MR Characterization of ovarian : 4 Pearls

Evan S. Siegelman MD University of Pennsylvania Medical Center 4:05 – 4:15pm

RADIOLOGY HUP MR Characterization of ovarian Neoplasms: 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 • T1 and T2 Hypointensity  – Fibrothecoma  Brenner Tumor Ovarian Neoplasms

• Papillary Projections  Epithelial ovarian • Multilocular cyst with varying T2 signal intensity  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 T1 Loss 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 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 T1 and T2 Hypointensity

• Fibrosis • Smooth Muscle T1 and T2 Hypointensity

• Exophytic Leiomyoma * • Fibroma / Fibrothecoma • Brenner Tumor

Jeff Weinreb - Not as simple as you think Weinreb, 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: – 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 E F F

Axial T1-WI Axial T2-WI F F F

F F F FS T2-WI 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 (LGSC) • High Grade Serous Cystadenocarcinoma (HGSC)

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

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.

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