AJR 2004; 182:1259-1265
© American Roentgen Ray Society
Benign Ovarian Tumors with Solid and Cystic Components That Mimic Malignancy
Kyeong Ah Kim1,
Cheol Min Park1,
Jean Hwa Lee1,
Hee Kyung Kim1,
Song Mee Cho2,
Bohyun Kim3 and
Hae Young Seol1
1 Department of Diagnostic Radiology and Medical Science Research Center, Guro
Hospital, Korea University School of Medicine, 97 Gurodong-Gil, Guro-Ku, Seoul
152-703, South Korea.
2 Department of Radiology, St. Paul's Hospital, Catholic University of Korea,
620-56 Junnong-Dong, Dongdaemun-Ku, Seoul 130-709, South Korea.
3 Department of Radiology, Samsung Medical Center, Sungkyunkwan University
School of Medicine, 50 Irwon-Dong, Kangnam-Ku, Seoul 135-710, South
Korea.
Received July 31, 2003;
accepted after revision September 22, 2003.
Address correspondence to C. M. Park
(cminpark{at}korea.ac.kr).
Introduction
Determining whether an ovarian tumor is malignant or benign before
operation, especially when the tumor has both solid and cystic components, is
often difficult. Excessive surgical procedures such as bilateral oophorectomy
with or without hysterectomy have sometimes been performed in patients with
benign ovarian tumor because the preoperative diagnosis was inaccurate.
The criteria most useful for the prediction of ovarian malignancy are
lesion size (> 4 cm); thickness (> 3 mm) of the walls and septa; and
internal structure, including papillary projections, nodularity, various
degrees of solid components, necrosis, and hemorrhage
[1]. However, imaging findings
in benign and malignant ovarian lesions overlap. Although contrast enhancement
usually increases the accuracy in differentiation of benign and malignant
lesions, its usefulness may be limited for some types of tumors.
The most useful tumor marker in the detection of ovarian cancer is cancer
antigen (CA) 125. The greatest problem of CA 125 determination is its lack of
specificity. An elevated level of CA 125 not only is found in malignancy but
can also be associated with fibroids, pregnancy, menstruation, endometriosis,
and liver disease.
The purpose of this pictorial essay is to show and discuss the various
benign ovarian tumors that can show both solid and cystic components that
mimic malignant ovarian tumors on CT and MRI.
Surface Epithelial–Stromal Tumors
Cystadenoma
Papillary projections are specific features of epithelial ovarian
neoplasms. Like ovarian cancer, cystadenoma may display papillary projections,
although it does so less frequently (9% of cases) than malignant tumors
[2]. Papillary projections
enhance after contrast material administration, thus facilitating
differentiation from intracystic clot or debris (Fig.
1A,
1B,
1C).
Cystadenofibroma
Cystadenofibroma is a subset of epithelial ovarian neoplasms that are
usually benign. A lesion with a solid portion that exhibits intense contrast
enhancement is the prominent feature of cystadenofibroma that mimics
malignancy (Fig. 2). The
presence of rims, plaques, or nodules that have low signal intensity on
T2-weighted images and that range from 2 mm to 4 cm in a multiloculated cystic
ovarian mass can suggest the diagnosis (Fig.
3A,
3B,
3C). The low-signal-intensity
foci correspond to intratumoral regions of dense fibrous tissue
[3].
View larger version (109K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A. —43-year-old woman with ovarian serous cystadenofibroma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced T1-weighted (C) MR images show
cystic lesion with solid nodular area (thin arrows) surrounded by
thickened septa and wall with moderate enhancement (thick
arrows).
|
|
View larger version (127K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B. —43-year-old woman with ovarian serous cystadenofibroma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced T1-weighted (C) MR images show
cystic lesion with solid nodular area (thin arrows) surrounded by
thickened septa and wall with moderate enhancement (thick
arrows).
|
|
View larger version (126K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C. —43-year-old woman with ovarian serous cystadenofibroma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced T1-weighted (C) MR images show
cystic lesion with solid nodular area (thin arrows) surrounded by
thickened septa and wall with moderate enhancement (thick
arrows).
|
|
Adenofibroma
To our knowledge, the imaging findings of ovarian adenofibroma have not
been described in the English-language literature. In a case we encountered,
this lesion appeared as a multiloculated cystic mass with enhancing septa and
solid portions on MR images (Fig.
4A,
4B,
4C).
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A. —62-year-old woman with ovarian clear cell adenofibroma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced T1-weighted (C) MR images show
large cystic mass with enhancing multiple septa and solid portions
(arrows). C = cystic portions of mass.
|
|
View larger version (163K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B. —62-year-old woman with ovarian clear cell adenofibroma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced T1-weighted (C) MR images show
large cystic mass with enhancing multiple septa and solid portions
(arrows). C = cystic portions of mass.
|
|
View larger version (162K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C. —62-year-old woman with ovarian clear cell adenofibroma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced T1-weighted (C) MR images show
large cystic mass with enhancing multiple septa and solid portions
(arrows). C = cystic portions of mass.
|
|
Brenner Tumor
Benign transitional cell (Brenner) tumors of the ovary compose
approximately 2% of epithelial ovarian neoplasms. Brenner tumors are often
discovered incidentally at surgery or pathologic examination. Extensive
amorphous calcification in a solid mass or a solid component in a multilocular
cystic mass is a characteristic finding. Low signal intensity on T2-weighted
MR images may result from the abundant fibrous stroma
[4] (Fig.
5A,
5B,
5C,
5D,
5E).
View larger version (128K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5C. —68-year-old woman with Brenner tumor. Axial T2-weighted
(TR/TE, 2,000/80) (C), axial T1-weighted (600/15) (D), and axial
contrast-enhanced T1-weighted (E) MR images show enhancing ovarian
solid mass (arrows). Low signal intensity on T2-weighted image is due
to abundant fibrous stroma.
|
|
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5D. —68-year-old woman with Brenner tumor. Axial T2-weighted
(TR/TE, 2,000/80) (C), axial T1-weighted (600/15) (D), and axial
contrast-enhanced T1-weighted (E) MR images show enhancing ovarian
solid mass (arrows). Low signal intensity on T2-weighted image is due
to abundant fibrous stroma.
|
|
View larger version (155K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5E. —68-year-old woman with Brenner tumor. Axial T2-weighted
(TR/TE, 2,000/80) (C), axial T1-weighted (600/15) (D), and axial
contrast-enhanced T1-weighted (E) MR images show enhancing ovarian
solid mass (arrows). Low signal intensity on T2-weighted image is due
to abundant fibrous stroma.
|
|
Sex Cord–Stromal Tumors
Fibroma
Ovarian fibromas are composed of spindle cells that form collagen and
usually display low signal intensity on both T1- and T2-weighted MRI. High
signal intensity on T2-weighted images corresponded to regions of
hyalinization and myxomatous changes
[5]. Intratumoral edema is also
common in larger fibromas. These tumors (Fig.
6A,
6B,
6C) have been confused with
other ovarian tumors, such as Krukenberg's tumor or epithelial cystic
neoplasm.
View larger version (151K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6A. —52-year-old woman with ovarian fibroma with prominent cystic
change. Axial T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted
(600/15) (B), and axial contrast-enhanced T1-weighted (C) MR
images show enhancing solid portion (arrows) in large cystic mass.
Solid portion with low signal intensity on T1- and T2-weighted images
corresponds to area of fibroma. High-signal-intensity area (C, A) on
T2-weighted image corresponds to region of cystic change.
|
|
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6B. —52-year-old woman with ovarian fibroma with prominent cystic
change. Axial T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted
(600/15) (B), and axial contrast-enhanced T1-weighted (C) MR
images show enhancing solid portion (arrows) in large cystic mass.
Solid portion with low signal intensity on T1- and T2-weighted images
corresponds to area of fibroma. High-signal-intensity area (C, A) on
T2-weighted image corresponds to region of cystic change.
|
|
View larger version (161K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6C. —52-year-old woman with ovarian fibroma with prominent cystic
change. Axial T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted
(600/15) (B), and axial contrast-enhanced T1-weighted (C) MR
images show enhancing solid portion (arrows) in large cystic mass.
Solid portion with low signal intensity on T1- and T2-weighted images
corresponds to area of fibroma. High-signal-intensity area (C, A) on
T2-weighted image corresponds to region of cystic change.
|
|
Sclerosing Stromal Tumor
Sclerosing stromal tumor is a rare ovarian tumor occurring predominantly in
young women in the second or third decade of life. Sonography shows a tumor
with multilocular cystic components and irregularly thickened septa and tumor
walls or a solid tumor including several small cystic components. On
T2-weighted images, signal intensities of the cystic components are high, and
those of the solid components are inhomogeneous, ranging from
intermediate–high to high. Dynamic MRI reveals marked early enhancement
of the solid components [6]
(Fig. 7A,
7B,
7C,
7D,
7E,
7F).
View larger version (118K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7D. —43-year-old woman with sclerosing stromal tumor of ovary.
Sagittal contrast-enhanced dynamic T1-weighted gradient-echo MR images from
rapid acquisition obtained before enhancement (D), after 60-sec delay
(E), and after 180-sec delay (F) show rapid, strong, prolonged
enhancement (arrows). Signal intensity of solid component of tumor is
higher than that of myometrium.
|
|
View larger version (155K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7E. —43-year-old woman with sclerosing stromal tumor of ovary.
Sagittal contrast-enhanced dynamic T1-weighted gradient-echo MR images from
rapid acquisition obtained before enhancement (D), after 60-sec delay
(E), and after 180-sec delay (F) show rapid, strong, prolonged
enhancement (arrows). Signal intensity of solid component of tumor is
higher than that of myometrium.
|
|
View larger version (170K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7F. —43-year-old woman with sclerosing stromal tumor of ovary.
Sagittal contrast-enhanced dynamic T1-weighted gradient-echo MR images from
rapid acquisition obtained before enhancement (D), after 60-sec delay
(E), and after 180-sec delay (F) show rapid, strong, prolonged
enhancement (arrows). Signal intensity of solid component of tumor is
higher than that of myometrium.
|
|
Germ Cell Tumors
Mature Cystic Teratoma
Mature teratoma is the most common benign ovarian tumor in women younger
than 45 years. In mature cystic teratomas, the enhancement of solid areas (the
dermoid plug) does not necessarily indicate malignancy
[7] (Fig.
8A,
8B,
8C). Extracapsular tumor
growth, however, may suggest malignant transformation.
View larger version (136K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8A. —34-year-old woman with benign cystic teratoma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced fat-suppression T1-weighted (C)
MR images show cystic (C) and fatty (F) mass. Note enhancing solid portion
(arrows) in mass.
|
|
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8B. —34-year-old woman with benign cystic teratoma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced fat-suppression T1-weighted (C)
MR images show cystic (C) and fatty (F) mass. Note enhancing solid portion
(arrows) in mass.
|
|
View larger version (136K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8C. —34-year-old woman with benign cystic teratoma. Axial
T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted (600/15)
(B), and axial contrast-enhanced fat-suppression T1-weighted (C)
MR images show cystic (C) and fatty (F) mass. Note enhancing solid portion
(arrows) in mass.
|
|
Struma Ovarii
Struma ovarii is an uncommon ovarian tumor containing thyroid tissue in the
ovarian mass and is associated with hyperthyroidism. A multicystic tumor with
a solid component, a multilobulated surface, and low signal intensity that
indicate the presence of viscid gelatinous materials appears to be a
characteristic MRI finding of struma ovarii
[8] (Fig.
9A,
9B,
9C).
View larger version (111K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9A. —67-year-old woman with struma ovarii. C = cystic portion of
tumor. Sagittal T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted
(600/15) (B), and axial contrast-enhanced T1-weighted (C) MR
images show multilobulated cystic tumor with enhancing solid component
(arrows, B and C). Low signal intensity on T2-weighted
image (arrows, A) is caused by viscid gelatinous material
(colloid in thyroid follicle).
|
|
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9B. —67-year-old woman with struma ovarii. C = cystic portion of
tumor. Sagittal T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted
(600/15) (B), and axial contrast-enhanced T1-weighted (C) MR
images show multilobulated cystic tumor with enhancing solid component
(arrows, B and C). Low signal intensity on T2-weighted
image (arrows, A) is caused by viscid gelatinous material
(colloid in thyroid follicle).
|
|
View larger version (120K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9C. —67-year-old woman with struma ovarii. C = cystic portion of
tumor. Sagittal T2-weighted (TR/TE, 2,000/80) (A), axial T1-weighted
(600/15) (B), and axial contrast-enhanced T1-weighted (C) MR
images show multilobulated cystic tumor with enhancing solid component
(arrows, B and C). Low signal intensity on T2-weighted
image (arrows, A) is caused by viscid gelatinous material
(colloid in thyroid follicle).
|
|
Conclusion
Various benign ovarian tumors with solid and cystic components can mimic
malignant ovarian tumors. Most enhancing solid components are the fibrous
components of ovarian tumors. The fibrous components of these masses tend to
have low signal intensity on T2-weighted images. Familiarity with imaging
findings of benign ovarian tumors allows an appropriate differential
diagnosis. Because of the size and complexity of benign ovarian tumors,
surgical removal is usually recommended; however, excessive surgical
intervention can be potentially avoided with an accurate diagnosis.
References
- Stevens SK, Hricak H, Stern JL. Ovarian lesions: detection and
characterization with gadolinium-enhanced MR imaging at 1.5 T.
Radiology1991; 181:481
–488[Abstract/Free Full Text]
- Ghossain MA, Buy JN, Ligneres C, et al. Epithelial tumors of the
ovary: comparison of MR and CT findings. Radiology1991; 181:863
–870[Abstract/Free Full Text]
- Outwater EK, Siegelman ES, Talerman A, Dunton C. Ovarian fibromas
and cystadenofibromas: MRI features of the fibrous component. J
Magn Reson Imaging 1997;7:465
–471[Medline]
- Moon WJ, Koh BH, Kim SK, et al. Brenner tumor of the ovary: CT and
MR findings. J Comput Assist Tomogr2000; 24:72
–76[Medline]
- Ueda J, Furukawa T, Higashino K, et al. Ovarian fibroma of high
signal intensity on T2-weighted MR image. Abdom
Imaging 1998;23:657
–658[Medline]
- Joja I, Okuno K, Tsunoda M, et al. Sclerosing stromal tumor of the
ovary: US, MR, and dynamic MR findings. J Comput Assist
Tomogr 2001;25:201
–206[Medline]
- Yamashita Y, Torashima M, Hatanaka Y, et al. Adnexal masses:
accuracy of characterization with transvaginal US and precontrast and
postcontrast MR imaging. Radiology1995; 194:557
–565[Abstract/Free Full Text]
- Joja I, Asakawa T, Mitsumori A, et al. Struma ovarii: appearance on
MR images. Abdom Imaging1998; 23:652
–656[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
S. B. Park, J. K. Kim, K.-R. Kim, and K.-S. Cho
Imaging Findings of Complications and Unusual Manifestations of Ovarian Teratomas
RadioGraphics,
July 1, 2008;
28(4):
969 - 983.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Surface Epithelial-Stromal...
