Ovarian fibromas and fibrothecomas: sonographic correlation with computed tomography and magnetic resonance imaging: a 5-year single-institution experience

A midline pelvic mass: Ovarian fibroma appearing vaginal in nature

Introduction

Ovarian fibroma is an uncommon, benign, stromal neoplasm that is a mixture of collagen-producing mesenchymal cells. There are varying sonographic and computed tomography features described in literature of smaller scale studies.

Case Report

We describe a case of an ovarian fibroma presenting as a midline pelvic mass mimicking a vaginal cuff tumour in a 67-year-old patient with surgical history of a hysterectomy. Computed tomography and ultrasound were utilised to evaluate the mass and guide management of the patient. The mass was initially suspected on CT-guided biopsy as a vaginal spindle cell epithelioma amongst other potential differential considerations. With robot-assisted laparoscopic surgery and histologic analysis, the true diagnosis of an ovarian fibroma was reached.

Discussion

An ovarian fibroma is an uncommon, benign, stromal ovarian tumour, representing just 1-4% of all ovarian tumours. Its widely varying imaging features present a challenge when radiologically evaluating ovarian fibromas or pelvic tumours, as the differential diagnoses are extensive and ovarian fibromas are often misdiagnosed until surgical resection. We highlight the features of ovarian fibromas and the potential value of pelvic/transvaginal ultrasonography in management of ovarian fibroma and other pelvic masses.

Conclusion

The use of computed tomography and ultrasound aided in the diagnostic and treatment pathway of this patient with a pelvic mass. There is high utility of sonography in evaluating such tumours to elucidate salient features, expedite diagnosis, and guide further management.

Surgical Treatment of a Rare Case of Ovarian Fibroma Associated With Elevated CA125 Levels in a Patient of Reproductive Age: A Case Report

Small ovarian fibromas (< 10cm) associated with elevated serum CA125 levels are rarely encountered, particularly in women of reproductive age. We report a rare case diagnosed in a 35-year-old patient after adnexectomy for a solid ovarian mass of approximately 5cm in maximum diameter, accompanied by elevated serum CA125 levels. In preoperative evaluation, no signs of inflammation from the genital tract were found, and no medical history of endometriosis, uterine leiomyomas, or non-gynecological cancer was reported. Intraoperative frozen section biopsy of surgical specimen obtained from the ovarian tumor had negative evaluation for malignancy. Histological examination of the surgical specimen confirmed the diagnosis of ovarian fibroma. The postoperative course was uneventful. Two months after surgery, the blood serum CA125 levels were within normal ranges. The patient is assessed at regular intervals in the gynecology outpatient clinic. In this paper, based on the data of the modern literature, a brief review of this rare nosological entity is made.

CT review of ovarian fibrothecoma

Objective:

The aim of this study was to investigate the CT imaging characteristics of ovarian fibrothecoma which may aid in the differentiation from early stage epithelial tumours.

Methods:

Comparison of 36 patients (41 lesions) with pathologically proven ovarian fibrothecoma tumours and 36 (52 lesions) serous papillary carcinomas (SPCs) lesions. We noted their laterality, size, density, calcifications, Hounsfield units (HUs) and introduced a novel HU comparison technique with the psoas muscle or the uterus. Patients’ clinical findings such as ascites, pleural effusion, carbohydrate antigen-125 levels, and lymphadenopathy findings were also included.

Results:

Average age was 67.8 and 66 across the fibrothecoma and SPC cohort respectively. Fibrothecoma tumours had diameters ranging from 24 to 207 mm (Median: 94 mm). 80.6% of the fibrothecoma cohort had ascites which was comparable to the 72.2% in the SPC cohort. 70.7% of fibrothecoma tumour favour a purely to predominantly solid structural configuration (p < 0.001). The average HU value for the fibrothecoma solid component was 44 ± 11.7 contrasting the SPC HU value of 66.8 ± 15. The psoas:tumour mass ratio demonstrated a median of 0.7, whereas SPCs shows a median of 1.1 (p < 0.001).

Conclusion:

Suspicion of ovarian fibrothecoma should be considered through interrogation of their structural density configuration, low psoas to mass HU ratio and a presence of ascites.

Advances in knowledge:

CT imaging can be a useful tool in diagnosing fibrothecoma tumours and subsequently reducing oncogynaecological tertiary centre referrals, financial burden and patient operative morbidity and mortality.

From diagnosis to treatment of androgen-secreting ovarian tumors: a practical approach

About 5% of all ovarian tumors develop some form of hormonal activity. Only 1% of ovarian tumors will secrete androgens causing clinical hyperandrogenism. Most androgen-secreting neoplasms (ASN) derive from sex cord or stroma cells of the ovary and may affect both premenopausal and postmenopausal women. Typically, a patient will present reporting symptoms of rapidly increasing hyperandrogenization such as: hirsutism, acne, frontal/male pattern balding, and in severe cases even virilization. Sertoli-Leydig Cell Tumors are the most frequent ASN and constitute about 0.5% of all ovarian neoplasms. Typically affecting women under 30 years of age, these tumors are usually unilateral and benign. They are also the most common tumor in postmenopausal women suffering with hyperandrogenism. Other tumors originating from the sex-cord stroma are also known to develop in this population, but the incidence of these is much lower. Approaching suspected hyperandrogenemia and its related symptoms in a clinical setting can be a significant diagnostic challenge. When evaluating a patient for hyperandrogenism, it is important to assess the severity of symptoms but most of all it is critical to assess the time of onset and dynamics of symptom progression. Diagnostic tools including laboratory tests and imaging studies should also be engaged. When deriving a differential diagnosis for androgen-secreting ovarian tumors, adrenal gland tumors should be considered as well as typical endocrine pathologies including polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing's disease, and acromegaly. Treatment options for an androgen-secreting ovarian tumors is mainly surgical, but in exceptional cases can involve pharmacotherapy alone.

Benign Brenner tumour of the ovary: CT and MRI features

AIM

To evaluate the computed tomography (CT) and magnetic resonance imaging (MRI) features of benign Brenner tumours (BBT) of the ovary.

MATERIAL AND METHODS

This was a retrospective two-centre study comprising 35 female patients with a definitive diagnosis of BBT at histology in whom CT and/or MRI examinations had been performed. Two experienced radiologists reviewed the CT and MRI features of 39 ovarian BBT retrospectively with consensus reading. The morphological appearance and size of each tumour were recorded. The presence or absence of calcifications within the solid portion was noted at CT. The reviewed characteristics at MRI included qualitative assessment of the signal intensity of the solid portion on diffusion sequence and contrast enhancement, compared to that of the myometrium.

RESULTS

CT and MRI images were available for 27 and 28 lesions, respectively. Sixteen patients had both CT and MRI examinations. BBT were unilateral in 89% of patients, and 49% of lesions were solid and 51% were mixed. Calcifications were depicted at CT in 70.4% of lesions. When present, the cystic portion was multilocular in 85% of cases and corresponded to a mucinous lesion in 74% of cases. Enhancement of the solid portion at MRI was inferior or equal to that of the myometrium in 89% of cases and signal on high b-values diffusion images was deemed low or moderate in 93% of cases.

CONCLUSION

The combined CT and MRI findings of a unilateral fibrous ovarian mass containing punctate calcifications often associated with a multilocular cyst suggest the diagnosis of ovarian BBT.

Ovarian sex cord-stromal tumors: an update on clinical features, molecular changes, and management

Sex cord stromal-tumors are rare tumors of the ovary that include numerous tumor subtypes of variable histological features and biological behavior. Surgery is the main therapeutic modality for the management of these tumors, while chemotherapy and hormonal therapy may be used in some patients with progressive and recurrent tumors. Several studies investigated molecular changes in the different tumor types. Understanding molecular changes underlying the development and progression of sex cord-stromal tumors provides valuable information for diagnostic and prognostic biomarkers and potential therapeutic targets for these tumors. In this review, we provide an update on the clinical presentation, molecular changes, and management of sex cord-stromal tumors.

Ultrasound features of immature ovarian teratomas: Case series and review of literature

INTRODUCTION

Immature ovarian teratomas are rare but account for 10-20% of ovarian cancers in women under the age of 20 years. This study aimed to characterise immature ovarian teratomas using grey-scale and Doppler ultrasonography and review the literature to refine the diagnosis of immature ovarian teratomas.

METHODS

Patients with a confirmed histological diagnosis of immature ovarian teratoma from years 2006-2018, who had undergone a transvaginal ultrasound at two large teaching hospitals, were identified. The imaging was retrieved from the centres clinical databases. Ultrasound scans were performed by experienced ultrasound examiners and described according to International Ovarian Tumour Analysis criteria.

RESULTS

Eight patients were identified in total with a mean age of 26 years (range 13-35). Half of the patients had a past history of a mature ovarian teratoma (3 ipsilateral, 1 contralateral). The cysts were generally large (median 115 mm), fast growing unilateral lesions with a single, peripheral predominantly solid component arising from the cyst wall. The solid component was hyperechoic with multiple foci of fibrosis and numerous small cysts. The cystic component typically formed less than 75% of the lesion and the cyst fluid was of low-level echogenicity. Subjective assessment of vascularity of the solid part of the tumours varied between scores of 1 and 2. Tumour markers showed a raised serum a-fetoprotein level in 42% of these patients.

CONCLUSION

Although there were no ultrasound features that were pathognomonic of immature teratoma, the diagnosis should be suspected in a young woman with a large ovarian cyst with a fibrotic, microcystic solid component, particularly if she has a past history of a dermoid cyst.

Ultrasound and Histopathologic Correlation of Ovarian Cystadenofibromas: Diagnostic Value of the "Shadow Sign"

OBJECTIVES

Cystadenofibromas (CAFs) are rare benign ovarian tumors without a widely accepted ultrasound (US) pattern. They are usually described by as thin-walled, unilocular or multilocular, and at times septated cysts with scant blood flow and no solid components. We describe a unique US feature, the "shadow sign," seen in prospectively diagnosed benign CAFs. We also provide the histopathologic basis for this typical US appearance.

METHODS

Ultrasound (US) examinations were performed in our obstetric and gynecologic US unit. Pathologic examinations were performed by a dedicated gynecologic pathology team. The US and pathology department's database was searched for the diagnosis of a CAF between 2010 and 2017.

RESULTS

We identified 20 patients who underwent transvaginal US examinations with a sole US diagnosis of a CAF, and the tumors were surgically removed. The common US feature across the 20 cases was the presence of hyperechoic avascular shadowing nodules. The correlating histologic features were unilocular or multilocular cysts with a smooth internal wall surface lined by a simple epithelium and occasional robust polypoid fibrous stroma.

CONCLUSIONS

This US marker helps in differentiating CAFs from borderline ovarian tumors, which do not show this US feature. We hope that recognizing the suggested shadow sign as an additional descriptor of CAFs will lead to minimizing their unnecessary removal and eliminating additional and unnecessary imaging by computed tomography and magnetic resonance imaging.

Action mechanisms of n-3 polyunsaturated fatty acids on the oocyte maturation and developmental competence: Potential advantages and disadvantages

Infertility is a growing problem worldwide. Currently, in vitro fertilization (IVF) is widely performed to treat infertility. However, a high percentage of IVF cycles fails, due to the poor developmental potential of the retrieved oocyte to generate viable embryos. Fatty acid content of the follicular microenvironment can affect oocyte maturation and the subsequent developmental competence. Saturated and monounsaturated fatty acids are mainly used by follicle components as primary energy sources whereas polyunsaturated fatty acids (PUFAs) play a wide range of roles. A large body of evidence supports the beneficial effects of n-3 PUFAs in prevention, treatment, and amelioration of some pathophysiological conditions including heart diseases, cancer, diabetes, and psychological disorders. Nevertheless, current findings regarding the effects of n-3 PUFAs on reproductive outcomes in general and on oocyte quality more specifically are inconsistent. This review attempts to provide a comprehensive overview of potential molecular mechanisms by which n-3 PUFAs affect oocyte maturation and developmental competence, particularly in the setting of IVF and thereby aims to elucidate the reasons behind current discrepancies around this topic.

Cellular Fibroma of Ovary Coexisting with Proliferative Endometrium Post Menopause: A Rare Presentation

Ovarian fibromas are benign sex cord stromal tumours occurring in peri-menopausal and post-menopausal women. These tumours are composed of spindle fibroblastic cells producing collagen. They are almost always endocrine-inert and are rarely associated with hormone production. We report herein a case of a 60-year-old Indian woman presenting as post-menopausal bleeding. Imaging studies and endometrial biopsy revealed a right ovarian solid tumour coexisting with thickened proliferative endometrium, other causes of hyperoestrogenism being excluded in the woman. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Histopathology showed cellular fibroma of right ovary and proliferative endometrium with foci of hyperplasia without atypia.

Computed tomography and magnetic resonance imaging features of ovarian fibrothecoma

The aim of the present study was to investigate the imaging characteristics of ovarian fibrothecoma. The cases of 25 female patients with pathologically confirmed ovarian fibrothecomas were retrospectively reviewed. Tumor location, size, density, signal intensity, cystic degeneration, calcification, enhancement pattern and ascites were assessed by computed tomography (CT) (n=20) and magnetic resonance imaging (MRI) (n=5). Clinical and histological features were also evaluated. The results revealed that 23 (92.0%) patients were postmenopausal, with a mean age ± standard deviation (SD) of 60.7±10.8 years old. All 25 tumors were unilateral and a thickened endometrium was observed in 7 (28.0%) patients. In total, 24 (96.0%) tumors appeared to have well-defined boundaries, with 1 (4%) tumor exhibiting an obscure boundary. Tumors had a mean size of 9.8±5.3 cm. Solid and predominantly solid masses were found in 16 cases (64.0%), and cystic and predominantly cystic masses were found in 9 patients (36.0%). Solid regions of masses exhibited hypodensity or isodensity in 24 patients (96.0%), with 1 patient (4.0%) exhibiting hyperdensity. The mean CT value (± SD) was 44.2±12.8 HU (range, 31-79HU) in unenhanced images. All masses exhibited isointensity or slight hypointensity on T1-weighted imaging, and tumor parenchyma also exhibited slight hypointensity or isointensity on T2-weighted imaging compared with the myometrium, with or without areas of patchy hyperintensity. Contrast-enhanced CT or MRI scans were performed on 19 patients, and the solid components (94.7%) exhibited mild to moderate enhancement in 18 patients and 1 patient (5.3%) exhibited intense enhancement. Tumor size was positively correlated with the tumor cystic degeneration (r=0.77, P<0.001) and ascites (r=0.41, P<0.001). Therefore, ovarian fibrothecoma typically presents as solid or predominant solid masses with clear boundaries; the parenchyma of the tumor exhibits isodensity on CT scans, slight hypointensity or isointensity on MRI and mild enhancement following contrast-medium injection. The thickened endometrium observed in postmenopausal woman may also be a valuable imaging feature.

Pitfalls of Sonographic Imaging of Uterine Leiomyoma

Leiomyomas are the most common uterine tumor and the most common cause of uterine enlargement in the nonpregnant patient. Sonography is the imaging modality of choice for the initial diagnosis and imaging workup of uterine leiomyomas and is also extremely helpful in determining the etiology of a broad range of pelvic symptoms in the female patient. Although the classic sonographic appearance of uterine leiomyomas is well established and easily recognizable, other pelvic masses may occasionally be confused with uterine leiomyomas, and the ability to distinguish between these entities is crucial in optimizing appropriate patient care. This article will review pelvic abnormalities that can be confused on ultrasound with uterine leiomyomas and potential methods that can be used to avoid these pitfalls.

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.

Ovarian thecoma-fibroma groups: clinical and sonographic features with pathological comparison

Background

Ovarian thecoma-fibroma groups (OTFG) are uncommon sex cord-stromal neoplasms. The objective of the study was to demonstrate clinical and sonographic features of OTFG and compare with surgical histopathology.

Methods

A total of 61 patients with surgically proven OTFG were enrolled in this retrospective study to demonstrate its clinical and sonographic features and to compare with pathological findings. Gray scale and color Doppler sonography were performed presurgically with either transabdominal or transvaginal approach to image pelvic structures and lesions. The clinical findings and sonographic appearances were compared with the types of the OTFG tumors based on the histopathological diagnosis.

Results

The mean patient age was 53.57 (range, 26–86) years. There were 63.93% (39/61) patients in postmenopausal and 63.93% (39/61) patients with no clinical symptoms. Ultrasound findings of OTFG revealed as solid tumors with a typical feature of well-demarcated hypoechoic masses in 70.49% (43/61), among which 74.41% (32/43) tumors were smaller than 5 cm in diameter. There were 17 mixed echogenic masses with calcification, hemorrhage, or cyst, among which 70.59% (12/17) lesions were larger than 5 cm in diameter. Acoustic attenuation of the tumor was presented in 44.26% (27/61) of the cases. Doppler flow signals within the tumors were found in 20 cases (32.79%), in which 80% (16/20) had minimal or moderate flow signals. Ascites was detected in 32.79% (20/61) of the cases, Megi’s syndrome was found in 1 case. Final pathology revealed 41 (67.21%) thecoma-fibromas, 15 (24.59%) fibromas, 4 (6.56%) thecomas and 1 (1.64%) fibrosarcoma. There were 58 patients underwent cancer antigen 125 (CA125) test, and 20.69% (12/58) showed an elevated level. The diameter of tumors was found to be significantly correlated with CA125 level (p < 0.01) and the amount of ascites fluid (p < 0.05).

Conclusions

The typical sonographic features of OTFG include adnexal hypoechoic masses with clear border and acoustic attenuation as well as minimal Doppler flow signals. All the aforementioned features could make ultrasound imaging as a assistent tool improve the preoperative diagnostic accuracy.

New sonographic morphology score for the differentiation of malignant from benign ovarian tumors

AIM

The aim of this study was to explore the efficacy of a new sonographic morphology score (SMS) to differentiate malignant from benign ovarian tumors.

METHODS

Data on 84 ovarian tumors in patients hospitalized in our hospital between 2013 and 2014 were retrospectively analyzed. We established a new sonographic morphology score for ovarian tumors based on volume and structure scores. The efficacy of the new SMS was compared with that of Ueland's index (the old SMS). Receiver-operator curves (ROC) of the two SMS were constructed, and the areas under the curve were calculated and compared. The ROC of the new SMS was also compared with those for the patients' CA-125 and CA-72-4 levels.

RESULTS

The area under the ROC of the new SMS for ovarian tumors was 0.836, while for the old SMS for ovarian tumors it was 0.709. By Z-test (Z = 2.452, P = 0.0384), there was a significant difference between the new SMS and the old SMS in the diagnosis of ovarian tumors. There was no significant difference in the area under the ROC between the new SMS and CA-125 and CA-72-4 in the diagnosis of ovarian tumors. With a cut-off value of 6, the sensitivity, specificity, positive prognostic value, and negative prognostic value of the new SMS were 0.797, 0.85, 0.944, and 0.567, respectively.

CONCLUSION

The new SMS may be used to differentiate malignant ovarian carcinomas from benign tumors except in the case of ovarian thecoma.

Value of diffusion-weighted imaging combined with conventional magnetic resonance imaging in the diagnosis of thecomas/fibrothecomas and their differential diagnosis with malignant pelvic solid tumors

Background

Our study aims to determine the value of diffusion-weighted imaging (DWI) combined with conventional magnetic resonance imaging (MRI) in the diagnosis of thecomas/fibrothecomas and their differential diagnosis with malignant pelvic solid tumors.

Methods

In total, 36 thecomas/fibrothecomas and 40 malignant pelvic solid tumors were included in our study. All patients underwent 1.5 T conventional MRI and DWI examinations except one patient with a fibrothecoma in whom DWI examination was not performed. The clinical features and characteristics of conventional MRI and DWI of these two groups were analyzed. Apparent diffusion coefficient (ADC) values were measured and compared between groups. Univariate analysis, multivariate logistic regression analysis, and the receiver operating characteristic curve were used for statistical analysis.

Results

All the thecomas/fibrothecomas showed isointensity on T1 weighted imaging (T1WI) and 77.8 % (28/36) lesions showed hypo- to isointensity on T2 weighted imaging (T2WI). After administration of contrast medium, 94.4 % (34/36) tumors appeared as minor to mild enhancement. On DWI, they showed a diversity of low to very high signal intensity. All malignant pelvic masses manifested as hyperintensity on T2WI and 87.5 % (35/40) tumors showed very high signal (grade 3) on DWI. Higher area under the curve (AUC) and specificity could be achieved by using the lowest ADC value than the mean ADC value. Multivariate logistic regression analysis showed that shape, signal intensity on T2WI, capsule, and the lowest ADC value were the important indicators in discriminating thecomas/fibrothecomas from malignant pelvic solid tumors.

Conclusions

The combination of DWI and conventional MRI is of great value in the diagnosis of thecomas/fibrothecomas and their differential diagnosis with malignant pelvic solid tumors.

Ovary preservation in the treatment of childhood Meigs syndrome

Meigs syndrome, the combination of benign ovarian tumor, ascites, and pleural effusion, is present in a small percentage of ovarian fibromas and is infrequently reported in children. When associated with elevated CA-125 suspicion is raised for malignancy, often prompting aggressive surgical intervention. We present a case of childhood Meigs syndrome and review the relevant literature with emphasis on ovary preservation. Out of nine identified pediatric cases, one involved ovary sparing treatment and none recurred or progressed to malignancy. Our report highlights the importance of presurgical identification of Meigs syndrome in order to curtail salpingo-oophorectomy when feasible.

CT diagnosis in the thecoma-fibroma group of the ovarian stromal tumors

The aim of this study was to investigate characteristic CT manifestations of the group of ovarian thecoma-fibroma. 24 patients (26 lesions) presenting with the ovarian thecoma-fibroma were analyzed retrospectively, and the diagnosis were confirmed by pathology after surgery. Our findings included: 22 patients were unilateral, while 2 were bilateral; 12 lesions were located in the right side of ovary, while 14 lesions were in the left side. Of the 26 lesions, there were ovarian thecoma (16 lesions), fibrothecoma (6 lesions), and fibroma (4 lesions). The largest diameters of tumor ranged from 37 to 231 mm with the mean value of 100 ± 44.29 mm. 14 patients were accompanied by ascites. All the tumors had well-defined borders. The shape of  22 lesions appeared round or oval, and 4 lesions were irregular. The tumors were solid in 19 lesions, cystic in 2 lesions, and mixed in 5 lesions. Most of the tumors were of heterogeneous density. There were no (20 lesions) or slight enhancement (6 lesions) after injection of the contrast medium. CT values of plain scan, arterial phase and venous among three groups had no significant difference. The enhancement were in the range of 0-5 HU in 10 lesions, and 6-17 HU in 16 lesions. In conclusion, the characteristic CT manifestations of the group of ovarian thecoma-fibroma were: often unilateral solid mass with the shape of oval and well defined border; no enhancement or slight enhancement; accompanied by small amount of ascites.

Large twisted ovarian fibroma in menopausal women: a case report

Ovarian fibroma is the most common benign solid tumors of the ovary, commonly misdiagnosed as uterine fibromaor as malignant ovarian tumors. It occurs generally in older perimenopausal and postmenopausal women. Occasionally large fibromas may undergo torsion causing acute abdominal pain. Doppler Ultrasonographyimaging is the choice study. CT and MRI are often needed for further characterization and differentiation from other solid ovarian masses. The choice treatment is surgical removal with intraoperative frozensection. Immunohistochemicalanalysis is recommended to rule out the differential diagnosis. Here we present a case of a postmenopausal woman with a large twisted ovarian fibroma reflecting diagnostic and management difficulties including potential misdiagnosis of the tumor as a malignant ovarian neoplasm that may influence the surgical approach.

The characteristic ultrasound features of specific types of ovarian pathology (review)

Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment. Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient. For example predicting a mucinous borderline tumor gives the opportunity for fertility sparing surgery, and will highlight the need for further gastrointestinal assessment. For benign disease, predicting the presence of an endometrioma and possible deeply infiltrating endometriosis is important when considering both who should perform and the extent of surgery. An examiner’s subjective assessment of the morphological and vascular features of a mass using ultrasonography has been shown to be highly effective for predicting whether a mass is benign or malignant. Many masses also have features that enable a reliable diagnosis of the specific pathology of a particular mass to be made. In this narrative review we aim to describe the typical morphological features seen on ultrasound of different adnexal masses and illustrate these by showing representative ultrasound images.

Algorithmic approach to solid adnexal masses and their mimics: utilization of anatomic relationships and imaging features to facilitate diagnosis

Solid adnexal masses, while less common than their cystic counterparts, may present a challenge for radiologists given the wide range of histologic entities that occur in this region. Pelvic masses, especially when large, can seem overwhelming at first but application of an algorithmic approach allows for more confident assessment. This approach focuses first on the use of anatomic relationships and interactions of various pelvic structures to localize the mass' origin. For instance, the directionality of ureteral displacement can suggest if a mass is intra or extraperitoneal. Then, key discriminating imaging features, such as the presence of fat, hypervascularity, or low T2 signal on magnetic resonance imaging (MRI) can be applied to further narrow the list of diagnostic possibilities. Entities such as leiomyomas, nerve sheath tumors, congenital uterine anomalies, and vascular abnormalities (ovarian torsion or iliac vessel aneurysm) in particular are often accurately characterized with sonography and/or MRI. For solid adnexal masses in which a definitive diagnosis by imaging is not reached, information germane to clinicians regarding further management can still be provided, principally with regard to surgical vs. nonsurgical treatment.