MR findings of ovarian tumors with hormonal activity, with emphasis on tumors other than sex cord-stromal tumors

A case of ovarian endometrioid carcinoma: Atypical MR imaging

Endometrioid carcinoma is the second most common ovarian tumor, classified as an epithelial-stromal ovarian tumor, and is usually characterized by a cystic tumor with partial solid components on magnetic resonance (MR) images. In this case report, we discuss an 81-year-old female who presented with atypical genital bleeding and distended abdomen, for which she underwent abdominal computed tomography and MR imaging. Solid endometrioid carcinoma of the ovary is very rare but was confirmed in our patient during the histological examination after surgery.

Characterization of Ovarian Granulosa Cell Tumors using Magnetic Resonance Imaging

PURPOSE

To identify the MRI features that aid in the characterization of ovarian granulosa cell tumors.

MATERIALS AND METHODS

11 MR pelvis of an adult woman with pathology-proven ovarian granulosa cell tumors with surgical pathology.We evaluated the patient's age, Ca-125, size, laterality, and with MRI features such as indirect signs (i.e., thickened endometrium > 0.9 cm), morphology (cystic, solid-cystic, or solid), subacute hemorrhage, T2 signal (low or intermediate-to-high), restricted diffusion (B values: 0, 50, 1000 sec/mm3/ADC), and dynamic enhancement (intense or similar to myometrium). Also, the presence of ascites, peritoneal implants, or adenopathy.

RESULTS

The final cohort included 11 women with a surgical-pathological diagnosis of granulosa cell tumors. The median age was 52.4 years (range, 17-80). The Ca-125 level was with a median within normal limits. The median size was 9.4 cm. Most cases were unilateral (81.8%) and more frequent on the left (54.5%).

MRI ANALYSIS

36.4% had endometrial thickening. Ovarian granulosa cell tumors were polymorphous: cystic (54.6%), mixed solid-cystic (9.1%), and solid (36.3%). Most GC had intermediate to high signal on T2 (90.9%), restricted diffusion (81.8%), intense enhancement (81.8%), and 36.4% had intraparenchymal bleeding. 9.1% had associated implants/adenopathy/ascites at diagnosis.

CONCLUSION

The MRI features characteristic of ovarian granulosa cell tumors were the polymorphous morphology, an intense enhancement to the myometrium, restricted diffusion, and the presence of intraparenchymal hemorrhage.

Lobulated ovary as a rare congenital anomaly: MR findings

The congenital anomaly of the ovary is classified as a supernumerary, accessory, and lobulated ovary (LO). Although the former two entities are anomalies of abnormal location, LO is a category of morphological abnormality of the ovary. There are several case reports of this entity; however, most of them were diagnosed during surgery or histopathologically. One case report included ultrasound findings, with the diagnosis confirmed during surgery. We report a young-adult case with LO diagnosed and followed up with MR. Although LO is a rare congenital anomaly, it might be misdiagnosed as malignant tumors, as in our case. Therefore, radiologists and gynecologists should look out for this entity in MR findings, which can prove to be crucial in preventing unnecessary surgery.

Ovarian thecoma: A very unusual cause of postmenopausal bleeding

We describe a 67-year-old woman with postmenopausal bleeding having ceased estrogen plus progestogen therapy nine months before. Transvaginal ultrasonography showed endometrial thickening with normal ovarian appearance. Hormonal studies revealed high estradiol and inhibin B levels but normal androgens and adrenal hormones. Magnetic resonance image demonstrated a 13-mm left ovarian tumour. Hysterectomy and bilateral salpingo-oophorectomy were performed, and the pathological study revealed an 8 mm ovarian thecoma. This case illustrates a very unusual cause of postmenopausal bleeding. We suggest a study protocol and discuss the differential diagnosis of this case.

Ovarian solid tumors: MR imaging features with radiologic-pathologic correlation

Ovarian solid tumors have variable histological types including benign and malignant tumors. In addition, non-neoplastic lesions sometimes show a tumor-like appearance. It is important to differentiate benign from malignant tumors. In general, low signal intensity (SI) on T2-weighted imaging (T2WI), low SI on diffusion-weighted imaging (DWI), and gradual increased pattern on dynamic contrast-enhanced magnetic resonance (MR) imaging are known to be suggestive of a benign tumor. Conversely, there are some cases in which these rules do not apply. We should, therefore, strive for a greater understanding of these exceptional cases. Several tumors show characteristic findings on MR imaging reflecting pathologic features, which leads to the correct diagnosis. Additionally, MR imaging provides important information other than the nature of tumors, such as secondary uterine changes. Furthermore, clinical findings and laboratory examination data also help in determining the correct diagnosis.

Adnexal masses associated with peritoneal involvement: diagnosis with CT and MRI

Given the unique intra-peritoneal anatomic location of the adnexa, tubo-ovarian diseases can commonly spread into the peritoneal cavity. Peritoneal seeding may occur in a spectrum of adnexal conditions including infectious diseases, endometriosis, and benign or malignant primary or secondary ovarian tumors. CT is usually the imaging modality on which the concomitant involvement of the peritoneum and the ovary is depicted. The first diagnosis to be considered by the radiologist is generally peritoneal carcinomatosis from ovarian cancer but other conditions cited above have also to be borne in mind and may be suggested on the basis of careful assessment of CT findings or on further MR findings. MRI may indeed help characterize the lesions in some cases. The purpose of this review is to describe the clinical and imaging patterns of peritoneal involvement that may be found in association with different ovarian lesions. Familiarity with these patterns and diagnoses will help the radiologist narrow the differential diagnosis and make an accurate diagnosis, thus facilitating patient management and avoiding unnecessary invasive treatment.

MRI diagnosis of ovarian fibrothecomas: tumour appearances and oestrogenic effect features

OBJECTIVE

To study MRI diagnosis of ovarian fibrothecomas.

METHODS

MRI appearances of 27 ovarian fibrothecomas 26 female patients confirmed by surgical pathology were retrospectively reviewed and correlated with clinical and histological findings.

RESULTS

Most patients were post-menopausal females 73.1% (19/26) of cases. 38.5% (10/26) of patients showed an elevated serum carbohydrate antigen 125 (CA-125) level (>35 U ml(-1)). On MR T2 weighted imaging, 3 distinct features were revealed. (1) Homogeneous hypointense masses in 25.9% (7/27) cases. (2) Heterogeneous tumours with mostly isointense and few patchy hyperintense areas in 51.9% (14/27) cases. (3) Heterogeneous tumours with predominantly hyperintense and few isointense parts in 22.2% (6/27) cases. On T1 weighted imaging, all the fibrothecomas turned out to be homogeneous masses except six cystic degeneration cases. After contrast, 70.4% (19/27) tumours showed homogeneous mild enhancement in all phases. Beyond the tumours, endometrial abnormality and uterus enlargement were found in 38.5% (10/26) and 15.4% (4/26) patients, respectively. Ascites were seen in 53.8% (14/26) patients. There was a statistically significant difference among the 3 T2 weighted image features (F = 7.024; p = 0.003) in terms of the size of fibrothecomas. The cystic tumours also had the tendency to show the ascite condition (p = 0.002) as well as elevated serum CA-125 levels (p = 0.014). Vimentin was positively stained in 10 (76.9%) of 13 cases who underwent the immunohistochemical analysis.

CONCLUSION

MRI has the superiority to show the distinct appearances of tumours as well as their functional features according to oestrogenic effect.

ADVANCES IN KNOWLEDGE

This study describes the unique features of fibrothecomas on MRI on a relatively large series of patients with tumours and the indirect oestrogenic effect findings.

Long-term estradiol-17β administration changes the population of paracervical ganglion neurons supplying the ovary in adult gilts

The aim of this study was to determine the influence of estradiol-17β (E(2)) overdose on the number and distribution of ovarian parasympathetic neurons in the paracervical ganglion (PCG) in adult pigs. To identify the neurons innervating gonads on day 3 of the estrous cycle, the ovaries of both the control and experimental gilts were injected with retrograde neuronal tracer Fast Blue. From next day to the expected day 20 of the second studied cycle, experimental gilts were injected with E(2), while control gilts received oil. The PCG were then collected and processed for double-labeling immunofluorescence. Injections of E(2) increased the E(2) level in the peripheral blood approximately four- to fivefold and reduced the following in the PCG: the total number of Fast Blue-positive neurons; the number of perikarya in the lateral part of the PCG; the numbers of vesicular acetylcholine transporter (VAChT)(+)/somatostatin(+), VAChT(+)/vasoactive intestinal polypeptide (VIP)(+), VAChT(+)/neuronal isoform of nitric oxide synthase(+), VAChT(+)/VIP(-), VAChT(+)/dopamine β-hydroxylase (DβH)(-), VAChT(-)/VIP(-), and VAChT(-)/DβH(-) perikarya; and the total number of perikarya expressing estrogen receptors (ERs) subtype α and/or β. In summary, long-term E(2) treatment of adult gilts downregulates the population of both cholinergic and ERs expressing the PCG ovary-projecting neurons. Our results suggest that elevated E(2) levels occurring during pathological states may regulate gonadal function(s) by affecting ovary-supplying neurons.

Exogenous long-term treatment with 17?-oestradiol alters the innervation pattern in pig ovary

The aim of the present study was to determine the effect of long-term 17β-oestradiol (E2) exposure, a simulation of pathological states that occur with oestrogen overproduction, on the innervation patterns of ovaries in adult gilts. The intraovarian distribution and density of nerve fibres immunoreactive (IR) to protein gene product (PGP) 9.5 and containing dopamine-β-hydroxylase (DBH), neuropeptide Y (NPY), somatostatin (SOM) and galanin (GAL) were determined. From Day 4 of the first oestrous cycle to Day 20 of the second cycle studied, experimental gilts were injected with E2 (1000 μg every 12 h) whereas control gilts were injected with corn oil. After E2 administration, there was an increase in the number of PGP9.5-, DBH-, NPY- and GAL-IR fibres. Numerous PGP9.5-IR terminals were observed within the ground plexus around secondary follicles and small or medium tertiary follicles. Long-term E2 treatment increased the density of DBH- and NPY-IR fibres in the cortical part of the ground plexus, DBH- and GAL-IR fibres in the medullary part of the ground plexus, DBH-IR fibres near small and medium tertiary follicles and NPY-IR fibres around medullary arteries. The data indicate that long-term exposure of gilts to E2 increases the total number of intraovarian fibres, including sympathetic fibres. These results suggest that elevated E2 levels that occur during pathological states may affect the innervation patterns of ovaries and their function(s).

Long term estradiol-17β administration changes population of the dorsal root ganglia neurons innervating the ovary in the sexually mature gilts

The influence of estradiol-17β (E₂) overdose on the number and distribution of neurons in the dorsal root ganglia (DRGs) supplying the ovary of adult pigs was investigated. The numbers of ovarian substance P (SP)-, calcitonin gene-related peptide (CGRP)-, galanin (GAL)-, pituitary adenylate cyclase-activating polypeptide (PACAP)-, neuronal isoform of nitric oxide synthase (nNOS)- and estrogen receptors (ERs)-immunoreactive perikarya were also determined. On day 3 of the estrous cycle, the ovaries of both the control and experimental gilts were injected with retrograde tracer Fast Blue. From day 4 of the estrous cycle to the expected day 20 of the second studied cycle, the experimental gilts were injected with E₂, while the control gilts received oil. The DRGs Th16-L5 were then collected and processed for double-labelling immunofluorescence. Injections of E₂ increased the E₂ level in the peripheral blood ∼4-5-fold and reduced the following in the DRGs: the total number of Fast Blue-positive perikarya, the number of large perikarya, the population of perikarya in the L2 and L3 ganglia, the numbers of SP- and/or CGRP-, PACAP-, nNOS-immunoreactive perikarya and the number of large perikarya expressing ERs subtype α and β. These results show that long-term E₂ treatment of adult gilts affects both the spatial and neurochemical organization pattern of ovary sensory innervation. Our findings suggest that elevated E₂ levels occurring during pathological states may regulate the transmission of sensory modalities from the ovary to the spinal cord.

Imaging features and pathologic characteristics of ovarian thecoma

OBJECTIVE

To analyze the imaging findings of ovarian thecoma and to better understand the tumor features based on aspect of computed tomography and magnetic resonance images.

METHODS

Nineteen ovarian thecomas confirmed by histopathologic examination were analyzed retrospectively. Image characteristics were analyzed and compared with those of the pathologic features.

RESULTS

The mean diameter of tumors was 9.6 cm. The masses were well defined (n = 17) or ill defined (n = 2) and appeared solid with cystic areas (n = 11), entirely solid (n = 4), or cystic with solid components (n = 4). On T2-weighted/spectral adiabatic inversion recovery (T2WI/SPAIR) images, 12 cases appeared isointense or slightly hyperintense. Of the 12 cases, 8 had patchy hypersignal areas. On computed tomographic images, 7 cases showed hypodensity or isodensity. All tumors exhibited mild enhancement. On pathologic examination, the tumor was composed of spindle cells with a moderate amount of cytoplasm.

CONCLUSION

Imaging manifestations of ovarian thecoma are various and nonspecific. However, a large, well-defined mildly enhanced solid mass with cystic areas and especially isointense or slightly hyperintense on T2WI/SPAIR sequence in pelvic cavity may suggest the diagnosis of ovarian thecoma.

Imaging of pediatric ovarian neoplasms

We review the clinical and imaging characteristics of the most common ovarian neoplasms in children and adolescents. Because of the widespread use of diagnostic imaging, incidental ovarian neoplasms might be encountered during the evaluation of abdominal pain, trauma or other indications and might pose a diagnostic dilemma. Conducting adequate imaging studies under these conditions is important, as management strategies differ according to the size and appearance of the lesion as well as the age of the patient. US dominates in gynecological imaging because of its excellent visualization, absence of ionizing radiation and sedation risks and comparatively low cost. For further examination of indeterminate lesions found using US, MRI is being used more progressively in this field, particularly for the evaluation of complex pelvic masses with the aim of distinguishing benign and malignant conditions and conditions requiring surgical intervention. CT is reserved primarily for tumor staging and follow-up and for emergency situations.

Long-term estradiol-17β administration reduces population of neurons in the sympathetic chain ganglia supplying the ovary in adult gilts

Elevated levels of endogenous estrogens occurring in the course of pathological states of ovaries (follicular cysts, tumors) as well as xenoestrogens may result in hyperestrogenism. In rat, a close relationship between estrogens and sympathetic and sensory neurons supplying the genito-urinary system was reported. Recently, we have shown that long-term estradiol-17β (E(2)) administration affected morphological and immunochemical organization of the sympathetic ovarian neurons in the caudal mesenteric ganglion of adult gilts. In this study, the influence of E(2) overdose on the number and distribution of neurons in the sympathetic chain ganglia (SChG) projecting to the ovary of adult pigs was investigated. The numbers of ovarian dopamine-β-hydroxylase (DβH-), neuropeptide Y (NPY-), somatostatin (SOM-), galanin (GAL-) and estrogen receptors (ERs-) immunoreactive perikarya as well as the density of the intraganglionic nerve fibers containing DβH and/or NPY, SOM, GAL were also determined. On day 3 of the estrous cycle the ovaries of both the control and experimental gilts were injected with retrograde neuronal tracer Fast Blue, to identify the neurons innervating gonads. From day 4 of the estrous cycle to the expected day 20 of the second studied cycle, the experimental gilts were injected with E(2), while the control gilts were receiving oil. After the last E(2)/oil injection, the SChG Th16-S2 were collected and processed for double-labeling immunofluorescence. Injections of E(2): (1) increased the E(2) level in the peripheral blood ~4-5 fold, (2) reduced the total number of Fast Blue-positive postganglionic neurons in the ganglia under investigation, (3) decreased the number of perikarya in the L2-L4 ganglia, (4) reduced the number of perikarya in the ventral, dorsal and central regions of the SChG, (5) decreased the numbers of DβH(+)/NPY(+) and DβH(+)/GAL(+) perikarya and the numbers of DβH(+) but NPY(-), SOM(-) and GAL(-) perikarya in the SChG, (6) decreased the number of perikarya expressing ERs subtype α and β, and (7) decreased the total number of the intraganglionic nerve fibers containing DβH and/or NPY. These results show that long-term E(2) treatment of adult gilts down-regulates the population of both noradrenergic and ERs expressing the SChG ovary supplying neurons. Our findings suggest also that elevated E(2) levels that occur during pathological states may regulate gonadal function(s) by affecting ovary supplying neurons.

Long-term estradiol-17β administration decreases the number of neurons in the caudal mesenteric ganglion innervating the ovary in sexually mature gilts

The effect of estradiol-17β (E(2)) on the number and distribution of neurons in the caudal mesenteric ganglion (CaMG) supplying the ovary of adult pigs was investigated. Also, the numbers of ovarian dopamine-β-hydroxylase (DβH-), neuropeptide Y (NPY-), somatostatin (SOM-), galanin (GAL-) and estrogen receptor (ER)-immunoreactive perikarya as well as the density of the intraganglionic nerve fibers containing DβH and/or NPY, SOM, GAL were determined. E(2) was administered i.m. from day 4 of the first studied estrous cycle to the expected day 20 of the second studied cycle. Injections of E(2) (1) increased the E(2) level in the peripheral blood approximately 4-5 fold, (2) decreased the number of small-sized Fast Blue-positive postganglionic neurons in the CaMG, (3) decreased the number of small perikarya in the ventral, dorsal and central regions of the CaMG, (4) decreased the number of large perikarya in the dorsal and central regions, (5) decreased the number of small and large perikarya in the CaMG that were DβH(+)/NPY(+), (6) decreased the number of small DβH(+) but NPY(-) perikarya, (7) decreased the number of small perikarya coded DβH(+)/SOM(+) and DβH(+)/SOM(-), (8) decreased the number of small DβH(+)/GAL(-) perikarya, (9) decreased the number of small and large perikarya expressing ER subtypes α and β and (10) decreased the total number of nerve fibers in the CaMG containing DβH and/or NPY and DβH and/or GAL. These results show that long-term E(2) treatment of adult gilts downregulates the populations of both noradrenergic and ERs expressing ovarian neurons in the CaMG. Our findings suggest also that elevated E(2) levels that occur during pathological states may regulate gonadal function(s) by affecting ovary supplying neurons.

Radiologic Evaluation of Mesenchymal Tumors of the Female Genital Tract

Mesenchymal neoplasms of the female genital tract are a diverse group of tumors, of which the most common are smooth muscle tumors. There is a significant overlap in the imaging characteristics of benign and malignant tumors and final diagnosis often requires pathologic correlation. However, familiarity with typical radiologic features, common imaging pitfalls, and the utility of different imaging modalities can be valuable in the evaluation of mesenchymal tumors. This article highlights the imaging features of the most commonly encountered mesenchymal tumors in the female genital tract.

[MR Imaging of primary ovarian tumors with pathologic correlation]

Ovarian tumors are classified based on the cell of origin into epithelial tumors, germ cell tumors and sex cord-stromal tumors. This pictorial essay illustrates the MR imaging features of the main ovarian tumors with pathologic correlation. These key features are helpful to suggest a specific diagnosis or narrow the differential diagnosis, in order to optimize the surgical approach.