This document discusses various types of ovarian cysts and tumors. It begins by distinguishing between functional/hemorrhagic cysts and real ovarian tumors. For reproductive aged women, most ovarian cysts are physiological or functional cysts. Ultrasound can often distinguish these from other cysts or tumors based on appearance. Real ovarian tumors are further broken down into epithelial, germ cell, sex cord-stromal tumors and metastases. Specific tumor types like teratomas, granulosa cell tumors and others are then described in terms of prevalence, appearance on imaging and other characteristics.

1. THORSANG R1
Prince of Songkla University
05.11.2014

2.  Functional/hemorrhagic cysts
 Real ovarian tumors

3.  Functional cysts
 Real ovarian tumors

5.  Reproductive age group  Most ovarian
cysts are physiological or functional
 dominant follicles
 follicular cysts (from failure of the follicle to
rupture or regress)
 corpus luteal cysts (may contain hemorrhage)
 US:
 thin walled (< 3 mm), unilocular, with posterior
acoustic enhancement

6.  Cyst with uniform internal echoes,
reticulations or septations
 hemorrhagic functional cyst
 endometrioma
 A follow up ultrasound in 6-12 wk should be
performed
 A functional hemorrhagic cyst shows complete
interval resolution
 an endometrioma persists or even slightly
increases in size

7.  MRI
 most functional cysts
▪ T1: low signal intensity
▪ T2: very high signal intensity
 Hemorrhagic corpus luteum cysts have a
characteristic appearance of blood products
▪ T1: relatively high signal intensity
▪ T2: intermediate to high signal intensity

10.  Polycystic ovarian syndrome (PCOS)
affecting 5%-10% of women of reproductive
age
 Characterized by menstrual irregularities,
hirsuitism, obesity and sclerotic ovaries

11.  TVUS (gold standard)
 an enlarged ovary with 10 or more peripherally
arranged cysts,
 each cyst of 2-8 mm diameter
 with an echogenic central stroma
 MRI: T2 weighted images in the long and
short axis of the uterus
 Peripherally arranged uniform sized high signal
intensity cysts with hypointense central stroma

13.  child bearing age
 80% implanted in the ovary
 pelvic pain, dysmenorrhea and infertility
 From cystic to complex

14.  US: cystic masses with diffuse low level internal
echoes with hyperechoic foci secondary to a
cholesterol cleft or blood clot in the wall
 Endometriomas and implants may mimic
malignant lesions on CT
 MRI:
 T1: very high signal intensity (light-bulb)
▪ persistent high signal on fat saturated T1-weighted image
confirms the absence of fat in the lesion
 T2: intermediate to low signal intensity from blood
products in various stages and decreased free water
content

16. OVARIAN
TUMOR
EPITHELIAL GERM CELL
SEX CORD-STROMAL
METASTASIS

17. OVARIAN
TUMOR
EPITHELIAL
GERM CELL
Serous Mucinous Endometriod Clear cell Brenner
SEX CORD-STROMAL
METASTASIS

18.  60% of all ovarian neoplasms
 85% of malignant ovarian neoplasms
 Age 50-70 years
 Serous
 mucinous
 Endometrioid
 Clear cell
 Brenner tumors

24.  Serous and mucinous tumors
 Mostly benign
 Endometrioid tumors
 Mostly malignant
 Clear cell carcinomas
 malignant

25.  Papillary projections
 Characteristic features of epithelial neoplasms of
the ovary
 represent folds of the proliferating neoplasmic
epithelium growing over a stromal core
 single best predictors of an epithelial neoplasm
and may correlate with the aggressiveness of the
tumor

26.  Papillary projections
 Benign
▪ usually absent
▪ generally small
 Low malignant
▪ profuse in epithelial tumors with
 Invasive carcinomas
▪ often present
▪ gross appearance is dominated by a solid component.

29.  Wall thickening, septa, and multilocularity
are less reliable indicators of malignancy
 Frequently seen in benign neoplasms
▪ cystadenofibromas
▪ mucinous cystadenomas
▪ endometriomas

30.  10%–15% of all ovarian carcinomas.
 Almost always malignant
 About 15%–30% are associated with
synchronous endometrial carcinoma or
endometrial hyperplasia
 Bilateral involvement is seen in 30%–
 50%
 Imaging findings are nonspecific
a large, complex cystic mass with solid components
Endometrial thickening

31.  Most common malignant neoplasm
 endometrioid carcinoma
 clear cell carcinoma

33.  5% of ovarian carcinomas
 always malignant
 The majority (75%) of clear cell carcinomas
are stage I disease
 prognosis appears to be better than that of other
ovarian cancers

34.  Most common malignant neoplasm
 endometrioid carcinoma
 clear cell carcinoma

35.  A unilocular or large cyst
 solid protrusions
 often both round and few in number
 The cyst margin is almost always smooth
 Always in DDx for serous tumor with
aggressive pattern

37.  composed of transitional cells with dense
stroma
 2%–3% of ovarian tumours
 rarely malignant
 usually small (2 cm)
 discovered incidentally, but affected patients
may present with a palpable mass or pain
 associated with other ovarian tumors in 30%
of cases

38.  a multilocular cystic mass with a solid
component
 a small, mostly solid mass
 CT: mildly enhanced solid components
 T2 MR: the dense fibrous stroma
 lower signal intensity
 Extensive amorphous calcification
 often present within the solid component

40. OVARIAN
TUMOR
EPITHELIAL GERM CELL
Teratoma
Dysgerminoma
Mature Immature
SEX CORD-STROMAL
Endodermal
sinus tumor
METASTASIS

41.  second most common group of ovarian
neoplasms
 15%–20% of all ovarian tumors
 Subtypes
 mature teratoma
 Immature teratoma
 Dysgerminoma
 endodermal sinus tumor
 embryonal carcinoma
 choriocarcinoma

42.  mature teratoma
 Only benign tumour in this group
 the most common lesion in this group
 Malignant germ cell tumors
 generally large and nonspecific
 a complex but predominantly solid imaging
appearance
 AFP and HCG also help establish the
diagnosis

43.  most common benign ovarian tumor
in women less than 45 years old
 composed of mature tissue from two or more
embryonic germ cell layers
 Monodermal type—less common

44.  Unilocular
 Filled with sebaceous material and lined by
squamous epithelium
 Hair follicles, skin glands, muscle, and others
 There is usually a raised protuberance projecting
into the cyst cavity
= the Rokitansky nodule
 Broad spectrum of findings, ranging from
 purely cystic
 mixed mass with all the components of the three
germ cell layers
 noncystic mass composed predominantly of fat

45.  US
 a cystic lesion with a densely echogenic tubercle
(Rokitansky nodule) projecting into the cyst lumen
 a diffusely or partially echogenic mass with the
echogenic area (sebaceous material and hair )
 CT
 fat attenuation within a cyst, with or without
calcification in the wall
 MR
 the sebaceous component has very high signal
intensity on T1

49.  Complications
 Torsion
 Rupture:
▪ leakage of the liquefied sebaceous contents into the
peritoneum and resulting in granulomatous peritonitis
 Malignant degeneration
▪ Squamous cell carcinoma

50.  Less common forms of mature teratomas are
the monodermal types
 struma ovarii
▪ mature thyroid tissue predominates
▪ Hyperthyroidism
 carcinoids

51.  less than 1% of all teratomas
 Contains immature tissue from all three germ
cell layers
 Age < 20 years
 malignant, immature teratomas
 Prominent solid components
 May demonstrate
internal necrosis or hemorrhage
UNLIKE Benign mature teratomas

52.  A large, complex mass with cystic and solid
components
 Scattered calcifications
 Mature teratomas, calcification is localized to
mural nodules
 Small foci of fat are also seen in immature
teratomas

54.  rare
 young women
 counterpart of seminoma of the testis
 5% of dysgerminomas
 Syncytiotrophoblastic giant cells  elevation of
serum HCG levels

55.  Speckled calcification
 Multilobulated solid masses with
prominent fibrovascular septa
 The anechoic, low signal-intensity, or low-attenuation
area of the tumor
represents necrosis and hemorrhage

58.  yolk sac tumor
 rare
 Malignant
 Age < 20 years
 A large, complex pelvic mass that extends into
the abdomen
 Contains both solid and cystic components
 The cystic areas are composed of epithelial line cysts
▪ produced by the tumor or of coexisting mature teratomas
 grow rapidly and have a poor prognosis
 Elevated serum AFP

60. OVARIAN
TUMOR
EPITHELIAL GERM CELL
SEX CORD-STROMAL
METASTASIS
Granulosa cell Fibrothecoma Sertoli-Leydig

61.  Gonadal cell types or mesenchymal cells
 8% of ovarian neoplasms
 All age groups
 The most common types
 granulosa cell tumors
 Fibrothecomas
 Sertoli-Leydig cell tumors
 hormonal effects !!!

62.  The vast majority of sex cord–stromal tumors
are either benign or confined to the ovary
 benign
▪ fibrothecoma, sclerosing stromal tumor
 confined to the ovary
▪ granulosa cell tumor, Sertoli-Leydig cell tumor

63.  Most common malignant sex cord–stromal
 most common estrogen-producing ovarian
tumor
 Predominantly in peri- and postmenopause
 Hyperestrogenemia
 endometrial hyperplasia, polyps, or carcinoma

64.  Imaging findings
 vary widely
▪ solid masses with varying degrees of hemorrhagic or
fibrotic changes
▪ multilocular cystic lesions
▪ completely cystic tumors
 heterogeneous
▪ From intratumoral bleeding, infarcts, fibrous
degeneration, and irregularly arranged tumor cells

65.  VS epithelial cell tumor
▪ do not have intracystic papillary projections,
have less propensity for peritoneal seeding,
and are confined to the ovary
 Estrogenic effects
▪ uterine enlargement
▪ endometrial thickening or hemorrhage

68.  Benign
 Thecal cell--estrogen
 Thecoma--estrogenic activity , few fibroblasts
 Fibroma--no estrogenic activity
 Both pre- and postmenopausal women

69.  Fibroma
 most common sex cord tumor
 composed of fibroblasts and collagen
 associated with
▪ Ascites
▪ Meigs syndrome (Right-sided pleural effusion)

70.  Fibroma
 US demonstrates a homogeneous hypoechoic
mass with posterior acoustic shadowing
 CT shows a homogeneous solid tumor with
delayed enhancement
 MR: T1 + T2 --low signal intensity
 Dense calcifications are often seen
 Scattered high-signal-intensity areas in the mass
represent edema or cystic degeneration

73.  very low signal intensity on T2
 Fibroma
 Fibrothecoma
 Cystadenofibroma
 Brenner tumor

74.  Age 10-30
 T2
 hyperintense cystic components
 heterogeneous solid component with intermediate
to high signal intensity
 CECT: early peripheral enhancement with
centripetal progression
 Striking early enhancement = the cellular areas with
their prominent vascular network
 An area of prolonged enhancement in the inner
portion = collagenous hypocellular area

76.  Age 30 years
 low-grade malignancy
 0.5% of ovarian tumors
 most common virilizing tumor
 However, only 30% of these tumors are hormonally
active
 composed of heterologous tissue
 Carcinoid, mesenchymal, and mucinous epithelial
tissues
 a well-defined, enhancing solid mass with
intratumoral cyst

78. OVARIAN
TUMOR
EPITHELIAL GERM CELL
SEX CORD-STROMAL
(Collision) METASTASIS

79.  coexistence of two adjacent but histologically
distinct tumors
 Rare
 most commonly
 Teratoma + cystadenoma
 Teratoma + cystadenocarcinoma
 Mechanism--uncertain
 Considered when
 an ovarian tumor cannot be subsumed under one
histologic type, especially teratoma

81. OVARIAN
TUMOR
EPITHELIAL GERM CELL
SEX CORD-STROMAL
METASTASIS

82.  Most common:
 colon and stomach
 breast, lung, and contralateral ovary
 lymphoma
 10% of all ovarian tumors
 reproductive years

83.  Metastatic tumors to the ovary that contain
mucin-secreting “signet ring” cells
 usually originate in the gastrointestinal tract
 Stomach
 Colon

84.  Non-specific
 consisting of predominantly solid components
 a mixture of cystic and solid areas
 Distinctive findings:
bilateral complex masses with
 T1: Hypointense solid components (dense stromal
reaction)
 T2: Internal hyperintensity (mucin)

86. • The imaging appearance ranges
from cystic to solid masses
• Although ovarian tumors have similar
clinical and radiologic findings,
specific key features are present

87.  a thin-walled, unilocular or multilocular
tumor filled with serous fluid
 very common
 may mimic
 a physiologic cyst
 an atypical mature cystic teratoma that lacks the
characteristic eccentric mural nodule

88.  almost always multilocular
 may be large

89.  a thick, irregular wall; thick septa
 papillary projections
 a large soft-tissue component with necrosis

90.  Endometrioid carcinoma
 Granulosa cell tumor
 Thecoma or fibrothecoma

91.  Fibrous
 Fibroma
 fibrothecoma
 Brenner tumor

92.  endometrioid carcinoma
 clear cell carcinoma

93.  The presence of fat is highly specific
 Mature
 predominantly cystic with
dense calcifications
 Immature teratomas
 predominantly solid with
small foci of lipid material
Scattered calcifications

94.  dysgerminoma
 endodermal sinus tumors
 large
 predominantly solid masses
 more common in younger women
 Dysgerminoma
 prominent fibrovascular septa

95.  Sclerosing stromal tumor
 Sertoli-Leydig cell tumor
 Struma ovarii
 cystadenofibroma

96.  serous epithelial tumor
 Fibrothecoma
 mature or immature teratoma
 Brenner tumor

97.  metastatic ovarian tumors
 serous epithelial tumors of the ovary

98.  When imaging findings that cannot be
subsumed under one histologic type
 especially in cases of ovarian teratoma

99.  Functional/hemorrhagic cysts
 Real ovarian tumors

100. OVARIAN
TUMOR
EPITHELIAL GERM CELL
SEX CORD-STROMAL
(Collision) METASTASIS

101. References
 Un Jung, Seung, et al. "CT and MR Imaging of Ovarian
Tumors with Emphasis on Differential
Diagnosis." Radiographics (2002): 1305-325. Web.
 Wasnik, Ashish P, et at. "Multimodality imaging of
ovarian cystic lesions: Review with an imaging based
algorithmic approach.“ World J Radiol (2013) March
28; 5(3): 113-125. Web.
 Zagoria, Ronald J., and Glenn A. Tung. Genitourinary
Radiology: The Requisites. St. Louis: Mosby, 1997.
Print.