AJR 2005; 184:1898-1900
© American Roentgen Ray Society
Borderline Serous Surface Papillary Tumor of the Ovary: MRI Characteristics
Sun Ho Kim1,
Dal Mo Yang2 and
Seung Hyup Kim1
1 Department of Radiology, Seoul National University College of Medicine, 28
Yongon-Dong, Chongno-Gu, Seoul 110-744, Korea.
2 Department of Radiology, Gachon Medical School Gil Medical Center, Incheon,
Korea.
Received June 6, 2004;
accepted after revision September 7, 2004.
Address correspondence to Seung H. Kim
(kimsh{at}radcom.snu.ac.kr).
Introduction
Serous surface papillary carcinoma (SSPC) is a distinct subtype of
serous tumor of the ovary, in which the tumor is confined to the ovarian
surface or shows focal, minimal invasion and the ovaries are of normal size
and shape [1]. It is not very
rare, but the imaging findings of the involved ovaries have been described in
a small number of articles and nonspecifically
[2]. We report a case of serous
surface papillary tumor of borderline malignancy in which MRI showed
characteristic ovarian features of this tumor, that is, tumors attached on the
ovarian surface preserving normal ovarian appearance. No report has clearly
shown such MRI findings of the ovaries involved by SSPC, which may be useful
in suggesting this diagnosis.
Case Report
A 26-year-old woman was admitted because of abdominal fullness and pain.
Sonography performed by a gynecologist discovered masses in both adnexal
regions, and the level of serum cancer antigen (CA)-125 was elevated. Under
the impression of ovarian malignancy, CT was performed. CT revealed irregular,
solid masses in the bilateral ovaries (Fig.
1A). A large amount of ascites with some septations and a mild
degree of omental infiltrations were noted, suggesting peritoneal seeding,
although no discrete, solid, peritoneal seeding mass was identified. For
further evaluation, MRI was performed.
View larger version (118K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —Borderline serous surface papillary tumors of bilateral
ovaries in 26-year-old woman. CT scan shows ill-defined, solid masses
(arrows) in both adnexal regions with large amount of ascites. U =
uterus.
|
|
On MRI (Figs. 1B,
1C,
1D,
1E,
1F), the ovarian masses had
irregular, nodular, or papillary margins, and internal branching patterns were
noted. Inside the masses, normal-appearing ovaries containing multiple
follicles could be clearly discriminated, although a mild degree of distortion
of the normal oval shape was present. The tumors showed intermediate signal
intensity on both T1- and T2-weighted images. After contrast enhancement, the
tumors were enhanced as much as the ovaries, but the sharp demarcation from
normal ovarian parenchyma was still maintained
(Fig. 1F). A large amount of
ascites was present, but no discrete peritoneal seeding mass was detected on
MRI. Bilateral salpingoophorectomy was performed, and the tumors were
confirmed pathologically as borderline serous surface papillary tumors of the
ovary. Microinvasion of ovarian parenchyma, noninvasive implantation in the
perimetrium, parametrium, salpingeal serosa, liver surface, and gutter area;
invasive implantation in the pelvic wall and diaphragm; and metastasis to the
salpinges and pelvic lymph nodes were also present.
View larger version (126K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —Borderline serous surface papillary tumors of bilateral
ovaries in 26-year-old woman. On T2-weighted axial image (B) (TR/TE,
3,977/99) and sagittal MR images (4,072/99) of right (C) and left
(D) ovaries, masses (arrows) are multilobulated and have
internal branching patterns (black arrowheads). Inside masses,
normal-appearing ovaries with multiple follicular cysts with distorted shape
are clearly discriminated (white arrowheads). Surfaces of ovaries
show dark signal intensity and are well maintained.
|
|
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —Borderline serous surface papillary tumors of bilateral
ovaries in 26-year-old woman. On T2-weighted axial image (B) (TR/TE,
3,977/99) and sagittal MR images (4,072/99) of right (C) and left
(D) ovaries, masses (arrows) are multilobulated and have
internal branching patterns (black arrowheads). Inside masses,
normal-appearing ovaries with multiple follicular cysts with distorted shape
are clearly discriminated (white arrowheads). Surfaces of ovaries
show dark signal intensity and are well maintained.
|
|
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D. —Borderline serous surface papillary tumors of bilateral
ovaries in 26-year-old woman. On T2-weighted axial image (B) (TR/TE,
3,977/99) and sagittal MR images (4,072/99) of right (C) and left
(D) ovaries, masses (arrows) are multilobulated and have
internal branching patterns (black arrowheads). Inside masses,
normal-appearing ovaries with multiple follicular cysts with distorted shape
are clearly discriminated (white arrowheads). Surfaces of ovaries
show dark signal intensity and are well maintained.
|
|
View larger version (119K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E. —Borderline serous surface papillary tumors of bilateral
ovaries in 26-year-old woman. On T1-weighted axial MR image (741/14), masses,
ovaries, and ascites show same signal intensity and are not discriminated.
|
|
View larger version (134K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F. —Borderline serous surface papillary tumors of bilateral
ovaries in 26-year-old woman. On contrast-enhanced T1-weighted sagittal MR
image (836/14), right ovarian mass (arrows) is enhanced as much as
ovary, but sharp demarcation between tumor and ovary (arrowheads) is
still clearly visible.
|
|
Discussion
SSPC has been called "peritoneal carcinoma" in many reports
(i.e., "SSPC of the peritoneum"), because it is controversial
whether this tumor originates from the peritoneum or ovarian surface
epithelium
[2-4].
SSPC of the ovary and SSPC of the peritoneum have a common histologic
appearance and the same responsiveness to surgical therapy and chemotherapy,
so they are treated similarly
[5]. However, some authors
believe that SSPC of the ovary is a distinct subtype of serous papillary
carcinoma of the ovary, rather than a primary carcinoma of the peritoneum with
secondary ovarian involvement
[2,
6]. We think that these two
entities are in a spectrum of one disease, differing in the proportions of
primary ovarian masses and peritoneal masses. Because this tumor is usually
highly malignant and has a tendency to spread to the peritoneal cavity rather
than invade ovarian stroma, most SSPCs manifest as extensive peritoneal masses
with large amount of ascites without definite masses in the ovaries of normal
size and shape on imaging. However, according to the degree of malignancy and
the differentiation of the tumors, ovarian masses may be more prominent than
peritoneal masses, as in our case. Thus, we will consider SSPC of the
peritoneum and SSPC of the ovary the same entity in the rest of this
section.
Confusion is also found regarding the "surface" of SSPC, which
pathologically means the tumor is confined to the ovarian surface, although
focal, minimal invasion into the ovarian parenchyma can be present
microscopically [1]. In
previous reports, the similar imaging findings were described as serous
papillary carcinoma of the peritoneum by some authors and as SSPC by others
[2,
7-10].
We think the term "surface" should be restricted to the name of
the tumor that meets the pathologic definition described earlier, that is,
only when the official pathologic diagnosis includes "surface" in
the name of an ovarian tumor.
Imaging findings described as SSPC of the ovary are limited
[2], whereas there are many
reports of serous papillary carcinoma of the peritoneum
[7-10].
However, the findings were similar between these two groups: a large amount of
ascites with extensive peritoneal seeding masses and no lesions or subtle
lesions in the ovary without enlargement. The ovarian lesions on CT in
previous reports were subtle and nonspecific. MRI findings reported by Kim et
al. [2] were also not
characteristic; small nodularities were found on the ovarian surface, uterus,
and pelvic peritoneum, but a discrete, large mass was not found.
Our case is different because gross, large, ovarian masses were main
lesions and no definite peritoneal seeding mass was detectable on CT and MRI,
although a large amount of ascites with some septations were associated with
them. These differences can be explained by the fact that this tumor was a
borderline malignancy and well differentiated. Thus, peritoneal seeding was
much milder than in usual SSPC and the tumor was located mainly on the ovary.
Papillary architecture with an internal branching pattern was also clearly
visible, which also reflects well-differentiated tumors.
Such features were well shown on MRI, and the findings were striking and
impressive. CT showed ill-defined, solid ovarian masses and failed to show
normal ovaries inside the masses because of the limitation of soft-tissue
contrast. However, MRI showed the presence of normal ovaries in the masses,
most clearly on T2-weighted images. Dark signal intensity of ovarian capsule
and high signal intensity of ovarian parenchyma due to multiple follicles were
well contrasted with the tumors of intermediate signal intensity on
T2-weighted MR images.
Although we think that such a striking appearance on MRI is seldom found in
other ovarian diseases or tumors, a differential diagnosis should be noted and
should include ovarian involvement by a secondary malignant tumor or by
peritoneal tuberculosis. These two entities could be ruled out by us
preoperatively because MRI findings suggested primary ovarian tumor and signs
of peritoneal involvement were relatively mild.
In conclusion, although SSPCs usually have subtle ovarian lesions on CT and
MRI, our case showed that ovarian masses were main lesions and preserved
normal ovaries inside on MRI. The low-grade malignancy of the tumor and good
soft-tissue contrast of MRI allowed us to see such characteristic ovarian
features of this tumor clearly.
References
- Mills SE, Andersen WA, Fechner RE, Austin MB. Serous surface
papillary carcinoma: a clinicopathologic study of 10 cases and comparison with
stage III-IV ovarian serous carcinoma. Am J Surg
Pathol 1988;12:827
-834[Medline]
- Kim SH, Cho JY, Park IA, Kang SB, Lee HP, Han MC. Radiological
findings in serous surface papillary carcinoma of the ovary: case reports.
Acta Radiol1997; 38:847
-849[Medline]
- Ayhan A, Tuncer ZS, Kucukali T, Yuce K, Aksu T. Serous surface
papillary carcinoma. Eur J Gynaecol Oncol1996; 17:137
-139[Medline]
- Mulhollan TJ, Silva EG, Tornos C, Guerrieri C, Fromm GL, Gershenson
D. Ovarian involvement by serous surface papillary carcinoma. Int J
Gynecol Pathol 1994;13:120
-126[Medline]
- Liapis A, Condi-Paphiti A, Pyrgiotis E, Zourlas PA. Ovarian surface
serous papillary carcinomas: a clinicopathologic study. Eur J
Gynaecol Oncol 1996;17:79
-82[Medline]
- Gooneratne S, Sassone M, Blaustein A, Talerman A. Serous surface
papillary carcinoma of the ovary: a clinicopathologic study of 16 cases.
Int J Gynecol Pathol1982; 1:258
-269[Medline]
- Chopra S, Laurie LR, Chintapalli KN, Valente PT, Dodd GD III.
Primary papillary serous carcinoma of the peritoneum: CT-pathologic
correlation. J Comput Assist Tomogr2000; 24:395
-399[Medline]
- Furukawa T, Ueda J, Takahashi S, et al. Peritoneal serous papillary
carcinoma: radiological appearance. Abdom Imaging1999; 24:78
-81[Medline]
- Stafford-Johnson DB, Bree RL, Francis IR, Korobkin M. CT appearance
of primary papillary serous carcinoma of the peritoneum.
AJR 1998;171:687
-689[Abstract/Free Full Text]
- Zissin R, Hertz M, Shapiro-Feinberg M, Bernheim J, Altaras M,
Fishman A. Primary serous papillary carcinoma of the peritoneum: CT findings.
Clin Radiol2001; 56:740
-745[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Introduction
Case Report
