Endovaginal sonographic appearance of benign ovarian masses

Ovarian Cystadenofibroma: An Innocent Tumor Causing Early Postoperative Small Bowel Obstruction and Perforation Peritonitis

Ovarian serous cystadenofibroma (CAF) is a relatively uncommon variant of benign epithelial tumors of the ovary. It is frequently misdiagnosed as malignant ovarian mass, on both ultrasound (USG) and computed tomography (CT). Although most cases are easily treatable by surgery, some cases can present with life-threatening complications increasing patient morbidity and mortality. The present case report briefs about a 69-year-old female, P4 L4, who presented to the gynecology outpatient department with a complaint of pain in the lower abdomen for 2-3 months. USG and CT were suggestive of a suspicious-looking ovarian mass favoring malignancy. A staging laparotomy with pelvic and para-aortic lymphadenectomy with omental biopsy was done. Although the tumor was benign, extensive surgery, due to the suspicion of malignancy led to the patient developing early postoperative small bowel obstruction, mandating a re-exploration. CAF is a specific type of ovarian tumor that exhibits a combination of benign characteristics. This tumor presents as a partly cystic (containing fluid-filled sacs) and partly solid (composed of fibrous tissue) growth within the ovary, displaying a diverse architectural pattern. Mostly the diagnosis is incidental, on USG done for some other indication. CAF of the ovary needs a very high index of suspicion for diagnosis as these are frequently misdiagnosed as malignant ovarian masses. Although an innocent tumor, extensive surgery done for CAF, under suspicion for malignancy, can sometimes lead to serious complications.

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.

Sonographic Evaluation of Serous Cystadenofibroma With Evidence of Intermittent Torsion

Serous cystadenofibromas are benign surface epithelial stromal tumors of the ovary. Many of the sonographic features of serous cystadenofibromas mimic what are traditionally considered possible characteristics of malignancy. Depending on the size of the ovarian neoplasm, there can be increased risk for ovarian torsion. Meticulous sonographic evaluation and appropriate optimization are critical for establishing the risk for malignancy and likelihood of torsion. This case describes how sonography was used to help identify a serous cystadenofibroma in a postmenopausal woman.

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

There are approximately 9.1 pelvic surgeries performed for every histologically confirmed adnexal malignancy in the United States, compared to 2.3 surgeries per malignancy (in oncology centers) and 5.9 surgeries per malignancy (in other centers) in Europe. An important prognostic factor in the long-term survival in patients with ovarian malignancy is the initial management by a gynecological oncologist. With high accuracy of imaging for adnexal mass characterization and consequent appropriate triage to subspecialty referral, the better use of gynecologic oncology can improve treatment outcomes. Ultrasound, including transabdominal, transvaginal, and duplex ultrasound, combined with MRI with contrast can diagnose adnexal masses as benign with specific features (ie, functional masses, dermoid, endometrioma, fibroma, pedunculated fibroid, hydrosalpinx, peritoneal inclusion cyst, Tarlov cyst), malignant, or indeterminate. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Nongynecological endometriosis presenting as an acute abdomen

Endometriosis is a highly prevalent disease that affects up to 10 % of menstruating women. Patients commonly present with pelvic pain or infertility, although the range of clinical symptoms varies widely. Affected women may be asymptomatic or experience mild, moderate, or severe pain that fluctuates with hormonal cycles. Patients who suffer extreme pain may seek immediate care and present to the emergency department with clinical signs of an acute abdomen. In the case of patients without a prior history of endometriosis, the differential diagnosis is broad and making the correct clinical and radiologic diagnosis in the emergency setting can be challenging. In some cases, the diagnosis is only made after surgical or histopathological analysis. Prompt and accurate clinical and radiological evaluation is necessary because complications of endometriosis, such as bowel obstruction and appendicitis, may require immediate surgical intervention. This pictorial essay analyzes nongynecological manifestations of endometriosis that may have a clinical presentation of an acute abdominal emergency. Atypical clinical presentations and unusual sites and complications of endometriosis are discussed, as well as the differential diagnostic considerations. The radiologic features of endometriosis are shown on multiple modalities, including computed tomography, magnetic resonance imaging, and ultrasound.

A case of Meigs syndrome mimicking metastatic breast carcinoma

Background

Adnexal masses are not uncommon in patients with breast cancer. Breast cancer and ovarian malignancies are known to be associated. In patients with breast cancer and co-existing pleural effusions, ascites and adnexal masses, the probability of disseminated disease is high. Nevertheless, benign ovarian masses can mimic this clinical picture when they are associated with Meigs' syndrome making the work-up and management of these patients challenging. To our knowledge, there are no similar reports in the literature and therefore we present this case to highlight this entity.

Case presentation

A 56-year old woman presented with a 4 cm, grade 2, invasive ductal carcinoma of her left breast. Pre-treatment staging investigations showed a 13.5 cm mass in her left ovary, a small amount of ascites and a large right pleural effusion. Serum tumour markers showed a raised CA125 supporting the malignant nature of the ovarian mass. The cytology from the pleural effusion was indeterminate but thoracoscopic biopsy failed to show malignancy. The patient was strongly against mastectomy and she was commenced on neo-adjuvant Letrozole 2.5 mg daily with a view to perform breast conserving surgery. After a good response to the hormone manipulation, the patient had breast conserving surgery, axillary sampling and laparoscopic excision of the ovarian mass which was eventually found to be a benign ovarian fibroma.

Conclusion

Despite the high probability of disseminated malignancy when an ovarian mass associated with ascites if found in a patient with a breast cancer and pleural effusion, clinicians should be aware about rare benign syndromes, like Meigs', which may mimic a similar picture and mislead the diagnosis and management plan.

Histologic, surgical, and imaging correlations of adnexal masses

OBJECTIVE

The purpose of this study was to quantify, categorize, and illustrate discrepancies between preoperative radiologic, surgical, and pathologic diagnoses and to assess the potential impact of discrepancies on clinical care.

METHODS

Adnexal masses reported by pathology during a 16-month period were included if prior imaging at our institution had been performed. Up to 3 sonographic, computed tomographic, and magnetic resonance imaging examinations were reviewed by a gynecologic sonographer and compared with the reported pathologic findings. Cases in which ambiguities were not resolved by consulting the surgical notes were reviewed by a gynecologic pathologist, who confirmed or modified the diagnosis and assigned a score to the pathology quality assurance issue: 0, no pathology quality assurance error; 1, differences in terminology; 2, discrepancy of diagnostic interpretation, benign findings; or 3, discrepancy of diagnostic interpretation, malignant findings.

RESULTS

Of 418 total masses, there was a discrepancy between imaging and pathology in 73 (17%) masses and 68 (21%) pathology reports. Twenty-five (6%) had pathology discrepancies resolved by correlation with the surgical notes alone (eg, torsion seen during surgery but not evident on pathologic examination). Histologic review was performed for 48 (11%) of 418 masses, with pathology errors identified in 34 (71%) of 48. Quality assurance scores were 0 (n = 14), 1 (n = 14), and 2 (n = 20), with no cases receiving a score of 3. Examples of pathology errors included gross (complex versus simple) and microscopic (neoplastic versus functional versus mesothelial) characterization of cysts, sizes of lesions not being described, characterization of fibrous lesions (cystadenofibroma versus cystadenoma), and lack of correlation with imaging (lesions not described).

CONCLUSIONS

This study illustrates the importance of imaging, surgical, and histologic correlation in assessing the diagnostic accuracy of sonography of adnexal masses.

MR features of fluid-fluid levels in ovarian masses

To evaluate retrospectively the frequency and imaging features of fluid-fluid levels (FFLs) in pathologically proven ovarian masses on magnetic resonance (MR) images. The authors reviewed the preoperative MR findings of 556 ovarian masses in 428 patients. Presence, numbers, and signal intensities (SI) of FFLs were analyzed. In non-teratomas, we assessed whether SI of the FFLs of benign masses and malignant neoplasms differed using the chi(2) test. FFLs were observed in 66 of 556 ovarian masses (11.9%) on MR images, fat-fluid levels were observed in 11 of 80 teratomas, and FFLs attributed to hemorrhage in 54 of 476 non-teratomas and one twisted teratoma. Non-neoplastic cystic lesions were most common non-teratomas to contain FFLs (27/197, 13.7%), followed by malignant neoplasms (23/177, 13.0%). Benign neoplasms rarely contained FFLs (4/102, 3.9%); those that did were commonly associated with complications such as torsion or inflammation. A hypointense supernatant layer together with a hyperintense dependent layer on T1-weighted images (T1WIs) was significantly more common in malignant neoplasms than in benign masses (P < 0.0001). FFLs occurred in various ovarian masses ranging from benign to malignant neoplasms on MR images. In non-teratomas, a hypointense supernatant layer and a hyperintense dependent layer on T1WIs may favor a diagnosis of malignancy.

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.

Value of Dynamic Enhanced Magnetic Resonance Imaging for Distinguishing Between Ovarian Fibroma and Subserous Uterine Leiomyoma

PURPOSE

The purpose of this study was to assess the accuracy of magnetic resonance imaging (MRI), particularly, dynamic MRI, in distinguishing ovarian fibromas from subserous uterine leiomyomas.

MATERIAL AND METHODS

Fifteen ovarian fibromas and 15 subserous uterine leiomyomas were retrospectively reviewed. All MR examinations included dynamic contrast-enhanced (DCE) sequences. Morphological criteria (size, T1 and T2 signals, ovarian tissue, associated uterine leiomyoma, and pelvic fluid), arterial vessels, time-intensity curves (maximal enhancement and signal intensity at 30, 60, and 90 seconds), and signal intensity on delayed T1-weighted images were compared between the 2 groups.

RESULTS

No significant difference in morphological criteria was noted between the 2 types of masses. Visualization of arterial vessels was more frequent in uterine leiomyomas than in ovarian fibromas (P= 0.002). The DCE MR enhancement rate was higher for uterine leiomyomas than for ovarian fibromas in terms of both maximal enhancement (P < 0.001) and enhancement rate at 30 (P = 0.009), 60 (P = 0.007), and 90 seconds (P = 0.0009). On delayed T1 postcontrast sequence, no statistical difference exists between signal intensity of ovarian fibromas and uterine leiomyomas.

CONCLUSION

Our findings suggest that DCE MRI can distinguish ovarian fibromas from uterine leiomyomas and should be used if sonography fails to show the origin of a pelvic mass.

Diagnosis of endometriosis with imaging: a review

Endometriosis corresponds to ectopic endometrial glands and stroma outside the uterine cavity. Clinical symptoms include dysmenorrhoea, dyspareunia, infertility, painful defecation or cyclic urinary symptoms. Pelvic ultrasound is the primary imaging modality to identify and differentiate locations to the ovary (endometriomas) and the bladder wall. Characteristic sonographic features of endometriomas are diffuse low-level internal echos, multilocularity and hyperchoic foci in the wall. Differential diagnoses include corpus luteum, teratoma, cystadenoma, fibroma, tubo-ovarian abscess and carcinoma. Repeated ultrasound is highly recommended for unilocular cysts with low-level internal echoes to differentiate functional corpus luteum from endometriomas. Posterior locations of endometriosis include utero-sacral ligaments, torus uterinus, vagina and recto-sigmoid. Sonographic and MRI features are discussed for each location. Although ultrasound is able to diagnose most locations, its limited sensitivity for posterior lesions does not allow management decision in all patients. MRI has shown high accuracies for both anterior and posterior endometriosis and enables complete lesion mapping before surgery. Posterior locations demonstrate abnormal T2-hypointense, nodules with occasional T1-hyperintense spots and are easier to identify when peristaltic inhibitors and intravenous contrast media are used. Anterior locations benefit from the possibility of MRI urography sequences within the same examination. Rare locations and possible transformation into malignancy are discussed.

Uteroovarian ligament torsion of the due to a paratubal cyst

Paratubal cysts rarely undergo torsion. When they do, typically they involve the infundibulopelvic ligament and affect the ovary and fallopian tube. We present a case and discussion of torsion of the uteroovarian ligament secondary to a large paratubal cyst with preservation of the ovary and fallopian tube.

Computed Tomography of Corpus Luteal Cysts

OBJECTIVE

To describe the computed tomography (CT) features of corpus luteal cysts.

METHODS

We retrospectively identified 10 patients with a diagnosis of corpus luteal cysts established by ultrasound who had also undergone contemporaneous CT. A single attending radiologist, without knowledge of other clinical or radiologic findings, recorded the morphologic features of the cysts based on the CT images.

RESULTS

The corpus luteal cyst seen at sonography was visible at CT in all 10 patients. All cysts were unilocular, with a mean density of 25 HU (range, 12 to 45). The mean maximum axial cyst diameter was 2.2 cm (range, 1.4 to 2.9). The mean cyst wall thickness was 3 mm (range, 2 to 4). All cyst walls were crenulated. Cyst wall enhancement was hyperdense in 6 cases, isodense in 3 cases, and hypodense in 1 case. Free fluid was seen in 9 of 10 patients.

CONCLUSIONS

At CT, corpus luteal cysts are typically less than 3 cm in diameter and are characterized by a thick, crenulated, or hyperdense wall. Recognition of these CT findings should prevent misinterpretation or inappropriate management.

CT and MRI findings of cystadenofibromas of the ovary

The aim of this study was to assess imaging findings on CT or MR images of histologically proven ovarian cystadenofibromas. In the period 1995-2001, 32 histologically proven ovarian cystadenofibromas were identified in 28 women. Of the 32 ovarian cystadenofibromas, 16 tumors were purely cystic and the remaining 16 were complex cystic on CT or MR images. Solid components of 16 complex cystic tumors were seen as nodular ( n=8) or trabecular ( n=9) solid areas. One tumor had both nodular and trabecular solid components. Among 16 complex cystic tumors, 14 had thick or irregular septa; thus, half of ovarian cystadenofibromas had morphological imaging features of malignancy on CT or MR images. On histology, solid components in the cystic tumors were correlated with fibrous stromas that occasionally made a false-positive result for malignancy on imaging.

"Ovarian vascular pedicle" sign revealing organ of origin of a pelvic mass lesion on helical CT

OBJECTIVE

We evaluated the "ovarian vascular pedicle" sign as a way of differentiating ovarian from subserosal uterine lesions on single-detector helical CT.

SUBJECTS AND METHODS

We prospectively evaluated 131 patients who had a pelvic mass suspected of originating in the ovary or subserosal zone of the uterus and had undergone helical CT before surgery. A total of 108 ovarian lesions and 23 subserosal uterine myomas were confirmed. CT images were analyzed prospectively by consensus of two radiologists who thoroughly evaluated the retrograde tracing of the gonadal veins to the ovary or pelvic mass. To assess the value of analyzing the ovarian vascular pedicle sign in identifying the organ of origin of a pelvic mass, we compared statistical proportions for the frequencies of the sign in ovarian tumors and subserosal uterine myomas by performing the chi-square test. The probabilities for the presence of the ovarian vascular pedicle sign as a positive finding for a pelvic mass of ovarian origin were calculated.

RESULTS

The presence of the ovarian vascular pedicle sign was identified in 92% (99/108) of ovarian masses and in 13% (3/23) of subserosal uterine myomas. The sign was statistically significant (p < 0.01) for differentiating a mass of ovarian origin from a mass of subserosal uterine origin. When the ovarian vascular pedicle sign on helical CT confirmed the ovarian origin, the sensitivity, specificity, positive predictive value and negative predictive value, and diagnostic accuracy were 92% (99/108), 87% (20/23), 97% (99/102), 69% (20/29), and 91% (119/131), respectively.

CONCLUSION

The presence of the ovarian vascular pedicle sign on helical CT is valuable for confirming the ovarian origin of a pelvic tumor and for differentiating an ovarian tumor from subserosal uterine myoma.

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.

Endometriomas: diagnostic performance of US

PURPOSE

To determine the diagnostic performance of specific ultrasonographic (US) features in discriminating endometriomas from other adnexal masses.

MATERIALS AND METHODS

Two sonologists independently reviewed the sonograms of 252 adnexal masses in 226 women and recorded US features by using a standardized checklist. The diagnostic performance of specific US features and overall reviewer impression in discriminating endometriomas from other adnexal masses were evaluated.

RESULTS

There were 40 endometriomas. Diffuse low-level internal echoes were present in 38 (95%) endometriomas and 40 (19%) nonendometriomas (positive likelihood ratio, 5). The positive likelihood ratio for the diagnosis of endometrioma increased to 8 if masses with neoplastic features at gray-scale US were excluded, allowing identification of 30 endometriomas (75%). The presence of multilocularity or hyperechoic wall foci further increased the positive likelihood ratio to 48, allowing the identification of 18 endometriomas (45%).

CONCLUSION

An adnexal mass with diffuse low-level internal echoes and absence of particular neoplastic features is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present. A patient with a mass with diffuse low-level internal echoes and other US features may benefit from additional imaging.

Cystic teratomas of the ovary: diagnostic value of sonography

OBJECTIVE

This study was undertaken to determine if the diagnosis of cystic teratomas of the ovary can be made by experienced sonologists using only specific associated sonographic features.

MATERIALS AND METHODS

Two sonologists independently reviewed the sonograms of 252 adnexal masses. For each mass, each sonologist recorded sonographic features using a standardized checklist, which included four descriptions associated with cystic teratomas. From a list of diagnostic possibilities, each reviewer chose one specific conclusion, with emphasis on achieving the highest combination of sensitivity and positive predictive value for any particular diagnosis. The sensitivity, positive predictive value, and positive likelihood ratio for the diagnosis of cystic teratoma were evaluated for each sonographic finding and for each sonologist's interpretation.

RESULTS

Of the 252 masses, 74 cystic teratomas were found, 55 of which showed two or more associated sonographic features. Each reviewer had a 98% positive predictive value with 85% sensitivity for the diagnosis and identification of cystic teratomas (positive likelihood ratio = 152). The positive predictive value was 100% when an adnexal mass had two or more sonographic features associated with dermoid masses. The positive predictive value for individual sonographic features associated with dermoid masses was 80% for a shadowing echodensity, 75% for regionally bright echoes, 50% for hyperechoic lines and dots, and 20% for a fluid-fluid level.

CONCLUSION

An adnexal mass showing two or more of the sonographic features associated with cystic teratomas can be confidently diagnosed as a cystic teratoma.

[Autoimmune hemolytic anemia associated with a mature ovarian teratoma]

The association of autoimmune hemolytic anemia and mature teratoma of the ovary is rare, particularly in childhood, but must be known and looked for since the treatment of teratoma allows to cure anemia as well.

CASE REPORT

A 9 year-old girl was admitted for hemolytic anemia. The etiologic work-up revealed an autoimmune mechanism (IgG autoantibodies with complement), as well as an ovarian tumor after ultrasound sonography of the abdomen and pelvis. Surgical excision of the tumor was complete and uncomplicated. Pathological examination concluded to a mature teratoma. Anemia, as well as the signs of autoimmunity, disappeared a few weeks later and the child is doing well with several months of follow-up.

CONCLUSION

This second reported pediatric case shows that an ovarian teratoma should be searched for with ultrasound sonography in any girl presenting with autoimmune hemolytic anemia, since surgical excision is sufficient to cure both anemia and the tumor.

Papillary projections in ovarian neoplasms: appearance on MRI

Papillary projections are distinctive pathologic features of epithelial ovarian neoplasms. We sought to determine whether these structures have recognizable features on MRI. A search of a database of 125 patients on whom MRI was performed with pelvic phased-array coil and abdominal surgical exploration was performed for suspected gynecologic disease identified 15 patients who had either MRI reports or pathology reports mentioning papillary projections in an adnexal mass. The MR images were reviewed to characterize the size, structure, and signal intensity of papillary projections. Pathologic correlation was performed on these and on four surgical specimens imaged with high resolution technique. Pathologic correlation showed that larger papillary projections had a distinctive structure of a fibrous stalk supporting clumps of edematous papillae with signal intensity similar to that of fluid on T2-weighted images. Smaller papillae showed nondescript intracystic projections of intermediate signal intensity on T2-weighted images. All papillary projections in vivo enhanced after injection of gadopentetate dimeglumine. Papillary projections have an appearance on MRI that reflects their histologic structure.

Ovarian fibromas and cystadenofibromas: MRI features of the fibrous component

Ovarian fibromas and cystadenofibromas are neoplasms that share a similar distinctive tissue component of dense fibrous tissue. We sought to describe the MRI features of these neoplasms and to determine if the fibrous component shows distinctive characteristics. Fourteen patients in whom MR images performed with multicoil and fast-spin-echo images and who subsequently underwent surgery for resection of ovarian fibromas or cystadenofibromas were identified from two institutions. Five patients had ovarian fibromas, and nine patients had fourteen cystadenofibromas. 1.5-T MR studies used T1-weighted spin echo and multiplanar T2-weighted fast-spin-echo images, with fat saturation gadolinium-enhanced fast multiplanar gradient-echo images in seven patients. Studies were reviewed for findings of low (approximately equal to skeletal muscle) signal intensity solid components on T2-weighted images, characteristics of gadolinium enhancement, and associated endometrial findings. Images were obtained ex vivo from three adnexal surgical specimens with an 8-cm field of view and correlated with histology. All five of the fibromas showed predominantly very low signal intensity, similar to skeletal muscle, on T2-weighted images. Two of five fibromas were in patients with endometrial polyps and increased amounts of fluid in the pelvis. Thirteen cystadenofibromas were multicystic masses with bands of very low signal intensity ranging from 2 to 20 mm in the wall of the mass, and one was predominantly solid fibrous tissue. Pathologic correlation with specimen images showed that the low signal intensity material was the subepithelial fibrous component of the cystadenofibromas. Fibrous components of ovarian fibromas and cystadenofibromas are demonstrable by MR as solid components representing fibrous tissue of very low signal intensity on T2-weighted images.