ovarian tumors
TRANSCRIPT
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THORSANG R1Prince of Songkla University05.11.2014
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Functional/hemorrhagic cysts
Real ovarian tumors
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Functional cysts
Real ovarian tumors
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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
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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
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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
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Polycystic ovarian syndrome (PCOS) affecting 5%-10% of women of reproductive age
Characterized by menstrual irregularities, hirsuitism, obesity and sclerotic ovaries
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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
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child bearing age 80% implanted in the ovary pelvic pain, dysmenorrhea and infertility From cystic to complex
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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
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OVARIAN TUMOR
EPITHELIAL GERM CELLSEX CORD-STROMAL
METASTASIS
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OVARIAN TUMOR
EPITHELIAL
Serous Mucinous Endometriod Clear cell Brenner
GERM CELLSEX CORD-STROMAL
METASTASIS
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60% of all ovarian neoplasms 85% of malignant ovarian neoplasms Age 50-70 years
Serous
mucinous
Endometrioid
Clear cell
Brenner tumors
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Serous and mucinous tumors
Mostly benign
Endometrioid tumors
Mostly malignant
Clear cell carcinomas
malignant
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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
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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.
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Wall thickening, septa, and multilocularityare less reliable indicators of malignancy
Frequently seen in benign neoplasms
▪ cystadenofibromas
▪ mucinous cystadenomas
▪ endometriomas
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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
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Most common malignant neoplasm
endometrioid carcinoma clear cell carcinoma
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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
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Most common malignant neoplasm
endometrioid carcinoma
clear cell carcinoma
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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
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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
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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
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OVARIAN TUMOR
EPITHELIAL GERM CELL
Teratoma
Mature Immature
DysgerminomaEndodermalsinus tumor
SEX CORD-STROMAL
METASTASIS
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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
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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
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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
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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
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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
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Complications
Torsion
Rupture:
▪ leakage of the liquefied sebaceous contents into the peritoneum and resulting in granulomatous peritonitis
Malignant degeneration
▪ Squamous cell carcinoma
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Less common forms of mature teratomas are the monodermal types
struma ovarii
▪ mature thyroid tissue predominates
▪ Hyperthyroidism
carcinoids
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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
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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
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rare young women counterpart of seminoma of the testis 5% of dysgerminomas
Syncytiotrophoblastic giant cells elevation of serum HCG levels
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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
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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
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OVARIAN TUMOR
EPITHELIAL GERM CELLSEX CORD-STROMAL
Granulosa cell Fibrothecoma Sertoli-Leydig
METASTASIS
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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 !!!
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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
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Most common malignant sex cord–stromal most common estrogen-producing ovarian
tumor Predominantly in peri- and postmenopause Hyperestrogenemia
endometrial hyperplasia, polyps, or carcinoma
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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
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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
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Benign Thecal cell--estrogen
Thecoma--estrogenic activity , few fibroblasts
Fibroma--no estrogenic activity
Both pre- and postmenopausal women
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Fibroma
most common sex cord tumor
composed of fibroblasts and collagen
associated with
▪ Ascites
▪ Meigs syndrome (Right-sided pleural effusion)
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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
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very low signal intensity on T2
Fibroma
Fibrothecoma
Cystadenofibroma
Brenner tumor
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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
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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
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OVARIAN TUMOR
EPITHELIAL GERM CELLSEX CORD-STROMAL
(Collision) METASTASIS
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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
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OVARIAN TUMOR
EPITHELIAL GERM CELLSEX CORD-STROMAL
METASTASIS
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Most common:
colon and stomach
breast, lung, and contralateral ovary
lymphoma
10% of all ovarian tumors reproductive years
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Metastatic tumors to the ovary that contain mucin-secreting “signet ring” cells
usually originate in the gastrointestinal tract
Stomach
Colon
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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)
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• The imaging appearance ranges from cystic to solid masses
• Although ovarian tumors have similar clinical and radiologic findings,
specific key features are present
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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
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almost always multilocular may be large
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a thick, irregular wall; thick septa papillary projections a large soft-tissue component with necrosis
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Endometrioid carcinoma Granulosa cell tumor
Thecoma or fibrothecoma
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Fibrous
Fibroma
fibrothecoma
Brenner tumor
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endometrioid carcinoma clear cell carcinoma
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The presence of fat is highly specific Mature
predominantly cystic withdense calcifications
Immature teratomas
predominantly solid withsmall foci of lipid materialScattered calcifications
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dysgerminoma endodermal sinus tumors
large predominantly solid masses more common in younger women Dysgerminoma
prominent fibrovascular septa
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Sclerosing stromal tumor Sertoli-Leydig cell tumor Struma ovarii cystadenofibroma
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serous epithelial tumor Fibrothecoma mature or immature teratoma Brenner tumor
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metastatic ovarian tumors serous epithelial tumors of the ovary
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When imaging findings that cannot be subsumed under one histologic type
especially in cases of ovarian teratoma
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Functional/hemorrhagic cysts Real ovarian tumors
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OVARIAN TUMOR
EPITHELIAL GERM CELLSEX CORD-STROMAL
(Collision) METASTASIS
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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.