trabecular and nested organization with Leydig cells between them and there was also a cystic area made of glandular structures lined with an intestinal muco-secreting epithelium. Next to these area, there were Sertoli cells and an oedematous stroma. The immunostaining showed that the Sertoli cells expressed, among others, the inhibine and the glands expressed the cytokeratins 7 and 20. A Sertoli and Leydig cells tumor of intermediate differentiation with heterologous elements diagnostic was made. This is a rare tumor, representing less than 0.5% of ovary tumors. Well differentiated tumors are not frequent. In one third of the cases, there are hypervirilisation symptoms, the imaging exams will serve to narrow the diagnosis and to do a full work-up to establish an extension. There are several histologic sub types caracterised by the existence of retiforms structures or heterologous elements. There are no specific immunostainings, this will only help to narrow the diagnosis and rule out some hypothesis. There are no guidelines for the management of the patients, indeed each center has its own practices. Those tumors have quite a good prognosis thanks to their early diagnosis at a stade where they are still confined to the ovary.

Value of Diffusion-Weighted Magnetic Resonance Imaging in the Characterization of Complex Adnexal Masses

Aims and background

The aim of the study was to define the role of diffusion-weighted imaging in the characterization of adnexal complex masses, with particular regard to the distinction between benign and malignant lesions. Conflicting results on this topic have emerged from studies in the last decade, with a consequent substantial limitation to the use of this relatively novel technique in clinical practice.

Methods and study design

Magnetic resonance imaging examinations performed on 91 patients with ovarian masses (56 benign, 35 malignant) were retrospectively evaluated by two observers unaware of the final histopathological diagnosis. Diffusion-weighted sequences with b values of 0, 500 and 1000 were performed in all cases, and apparent diffusion coefficient maps were automatically generated. The signals of both the cystic and solid components of the ovarian masses were evaluated on T2-weighted and diffusion-weighted images acquired with a b value of 1000. Apparent diffusion coefficient values were measured in all cases.

Results

With regard to the solid components, hypointensity on both the T2-weighted and diffusion-weighted images has proved to be a reliable indicator of benignancy. In contrast, hyperintensity on both sequences was suggestive of malignancy. Signal intensity of the cystic components and apparent diffusion coefficient values of both components have not proven useful in characterization of the masses.

Conclusions

Only the definition of the signal intensities on diffusion-weighted images obtained with the use of high b values on the solid component of a complex adnexal mass is useful to characterize an ovarian mass as benign or malignant.

An elderly woman with a mediastinal granulosa cell tumour: a rare presentation

Mediastinal lesions occur in a wide variety of clinical conditions. Metastatic granulosa cell tumour (GCT) in the mediastinum is a rare occurrence. We report a case of a woman who had a metastatic (GCT) in her mediastinum 40 years after treatment of the initial neoplasm. Surgical resection of the mediastinal mass revealed a low‐grade epithelioid neoplasm with coffee bean‐shaped nuclei and immunohistochemical stains that were consistent with metastatic GCT.

MRI features and score for differentiating borderline from malignant epithelial ovarian tumors

PURPOSE

To identify the MRI features of borderline epithelial ovarian tumors (BEOTs) and to differentiate BEOTs from malignant epithelial ovarian tumors (MEOTs).

MATERIALS AND METHODS

The clinical and MRI data of 89 patients with a BEOT and 109 patients with a MEOT proven by surgery and histopathology were retrospectively reviewed. MRI features, including bilaterality, size, shape, margin, cystic-solid interface, configuration, papillae or nodules, signal intensity, enhancement, presence of an ipsilateral ovary, peritoneal implants and ascites were analyzed and compared. Based on the odds ratio (OR) values, the significant risk features for BEOTs were scored as 3 (OR≈∞), 2 (5≤OR<∞) or 1 (OR<5).

RESULTS

There were 89 BEOT patients with 113 tumors [mean size of (13±6.7)cm], with bilateral ovary involvement in 24 cases. There were 109 MEOT patients with 142 tumors [(9.3±4.2)cm] with bilateral ovary involvement in 33 cases. There were eight significant risk factors for BEOTs, including round or oval shape (OR=2.714), well-defined margins (OR=3.318), clear cystic-solid interfaces (OR=5.593), purely cystic (OR=15.206), predominantly cystic with papillae or nodules (OR=2.579), exophytic papillae or nodules (OR=5.351), branching papilla (OR≈∞) and the presence of an ipsilateral ovary (OR≈∞). Based on the scoring of the eight risk factors, a cut-off score of 3.5 yielded a differential sensitivity, specificity, and accuracy of 82%, 85% and 84%, respectively.

CONCLUSION

In contrast to MEOTs, BEOTs frequently had the following features on MRI: round or oval, with well-defined margins and clear cystic-solid interfaces, purely cystic or predominantly cystic with papillae or nodules, branching or exophytic papillae, with the presence of an ipsilateral ovary. MRI can reveal the distinct morphological features of BEOTs and MEOTs and facilitate their discrimination.

Features of ovarian Brenner tumors: Experience of a single tertiary center

Objective:

Brenner tumors are rare neoplasms of the ovary. The aim of this study was to investigate the clinical features of Brenner tumors.

Materials and Methods:

The clinical features of 22 patients who were treated in Ankara University Faculty of Medicine Obstetrics and Gynecology Department between 2005 and 2015 were evaluated retrospectively from hospital medical records.

Results:

The patients were aged 34 to 79 years at the time of diagnosis and the mean age was 55.1 years. Two (9.1%) patients were pre-menopausal, five (22.7%) were peri-menopausal, and 25 (68.2%) patients were postmenopausal. One patient was pregnant. Twenty of the neoplasms were benign, one was malignant, and one was both malignant and benign. There was no recurrence in the malignant cases. Six (27.2%) patients had mixed tumors consisting of Brenner tumor and another ovarian pathology. Specifically, the other component of these tumors was mucinous cystadenoma in four patients, endometriosis externa in one patient, and high-grade serous papillary cyst adenocarcinoma in one patient.

Conclusion:

Brenner tumors are usually incidental benign pathologic findings of surgical procedures in postmenopausal women. They can be found with other ovarian pathologies such as mucinous ovarian tumors and can coexist with other female genital tumors. Further studies are needed to completely understand the clinical features of Brenner tumors.

Malignant Brenner tumor of the ovary: Review and case report

Ovarian neoplasms are a heterogeneous group of tumors with varying incidence in the general population. The most common are the surface epithelial tumors which include transitional cell tumors. Transitional cell tumors include both transitional cell carcinoma and Brenner tumor. The vast majority of Brenner tumors are benign, often incidental findings; however, malignant Brenner tumors (MBT) do occasionally occur. MBT present similarly to other ovarian neoplasms with abdominal pain and bulk symptoms. On imaging, these tumors demonstrate nonspecific findings. Microscopically, they demonstrate areas of conventional benign Brenner tumor juxtaposed with regions of frank malignancy showing marked cytologic atypia and infiltration. There is no consistent tumor marker for these tumors, but CA-125, CA 72-4 and SCC have been reported in singular instances. Tumors express several immunohistochemical markers of urothelial differentiation including uroplakin III, thrombomodulin, GATA3, p63, as well as cytokeratin 7. The primary treatment modality is surgical excision. Due to their rarity, the precise role and regimen of adjuvant chemo-radiation therapy for MBT has not been established. We herein review a case of MBT with emphasis on primary treatment and treatment of recurrent disease, including the use of adjuvant pelvic radiation, discuss the current state of the literature and standards of practice regarding this malignancy.

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Histologic differentiation of MBT from TCC is critical for diagnosis.

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Surgical staging should be performed for all cases of MBT.

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The role of adjuvant strategies for MBT is poorly defined.

BRCA-associated Cancers: Role of Imaging in Screening, Diagnosis, and Management

Harmful mutations of the BRCA tumor suppressor genes result in a greater lifetime risk for malignancy-breast and ovarian cancers in particular. An increased risk for male breast, fallopian tube, primary peritoneal, pancreatic, prostate, and colon cancers also has been reported. The BRCA gene is inherited in an autosomal dominant pattern and tends to be highly penetrant; thus, there is an increased incidence of these cancers in affected families. Compared with sporadic tumors, BRCA-associated malignancies have unique manifestations, clinical features, and pathologic profiles. Manifestation at an early patient age, high-grade tumors, and an aggressive clinical course are common features of BRCA-associated malignancies. Understanding the behavior of these cancers aids in identification of affected individuals and families, who can then make informed decisions regarding their future health. Enhanced screening, prophylactic surgery, and chemoprevention are options for managing cancer risk factors in these individuals. Imaging has an important role in the screening, evaluation, staging, and follow-up of BRCA-associated malignancies. Supplemental screening of BRCA mutation carriers often begins at an early age and is critical for early and accurate cancer diagnoses. The authors review the etiopathogenesis and imaging features of BRCA-associated malignancies, the importance of a multidisciplinary approach to determining the diagnosis, and the treatment of patients who have these mutations to improve their outcomes. ^© RSNA, 2017.

MR Imaging for Incidental Adnexal Mass Characterization

Incidentally detected adnexal masses are common, and the overwhelming majority of them are benign. As many of these adnexal masses are considered indeterminate at CT or US, a large number of benign oophorectomies occur. Of the malignant adnexal masses, high-grade primary ovarian neoplasms with fast doubling times and early dissemination are the most common. Due to their aggressive behavior, diagnosis of malignancy by interval growth on surveillance imaging represents an undesirable option. Immediate MR characterization allows for a decreased rate of benign oophorectomies and expedited triage of patients to definitive treatment when malignancy is suspected.

Pelvic splenosis-a very unusual location

We present a rare case of pelvic splenosis, and its imaging findings, in a 54-year-old female complaining of pelvic pain and vaginal bleeding for several months. Splenosis is a benign acquired condition defined as heterotopic auto-transplantation of splenic tissue to other compartments of the body and occurs after rupture of the spleen, either traumatic or iatrogenic. Symptoms are unspecific and vary according to the location of the implants; commonly the presenting symptom is abdominal pain or enlarging abdominal mass. Owing to its intrinsic properties and safety, magnetic resonance imaging is a valuable imaging modality, in which the splenosis implants may be securely identified, showing the same signal characteristics and enhancing patterns of the normal spleen, especially visualization of serpiginous enhancement on the arterial phase is virtually diagnostic.

Age-Specific Frequencies and Characteristics of Ovarian Cysts in Children and Adolescents

OBJECTIVE

The aim of the present study was to document ovarian cyst frequency and characteristics as well as distribution of these parameters with respect to age in children and adolescents.

METHODS

We retrospectively analyzed the medical records of 1009 girls between the ages of 5-18 years who presented to our pediatric emergency department (PED) with pelvic pain and therefore underwent pelvic ultrasound examination between June 2011 and May 2014.

RESULTS

In total, 132 of 1009 girls (13.1%) were identified as having ovarian cysts ≥1 cm in diameter. The frequency of ovarian cysts was found to be 1.8% (6/337) in children aged 5-9 years and 18.8% (126/672) in those aged 10-18 years. All the cysts detected in children aged 5-9 years were small (<3 cm) and simple with age-specific frequencies ranging between 1.5-2.7%. With the onset of adolescence, ovarian cyst frequency started to increase with age and ranged between 3.8-31.3% throughout adolescence. Age of peak ovarian cyst frequency was 15 years with a rate of 31.3%. Large ovarian cysts (>5 cm) were identified in 19 adolescents (15.1%) with most occurring during middle adolescence. Of the 19 adolescents, five were found to have cyst-related significant ovarian pathologies including cystadenoma (n=3) and ovarian torsion (n=2).

CONCLUSION

In children aged 5-9 years, ovarian cysts were infrequent and small (<3 cm). Peak ovarian cyst frequency was detected at the age of 15 years. All patients diagnosed with cyst-related significant ovarian pathologies were adolescents having a cyst >5 cm in diameter with a complex appearance in most.

A possible Echinococcus granulosus calcified cyst found in a medieval adult female from the churchyard of Santo Domingo de Silos (Prádena del Rincón, Madrid, Spain)

Calcification, or mineralisation, can occur as part of a natural process, or by pathological processes. The purpose of this work is to examine an unidentified semi-spherical and perforate hollow mass, found near the pelvis of an adult female, dated 12th-13th century AD, exhumed of the Church of Santo Domingo de Silos (Prádena del Ricón, Madrid, Spain). The mass was examined by SEM and Energy Dispersive X-Ray Spectroscopy. These procedures revealed a heterogeneous inner surface with both smooth and irregular areas. A larger spherical and several smaller crescent-shaped perforations were noticed. X-ray microanalysis revealed the presence of the elements C, K, P, Ca, Al, Si, Fe, and Mg. The co-localisation of Ca and P suggests that they may be combined in a mineral matrix, likely formed in vivo. Other minerals probably came from the soil, although Fe could be related to the presence of blood. The macroscopic and microscopic appearances, chemical composition, and location of the calcified mass point to a possible hydatid cyst from Echinococcus granulosus, common in agricultural populations. This study used a suite of analytical techniques that are useful in the diagnosis of unknown calcified masses and can, therefore, be recommended for use in future analytical work.

Imaging Patterns of Intratumoral Calcification in the Abdominopelvic Cavity

Intratumoral calcification is one of the most noticeable of radiologic findings. It facilitates detection and provides information important for correctly diagnosing tumors. In the abdominopelvic cavity, a wide variety of tumors have calcifications with various imaging features, though the majority of such calcifications are dystrophic in nature. In this article, we classify the imaging patterns of intratumoral calcification according to number, location, and morphology. Then, we describe commonly-encountered abdominopelvic tumors containing typical calcification patterns, focusing on their differentiable characteristics using the imaging patterns of intratumoral calcification.

Imaging of Extranodal Genitourinary Lymphoma

The genitourinary (GU) system is commonly affected by disseminated lymphoma. Rarely, lymphoma can originate from and remain localized to one of the GU organs and thus presents as primary extranodal disease. Up to 40% of lymphomas present as extranodal disease, with only 3% having the GU system as the primary site of involvement. This article describes and correlates the radiologic and pathologic features of extranodal lymphomatous disease affecting the GU system with specific focus on the kidneys, adrenal glands, testicles, and ovaries. Lymphoma of the uterine body and cervix, external female genitalia, urinary bladder, and prostate gland is briefly discussed.

Sex cord-stromal tumors of the ovary: a comprehensive review and update for radiologists

Ovarian sex cord-stromal tumors are infrequent and represent approximately 7% of all primary ovarian tumors. This histopathologic ovarian tumor group differs considerably from the more prevalent epithelial ovarian tumors. Although sex cord-stromal tumors present in a broad age group, the majority tend to present as a low-grade disease that usually follows a nonaggressive clinical course in younger patients. Furthermore, because the constituent cells of these tumors are engaged in ovarian steroid hormone production (e.g., androgens, estrogens, and corticoids), sex cord-stromal tumors are commonly associated with various hormone-mediated syndromes and exhibit a wide spectrum of clinical features ranging from hyperandrogenic virilizing states to hyperestrogenic manifestations. The World Health Organization sex cord-stromal tumor classification has recently been revised, and currently these tumors have been regrouped into the following clinicopathologic entities: pure stromal tumors, pure sex cord tumors, and mixed sex cord-stromal tumors. Moreover, some entities considered in the former classification (e.g., stromal luteoma, stromal tumor with minor sex cord elements, and gynandroblastoma) are no longer considered separate tumors in the current classification. Herein, we discuss and revise the ultrasonography, computed tomography, and magnetic resonance imaging characteristics of the different histopathologic types and clinicopathologic features of sex cord-stromal tumors to allow radiologists to narrow the differential diagnosis when facing ovarian tumors.

Magnetic Resonance Imaging of Gynecological Malignancies: Role in Personalized Management

Gynecological malignancies are a leading cause of mortality and morbidity in women and pose a significant health problem around the world. Currently used staging systems for management of gynecological malignancies have unresolved issues, the most important being recommendations on the use of imaging. Although not mandatory as per the International Federation of Gynecology and Obstetrics recommendations, preoperative cross-sectional imaging is strongly recommended for adequate and optimal management of patients with gynecological malignancies. Standardized disease-specific magnetic resonance imaging protocols help assess disease spread accurately and avoid pitfalls. Multiparametric imaging holds promise as a roadmap to personalized management in gynecological malignancies. In this review, we will highlight the role of magnetic resonance imaging in cervical, endometrial, and ovarian carcinomas.

Concomitant Heart, Ovaries, and Renal Neoplasms: Atypical Findings During Hypertension Evaluation

Multiple primary tumors is defined as the occurrence of two or more primary lesions, benign or malignant, where each tumor occur in separate sites and is neither an extension, recurrence, nor metastasis [1]. The occurrence of multiple primary tumors is extremely rare with an incidence of less than 4 % [2] of the total tumor cases. We present a case of synchronous heart, ovaries, and kidney tumors in a 63-year-old Caucasian female patient whom primarily attended our institution for a hypertension evaluation. The case we report relates to diagnosis and treatment of the three synchronous lesions unveiled during the work-up.

An Unusual Evolution of Krukenberg Tumour: A Case Report

Krukenberg tumours are rare metastatic tumours of the ovaries characterized by the presence of mucin-producing neoplastic Signet Ring Cell Carcinoma (SRCC). At first glance, this tumour may be confused with a primary ovarian tumour. Surgery and chemotherapy combination have led to improvement in prognosis, but it still remains severe. We report the case of a 60-year-old woman with a Krukenberg tumour rising from a low differentiated gastric adenocarcinoma. The patient was clinically stable for 26 months after surgery until she experienced a prompt decline and died of cerebral haemorrhage within two weeks. The aim of this article was to give an overview of the Krukenberg tumour starting from our case report and comparing it with clinicopathological characteristics of this pathology derived from a review of recent literature.

Endometrioid adenocarcinoma of the ovary: MRI findings with emphasis on diffusion-weighted imaging for the differentiation of ovarian tumors

BACKGROUND

Preoperative differentiation of ovarian malignant tumors still remains a challenge. Diffusion-weighted imaging (DWI) provides information about cellularity of the lesion and might facilitate discrimination between different malignant ovarian lesions.

PURPOSE

To evaluate magnetic resonance imaging (MRI) findings of endometrioid adenocarcinoma of the ovary and to determine the value of DWI in the differential diagnosis of malignant and benign adnexal tumors.

MATERIAL AND METHODS

The following MRI findings were reviewed in 162 patients (21 endometrioid adenocarcinoma, 103 other malignant tumors, 38 benign tumors): lesion size, morphological appearance, T2-weighted (T2W) signal intensity, T1-weighted (T1W) signal intensity, contrast-enhancement pattern, DWI signals with apparent diffusion coefficient (ADC) calculated for b = 800 s/mm(2) in solid tumor components.

RESULTS

The most common morphological appearance was predominantly cystic lesion, found in 90.3% of patients with endometriod adenocarcinoma. The solid parts were slightly hyperintense on T2W images in 19 patients with marked enhancement after contrast administration. No significant difference (P = 0.13) in conventional MRI features was found between endometrioid adenocarcinoma and other malignant ovarian tumors. Hyperintensity on DWI was more frequently observed in malignant tumors than in benign lesions (P < 0.001). ADC values were significantly lower in endometrioid adenocarcinoma than other malignant tumors (0.79 ± 0.21 vs. 0.90 ± 0.19; P = 0.04) and in all malignant lesions compared with benign tumors (0.88 ± 0.31 vs. 1.33 ± 0.17; P < 0.001).

CONCLUSION

DWI with ADC measurement could indicate the presence of endometrioid adenocarcinomas due to a slightly but significantly lower ADC values compared to other malignant ovarian lesions. Thus, DWI is beneficial and should be part of a standard protocol for the evaluation of indeterminate adnexal lesions.

MRI of endometrium cancer - how we do it

Endometrial cancer is the most common malignancy of the female pelvis. New concepts in endometrial cancer treatment emphasize the value of MRI as a major predictor of lymph node metastasis and tumour recurrence. MRI findings aid in triaging patients for a more tailored therapeutic regimen.This review discusses the value of MRI in the preoperative assessment of endometrial cancer and provides a practical approach how to image and report endometrial cancer. Practical tips are provided how to increase the diagnostic accuracy in staging of endometrial cancer and how to avoid pitfalls.

Differentiation between borderline and benign ovarian tumors: combined analysis of MRI with tumor markers for large cystic masses (≥5 cm)

BACKGROUND

There is overlap in imaging features between borderline and benign ovarian tumors.

PURPOSE

To analyze diagnostic performance of magnetic resonance imaging (MRI) combined with tumor markers for differentiating borderline from benign ovarian tumor.

MATERIAL AND METHODS

Ninety-nine patient with MRI and surgically confirmed ovarian tumors 5 cm or larger (borderline, n = 37; benign, n = 62) were included. On MRI, tumor size, septal number (0; 1-4; 5 or more), and presence of solid portion such as papillary projection or septal thickening 0.5 cm or larger were investigated. Serum tumor markers (carbohydrate antigen 125 [CA 125] and CA 19-9) were recorded. Multivariate analysis was conducted for assessing whether combined MRI with tumor markers could differentiate borderline from benign tumor. The diagnostic performance was also analyzed.

RESULTS

Incidence of solid portion was 67.6% (25/37) in borderline and 3.2% (2/62) in benign tumors (P < 0.05). In all patients, without combined analysis of MRI with tumor markers, multivariate analysis revealed solid portion (P < 0.001) and CA 125 (P = 0.039) were significant for predicting borderline tumors. When combined analysis of MRI with CA 125 ((i) the presence of solid portion or (ii) CA 125 > 44.1 U/mL with septal number ≥5 for borderline tumor) is incorporated to multivariate analysis, it was only significant (P = 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of combined analysis of MRI with CA 125 were 89.1%, 91.9%, 86.8%, 93.4, and 90.9%, respectively.

CONCLUSION

Combined analysis of MRI with CA 125 may allow better differentiation between borderline and benign ovarian tumor compared with MRI alone.

CT findings of sclerosing stromal tumor of the ovary: A report of two cases and review of the literature

Sclerosing stromal tumor (SST) of the ovary, which was first described by Chalvardjian and Scully in 1973, is a rare ovarian neoplasm, occurring predominantly in young women. The most common clinical symptom in patients with SST is menstrual irregularities. Microscopically, the tumor is characterized by the presence of pseudo-lobulated cellular areas, with a prominent tendency to sclerosis, marked vascularity and pronounced variation in cellular size and shape. In the current study, 2 cases of SST of the ovary are presented. These cases were confirmed by imaging, surgical and histological examination. No adjuvant therapy was administered to the patients and the two patients were disease-free with no imaging findings of recurrence or metastasis 24 months following surgery.

A rare benign ovarian tumour

Sclerosing stromal tumour (SST) of the ovary is an extremely rare and benign ovarian neoplasm, accounting for 6% of the sex cord stromal ovarian tumours subtype. Usually, it is found during the second and third decades of life. Patients commonly present with pelvic pain, a palpable pelvic mass or menstrual irregularity. We report a case of a 20-year-old woman reporting of mild pelvic pain, with normal laboratory data. On imaging examinations, a large right adnexal tumour was found, with features suggesting an ovarian sex cord tumour. The patient underwent right salpingo-oophorectomy, diagnosing a SST of the ovary. This paper also reviews the literature, and emphasises the typical pathological and imaging characteristics of these rare benign ovarian lesions, and their impact, in a conservative surgery.

MR imaging of ovarian masses: classification and differential diagnosis

OBJECTIVE

We propose a Magnetic Resonance Imaging (MRI) guided approach to differential diagnosis of ovarian tumours based on morphological appearance.

BACKGROUND

Characterization of ovarian lesions is of great importance in order to plan adequate therapeutic procedures, and may influence patient's management. Optimal assessment of adnexal masses requires a multidisciplinary approach, based on physical examination, laboratory tests and imaging techniques. Primary ovarian tumours can be classified into three main categories according to tumour origin: epithelial, germ cell and sex cord-stromal tumours. Ovarian neoplasms may be benign, borderline or malignant. Using an imaging-guided approach based on morphological appearance, we classified adnexal masses into four main groups: unilocular cyst, multilocular cyst, cystic and solid, predominantly solid. We describe MR signal intensity features and enhancement behaviour of ovarian lesions using pathologically proven examples from our institution.

CONCLUSION

MRI is an essential problem-solving tool to determine the site of origin of a pelvic mass, to characterize an adnexal mass, and to detect local invasion. The main advantages of MRI are the high contrast resolution and lack of ionizing radiation exposure. Although different pathological conditions may show similar radiologic manifestations, radiologists should be aware of MRI features of ovarian lesions that may orientate differential diagnosis.

TEACHING POINTS

• Diagnostic imaging plays a crucial role in detection, characterization and staging of adnexal masses. • Characterization of an ovarian lesion may influence patient's management. • Different pathological conditions may have similar radiologic manifestations. • Non-neoplastic lesions should always be taken into consideration.

A Rare Presentation of Paraovarian Sclerosing Stromal Tumor with High Mitotic Activity

BACKGROUND

Sclerosing stromal tumor is an extremely rare type of benign ovarian sex cord stromal tumor.

CASE

The benign characteristic of this tumor is well known but we present an uncommon case of paraovarian sclerosing stromal tumor with high mitotic activity.

RESULTS AND CONCLUSION

Despite this potential malignancy, our patient was treated successfully with enucleation only.

Stromal Overgrowth in a Brenner Tumor or Ovarian Fibroma With Minor Sex Cord Elements?

Computed tomography obtained as part of a urinary tract assessment in a 68-year-old woman incidentally detected a solid adnexal mass. Bilateral salpingo-oophorectomy revealed a unilateral, 4-cm, white to tan-yellow colored, focally calcified, left ovarian mass. Microscopically, the tumor was composed of bland fibroblasts, abundant collagen, and areas of calcification with a minor component composed of nests of epithelial cells with nuclear clefts focally evident, some of which contained central lumens with eosinophilic secretions. The major considerations were fibromatous overgrowth in a Brenner tumor or ovarian fibroma with minor sex cord elements. Immunostains for cytokeratin 7 showed diffuse positivity in the epithelial nests, whereas cytokeratin 20 and inhibin were negative, further supporting the diagnosis of a Brenner tumor.

Do hereditary syndrome-related gynecologic cancers have any specific features?

Abstract

Hereditary syndromes are responsible for 10 % of gynaecologic cancers, among which hereditary breast-ovarian cancer and hereditary non-polyposis colon cancer syndromes, known as HBOC and Lynch syndromes respectively, present the highest relative risk. The latter predisposes to endometrial cancer and both contribute to ovarian cancer. Cowden syndrome-related endometrial cancer and the increased risk of ovarian, uterine and cervical cancers associated with Peutz-Jeghers syndrome, are also demonstrated, while Li-Fraumeni syndrome patients are prone to develop ovarian and endometrial cancers. Despite these syndromes’ susceptibility to gynaecologic cancers being consensual, it is still not clear whether these tumours have any epidemiologic, clinical, pathologic or imaging specific features that could allow any of the intervening physicians to raise suspicion of a hereditary syndrome in patients without known genetic risk. Moreover, controversy exists regarding both screening and surveillance schemes. Our literature review provides an updated perspective on the evidence-based specific features of tumours related to each of these syndromes as well as on the most accepted screening and surveillance guidelines. In addition, some illustrative cases are presented.

Teaching Points

• HBOC syndrome is mainly associated with ovarian HGSC, which arises in fallopian fimbriae.

• LS-related endometrial tumours show histological diversity and predilection for lower uterine segment.

• LS and CS-related ovarian cancers are mostly of non-serous type, usually endometrioid.

• Ovarian SCTAT and cervical adenoma malignum are strongly associated with PJS.

• Unfortunately, hereditary gynaecologic cancers do not seem to have distinctive imaging features.

The performance of contrast-enhanced FDG PET/CT for the differential diagnosis of unexpected ovarian mass lesions in patients with nongynecologic cancer

PURPOSE

This study aimed to evaluate the diagnostic accuracy of contrast-enhanced FDG PET/CT for unexpected ovarian lesions in patients with nongynecologic cancers.

PATIENTS AND METHODS

The present retrospective study was approved by the hospital institutional review board. We enrolled 72 nongynecologic cancer patients (33 colorectal cancer, 20 breast cancer, and 19 gastric cancer) who showed unexpected ovarian lesions on contrast-enhanced FDG PET/CT and subsequently underwent surgical resection of the ovarian lesions. The SUVmax values of the ovarian lesions were compared according to the histopathological results, and the accuracy of PET/CT was evaluated.

RESULTS

A total of 103 ovarian lesions were surgically resected from 72 patients (64 ovarian lesions were metastases, 21 were benign, and 18 were malignant primary ovarian cancer). SUVmax among the 3 groups were different (P < 0.0001). Using a cutoff SUVmax of 2.5, the sensitivity, specificity, and accuracy of PET/CT for detecting malignant ovarian lesions were 80.5%, 81.0%, and 80.6%, respectively. Detection rates of PET/CT for colorectal, breast, and gastric cancer metastases, as well as primary ovarian cancers were 91.4%, 83.3%, 47.8%, and 100.0%, respectively. Using contrast-enhanced CT findings with SUVmax, the sensitivity, specificity, and accuracy of contrast-enhanced FDG PET/CT were improved to 95.1%, 76.2%, and 91.3%, respectively (P = 0.003).

CONCLUSIONS

Conventional FDG PET/CT showed moderate diagnostic accuracy for the detection of malignant ovarian lesions mainly due to low detection rate in gastric cancer metastases. The PET/CT detection rate of malignant ovarian lesions can be improved using contrast-enhanced CT findings with FDG uptake measurement.

Imaging features of complex solid and multicystic ovarian lesions: proposed algorithm for differential diagnosis

Complex solid and multicystic ovarian lesions are broad-spectrum diseases, ranging from benign to malignant. This article describes the broad-spectrum and imaging features of complex solid and multicystic ovarian lesions and illustrates an algorithmic approach to such lesions, focusing on the ultrasonography and magnetic resonance imaging features that allow one to hone the differential diagnosis. Multimodality imaging workup plays an important role in the characterization and differential diagnosis of these diseases. Also, knowledge of the clinical setting and imaging features for the spectrum of complex solid and multicystic ovarian lesions can lead to appropriate management.

Magnetic Resonance Imaging Characteristics of Ovarian Clear Cell Carcinoma

PURPOSE

To probe the magnetic resonance imaging (MRI) features of ovarian clear cell carcinoma (OCCC).

METHODS

This study retrospectively collected MRI data for 21 pathology-confirmed OCCCs from 19 female patients. The MRI findings were analyzed to determine the tumor size, shape/edge, shape and number of protrusions within the cyst, cystic or necrotic components, signal intensity (SI) and enhancement features.

RESULTS

The age of the 19 patients ranged from 28 to 63 years (mean age: 53 years). Unilateral tumors were found in 17 patients (17/19, 89%); the average size of all tumors was 10.8 cm. The tumors on MRI were classified into two categories: (a) "cystic adnexal mass with solid protrusions" in 12 (57%) and (b) "solid adnexal mass with cystic areas or necrosis" in 9 (43%). For group a, high to very high SI was observed for most tumors (10/12, 83%) on T1-weighted images (T1WIs), and very high SI was observed on T2-weighted images (T2WIs) for all 12 tumors. Most solid protrusions were irregular and few in number and exhibited heterogeneous intermediate SI on T1WIs and T2WIs and prolonged enhanced SI in the contrast study. All 9 OCCCs in group b were predominantly solid masses with unequally sized necrotic or cystic areas in which some cysts were located at the periphery of the tumor (4/9, 44%). The solid components in all 9 tumors showed iso- or slightly high SI on T1WIs, heterogeneous iso-high SI on T2WIs and heterogeneous prolonged enhancement. According to FIGO classification, 14 tumors (14/19, 74%) were stages I-II, and 5 (5/19, 26%) were stages III-IV.

CONCLUSIONS

On MRI, OCCCs present as large unilateral multilocular or unilocular cystic masses with irregular intermediate SI solid protrusions or predominantly solid masses with cysts or necrosis at an early FIGO stage.

Semi-quantitative contrast-enhanced MR analysis of indeterminate ovarian tumours: when to say malignancy?

OBJECTIVE

To evaluate the ability of dynamic post-contrast sequence to specify indeterminate ovarian masses with inconclusive MR features of malignancy. Since management is dramatically different, special focus on the ability to differentiate borderline from invasive malignancy was considered.

METHODS

150 ovarian masses were detected by pelvic ultrasound in 124 patients. Masses had been considered for dynamic post-contrast MRI. We expressed the kinetic parameters (i.e. enhancement amplitude, time peak of maximal uptake and maximal slope) in the form of maximum relative enhancement percentage (MRE%), time of maximal peak of contrast uptake (Tmax) and slope enhancement ratio (SER) curves. Histological findings were the gold standard of reference.

RESULTS

Malignant ovarian masses showed higher MRE% than benign and borderline masses (p < 0.001). Tmax was shorter for malignant than benign (p < 0.01) and borderline (p < 0.001) ovarian masses. SER curves were the most suggestive of malignancy with a specificity and accuracy of 85.7% and 84.7%, respectively.

CONCLUSION

Dynamic contrast-enhanced MRI could be a specific sequence to differentiate ovarian masses with indeterminate MR morphology with a special discrimination for low potential from invasive ovarian malignancy.

ADVANCES IN KNOWLEDGE

The study evaluated the diagnostic performance of the individual parameters of dynamic post-contrast MR sequence in evaluating ovarian masses. Management divert between benign, borderline and invasive malignant masses; our work presented a cut-off value for the peak of contrast uptake of 120%, which helped in the differentiation between benign and malignant tumours; the SER curves with Type III (early washout) pattern that was indicative of invasive malignancy was more specific than borderline malignancy.

CT imaging of ovarian yolk sac tumor with emphasis on differential diagnosis

Ovarian yolk sac tumors (YSTs) are rare neoplasms. No radiological study has been done to compare the imaging findings between this type of tumor and other ovarian tumors. Here we analyzed the CT findings of 11 pathologically proven ovarian YSTs and compared their imaging findings with 18 other types of ovarian tumors in the same age range. Patient age, tumor size, tumor shape, ascites and metastasis of two groups did not differ significantly (P > 0.05). A mixed solid-cystic nature, intratumoral hemorrhage, marked enhancement and dilated intratumoral vessel of two groups differed significantly (P < 0.05). The area under the ROC curve of four significant CT features was 0.679, 0.707, 0.705, and 1.000, respectively. Multivariate logistic regression analysis identified two independent signs of YST: intratumoral hemorrhage and marked enhancement. Our results show that certain suggestive CT signs that may be valuable for improving the accuracy of imaging diagnosis of YST and may be helpful in distinguishing YST from other ovarian tumors.

F-18 FDG PET/CT findings of metastatic ovarian tumors from gastrointestinal tract origin

PURPOSE

To review the F-18 FDG PET/CT findings of metastatic ovarian tumors and to determine any correlation between FDG uptake by metastatic ovarian tumors and that by the primary tumors.

METHODS

PET/CT performed from June 2005 to March 2011 on patients with metastatic ovarian tumors of gastrointestinal tract origin malignancies was analyzed retrospectively. The SUV(max) of metastatic ovarian tumors and primary tumors, when available, was measured.

RESULTS

Thirty-two patients were included. Of the 32 cases, 20 had metastatic tumors in bilateral ovaries and 12 had in a single ovary. The mean SUV(max) of the 52 total lesions was 4.1 ± 3.1 (range 1.2-13.3), and 46 lesions showed a heterogeneous FDG uptake pattern. In 22 cases with available primary tumor SUV(max) values, there was a moderate positive correlation with the SUV(max) of the corresponding metastatic tumors (r = 0.559, p = 0.007). There was no significant correlation between the size and SUV(max) of metastatic ovarian tumors (p = 0.128). The mean SUV(max) of metastatic ovarian tumors from colorectal cancers was significantly higher than that of stomach cancers (p = 0.039).

CONCLUSIONS

Metastatic ovarian tumors showed FDG uptake of variable intensity, depending on the primary tumor type. The FDG uptake pattern was heterogeneous by PET imaging in vast majority of the cases. When the primary tumor demonstrates a low FDG uptake, careful evaluation is necessary since the metastatic ovarian tumors may also show low FDG uptake.

Ovarian Sertoli-Leydig cell tumor with heterologous elements of gastrointestinal type associated with elevated serum alpha-fetoprotein level: an unusual case and literature review

Here we describe the case of a 19-year-old woman with a poorly differentiated ovarian Sertoli-Leydig cell tumor and an elevated serum alpha-fetoprotein level. The patient presented with diffuse abdominal pain and bloating. Physical examination, ultrasound, and magnetic resonance imaging revealed a right ovarian tumor that was histopathologically diagnosed as a poorly differentiated Sertoli-Leydig cell tumor with heterologous elements. Her alpha-fetoprotein serum level was undetectable after tumor resection. Sertoli-Leydig cell tumors are rare sex cord-stromal tumors that account for 0.5% of all ovarian neoplasms. Sertoli-Leydig cell tumors tend to be unilateral and occur in women under 30 years of age. Although they are the most common virilizing tumor of the ovary, about 60% are endocrine-inactive tumors. Elevated serum levels of alpha-fetoprotein are rarely associated with Sertoli-Leydig cell tumors, with only approximately 30 such cases previously reported in the literature. The differential diagnosis should include common alpha-fetoprotein-producing ovarian entities such as germ cell tumors, as well as other non-germ cell tumors that have been rarely reported to produce this tumor marker.

Clear cell carcinoma of the ovary: multi-slice computed tomography findings

Background

The aim of the study was to describe the multi-slice computed tomography (MSCT) features of clear cell carcinoma (CCC) of the ovary.

Methods

Twenty patients with histology-confirmed CCC of the ovary were retrospectively reviewed. All patients underwent preoperative plain and contrast-enhanced MSCT examinations. Imaging studies were evaluated for the following: (a) location; (b) maximal transverse diameter; (c) shape (round, oval, lobular, or irregular); (d) margin (well defined or ill defined); (e) solid, solid with cystic regions, or cystic; (f) attenuation of the cystic portion; (g) enhancement pattern of the solid portions of the tumor; and (h) the secondary manifestations.

Results

The mean age of the patients was 63 years (range, 44 to 77 years). Tumors were unilateral in 19 patients and bilateral on 1 patient. The maximal transverse diameter of the tumors was relatively larger with a mean diameter of 105.7 mm (range, 45.5 to 260.6 mm). CCCs demonstrated cystic masses with solid regions in 20 lesions. Most lesions were ovoid (15/21), unilocular (16/21), and well-defined (17/21). The CT value of cystic or necrotic portion ranged from 12 to 28 HU (average, 18 HU) on plain image. The solid protrusions of the cystic masses were both few and round with obviously heterogeneous enhancements after contrast.

Conclusions

The ovarian CCCs typically present as a large, well-defined, unilocular cystic mass with solid protrusion and relatively high attenuated cystic or necrotic portions. The solid protrusions are usually both round and few in number with obviously heterogeneous enhancement.

Ovarian malignant germ cell tumors: cellular classification and clinical and imaging features

Ovarian malignant germ cell tumors (OMGCTs) are heterogeneous tumors that are derived from the primitive germ cells of the embryonic gonad. OMGCTs are rare, accounting for about 2.6% of all ovarian malignancies, and typically manifest in adolescence, usually with abdominal pain, a palpable mass, and elevated serum tumor marker levels, which may serve as an adjunct in the initial diagnosis, monitoring during therapy, and posttreatment surveillance. Dysgerminoma, the most common malignant germ cell tumor, usually manifests as a solid mass. Immature teratomas manifest as a solid mass with scattered foci of fat and calcifications. Yolk sac tumors usually manifest as a mixed solid and cystic mass. Capsular rupture or the bright dot sign, a result of increased vascularity and the formation of small vascular aneurysms, may be present. Embryonal carcinomas and polyembryomas rarely manifest in a pure form and are more commonly part of a mixed germ cell tumor. Some OMGCTs have characteristic features that allow a diagnosis to be confidently made, whereas others have nonspecific features, which make them difficult to diagnose. However, imaging features, the patient's age at presentation, and tumor markers may help establish a reasonable differential diagnosis. Malignant ovarian germ cell tumors spread in the same manner as epithelial ovarian neoplasms but are more likely to involve regional lymph nodes. Preoperative imaging may depict local extension, peritoneal disease, and distant metastases. Suspicious areas may be sampled during surgery. Because OMGCTs are almost always unilateral and are chemosensitive, fertility-sparing surgery is the standard of care.

CT features of low grade serous carcinoma of the ovary

Objective

To evaluate the CT features of pathologically proven low grade serous carcinoma (LGSC) of the ovary.

Methods

Patients with a pathologic diagnosis of LGSC and CT prior to oophorectomy were retrospectively identified. The CT scans in 14 patients were available and were analyzed for an adnexal mass, peritoneal mass and ascites. The adnexal mass was characterized as complex primarily cystic, mixed cystic solid, or primarily solid. Calcification in the adnexal and peritoneal masses and nodes was noted.

Results

Pathology revealed 6 patients had LGSC and 8 patients had a combined diagnosis of LGSC and serous borderline tumor (SBT) of the ovary. Of the 6 patients with only LGSC, 4 had primarily solid or mixed solid cystic adnexal masses and 5 had peritoneal masses. Calcification was present in the adnexal and peritoneal masses in 4 patients, and in nodes in 2 patients. Of the 8 patients with co-existing LGSC and SBT, 7 had complex primarily cystic adnexal masses and 6 had peritoneal masses. Calcification was present in the adnexal and peritoneal masses in 5 patients and in nodes in 2 patients.

Conclusion

LGSC can appear as a solid, mixed solid cystic, or complex primarily cystic ovarian mass, and the appearance may be due to a co-existing SBT. Calcification of the adnexal and peritoneal masses appears to be common. LGSC is a diagnostic consideration in patients with a calcified adnexal mass and concurrent peritoneal masses or calcified nodes on CT.