THORSANG R1Prince of Songkla University05.11.2014

Functional/hemorrhagic cysts

Real ovarian tumors

Functional cysts

Real ovarian tumors

Reproductive age group Most ovarian cysts are physiological or functional

dominant follicles

follicular cysts (from failure of the follicle to rupture or regress)

corpus luteal cysts (may contain hemorrhage)

US:

thin walled (< 3 mm), unilocular, with posterior acoustic enhancement

Cyst with uniform internal echoes, reticulations or septations hemorrhagic functional cyst endometrioma

A follow up ultrasound in 6-12 wk should be performed A functional hemorrhagic cyst shows complete

interval resolution

an endometrioma persists or even slightly increases in size

MRI

most functional cysts

▪ T1: low signal intensity

▪ T2: very high signal intensity

Hemorrhagic corpus luteum cysts have a characteristic appearance of blood products

▪ T1: relatively high signal intensity

▪ T2: intermediate to high signal intensity

Polycystic ovarian syndrome (PCOS) affecting 5%-10% of women of reproductive age

Characterized by menstrual irregularities, hirsuitism, obesity and sclerotic ovaries

TVUS (gold standard)

an enlarged ovary with 10 or more peripherally arranged cysts,

each cyst of 2-8 mm diameter

with an echogenic central stroma

MRI: T2 weighted images in the long and short axis of the uterus

Peripherally arranged uniform sized high signal intensity cysts with hypointense central stroma

child bearing age 80% implanted in the ovary pelvic pain, dysmenorrhea and infertility From cystic to complex

US: cystic masses with diffuse low level internal echoes with hyperechoic foci secondary to a cholesterol cleft or blood clot in the wall

Endometriomas and implants may mimic malignant lesions on CT

MRI: T1: very high signal intensity (light-bulb)

▪ persistent high signal on fat saturated T1-weighted image confirms the absence of fat in the lesion

T2: intermediate to low signal intensity from blood products in various stages and decreased free water content

OVARIAN TUMOR

EPITHELIAL GERM CELLSEX CORD-STROMAL

METASTASIS

OVARIAN TUMOR

EPITHELIAL

Serous Mucinous Endometriod Clear cell Brenner

GERM CELLSEX CORD-STROMAL

METASTASIS

60% of all ovarian neoplasms 85% of malignant ovarian neoplasms Age 50-70 years

Serous

mucinous

Endometrioid

Clear cell

Brenner tumors

Serous and mucinous tumors

Mostly benign

Endometrioid tumors

Mostly malignant

Clear cell carcinomas

malignant

Papillary projections

Characteristic features of epithelial neoplasms of the ovary

represent folds of the proliferating neoplasmicepithelium growing over a stromal core

single best predictors of an epithelial neoplasm and may correlate with the aggressiveness of the tumor

Papillary projections

Benign

▪ usually absent

▪ generally small

Low malignant

▪ profuse in epithelial tumors with

Invasive carcinomas

▪ often present

▪ gross appearance is dominated by a solid component.

Wall thickening, septa, and multilocularityare less reliable indicators of malignancy

Frequently seen in benign neoplasms

▪ cystadenofibromas

▪ mucinous cystadenomas

▪ endometriomas

10%–15% of all ovarian carcinomas. Almost always malignant About 15%–30% are associated with

synchronous endometrial carcinoma or endometrial hyperplasia

Bilateral involvement is seen in 30%– 50% Imaging findings are nonspecific

a large, complex cystic mass with solid components Endometrial thickening

Most common malignant neoplasm

endometrioid carcinoma clear cell carcinoma

5% of ovarian carcinomas always malignant The majority (75%) of clear cell carcinomas

are stage I disease

prognosis appears to be better than that of other ovarian cancers

Most common malignant neoplasm

endometrioid carcinoma

clear cell carcinoma

A unilocular or large cyst solid protrusions

often both round and few in number

The cyst margin is almost always smooth

Always in DDx for serous tumor with aggressive pattern

composed of transitional cells with dense stroma

2%–3% of ovarian tumours rarely malignant usually small (2 cm) discovered incidentally, but affected patients

may present with a palpable mass or pain

associated with other ovarian tumors in 30% of cases

a multilocular cystic mass with a solid component

a small, mostly solid mass

CT: mildly enhanced solid components T2 MR: the dense fibrous stroma

lower signal intensity

Extensive amorphous calcification

often present within the solid component

OVARIAN TUMOR

EPITHELIAL GERM CELL

Teratoma

Mature Immature

DysgerminomaEndodermalsinus tumor

SEX CORD-STROMAL

METASTASIS

second most common group of ovarian neoplasms 15%–20% of all ovarian tumors

Subtypes mature teratoma

Immature teratoma

Dysgerminoma

endodermal sinus tumor

embryonal carcinoma

choriocarcinoma

mature teratoma Only benign tumour in this group

the most common lesion in this group Malignant germ cell tumors generally large and nonspecific

a complex but predominantly solid imaging appearance

AFP and HCG also help establish the diagnosis

most common benign ovarian tumorin women less than 45 years old

composed of mature tissue from two or more embryonic germ cell layers

Monodermal type—less common

Unilocular Filled with sebaceous material and lined by

squamous epithelium Hair follicles, skin glands, muscle, and others

There is usually a raised protuberance projecting into the cyst cavity= the Rokitansky nodule

Broad spectrum of findings, ranging from purely cystic mixed mass with all the components of the three

germ cell layers noncystic mass composed predominantly of fat

US a cystic lesion with a densely echogenic tubercle

(Rokitansky nodule) projecting into the cyst lumen

a diffusely or partially echogenic mass with the echogenic area (sebaceous material and hair )

CT fat attenuation within a cyst, with or without

calcification in the wall MR the sebaceous component has very high signal

intensity on T1

Complications

Torsion

Rupture:

▪ leakage of the liquefied sebaceous contents into the peritoneum and resulting in granulomatous peritonitis

Malignant degeneration

▪ Squamous cell carcinoma

Less common forms of mature teratomas are the monodermal types

struma ovarii

▪ mature thyroid tissue predominates

▪ Hyperthyroidism

carcinoids

less than 1% of all teratomas Contains immature tissue from all three germ

cell layers Age < 20 years malignant, immature teratomas

Prominent solid components

May demonstrate internal necrosis or hemorrhage

UNLIKE Benign mature teratomas

A large, complex mass with cystic and solid components

Scattered calcifications

Mature teratomas, calcification is localized to mural nodules

Small foci of fat are also seen in immature teratomas

rare young women counterpart of seminoma of the testis 5% of dysgerminomas

Syncytiotrophoblastic giant cells elevation of serum HCG levels

Speckled calcification

Multilobulated solid masses with prominent fibrovascular septa

The anechoic, low signal-intensity, or low-attenuation area of the tumor represents necrosis and hemorrhage

yolk sac tumor rare Malignant

Age < 20 years A large, complex pelvic mass that extends into

the abdomen Contains both solid and cystic components The cystic areas are composed of epithelial line cysts

▪ produced by the tumor or of coexisting mature teratomas

grow rapidly and have a poor prognosis Elevated serum AFP

OVARIAN TUMOR

EPITHELIAL GERM CELLSEX CORD-STROMAL

Granulosa cell Fibrothecoma Sertoli-Leydig

METASTASIS

Gonadal cell types or mesenchymal cells 8% of ovarian neoplasms All age groups The most common types

granulosa cell tumors

Fibrothecomas

Sertoli-Leydig cell tumors

hormonal effects !!!

The vast majority of sex cord–stromal tumors are either benign or confined to the ovary

benign

▪ fibrothecoma, sclerosing stromal tumor

confined to the ovary

▪ granulosa cell tumor, Sertoli-Leydig cell tumor

Most common malignant sex cord–stromal most common estrogen-producing ovarian

tumor Predominantly in peri- and postmenopause Hyperestrogenemia

endometrial hyperplasia, polyps, or carcinoma

Imaging findings

vary widely

▪ solid masses with varying degrees of hemorrhagic or fibrotic changes

▪ multilocular cystic lesions

▪ completely cystic tumors

heterogeneous

▪ From intratumoral bleeding, infarcts, fibrous degeneration, and irregularly arranged tumor cells

VS epithelial cell tumor

▪ do not have intracystic papillary projections, have less propensity for peritoneal seeding, and are confined to the ovary

Estrogenic effects

▪ uterine enlargement

▪ endometrial thickening or hemorrhage

Benign Thecal cell--estrogen

Thecoma--estrogenic activity , few fibroblasts

Fibroma--no estrogenic activity

Both pre- and postmenopausal women

Fibroma

most common sex cord tumor

composed of fibroblasts and collagen

associated with

▪ Ascites

▪ Meigs syndrome (Right-sided pleural effusion)

Fibroma

US demonstrates a homogeneous hypoechoicmass with posterior acoustic shadowing

CT shows a homogeneous solid tumor with delayed enhancement

MR: T1 + T2 --low signal intensity

Dense calcifications are often seen

Scattered high-signal-intensity areas in the mass represent edema or cystic degeneration

very low signal intensity on T2

Fibroma

Fibrothecoma

Cystadenofibroma

Brenner tumor

Age 10-30 T2 hyperintense cystic components

heterogeneous solid component with intermediate to high signal intensity

CECT: early peripheral enhancement with centripetal progression Striking early enhancement = the cellular areas with

their prominent vascular network

An area of prolonged enhancement in the inner portion = collagenous hypocellular area

Age 30 years low-grade malignancy 0.5% of ovarian tumors most common virilizing tumor However, only 30% of these tumors are hormonally

active composed of heterologous tissue Carcinoid, mesenchymal, and mucinous epithelial

tissues a well-defined, enhancing solid mass with

intratumoral cyst

OVARIAN TUMOR

EPITHELIAL GERM CELLSEX CORD-STROMAL

(Collision) METASTASIS

coexistence of two adjacent but histologically distinct tumors

Rare most commonly Teratoma + cystadenoma

Teratoma + cystadenocarcinoma Mechanism--uncertain Considered when an ovarian tumor cannot be subsumed under one

histologic type, especially teratoma

OVARIAN TUMOR

EPITHELIAL GERM CELLSEX CORD-STROMAL

METASTASIS

Most common:

colon and stomach

breast, lung, and contralateral ovary

lymphoma

10% of all ovarian tumors reproductive years

Metastatic tumors to the ovary that contain mucin-secreting “signet ring” cells

usually originate in the gastrointestinal tract

Stomach

Colon

Non-specific

consisting of predominantly solid components

a mixture of cystic and solid areas

Distinctive findings: bilateral complex masses with

T1: Hypointense solid components (dense stromal reaction)

T2: Internal hyperintensity (mucin)

• The imaging appearance ranges from cystic to solid masses

• Although ovarian tumors have similar clinical and radiologic findings,

specific key features are present

a thin-walled, unilocular or multiloculartumor filled with serous fluid

very common may mimic

a physiologic cyst

an atypical mature cystic teratoma that lacks the characteristic eccentric mural nodule

almost always multilocular may be large

a thick, irregular wall; thick septa papillary projections a large soft-tissue component with necrosis

Endometrioid carcinoma Granulosa cell tumor

Thecoma or fibrothecoma

Fibrous

Fibroma

fibrothecoma

Brenner tumor

endometrioid carcinoma clear cell carcinoma

The presence of fat is highly specific Mature

predominantly cystic withdense calcifications

Immature teratomas

predominantly solid withsmall foci of lipid materialScattered calcifications

dysgerminoma endodermal sinus tumors

large predominantly solid masses more common in younger women Dysgerminoma

prominent fibrovascular septa

Sclerosing stromal tumor Sertoli-Leydig cell tumor Struma ovarii cystadenofibroma

serous epithelial tumor Fibrothecoma mature or immature teratoma Brenner tumor

metastatic ovarian tumors serous epithelial tumors of the ovary

When imaging findings that cannot be subsumed under one histologic type

especially in cases of ovarian teratoma

Functional/hemorrhagic cysts Real ovarian tumors

OVARIAN TUMOR

EPITHELIAL GERM CELLSEX CORD-STROMAL

(Collision) METASTASIS

References Un Jung, Seung, et al. "CT and MR Imaging of Ovarian

Tumors with Emphasis on Differential Diagnosis." Radiographics (2002): 1305-325. Web.

Wasnik, Ashish P, et at. "Multimodality imaging of ovarian cystic lesions: Review with an imaging based algorithmic approach.“ World J Radiol (2013) March 28; 5(3): 113-125. Web.

Zagoria, Ronald J., and Glenn A. Tung. Genitourinary Radiology: The Requisites. St. Louis: Mosby, 1997. Print.