Ovarian tumors can be epithelial, germ cell, or stromal-sex cord in origin. Epithelial tumors are the most common and include serous cystadenocarcinomas, mucinous cystadenocarcinomas, endometrioid carcinomas, and clear cell carcinomas. Germ cell tumors include mature cystic teratomas, immature teratomas, dysgerminomas, and yolk sac tumors. Stromal-sex cord tumors include granulosa cell tumors and Sertoli-Leydig cell tumors. Imaging can identify characteristics suggestive of malignancy like solid components, irregular walls, thick septations, necrosis, and ascites.

1. OVARIAN TUMORS
By:
Jitendra K Patil
D.Y.Patil Hospital
kolhapur

2. • Ovarian cancer is the second most common gynecological malignancy - highest
in developed nations.
• The high mortality rates of ovarian cancer are partly due to its late detection, with
67% of patients presenting with advanced disease.
• Majority are Epithelial tumors
• Others include:
germ cell tumors
stromal-sex cord tumors
metastatic cancers from extra-ovarian primary sites.

3. • The ovaries are extraperitoneal organs, Oval in structures, vary in size and
appearance depending on the woman's age, hormonal status, and stage of the
menstrual cycle.
• The adult ovary is about
2.5–5 cm long
1.5–3 cm wide
1–2 cm thick
• The Ovary lies against the Lateral Wall of the
Pelvis in a depression called the Ovarian
Fossa
• Bounded by the:
External iliac vessels above and by the Internal
iliac vessels behind.

4. • Posterior surface of the ovary is attached to the broad ligament by
the mesovarium
• Uterine body by the utero-ovarian ligament
• Lateral pelvic wall by the suspensory ligaments.
• Tumor can spread via these ligaments to the
adjacent pelvic organs.

5. NORMAL SONOGRAPHIC APPEARANCE
• Relatively homogeneous echotexture with a central, more echogenic
medulla.
• Small, well-defined anechoic or cystic follicles may be seen peripherally in
the cortex.
TVS: Dominant follicle developing in a normal
ovary.

6. NORMAL CT ANATOMY

7. Normal ovaries on MR imaging
• The landmark of the ovaries is the follicles
• Follicules are cortical cysts of high T2 signal.
• The average size of a functional follicle is 1 cm
• The follicles are of low to intermediate signal on T1Wls

10. Morphologic features at US that are suggestive of ovarian malignancy
include:
• an irregular solid mass
• an irregular multilocular cystic mass
• solid components or papillary
• vegetations on the cyst wall
• high flow within solid components
• on color Doppler images
• (low impedance flow: RI <0.6)
• ascites
• peritoneal nodules, lymphadenopathy
• Solid components or papillary projections in a cystic adnexal mass on gray-scale US images
are the most significant indicators of malignancy.

11. Computed Tomography
• Morphologic information from the use of enhanced CT, e.g. presence of a complex cystic
mass with enhancing solid components.
• Calcification is occasionally seen in papillary serous adenocarcinoma and Brenner tumor.
• Ancillary findings of malignancy, such as ascites, peritoneal deposits, lymphadenopathy and
pleural effusion may also be seen.
• Involvement of uterus, rectum, colon and small bowel by the tumor.
• Deposits on peritoneum, liver or bowel surfaces.

12. MR morphologic features that are indicative of a malignant adnexal mass
include
• the presence of both solid and cystic areas within a lesion;
• necrosis within a solid lesion;
• papillary projections from the wall or septum of a cystic lesion;
• an irregular septum or wall;
• multiple thickened (>3 mm) septations;
• a large size (>6 cm);
• bilateral lesions;
• ascites, peritoneal disease, or lymphadenopathy

13. Epithelial tumors:
Serous cystadenocarcinoma
• predominantly cystic masses.
• They may show wall thickening
and nodularity, internal solid
areas and septations.
• Malignant tumors tend to have
more nodularity and solid areas
than their benign counterpart

14. Classic Signs:
Classic signs of serous cystadenocarcinoma include bilateral thick-walled adnexal cystic lesions with solid
components or papillary projections with ascites and peritoneal carcinomatosis.

15. Mucinous cystadenocarcinomas
Predominantly large cystic masses but
tend to be multiloculated with multiple
thick internal septations.
Diffuse internal echoes due to their
high mucin content.

17. Endometrioid Carcinoma
• 10%-15% of all ovarian carcinomas.
• Almost always malignant.
• About 15%-30% - synchronous endometrial carcinoma or
endometrial hyperplasia.
• Although rare, endometrioid carcinoma is the most common
malignant neoplasm arising from endometriosis, followed by
clear cell carcinoma.
• Bilateral involvement is seen in 30% - 50% of cases.
• Imaging findings are nonspecific and include a large, complex
• cystic mass with solid components.

19. Clear Cell Carcinoma
• ~5% of ovarian carcinomas and are always
malignant.
• Majority in stage I at the time of diagnosis and
tends to have a better prognosis than other
ovarian malignancies.
• Second most common malignancy occurring in
patients with endometriosis.

22. Brenner's tumors
• Rare lesions (2% to 3% of all ovarian tumors), and are
composed of transitional cells and dense stroma.
• Rarely malignant, usually less than 2 cm, and typically
discovered incidentally.
• Appears as either a multilocular cystic mass with a solid
component or as a small predominately solid mass - mild or
moderate enhancement at CT.
• Extensive calcification within the solid component is often
present.
• MRI: dense stroma - low T2-weighted signal similar to that of
a fibroma.

24. Germ cell tumors
Benign cystic teratoma - "Dermoid cyst"
• Most common germ cell neoplasm of the ovary - B/L
in 15-25% cases.
• Mature elements derived from ectoderm,
mesoderm, or endoderm, resulting in a broad
range of appearances.
• Age 10-30 yrs.
• Predominantly cystic, presence of mature
ectodermal elements such as bone, teeth and hair
give them a complex or varied appearance.

25. Characteristic USG features of a mature cystic teratoma:
Hypoechoic mass with hyperechoic nodule (Rokitansky nodule or dermoid plug)
Usually unilocular (90%)
• Calcifications (30%)
• May contain hyperechoic lines caused by floating hair.
• May contain a fat-fluid level, i.e. fat floating on aqueous fluid

27. Immature teratoma
• Immature teratoma represents less than 1% of all teratomas and contains immature
tissue from all three germ cell layers
• Malignant immature teratomas have prominent solid components and may demonstrate
internal necrosis or hemorrhage.
• Usually a unilateral solid mass with coarse calcifications and rarely intratumoral fat.
• Peritoneal spread is common.
• Gliomatosis peritonei - multiple benign or low grade malignant deposits of immature
teratoma
throughout the peritoneal cavity.

29. Dysgerminoma
• Most common ovarian malignancy in children and young adults with 80% of patient under 30 years of
age.
• Large, unilateral, well-defined solid mass - usually homogeneous; however, varying degree of necrosis.
or hemorrhage may be present.
• Characteristic imaging findings include multilobulated solid masses with prominent fibrovascular septa

32. Yolk sac or endodermal sinus tumor
• Highly malignant ovarian tumor characterized by rapid growth and early
metastases
• On CT and MRI - seen as complex cystic or solid tumors with
heterogeneous and intense contrast enhancement.
• Areas of necrosis and hemorrhages are often present.

33. Sex Cord–Stromal Tumors
Granulosa Cell Tumor
mostcommon malignant sex cord–stromal tumor as well as the most common
estrogen-producingovarian tumor.
The hyperestrogenemia may produce combined endometrial hyperplasia, polyps, or
carcinoma.
granulosa cell tumors do not have intracystic papillary projec-tions, have less
propensity for peritoneal seeding

35. FIBROTHECOMA
• Fibroma and thecoma are forms of a spectrum of benign tumors.
• Lipid-rich thecoma demonstrates estrogenic activity and few fibroblasts.
• Fibroma has no thecal cells and demonstrates no estrogenic activity.
• Fibroma is composed of whorled bundles of cytologically bland, benign,
spindle-shaped fibroblasts and collagen .
• They are associated with ascites or Meigs syndrome

38. Sertoli-Leydig Cell Tumor
• occur in young women (30 years of age)
and are considered to be a low-grade
malignancy.
• The tumor is composed of heterologous
tissue and manifests as a well-defined,
enhancing solid mass with intratumoral
cysts

39. Metastases to ovaries
• Most commonly arise from primary tumors of the stomach, colon, pancreas or breast.
• May be solid, cystic or complex ovarian masses, frequently bilateral and usually associated
with ascites.
• Less likely to be multilocular than primary ovarian tumors but otherwise there are no
specific distinguishing features.
• 'Krukenberg tumor' - specific histological pattern of mucin-secreting signet cells with
sarcomatous stroma, usually from a gastric primary.

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