The MRI features of histologically proven ovarian cystadenofibromas-an assessment of the morphological and enhancement patterns

ACR Appropriateness Criteria® Clinically Suspected Adnexal Mass, No Acute Symptoms: 2023 Update

Asymptomatic adnexal masses are commonly encountered in daily radiology practice. Although the vast majority of these masses are benign, a small subset have a risk of malignancy, which require gynecologic oncology referral for best treatment outcomes. Ultrasound, using a combination of both transabdominal, transvaginal, and duplex Doppler technique can accurately characterize the majority of these lesions. MRI with and without contrast is a useful complementary modality that can help characterize indeterminate lesions and assess the risk of malignancy is those that are suspicious. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Isolated torsion of fallopian tube with associated torsed paratubal cystadenofibroma: A case report

Cystadenofibromas (CAF) and adenofibromas (AF) are rare benign gynecologic neoplasms of epithelial origin. They can be composed predominantly of solid fibrous tissue, adenofibromas, or contain cystic components, as seen in cystadenofibromas; which can be further classified by their epithelial cell type (serous, mucinous, etc.). They most commonly arise from the ovary; however, CAF/AF associated with the fallopian tube have also been reported. CAF/AF is typically asymptomatic and found incidentally. Like other adnexal and ovarian masses, patients are at increased risk of ovarian/adnexal torsion, with increasing risk with lesion size. Herein, we present the case of a patient with isolated torsion of a fallopian tube with associated torsed paratubal serous cystadenofibroma. To our knowledge, this is the first reported case of isolated torsion of a fallopian tube with associated para-tubal cystadenofibroma.

Manifestations of Ovarian Cancer in Relation to Other Pelvic Diseases by MRI

Imaging plays a pivotal role in the diagnostic approach of women with suspected ovarian cancer. MRI is widely used for preoperative characterization and risk stratification of adnexal masses. While epithelial ovarian cancer (EOC) has typical findings on MRI; there are several benign and malignant pelvic conditions that may mimic its appearance on imaging. Knowledge of the origin and imaging characteristics of a pelvic mass will help radiologists diagnose ovarian cancer promptly and accurately. Finally, in special subgroups, including adolescents and gravid population, the prevalence of various ovarian tumors differs from that of the general population and there are conditions which uniquely manifest during these periods of life.

Endometrioid adenofibroma of ovary: A case report and review of literature

RATIONALE

Endometrioid adenofibroma is a benign epithelial neoplasm of the ovary, most of which are often unilateral. The symptoms of endometrioid adenofibroma are often nonspecific and misleading. Therefore, a full understanding of the characteristics, diagnosis, and treatment methods of this disease is of great importance. In this study, we report a 34-year-old woman who was found with an unidentified mass on the right ovary during the physical examination 3 years ago with nosymptoms or signs.

PATIENT CONCERNS

A 34-year-old Chinese female was found with an unidentified 6 cm mass on the right ovary for 3 years that presented with no symptoms or signs.

DIAGNOSIS

Pelvic ultrasound revealed a 6 cm cystic solid mixed mass on the right ovary. Through histological and immunohistochemical examinations, the tumor mass was finally diagnosed as endometrioid adenofibroma of ovary.

INTERVENTIONS

To confirm the diagnosis, the ovarian tumor was laparoscopically resected.

OUTCOMES

The patient returned to hospital after 3 months with no recurrence or postoperative complications.

LESSONS

Endometrioid adenofibroma is a benign epithelial neoplasm of the ovary. Complete surgical resection is required and rare cases can recur. Postsurgical pathologic and immunohistochemical testing can confirm a diagnosis of endometrioid adenofibroma. It is important to understand of the key points of differential diagnosis of the disease due to the different prognosis and clinical treatment.

Ultrasound Characteristics of Cystadenofibromas: A Retrospective Multicenter Study

ABSTRACT

Cystadenofibromas (CAFs) are relatively rare benign ovarian tumors. This study was to describe the ultrasound (US) findings of CAFs. Preoperative US information of 86 CAFs was retrospectively collected. To better illustrate their characteristic, 173 cystadenomas (CADs), 103 borderline ovarian tumors (BOTs), and 129 cystadenocarcinomas (CACs) were recruited as match groups. Besides morphology evaluation, tumors were categorized by the Ovarian-Adnexal Reporting and Data System US system. Higher-risk stratification in CAFs was more often being seen than CADs (63% of CAFs classified as Ovarian-Adnexal Reporting and Data System 4 or 5 vs 35% in CADs). Cystadenofibromas more commonly appeared as unilocular or multilocular solid than CADs. Solid components presented in 59% of CAFs and papillary projections presented in 45%. More CAFs contained solid components and papillary projections than CADs (P < 0.0001). When compared with BOTs and CACs, less CAFs contained solid components (P < 0.017 and P < 0.0001). However, no significant difference was found in CAFs versus BOTs or CACs about the presence of papillary projections. Shadowing was identified in 58% of CAFs; however, in CADs, BOTs, and CACs, the proportion was 2%, 11%, and 11%, respectively. Presence of shadowing in CAFs was noticeably more than CADs, BOTs, and CACs (P < 0.017 or P < 0.0001). Similar to CADs, most CAFs were avascular (76%) and without ascites (99%), which were significantly different from BOTs and CACs. We concluded that the sonographic markers for CAFs that differ from malignant were presence of shadowing, avascular, and absence of ascites.

Pearls and Potential Pitfalls for Correct Diagnosis of Ovarian Cystadenofibroma in MRI: A Pictorial Essay

Ovarian cystadenofibroma is a benign ovarian tumor that is characterized by a consistent percentage of masses, which remain indeterminate in ultrasonography and require magnetic resonance (MR) investigation; they may mimic borderline or malignant lesions. Three main morphologic patterns, resembling different ovarian neoplasms, can be identified in cystadenofibromas: multilocular solid lesions, unilocular cystic lesions with parietal thickening, and purely cystic masses. However, a cystoadenofibroma has typical features, such as T2-weighted hypointensity associated with no restrictions in diffusion-weighted imaging (the so-called "dark-dark appearance") and progressive post-contrast enhancement (type I perfusion curve). The purpose of this study was to review the features of ovarian cystadenofibromas in MR imaging and to suggest pearls and pitfalls regarding their correct diagnosis.

Diagnostic performance of dynamic contrast-enhanced magnetic resonance imaging for malignant ovarian tumors: a systematic review and meta-analysis

BACKGROUND

Accurate preoperative diagnosis of malignant ovarian tumors (MOTs) is particularly important for selecting the optimal treatment strategy and avoiding overtreatment.

PURPOSE

To evaluate the diagnostic efficacy of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for MOTs.

MATERIAL AND METHODS

A systematic search was performed in PubMed, Embase, the Cochrane Library, and Web of Science databases to find relevant original articles up to October 2019. The included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Studies on the diagnosis of MOTs with quantitative or semi-quantitative DCE-MRI were analyzed separately. The bivariate random-effects model was used to assess the diagnostic authenticity. Meta-regression analyses were performed to analyze the potential heterogeneity.

RESULTS

For semi-quantitative DCE-MRI, the pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and the area under the summary receiver operating characteristic curves (AUC) were 85% (95% confidence interval [CI] 0.75-0.92), 85% (95% CI 0.77-0.91), 5.8 (95% CI 3.8-8.8), 0.17 (95% CI 0.10-0.30), 33 (95% CI 18-61), and 0.92 (95% CI 0.89-0.94), respectively. For quantitative DCE-MRI, the pooled sensitivity, specificity, positive LR, negative LR, DOR, and AUC were 88% (95% CI 0.65-0.96), 93% (95% CI 0.78-0.98), 12.3 (95% CI 3.4-43.9), 0.13 (95% CI 0.04-0.45), 91 (95% CI 10-857), and 0.96 (95% CI 0.94-0.98), respectively.

CONCLUSION

DCE-MRI has great diagnostic value for MOTs. Semi-quantitative DCE-MRI may be a relatively mature approach; however, quantitative DCE-MRI appears to be more promising than semi-quantitative DCE-MRI.

Multimodality Imaging Approach to Ovarian Neoplasms with Pathologic Correlation

Ovarian neoplasms can be categorized on the basis of histopathologic features into epithelial surface cell tumors, germ cell tumors, sex cord-stromal tumors, and metastases. While their imaging appearance is often nonspecific, it closely parallels the gross pathologic appearance, and radiologic-pathologic correlation is helpful to aid in a deeper understanding of the subtypes. Epithelial cell neoplasms are the most common category, and they can be benign, borderline, or malignant. Specific subtypes include serous (most common), mucinous, seromucinous, endometrioid, clear cell, Brenner, and undifferentiated. High-grade serous cystadenocarcinoma accounts for the majority of malignant ovarian tumors and the most ovarian cancer deaths. While serous neoplasms are often unilocular and bilateral, mucinous neoplasms are larger, unilateral, and multilocular. Solid components, thickened septa, and papillary projections, particularly with vascularity, indicate borderline or malignant varieties. Endometrioid and clear cell carcinomas can arise within endometriomas. Fibrous tumors (cystadenofibroma, adenofibroma, fibroma or fibrothecoma, and Brenner tumors) demonstrate low T2-weighted signal intensity of their solid components, while teratomas contain lipid. The nonspecific imaging appearance of additional malignant ovarian germ cell tumors can be narrowed with tumor marker profiles. Sex cord-stromal tumors are often solid, and secondary signs from their hormonal secretion can be a clue to their diagnosis. The authors review the anatomy of the ovary and distal fallopian tube, the proposed origins of the histologic subtypes of tumors, the clinical features and epidemiology of ovarian neoplasms, and the applications of US, CT, and MRI in imaging ovarian neoplasms. The main focus is on the radiologic and pathologic features of the multiple ovarian neoplasm subtypes. An algorithmic approach to the diagnosis of ovarian neoplasms is presented. Online supplemental material is available for this article. ^©RSNA, 2020.

Adnexal masses characterized on 3 tesla magnetic resonance imaging - added value of diffusion techniques

Background

To assess different types of adnexal masses as identified by 3T MRI and to discuss the added value of diffusion techniques compared with conventional sequences.

Patients and methods

174 women age between 13 and 87 underwent an MRI examination of the pelvis for a period of three years. Patients were examined in two radiology departments – 135 of them on 3 Tesla MRI Siemens Verio and 39 on 3 Tesla MRI Philips Ingenia. At least one adnexal mass was diagnosed in 98 patients and they are subject to this study. Some of them were reviewed retrospectively. Data from patients’ history, physical examination and laboratory tests were reviewed as well.

Results

124 ovarian masses in 98 females’ group of average age 47.2 years were detected. Following the MRI criteria, 59.2% of the cases were considered benign, 30.6% malignant and 10.2% borderline. Out of all masses 58.1% were classified as cystic, 12.9% as solid and 29% as mixed. Оf histologically proven tumors 74.4% were benign and 25.6% were malignant. All of the malignant tumors had restricted diffusion. 64 out of all patients underwent contrast enhancement. (34 there were a subject of contraindications). 39 (61%) of the masses showed contrast enhancement.

Conclusions

Classifying adnexal masses is essential for the preoperative management of the patients. 3T MRI protocols, in particular diffusion techniques, increase significantly the accuracy of the diagnostic assessment.

Microcystic pattern and shadowing are independent predictors of ovarian borderline tumors and cystadenofibromas in ultrasound

OBJECTIVES

To determine the sonographic characteristics of borderline tumors (BoTs) and cystadenofibromas (CAFs).

METHODS

Preoperative sonograms from consecutive patients who had at least one primary epithelial tumor in the adnexa were retrospectively collected. All tumors were described using the International Ovarian Tumor Analysis terminology. Ultrasound variables were tested using multinomial logistic regression after univariate analysis.

RESULTS

A total of 650 patients were included in this study. Of these, 110 had a CAF, 128 had a BoT, 249 had a cystadenoma (CAD), and 163 had a cystadenocarcinoma (CAC). Nearly half of CAFs and more than half of BoTs and CACs appeared to be unilocular and multilocular solid on the ultrasound images, while CADs were predominantly uni- or multilocular (p < 0.001). Overall, shadowing was identified in 82/650 cases. Sixty-five of 110 (59.1%) CAFs exhibited an acoustic shadow, compared with only 4/249 (1.6%) in CADs, 7/128 (5.5%) in BoTs, and 6/163 (3.7%) in CACs (p < 0.001). Furthermore, 112/650 cases demonstrated microcystic pattern (MCP). Sixty-eight of 128 (53.1%) BoTs exhibited MCP, compared with only 5/249 (2.0%) in CADs, 19/163 (11.7%) in CACs, and 20/110 (18.2%) in CAFs (p < 0.001). Logistic regression analysis revealed that shadowing is an independent predictor of CAFs, while MCP is an independent predictor of BoTs.

CONCLUSIONS

Sonographic findings for CAFs and BoTs were complex and partly overlapped with those for CACs. However, proper recognition and utilization of shadowing or MCP may help to correctly discriminate CAFs and BoTs.

KEY POINTS

• Sonographic findings for borderline tumors and cystadenofibromas are complex and mimic malignancy. • Microcystic pattern and shadowing are independent predictors of borderline tumors and cystadenofibromas respectively.

Role of Imaging in Fertility-sparing Treatment of Gynecologic Malignancies

Treatments for gynecologic cancer usually result in loss of fertility due to surgery or radical radiation therapy in the pelvis. In countries with an established screening program for cervical cancer, the majority of gynecologic malignancies occur in postmenopausal women. However, a substantial number of affected women are of childbearing age and have not completed their families. In these younger women, consideration of fertility preservation may be important. This article describes the fertility-sparing treatment options that are currently available and outlines the role of imaging in the selection of eligible patients on the basis of a review of the literature. In the setting of cervical cancer, magnetic resonance (MR) imaging is used to delineate the size, position, and stage of the tumor for selection of patients who are suitable for radical trachelectomy. In patients with solitary complex adnexal masses, diffusion- and perfusion-weighted MR imaging sequences are used to categorize the likelihood of invasive or borderline malignancy for consideration of unilateral ovarian resection, with fertility preservation when possible. In patients with endometrial cancer, MR imaging is used to rule out signs of invasive disease before hormone therapy is considered. Imaging is also used at patient follow-up to detect recurrent disease; however, evidence to support this application is limited. In conclusion, imaging is an essential tool in the care of patients with gynecologic malignancies who are considering fertility-preserving treatment options. ^©RSNA, 2016.

ESUR recommendations for MR imaging of the sonographically indeterminate adnexal mass: an update

Abstract

An update of the 2010 published ESUR recommendations of MRI of the sonographically indeterminate adnexal mass integrating functional techniques is provided. An algorithmic approach using sagittal T2 and a set of transaxial T1 and T2WI allows categorization of adnexal masses in one of the following three types according to its predominant signal characteristics. T1 'bright' masses due to fat or blood content can be simply and effectively determined using a combination of T1W, T2W and FST1W imaging. When there is concern for a solid component within such a mass, it requires additional assessment as for a complex cystic or cystic-solid mass. For low T2 solid adnexal masses, DWI is now recommended. Such masses with low DWI signal on high b value image (e.g. > b 1000 s/mm²) can be regarded as benign. Any other solid adnexal mass, displaying intermediate or high DWI signal, requires further assessment by contrast-enhanced (CE)T1W imaging, ideally with DCE MR, where a type 3 curve is highly predictive of malignancy. For complex cystic or cystic-solid masses, both DWI and CET1W—preferably DCE MRI—is recommended. Characteristic enhancement curves of solid components can discriminate between lesions that are highly likely malignant and highly likely benign.

Key Points

• MRI is a useful complementary imaging technique for assessing sonographically indeterminate masses.

• Categorization allows confident diagnosis in the majority of adnexal masses.

• Type 3 contrast enhancement curve is a strong indicator of malignancy.

• In sonographically indeterminate masses, complementary MRI assists in triaging patient management.

Electronic supplementary material

The online version of this article (doi:10.1007/s00330-016-4600-3) contains supplementary material, which is available to authorized users.

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.

Added Value of Assessing Adnexal Masses with Advanced MRI Techniques

This review will present the added value of perfusion and diffusion MR sequences to characterize adnexal masses. These two functional MR techniques are readily available in routine clinical practice. We will describe the acquisition parameters and a method of analysis to optimize their added value compared with conventional images. We will then propose a model of interpretation that combines the anatomical and morphological information from conventional MRI sequences with the functional information provided by perfusion and diffusion weighted sequences.