MR Characterization of ovarianNeoplasms: 4 Pearls

Evan S. Siegelman MDUniversity of Pennsylvania

Medical Center4:05 – 4:15pm

RADIOLOGY

HUP

MR Characterization of ovarianNeoplasms: 4 Pearls in Ten Minutes

If I am to speak ten minutes, I need a week for preparation; if fifteen minutes, three days; if half an hour, two days; if an hour, I am ready now.

Woodrow Wilson

Ovarian Neoplasms

• Germ Cell Neoplasms: 15-30% • Sex Cord Stromal Tumors: 5-10%• Epithelial Ovarian Tumors: 60%

– 85% of ovarian cancers– 45% of benign ovarian tumors

• Krukenberg Tumors: 5%

Ovarian Neoplasms

Ovarian Neoplasms: 4 Pearls

• Fat• T1 and T2 Hypointensity• Papillary Projections• Multilocular cyst with varying T2 signal intensity

Ovarian Neoplasms

• Fat Mature Cystic Teratoma

• T1 and T2 Hypointensity Fibroma – Fibrothecoma Brenner Tumor

Ovarian Neoplasms

• Papillary Projections Epithelial ovarian neoplasm

• Multilocular cyst with varying T2 signal intensity Mucinous Cystadenoma

T1 Hyperintensity: Differential Diagnosis – High Five

• Fat• Hemorrhage • Protein• Flow• Paramagnetic Effects

Adnexal T1 Hyperintensity

• Mature Cystic Teratoma (MCT)– Dermoid Cyst

• Endometrioma• Functional Cyst

High Signal on T1Loss of SI with Fat Saturation

• Tissue is Characterized as Fat• Dx: Mature Cystic Teratoma

Mature Cystic Teratoma

• > 95% of germ cell neoplasms• The only benign subtype• Most common ovarian tumor of adolescence and pregnancy

• Radiography: Bone and teeth

Mature Cystic Teratoma

• Bilateral: 10%• Rx: Laparoscopic removal

– Torsion: 10% at presentation– < 1% Malignant degeneration– Preserve remainder of ovary

T1 and T2 Hypointensity

• Fibrosis• Smooth Muscle

T1 and T2 Hypointensity

• Exophytic Leiomyoma *• Fibroma / Fibrothecoma• Brenner Tumor

Jeff Weinreb - Not as simple as you thinkWeinreb, J. C., Barkoff, et al. (1990). "The value of MR imaging in distinguishing leiomyomas from other solid pelvic masses when sonography is indeterminate." AJR Am J Roentgenol 1990 154: 295-9.

Sex cord – Stromal Tumors

• Fibroma - Fibrothecoma• Granulosa cell tumor• Sertoli- Leydig cell tumor

Ovarian Fibroma-Fibrothecoma

• 50% of sex cord stromal tumors• Variable combination of fibroblasts

and theca luteum cells– Absent theca cells: Fibroma– Absent fibroblasts: Thecoma– Mixed population: Fibrothecoma

Ovarian Fibroma-Fibrothecoma: MRI

• Low SI on T1 and T2-WI suggestive• Claw sign with adjacent ovary• Widened endometrial complex

– Fibrothecoma• Larger lesions have high T2 Signal

– Intratumoral cyst, edema– Myxoid change

F F

Axial T1-WI Axial T2-WI

E

FFF

F FF

T2-WIFS T2-WI

T1-WI T2-WI

T2-WI FS T1-WI Enhanced

2007

2009

Brenner Tumor

• < 1% Epithelial Ovarian Neoplasms• >98% Benign• Ovarian Transitional Cells Surrounds by dense fibrous tissue

• 30% Ipsilateral or Contralateral Benign Ovarian Tumor

Papillary Projections

• Epithelial Ovarian Neoplasm • Not Specific for Malignancy• T2 Zonal Anatomy

– Inner SI Fibrous Core– Outer SI Edematous Stroma

Serous Ovarian Neoplasms

• Serous Cystadenoma• Serous Borderline Tumor (BOT)• Low Grade Serous Cystadenocarcinoma

(LGSC)• High Grade Serous Cystadenocarcinoma

(HGSC)

An immunohistochemical comparison between low-grade and high-grade ovarian serous carcinomas: significantly higher expression of p53, MIB1, BCL2, HER-2/neu, and C-KIT in high-grade neoplasms. 2005 Am J Surg Pathol 29(8): 1034-41.

AJR Feb 2010: 194(2): 349-54.

Mucinous Cystadenoma

• Huge Adnexal Neoplasms• Large Size Malignancy• MR Imaging Features

– Multiple Locules– No Ascites, Papillary Projections– Varying degrees of mild T1 and T2 Shortening Viscous Mucin

Axial T1-WI Axial T2-WI

M

Axial T1-WI FS Enhanced T1-WI

T2 FSE

FS T1 pre

and Post Gd