AJR 2002; 178:749-751
© American Roentgen Ray Society
Xanthogranulomatous Oophoritis
MR Imaging Findings with Pathologic Correlation
Seung Eun Jung1,
Jae Mun Lee1,
Kyo-Young Lee2,
Ku Taek Han3 and
Seong Tai Hahn1
1
Department of Radiology, St. Mary's Hospital, The Catholic University of
Korea, #62 Youido-dong Yongdungpo-gu, Seoul 150-713, Korea.
2
Department of Clinical Pathology, St. Mary's Hospital, The Catholic University
of Korea, Seoul 150-713, Korea.
3
Department of Obstetrics and Gynecology, St. Mary's Hospital, The Catholic
University of Korea, Seoul 150-713, Korea.
Received January 11, 2001;
accepted after revision June 22, 2001.
Address correspondence to J. M. Lee
Introduction
Xanthogranulomatous inflammation is an uncommon, nonneoplastic, chronic
process in which the tissue of the affected organ is destroyed and is replaced
by a striking cellular infiltrate of foamy histiocytes admixed with
multinucleated giant cells, plasma cells, fibroblasts, neutrophils, and foci
of necrosis. The etiology of xanthogranulomatous oophoritis is unknown, but
this rare disease has a gross and microscopic appearance similar to
xanthogranulomatous change occurring in other organs, such as the gallbladder
and kidney [1,
2].
To our knowledge, the MR imaging findings of xanthogranulomatous oophoritis
have not been previously reported. We describe a rare case of bilateral
xanthogranulomatous oophoritis that we studied using MR imaging with
pathologic correlation. We also describe the considerable resemblance in the
imaging findings of xanothogranulomatous oophoritis and xanthogranulomatous
cholecystitis.
Case Report
A 48-year-old woman presented with a 3-day history of lower abdominal pain
and fever. Pelvic sonography showed a well-defined cystic mass with a
honeycombed appearance in the right adnexa uteri as well as a multichambered
cystic mass with debris in the left adnexa. To further characterize the
masses, we performed an MR imaging examination of the pelvis with a phased
array coil at 1.5 T (Magnetom Vision Plus; Siemens, Erlangen, Germany). The MR
images showed a cystic mass measuring approximately 9 cm in the right adnexa
and another cystic mass with three chambers measuring approximately 9 cm in
the left adnexa. The right-sided mass had a high signal intensity similar to
that of water and multiple low-signal-intensity internal septations visible on
T2-weighted turbo spin-echo images (TR/TE, 3900/99) (Figs.
1A and
1B). This mass had an unevenly
thickened wall with heterogeneous signal intensity. Within the wall, multiple
clustered hyperintense nodules ranging from 0.5 to 2.0 cm in diameter were
visualized. On T1-weighted spin-echo images (800/12), the right-sided mass
revealed a low signal intensity (Fig.
1C). The left-sided mass had high signal intensity, a thin wall,
and thin uniform septations on T2-weighted images and had a different signal
in each chamber on T1-weighted images. One chamber showed bright signal
intensity, indicating hemorrhagic cyst (Fig.
1A,1B,1C,1D,1E,1F).
On contrast-enhanced T1-weighted images after IV administration of
gadopentetate dimeglumine (0.1 mmol/kg), the right-sided mass showed marked
enhancement of the thickened wall and multiple clustered unenhanced nodules in
the wall. No internal septal enhancement was seen in the right-sided mass.
Extensive parametrial strands were also combined
(Fig. 1D). The initial
diagnosis, given the patient's history, was thought to be right-sided
tuboovarian abscess and left-sided endometrial cyst. The possibility of
carcinoma of the right ovary was also considered because of the unevenly
thickened wall.
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Fig. 1A. —48-year-old woman with xanthogranulomatous oophoritis. Axial
T2-weighted turbo spin-echo MR image (TR/TE, 3900/99) (A) and axial
T2-weighted image obtained 15 mm caudad to A(B) reveal right-sided
xanthogranulomatous oophoritis (solid arrows) with high signal
intensity (similar to that of water) and multiple low-signal-intensity
internal septations. Lesion shows unevenly thickened wall with multiple
clustered hyperintense nodules (arrowheads). Left-sided hemorrhagic
cyst (open arrows) shows three chambers with high signal
intensity.
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Fig. 1B. —48-year-old woman with xanthogranulomatous oophoritis. Axial
T2-weighted turbo spin-echo MR image (TR/TE, 3900/99) (A) and axial
T2-weighted image obtained 15 mm caudad to A(B) reveal right-sided
xanthogranulomatous oophoritis (solid arrows) with high signal
intensity (similar to that of water) and multiple low-signal-intensity
internal septations. Lesion shows unevenly thickened wall with multiple
clustered hyperintense nodules (arrowheads). Left-sided hemorrhagic
cyst (open arrows) shows three chambers with high signal
intensity.
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Fig. 1C. —48-year-old woman with xanthogranulomatous oophoritis. Axial
T1-weighted spin-echo MR image (800/12) shows right-sided xanthogranulomatous
oophoritis (arrows) with low signal intensity and left-sided
hemorrhagic cyst (arrowheads) with different signal in each
chamber.
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Fig. 1D. —48-year-old woman with xanthogranulomatous oophoritis. On
fat-suppressed T1-weighted MR image obtained after gadolinium enhancement,
right-sided xanthogranulomatous oophoritis shows marked enhancement of
thickened wall (arrowheads) and multiple clustered unenhanced
intramural nodules (arrows).
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Fig. 1E. —48-year-old woman with xanthogranulomatous oophoritis.
Photograph of histopathologic specimen of right-sided xanthogranulomatous
oophoritis shows yellowish intramural nodules (arrows) representing
xanthogranuloma within thickened wall.
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Fig. 1F. —48-year-old woman with xanthogranulomatous oophoritis.
Photomicrograph of histopathologic specimen shows abundant foamy histiocytes,
multinucleated giant cells, and chronic inflammatory cells. (H and E,
x100)
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The patient underwent exploratory laparotomy with hysterectomy and
bilateral oophorectomy. Pathologic examination of the right adnexa showed a
7-cm-diameter cystic mass with a thick (8-mm) wall, which had multiple
yellowish intramural nodules, dark serosanguinous fluid, and necrotic debris
(Fig. 1E). An 8-cm-diameter
three-chambered mass with serosanguinous fluid was found in the left adnexa.
Extensive pelvic adhesions were noted. On microscopic examination of the right
ovary, we found foamy histiocytes with varying amounts of associated
multinucleated giant cells, other chronic inflammatory cells, necrosis,
calcium, and cholesterol clefts (Fig.
1F). The final pathologic diagnosis was right-sided
xathogranulomatous oophoritis.
Discussion
Xanthogranulomatous inflammation of the female genital tract is unusual and
is essentially limited to the endometrium. Only a few cases involving the
ovary have been reported [1,
2]. The average age of patients
with affected ovaries is 31 years. Although the pathogenesis of ovarian
lesions is not fully understood, rarely does a chronic ovarian abscess result
in a solid tumorlike mass, which is is called either an ovarian
xanthogranuloma or xanthogranulomatous oophoritis. This lesion occurs in
patients with recurrent pelvic inflammatory disease. The involved ovary in
each of the previously reported cases was replaced by a solid, yellow,
lobulated mass that was well circumscribed and consisted of
xanthogranulomatous inflammation
[1,2,3,4].
Xanthogranulomatous inflammation is a well-established histopathologic
entity in the gallbladder and kidney, and its imaging findings have been well
described
[5,6,7].
Imaging findings of xanthogranulomatous cholecystitis include the presence of
intramural nodules or bands in a thickened gallbladder wall with calculi
[5,
6]. The classic radiographic
appearance of xanthogranulomatous pyelonephritis is an enlarged nonfunctioning
kidney associated with an obstructing calculus at the ureteropelvic junction.
The definitive CT finding of xanthogranulomatous pyelonephritis is an
inflammatory mass that has the density of fat and is associated with calculus
[7].
To our knowledge, no radiologic description of a xanthogranulomatous
oophoritis exists. In our patient, the right-sided mass was cystic with a
thick wall and multiple intramural nodules. The intramural nodules were
hypointense relative to the myometrium on T1-weighted images and hyperintense
(similar to the intensity of water) on T2-weighted images; the nodules showed
no enhancement after IV injection of gadopentetate dimeglumine.
Pathologically, intramural nodules were xanthogranulomas composed of
granulomatous inflammatory lesions with foamy histiocytes, lymphocytes, and
multinucleated giant cells. Therefore, we assume that the characteristic MR
imaging findings of xanthogranulomatous oophoritis are multiple intramural
nodules in a thickened wall with high signal intensity on T2-weighted images
and low signal intensity on T1-weighted images and on images obtained without
enhancement. The appearance of the striking intramural nodules was reminiscent
of that seen in xanthogranulomatous cholecystitis. Intramural nodules in
patients with xanthogranulomatous cholecystitis were found at histologic
examination to represent abscesses or xanthogranulomas
[6].
In conclusion, we believe that the presence of nonenhancing intramural
nodules in the thickened wall of an ovarian cystic mass may be a unique MR
indicator of xanthogranulomatous oophoritis. Although a correct diagnosis is
made chiefly through histology, a suggestive preoperative diagnosis of
xanthogranulomatous oophoritis could lead to less radical surgery.
Acknowledgments
We thank Bonnie Hami, Department of Radiology, University Hospitals Health
System, Cleveland, OH, for editorial assistance in preparing the
manuscript.
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Introduction
Case Report
