DOI: 10.1148/rg.24si045501
Functioning Ovarian Tumors: Direct and Indirect Findings at MR Imaging1
Yumiko O. Tanaka, MD,
Hajime Tsunoda, MD,
Yumiko Kitagawa, MD,
Teruko Ueno, MD,
Hiroyuki Yoshikawa, MD and
Yukihisa Saida, MD
1 From the Departments of Radiology (Y.O.T., Y.K., T.U., Y.S.) and Obstetrics and Gynecology (H.T., H.Y.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan. Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA scientific assembly. Received January 28, 2004; revision requested March 4 and received April 26; accepted May 5. All authors have no financial relationships to disclose. Address correspondence to Y.O.T. (e-mail: ytanaka@md.tsukuba.ac.jp).
View larger version (50K):
[in a new window]
|
Figure 1. Synthesis of sex steroids. Androgens are steroids that stimulate the development of male secondary sex characteristics. In nonpregnant women, androgens and their precursors are produced by both the adrenal glands and the ovaries in response to their respective tropic hormones: corticotropin (ACTH) and luteinizing hormone (LH). In the ovaries, androgens are produced as precursors in the synthesis of estrogen and estradiol. The theca cells of preantral (secondary) ovarian follicles produce androstenedione and testosterone in response to luteinizing hormone. In response to follicle-stimulating hormone (FSH), the granulosa cells aromatize these androgens to the estrogens. CRF = corticotropin-releasing factor, LH-RH = luteinizing hormone-releasing hormone.
|
|
View larger version (45K):
[in a new window]
|
Figure 2. Hyperandrogenism in women. An excess of androgens causes hirsutism and, in severe cases, virilization. Hirsutism involves the presence of hair that does not normally appear in women, such as a mustache. Virilization includes male-pattern baldness, coarsening of the voice, a decrease in breast size, an increase in muscle mass, loss of female body contour, and enlargement of the clitoris.
|
|
View larger version (56K):
[in a new window]
|
Figure 3. Potential effects of excess estrogen. Clinical symptoms caused by excess estrogen vary and are dependent on the patient’s age. Excess estrogen makes the endometrium thicker owing to benign hyperplasia or cancerous proliferation. The myometrium also gets thicker with excess estrogen. These morphologic uterine changes are clinically related to atypical genital bleeding in postmenopausal women and isosexual pseudoprecocity in premenarchal girls. In women of reproductive age, it seldom causes metropathia hemorrhagica.
|
|
View larger version (148K):
[in a new window]
|
Figure 4a. Sagittal T2-weighted MR images demonstrate uterine morphologic changes according to age and intrinsic or exogenous sex hormones. (a) Image of the uterus obtained during the reproductive period (in a 24-year-old woman) shows that the uterus is 6-9 cm in length and the cervix is smaller than the corpus. There are three zones: an innermost zone of high signal intensity, a middle zone of low signal intensity, and an outermost zone of intermediate signal intensity. These zones correspond to the endometrium, junctional zone, and outer myometrium, respectively. (b, c) MR images of the uterus obtained during childhood (in a 3-year-old girl) (b) and after menopause (in a 65-year-old woman) (c) show that the uterus is small and the zonal anatomy is indistinct (arrows in b). (d) MR image obtained during the reproductive period (in a 34-year-old woman) after the administration of oral contraceptives. The outer myometrium is thicker and brighter, and the junctional zone and the endometrium are thinner. (e) MR image obtained after the administration of a gonadotropin-releasing hormone analogue in a 36-year-old woman with an endometriotic cyst of the ovary (arrow) and adenomyosis. The gonadotropin-releasing hormone analogue caused a hypoestrogenic state and resulted in marked atrophy of the endometrium and an alteration in myometrial signal intensity (arrowheads).
|
|
View larger version (114K):
[in a new window]
|
Figure 4b. Sagittal T2-weighted MR images demonstrate uterine morphologic changes according to age and intrinsic or exogenous sex hormones. (a) Image of the uterus obtained during the reproductive period (in a 24-year-old woman) shows that the uterus is 6-9 cm in length and the cervix is smaller than the corpus. There are three zones: an innermost zone of high signal intensity, a middle zone of low signal intensity, and an outermost zone of intermediate signal intensity. These zones correspond to the endometrium, junctional zone, and outer myometrium, respectively. (b, c) MR images of the uterus obtained during childhood (in a 3-year-old girl) (b) and after menopause (in a 65-year-old woman) (c) show that the uterus is small and the zonal anatomy is indistinct (arrows in b). (d) MR image obtained during the reproductive period (in a 34-year-old woman) after the administration of oral contraceptives. The outer myometrium is thicker and brighter, and the junctional zone and the endometrium are thinner. (e) MR image obtained after the administration of a gonadotropin-releasing hormone analogue in a 36-year-old woman with an endometriotic cyst of the ovary (arrow) and adenomyosis. The gonadotropin-releasing hormone analogue caused a hypoestrogenic state and resulted in marked atrophy of the endometrium and an alteration in myometrial signal intensity (arrowheads).
|
|
View larger version (143K):
[in a new window]
|
Figure 4c. Sagittal T2-weighted MR images demonstrate uterine morphologic changes according to age and intrinsic or exogenous sex hormones. (a) Image of the uterus obtained during the reproductive period (in a 24-year-old woman) shows that the uterus is 6-9 cm in length and the cervix is smaller than the corpus. There are three zones: an innermost zone of high signal intensity, a middle zone of low signal intensity, and an outermost zone of intermediate signal intensity. These zones correspond to the endometrium, junctional zone, and outer myometrium, respectively. (b, c) MR images of the uterus obtained during childhood (in a 3-year-old girl) (b) and after menopause (in a 65-year-old woman) (c) show that the uterus is small and the zonal anatomy is indistinct (arrows in b). (d) MR image obtained during the reproductive period (in a 34-year-old woman) after the administration of oral contraceptives. The outer myometrium is thicker and brighter, and the junctional zone and the endometrium are thinner. (e) MR image obtained after the administration of a gonadotropin-releasing hormone analogue in a 36-year-old woman with an endometriotic cyst of the ovary (arrow) and adenomyosis. The gonadotropin-releasing hormone analogue caused a hypoestrogenic state and resulted in marked atrophy of the endometrium and an alteration in myometrial signal intensity (arrowheads).
|
|
View larger version (132K):
[in a new window]
|
Figure 4d. Sagittal T2-weighted MR images demonstrate uterine morphologic changes according to age and intrinsic or exogenous sex hormones. (a) Image of the uterus obtained during the reproductive period (in a 24-year-old woman) shows that the uterus is 6-9 cm in length and the cervix is smaller than the corpus. There are three zones: an innermost zone of high signal intensity, a middle zone of low signal intensity, and an outermost zone of intermediate signal intensity. These zones correspond to the endometrium, junctional zone, and outer myometrium, respectively. (b, c) MR images of the uterus obtained during childhood (in a 3-year-old girl) (b) and after menopause (in a 65-year-old woman) (c) show that the uterus is small and the zonal anatomy is indistinct (arrows in b). (d) MR image obtained during the reproductive period (in a 34-year-old woman) after the administration of oral contraceptives. The outer myometrium is thicker and brighter, and the junctional zone and the endometrium are thinner. (e) MR image obtained after the administration of a gonadotropin-releasing hormone analogue in a 36-year-old woman with an endometriotic cyst of the ovary (arrow) and adenomyosis. The gonadotropin-releasing hormone analogue caused a hypoestrogenic state and resulted in marked atrophy of the endometrium and an alteration in myometrial signal intensity (arrowheads).
|
|
View larger version (172K):
[in a new window]
|
Figure 4e. Sagittal T2-weighted MR images demonstrate uterine morphologic changes according to age and intrinsic or exogenous sex hormones. (a) Image of the uterus obtained during the reproductive period (in a 24-year-old woman) shows that the uterus is 6-9 cm in length and the cervix is smaller than the corpus. There are three zones: an innermost zone of high signal intensity, a middle zone of low signal intensity, and an outermost zone of intermediate signal intensity. These zones correspond to the endometrium, junctional zone, and outer myometrium, respectively. (b, c) MR images of the uterus obtained during childhood (in a 3-year-old girl) (b) and after menopause (in a 65-year-old woman) (c) show that the uterus is small and the zonal anatomy is indistinct (arrows in b). (d) MR image obtained during the reproductive period (in a 34-year-old woman) after the administration of oral contraceptives. The outer myometrium is thicker and brighter, and the junctional zone and the endometrium are thinner. (e) MR image obtained after the administration of a gonadotropin-releasing hormone analogue in a 36-year-old woman with an endometriotic cyst of the ovary (arrow) and adenomyosis. The gonadotropin-releasing hormone analogue caused a hypoestrogenic state and resulted in marked atrophy of the endometrium and an alteration in myometrial signal intensity (arrowheads).
|
|
View larger version (104K):
[in a new window]
|
Figure 5a. Retiform Sertoli-Leydig cell tumor of intermediate differentiation in a 32-year-old pregnant woman. (a) Axial T2-weighted MR image shows a large, lobulated, solid mass (arrowheads) with peripheral cysts (arrow). (b) Axial T1-weighted MR image shows that the contents of the cyst have slightly high signal intensity (arrow). Ut = uterus. Because the patient’s pregnancy was in the 12th gestational week, contrast material was not administered. The surgical specimen obtained at left salpingo-oophorectomy revealed a lobulated mass with rich solid components. (c) High-power photomicrograph (hematoxylin-eosin [H-E] stain) shows that thin cords of darkly staining Sertoli cells lie in the edematous stroma. The pathologic diagnosis was a Sertoli-Leydig cell tumor of intermediate differentiation with a retiform component. Although Sertoli-Leydig cell tumors are reported as predominantly solid masses, cyst formation is common in retiform subtypes and those with heterologous elements. The patient did not show any virilization; however, the serum level of inhibin A was elevated (190.2 pg/mL; normal level, <150 pg/mL), a finding that is another marker of a sex steroid-producing tumor.
|
|
View larger version (121K):
[in a new window]
|
Figure 5b. Retiform Sertoli-Leydig cell tumor of intermediate differentiation in a 32-year-old pregnant woman. (a) Axial T2-weighted MR image shows a large, lobulated, solid mass (arrowheads) with peripheral cysts (arrow). (b) Axial T1-weighted MR image shows that the contents of the cyst have slightly high signal intensity (arrow). Ut = uterus. Because the patient’s pregnancy was in the 12th gestational week, contrast material was not administered. The surgical specimen obtained at left salpingo-oophorectomy revealed a lobulated mass with rich solid components. (c) High-power photomicrograph (hematoxylin-eosin [H-E] stain) shows that thin cords of darkly staining Sertoli cells lie in the edematous stroma. The pathologic diagnosis was a Sertoli-Leydig cell tumor of intermediate differentiation with a retiform component. Although Sertoli-Leydig cell tumors are reported as predominantly solid masses, cyst formation is common in retiform subtypes and those with heterologous elements. The patient did not show any virilization; however, the serum level of inhibin A was elevated (190.2 pg/mL; normal level, <150 pg/mL), a finding that is another marker of a sex steroid-producing tumor.
|
|
View larger version (148K):
[in a new window]
|
Figure 5c. Retiform Sertoli-Leydig cell tumor of intermediate differentiation in a 32-year-old pregnant woman. (a) Axial T2-weighted MR image shows a large, lobulated, solid mass (arrowheads) with peripheral cysts (arrow). (b) Axial T1-weighted MR image shows that the contents of the cyst have slightly high signal intensity (arrow). Ut = uterus. Because the patient’s pregnancy was in the 12th gestational week, contrast material was not administered. The surgical specimen obtained at left salpingo-oophorectomy revealed a lobulated mass with rich solid components. (c) High-power photomicrograph (hematoxylin-eosin [H-E] stain) shows that thin cords of darkly staining Sertoli cells lie in the edematous stroma. The pathologic diagnosis was a Sertoli-Leydig cell tumor of intermediate differentiation with a retiform component. Although Sertoli-Leydig cell tumors are reported as predominantly solid masses, cyst formation is common in retiform subtypes and those with heterologous elements. The patient did not show any virilization; however, the serum level of inhibin A was elevated (190.2 pg/mL; normal level, <150 pg/mL), a finding that is another marker of a sex steroid-producing tumor.
|
|
View larger version (144K):
[in a new window]
|
Figure 6a. Juvenile GCT in a 2-year-old girl who showed development of the breasts, the appearance of pubic hair, and atypical genital bleeding. (a) Sagittal T2-weighted MR image demonstrates a large solid mass with high signal intensity (arrows) and an enlarged uterus with thick endometrium (arrowheads). Ascites is also seen. (b) Sagittal contrast material-enhanced T1-weighted MR image shows that the tumor (arrows) is homogeneously enhanced. (c) Photomicrograph (original magnification, x10; H-E stain) shows that the tumor cells have abundant eosinophilic cytoplasm and round nuclei and are growing in solid nodules. The patient’s elevated serum estradiol level (33.7 pg/mL [123.7 pmol/L]) decreased (<10 pg/mL [36.7 pmol/L]) immediately after right salpingo-oophorectomy.
|
|
View larger version (152K):
[in a new window]
|
Figure 6b. Juvenile GCT in a 2-year-old girl who showed development of the breasts, the appearance of pubic hair, and atypical genital bleeding. (a) Sagittal T2-weighted MR image demonstrates a large solid mass with high signal intensity (arrows) and an enlarged uterus with thick endometrium (arrowheads). Ascites is also seen. (b) Sagittal contrast material-enhanced T1-weighted MR image shows that the tumor (arrows) is homogeneously enhanced. (c) Photomicrograph (original magnification, x10; H-E stain) shows that the tumor cells have abundant eosinophilic cytoplasm and round nuclei and are growing in solid nodules. The patient’s elevated serum estradiol level (33.7 pg/mL [123.7 pmol/L]) decreased (<10 pg/mL [36.7 pmol/L]) immediately after right salpingo-oophorectomy.
|
|
View larger version (170K):
[in a new window]
|
Figure 6c. Juvenile GCT in a 2-year-old girl who showed development of the breasts, the appearance of pubic hair, and atypical genital bleeding. (a) Sagittal T2-weighted MR image demonstrates a large solid mass with high signal intensity (arrows) and an enlarged uterus with thick endometrium (arrowheads). Ascites is also seen. (b) Sagittal contrast material-enhanced T1-weighted MR image shows that the tumor (arrows) is homogeneously enhanced. (c) Photomicrograph (original magnification, x10; H-E stain) shows that the tumor cells have abundant eosinophilic cytoplasm and round nuclei and are growing in solid nodules. The patient’s elevated serum estradiol level (33.7 pg/mL [123.7 pmol/L]) decreased (<10 pg/mL [36.7 pmol/L]) immediately after right salpingo-oophorectomy.
|
|
View larger version (168K):
[in a new window]
|
Figure 7a. Adult GCT in a 68-year-old woman. (a, b) Axial T2-weighted (a) and sagittal T1-weighted (b) MR images demonstrate a multilocular cystic mass (arrows) with relatively thick septa. The septa have low signal intensity on the T2-weighted image (a). The signal intensity of the fluid within the cysts is very high on the T1-weighted image (b), a finding indicative of hemorrhagic contents. Compared with those seen in healthy postmenopausal women, the uterus is bigger and the endometrium is brighter on the T2-weighted image (arrowheads in a). (c) Sagittal contrast-enhanced T1-weighted MR image obtained with fat saturation shows that the septa have intense enhancement (arrows). A multilocular hemorrhagic mass was removed. (d) High-power photomicrograph (H-E stain) shows cells with oval and angular nuclei and scanty cytoplasm proliferating in trabeculae and cords separated by fibrous tissue. Some red blood cells are also seen, a finding that corresponds to the hypervascular nature evident at imaging. This case demonstrates the most common imaging appearance of GCT—a microfollicular pattern. The elevated serum estradiol level (69.6 pg/mL [255.4 pmol/L]) returned to normal (<8 pg/mL [29.4 pmol/L]) after surgery.
|
|
View larger version (156K):
[in a new window]
|
Figure 7b. Adult GCT in a 68-year-old woman. (a, b) Axial T2-weighted (a) and sagittal T1-weighted (b) MR images demonstrate a multilocular cystic mass (arrows) with relatively thick septa. The septa have low signal intensity on the T2-weighted image (a). The signal intensity of the fluid within the cysts is very high on the T1-weighted image (b), a finding indicative of hemorrhagic contents. Compared with those seen in healthy postmenopausal women, the uterus is bigger and the endometrium is brighter on the T2-weighted image (arrowheads in a). (c) Sagittal contrast-enhanced T1-weighted MR image obtained with fat saturation shows that the septa have intense enhancement (arrows). A multilocular hemorrhagic mass was removed. (d) High-power photomicrograph (H-E stain) shows cells with oval and angular nuclei and scanty cytoplasm proliferating in trabeculae and cords separated by fibrous tissue. Some red blood cells are also seen, a finding that corresponds to the hypervascular nature evident at imaging. This case demonstrates the most common imaging appearance of GCT—a microfollicular pattern. The elevated serum estradiol level (69.6 pg/mL [255.4 pmol/L]) returned to normal (<8 pg/mL [29.4 pmol/L]) after surgery.
|
|
View larger version (168K):
[in a new window]
|
Figure 7c. Adult GCT in a 68-year-old woman. (a, b) Axial T2-weighted (a) and sagittal T1-weighted (b) MR images demonstrate a multilocular cystic mass (arrows) with relatively thick septa. The septa have low signal intensity on the T2-weighted image (a). The signal intensity of the fluid within the cysts is very high on the T1-weighted image (b), a finding indicative of hemorrhagic contents. Compared with those seen in healthy postmenopausal women, the uterus is bigger and the endometrium is brighter on the T2-weighted image (arrowheads in a). (c) Sagittal contrast-enhanced T1-weighted MR image obtained with fat saturation shows that the septa have intense enhancement (arrows). A multilocular hemorrhagic mass was removed. (d) High-power photomicrograph (H-E stain) shows cells with oval and angular nuclei and scanty cytoplasm proliferating in trabeculae and cords separated by fibrous tissue. Some red blood cells are also seen, a finding that corresponds to the hypervascular nature evident at imaging. This case demonstrates the most common imaging appearance of GCT—a microfollicular pattern. The elevated serum estradiol level (69.6 pg/mL [255.4 pmol/L]) returned to normal (<8 pg/mL [29.4 pmol/L]) after surgery.
|
|
View larger version (160K):
[in a new window]
|
Figure 7d. Adult GCT in a 68-year-old woman. (a, b) Axial T2-weighted (a) and sagittal T1-weighted (b) MR images demonstrate a multilocular cystic mass (arrows) with relatively thick septa. The septa have low signal intensity on the T2-weighted image (a). The signal intensity of the fluid within the cysts is very high on the T1-weighted image (b), a finding indicative of hemorrhagic contents. Compared with those seen in healthy postmenopausal women, the uterus is bigger and the endometrium is brighter on the T2-weighted image (arrowheads in a). (c) Sagittal contrast-enhanced T1-weighted MR image obtained with fat saturation shows that the septa have intense enhancement (arrows). A multilocular hemorrhagic mass was removed. (d) High-power photomicrograph (H-E stain) shows cells with oval and angular nuclei and scanty cytoplasm proliferating in trabeculae and cords separated by fibrous tissue. Some red blood cells are also seen, a finding that corresponds to the hypervascular nature evident at imaging. This case demonstrates the most common imaging appearance of GCT—a microfollicular pattern. The elevated serum estradiol level (69.6 pg/mL [255.4 pmol/L]) returned to normal (<8 pg/mL [29.4 pmol/L]) after surgery.
|
|
View larger version (143K):
[in a new window]
|
Figure 8a. Thecoma in a 17-year-old girl with marked virilization and primary amenorrhea. (a) Axial T2-weighted MR image shows a mixed solid and cystic left ovarian mass; the solid part has marked low signal intensity (arrowheads). (b) Axial T1-weighted MR images obtained before (left) and 120 seconds after (right) contrast material administration show a multilocular cystic component on the ventral side of the tumor; the cystic component is filled with high-signal-intensity fluid (arrow). The solid part of the mass is intensely enhanced during the early phase of the dynamic contrast material study (right). (c) Sagittal T2-weighted MR image shows an atrophic uterus (arrows). The patient also had hirsutism, a hypertrophic clitoris, mild obesity, and deepening of the voice. (d) High-power photomicrograph (H-E stain) of a specimen from the yellowish, predominantly solid tumor removed from the patient. The tumor is composed of oval or round tumor cells and has abundant pale cytoplasm containing lipid within a fibromatous background. The elevated serum testosterone level (113.9 ng/dL [4.0 nmol/L]; normal range, 6-86 ng/dL [0.2-3.0 nmol/L]) decreased immediately after surgery (29.6 ng/dL [1.0 nmol/L]).
|
|
View larger version (88K):
[in a new window]
|
Figure 8b. Thecoma in a 17-year-old girl with marked virilization and primary amenorrhea. (a) Axial T2-weighted MR image shows a mixed solid and cystic left ovarian mass; the solid part has marked low signal intensity (arrowheads). (b) Axial T1-weighted MR images obtained before (left) and 120 seconds after (right) contrast material administration show a multilocular cystic component on the ventral side of the tumor; the cystic component is filled with high-signal-intensity fluid (arrow). The solid part of the mass is intensely enhanced during the early phase of the dynamic contrast material study (right). (c) Sagittal T2-weighted MR image shows an atrophic uterus (arrows). The patient also had hirsutism, a hypertrophic clitoris, mild obesity, and deepening of the voice. (d) High-power photomicrograph (H-E stain) of a specimen from the yellowish, predominantly solid tumor removed from the patient. The tumor is composed of oval or round tumor cells and has abundant pale cytoplasm containing lipid within a fibromatous background. The elevated serum testosterone level (113.9 ng/dL [4.0 nmol/L]; normal range, 6-86 ng/dL [0.2-3.0 nmol/L]) decreased immediately after surgery (29.6 ng/dL [1.0 nmol/L]).
|
|
View larger version (122K):
[in a new window]
|
Figure 8c. Thecoma in a 17-year-old girl with marked virilization and primary amenorrhea. (a) Axial T2-weighted MR image shows a mixed solid and cystic left ovarian mass; the solid part has marked low signal intensity (arrowheads). (b) Axial T1-weighted MR images obtained before (left) and 120 seconds after (right) contrast material administration show a multilocular cystic component on the ventral side of the tumor; the cystic component is filled with high-signal-intensity fluid (arrow). The solid part of the mass is intensely enhanced during the early phase of the dynamic contrast material study (right). (c) Sagittal T2-weighted MR image shows an atrophic uterus (arrows). The patient also had hirsutism, a hypertrophic clitoris, mild obesity, and deepening of the voice. (d) High-power photomicrograph (H-E stain) of a specimen from the yellowish, predominantly solid tumor removed from the patient. The tumor is composed of oval or round tumor cells and has abundant pale cytoplasm containing lipid within a fibromatous background. The elevated serum testosterone level (113.9 ng/dL [4.0 nmol/L]; normal range, 6-86 ng/dL [0.2-3.0 nmol/L]) decreased immediately after surgery (29.6 ng/dL [1.0 nmol/L]).
|
|
View larger version (164K):
[in a new window]
|
Figure 8d. Thecoma in a 17-year-old girl with marked virilization and primary amenorrhea. (a) Axial T2-weighted MR image shows a mixed solid and cystic left ovarian mass; the solid part has marked low signal intensity (arrowheads). (b) Axial T1-weighted MR images obtained before (left) and 120 seconds after (right) contrast material administration show a multilocular cystic component on the ventral side of the tumor; the cystic component is filled with high-signal-intensity fluid (arrow). The solid part of the mass is intensely enhanced during the early phase of the dynamic contrast material study (right). (c) Sagittal T2-weighted MR image shows an atrophic uterus (arrows). The patient also had hirsutism, a hypertrophic clitoris, mild obesity, and deepening of the voice. (d) High-power photomicrograph (H-E stain) of a specimen from the yellowish, predominantly solid tumor removed from the patient. The tumor is composed of oval or round tumor cells and has abundant pale cytoplasm containing lipid within a fibromatous background. The elevated serum testosterone level (113.9 ng/dL [4.0 nmol/L]; normal range, 6-86 ng/dL [0.2-3.0 nmol/L]) decreased immediately after surgery (29.6 ng/dL [1.0 nmol/L]).
|
|
View larger version (196K):
[in a new window]
|
Figure 9a. Fibrothecoma in a 60-year-old woman. (a) Sagittal T2-weighted MR image shows a large, lobulated, entirely solid tumor (arrows). Although a supravaginal resection had been performed before the MR imaging examination, the remaining portion of the uterus is enlarged and cervical glands (arrowheads) show very high signal intensity. (b) Sagittal contrast-enhanced T1-weighted MR image shows that only the peripheral portion of the tumor (arrows) is weakly enhanced. A solid yellow mass was removed. (c) Low-power photomicrograph obtained with fat stain (oil red-O stain) reveals that the tumor cells contain abundant intracytoplasmic lipid within fibromatous tissue. (Reprinted, with permission, from reference 30.)
|
|
View larger version (187K):
[in a new window]
|
Figure 9b. Fibrothecoma in a 60-year-old woman. (a) Sagittal T2-weighted MR image shows a large, lobulated, entirely solid tumor (arrows). Although a supravaginal resection had been performed before the MR imaging examination, the remaining portion of the uterus is enlarged and cervical glands (arrowheads) show very high signal intensity. (b) Sagittal contrast-enhanced T1-weighted MR image shows that only the peripheral portion of the tumor (arrows) is weakly enhanced. A solid yellow mass was removed. (c) Low-power photomicrograph obtained with fat stain (oil red-O stain) reveals that the tumor cells contain abundant intracytoplasmic lipid within fibromatous tissue. (Reprinted, with permission, from reference 30.)
|
|
View larger version (164K):
[in a new window]
|
Figure 9c. Fibrothecoma in a 60-year-old woman. (a) Sagittal T2-weighted MR image shows a large, lobulated, entirely solid tumor (arrows). Although a supravaginal resection had been performed before the MR imaging examination, the remaining portion of the uterus is enlarged and cervical glands (arrowheads) show very high signal intensity. (b) Sagittal contrast-enhanced T1-weighted MR image shows that only the peripheral portion of the tumor (arrows) is weakly enhanced. A solid yellow mass was removed. (c) Low-power photomicrograph obtained with fat stain (oil red-O stain) reveals that the tumor cells contain abundant intracytoplasmic lipid within fibromatous tissue. (Reprinted, with permission, from reference 30.)
|
|
View larger version (137K):
[in a new window]
|
Figure 10a. Sclerosing stromal tumor in a 32-year-old woman. Sagittal T2- and T1-weighted MR images show that there is a huge, predominantly solid mass in front of the uterus. (a) T2-weighted image shows that the mass is composed of an admixture of low-signal-intensity nodules (arrows) set against the high-signal-intensity stroma. (b) Contrast-enhanced T1-weighted image shows that the nodules (arrows) enhance more than the stroma. The resected specimen was a huge, yellowish, solid tumor with edematous change and weighed 1,550 g. (c) Loupe image of the specimen (H-E stain) shows a pseudolobular pattern, in which cellular pseudolobules are separated by edematous hypocellular fibrous tissue. The finding of low-signal-intensity nodules within the high-signal-intensity stroma at T2-weighted imaging corresponds to the pseudolobular pattern. The cellular components of the nodules consist of a disorganized admixture of fibroblasts and rounded, vacuolated cells.
|
|
View larger version (119K):
[in a new window]
|
Figure 10b. Sclerosing stromal tumor in a 32-year-old woman. Sagittal T2- and T1-weighted MR images show that there is a huge, predominantly solid mass in front of the uterus. (a) T2-weighted image shows that the mass is composed of an admixture of low-signal-intensity nodules (arrows) set against the high-signal-intensity stroma. (b) Contrast-enhanced T1-weighted image shows that the nodules (arrows) enhance more than the stroma. The resected specimen was a huge, yellowish, solid tumor with edematous change and weighed 1,550 g. (c) Loupe image of the specimen (H-E stain) shows a pseudolobular pattern, in which cellular pseudolobules are separated by edematous hypocellular fibrous tissue. The finding of low-signal-intensity nodules within the high-signal-intensity stroma at T2-weighted imaging corresponds to the pseudolobular pattern. The cellular components of the nodules consist of a disorganized admixture of fibroblasts and rounded, vacuolated cells.
|
|
View larger version (156K):
[in a new window]
|
Figure 10c. Sclerosing stromal tumor in a 32-year-old woman. Sagittal T2- and T1-weighted MR images show that there is a huge, predominantly solid mass in front of the uterus. (a) T2-weighted image shows that the mass is composed of an admixture of low-signal-intensity nodules (arrows) set against the high-signal-intensity stroma. (b) Contrast-enhanced T1-weighted image shows that the nodules (arrows) enhance more than the stroma. The resected specimen was a huge, yellowish, solid tumor with edematous change and weighed 1,550 g. (c) Loupe image of the specimen (H-E stain) shows a pseudolobular pattern, in which cellular pseudolobules are separated by edematous hypocellular fibrous tissue. The finding of low-signal-intensity nodules within the high-signal-intensity stroma at T2-weighted imaging corresponds to the pseudolobular pattern. The cellular components of the nodules consist of a disorganized admixture of fibroblasts and rounded, vacuolated cells.
|
|
View larger version (122K):
[in a new window]
|
Figure 11a. Ovarian carcinoid with testosterone-producing stroma in a 54-year-old woman. (a) Sagittal T2-weighted MR image shows a multilocular cystic mass with fluid of varying signal intensities in the lower abdomen. The mass contains a relatively large mural nodule (arrows), which has low signal intensity. (b) Sagittal contrast-enhanced T1-weighted MR image shows that the nodule has homogeneous enhancement (arrows). The patient had hirsutism and slight clitoromegaly. Laboratory data showed increased concentrations of serum testosterone (371.2 ng/dL [12.9 nmol/L]). Therefore, the preoperative radiologic diagnosis was a Sertoli-Leydig cell tumor. The cut surface of the resected specimen showed a multilocular cystic mass with a large white mural nodule. (c) Low-power photomicrograph (H-E stain) reveals medium-sized tumor cells proliferating in a solid and insular pattern accompanied by a delicate fibrous stroma. The tumor was positive for neuroendocrine markers at immunohistochemical staining, which helped determine the diagnosis of ovarian carcinoid. (d) High-power photomicrograph shows that the stroma is also positive for  -inhibin stain (arrows), a finding that indicates that the stroma produces androgen. The serum testosterone level returned to normal after surgery (8.2 ng/dL [0.3 nmol/L]). (Reprinted, with permission, from reference 36.)
|
|
View larger version (153K):
[in a new window]
|
Figure 11b. Ovarian carcinoid with testosterone-producing stroma in a 54-year-old woman. (a) Sagittal T2-weighted MR image shows a multilocular cystic mass with fluid of varying signal intensities in the lower abdomen. The mass contains a relatively large mural nodule (arrows), which has low signal intensity. (b) Sagittal contrast-enhanced T1-weighted MR image shows that the nodule has homogeneous enhancement (arrows). The patient had hirsutism and slight clitoromegaly. Laboratory data showed increased concentrations of serum testosterone (371.2 ng/dL [12.9 nmol/L]). Therefore, the preoperative radiologic diagnosis was a Sertoli-Leydig cell tumor. The cut surface of the resected specimen showed a multilocular cystic mass with a large white mural nodule. (c) Low-power photomicrograph (H-E stain) reveals medium-sized tumor cells proliferating in a solid and insular pattern accompanied by a delicate fibrous stroma. The tumor was positive for neuroendocrine markers at immunohistochemical staining, which helped determine the diagnosis of ovarian carcinoid. (d) High-power photomicrograph shows that the stroma is also positive for -inhibin stain (arrows), a finding that indicates that the stroma produces androgen. The serum testosterone level returned to normal after surgery (8.2 ng/dL [0.3 nmol/L]). (Reprinted, with permission, from reference 36.)
|
|
View larger version (145K):
[in a new window]
|
Figure 11c. Ovarian carcinoid with testosterone-producing stroma in a 54-year-old woman. (a) Sagittal T2-weighted MR image shows a multilocular cystic mass with fluid of varying signal intensities in the lower abdomen. The mass contains a relatively large mural nodule (arrows), which has low signal intensity. (b) Sagittal contrast-enhanced T1-weighted MR image shows that the nodule has homogeneous enhancement (arrows). The patient had hirsutism and slight clitoromegaly. Laboratory data showed increased concentrations of serum testosterone (371.2 ng/dL [12.9 nmol/L]). Therefore, the preoperative radiologic diagnosis was a Sertoli-Leydig cell tumor. The cut surface of the resected specimen showed a multilocular cystic mass with a large white mural nodule. (c) Low-power photomicrograph (H-E stain) reveals medium-sized tumor cells proliferating in a solid and insular pattern accompanied by a delicate fibrous stroma. The tumor was positive for neuroendocrine markers at immunohistochemical staining, which helped determine the diagnosis of ovarian carcinoid. (d) High-power photomicrograph shows that the stroma is also positive for -inhibin stain (arrows), a finding that indicates that the stroma produces androgen. The serum testosterone level returned to normal after surgery (8.2 ng/dL [0.3 nmol/L]). (Reprinted, with permission, from reference 36.)
|
|
View larger version (147K):
[in a new window]
|
Figure 11d. Ovarian carcinoid with testosterone-producing stroma in a 54-year-old woman. (a) Sagittal T2-weighted MR image shows a multilocular cystic mass with fluid of varying signal intensities in the lower abdomen. The mass contains a relatively large mural nodule (arrows), which has low signal intensity. (b) Sagittal contrast-enhanced T1-weighted MR image shows that the nodule has homogeneous enhancement (arrows). The patient had hirsutism and slight clitoromegaly. Laboratory data showed increased concentrations of serum testosterone (371.2 ng/dL [12.9 nmol/L]). Therefore, the preoperative radiologic diagnosis was a Sertoli-Leydig cell tumor. The cut surface of the resected specimen showed a multilocular cystic mass with a large white mural nodule. (c) Low-power photomicrograph (H-E stain) reveals medium-sized tumor cells proliferating in a solid and insular pattern accompanied by a delicate fibrous stroma. The tumor was positive for neuroendocrine markers at immunohistochemical staining, which helped determine the diagnosis of ovarian carcinoid. (d) High-power photomicrograph shows that the stroma is also positive for -inhibin stain (arrows), a finding that indicates that the stroma produces androgen. The serum testosterone level returned to normal after surgery (8.2 ng/dL [0.3 nmol/L]). (Reprinted, with permission, from reference 36.)
|
|
View larger version (103K):
[in a new window]
|
Figure 12a. Metastatic ovarian tumor with androgen-producing stroma in a 52-year-old woman. (a) Axial T2-weighted MR image shows a lobulated solid mass (arrows) with relatively low signal intensity adjacent to the uterus. The tumor does not seem to originate from the uterus, and no bridging vascular sign is noted. (b) Axial MR images obtained before (left) and 60 seconds after (right) contrast material administration show that the tumor enhances rapidly and strongly. This enhancing pattern eliminates the possibility of a fibroma. The patient had a history of advanced gastric cancer 3 years before the MR imaging examination. (c) Low-power photomicrograph (H-E stain) reveals signet ring cells (of the same histologic subtype as the formerly treated gastric cancer) strewn in small clusters within an ovarian stoma. The increased serum testosterone level (140.9 ng/dL [4.9 nmol/L]) normalized after surgery (12.5 ng/dL [0.4 nmol/L]).
|
|
View larger version (58K):
[in a new window]
|
Figure 12b. Metastatic ovarian tumor with androgen-producing stroma in a 52-year-old woman. (a) Axial T2-weighted MR image shows a lobulated solid mass (arrows) with relatively low signal intensity adjacent to the uterus. The tumor does not seem to originate from the uterus, and no bridging vascular sign is noted. (b) Axial MR images obtained before (left) and 60 seconds after (right) contrast material administration show that the tumor enhances rapidly and strongly. This enhancing pattern eliminates the possibility of a fibroma. The patient had a history of advanced gastric cancer 3 years before the MR imaging examination. (c) Low-power photomicrograph (H-E stain) reveals signet ring cells (of the same histologic subtype as the formerly treated gastric cancer) strewn in small clusters within an ovarian stoma. The increased serum testosterone level (140.9 ng/dL [4.9 nmol/L]) normalized after surgery (12.5 ng/dL [0.4 nmol/L]).
|
|
View larger version (132K):
[in a new window]
|
Figure 12c. Metastatic ovarian tumor with androgen-producing stroma in a 52-year-old woman. (a) Axial T2-weighted MR image shows a lobulated solid mass (arrows) with relatively low signal intensity adjacent to the uterus. The tumor does not seem to originate from the uterus, and no bridging vascular sign is noted. (b) Axial MR images obtained before (left) and 60 seconds after (right) contrast material administration show that the tumor enhances rapidly and strongly. This enhancing pattern eliminates the possibility of a fibroma. The patient had a history of advanced gastric cancer 3 years before the MR imaging examination. (c) Low-power photomicrograph (H-E stain) reveals signet ring cells (of the same histologic subtype as the formerly treated gastric cancer) strewn in small clusters within an ovarian stoma. The increased serum testosterone level (140.9 ng/dL [4.9 nmol/L]) normalized after surgery (12.5 ng/dL [0.4 nmol/L]).
|
|
View larger version (133K):
[in a new window]
|
Figure 13a. Mucinous cystadenoma with stromal hyperplasia in a 65-year-old woman. (a, b) Coronal T2-weighted (a) and contrast-enhanced fat-saturated T1-weighted (b) MR images show a multilocular cystic mass (arrows) containing fluid with varying signal intensities on the right cranial side of the enlarged uterus (arrowheads in a). The patient presented with atypical genital bleeding, and the endometrium has higher signal intensity than that normally seen in postmenopausal women on the T2-weighted image (a). This appearance is similar to that of a GCT with a macrofollicular pattern. (c) Photomicrograph (original magnification, x10; H-E stain) reveals that the tumor is composed of cysts, the epithelial lining of which is mucin-filled columnar cells (arrows). The histopathologic diagnosis was mucinous cystadenoma. Conversely, this tumor has relatively rich stroma, which can contain testosterone-aromatizing enzymes. The increased serum estradiol level returned to normal after surgery. (Reprinted, with permission, from reference 36.)
|
|
View larger version (145K):
[in a new window]
|
Figure 13b. Mucinous cystadenoma with stromal hyperplasia in a 65-year-old woman. (a, b) Coronal T2-weighted (a) and contrast-enhanced fat-saturated T1-weighted (b) MR images show a multilocular cystic mass (arrows) containing fluid with varying signal intensities on the right cranial side of the enlarged uterus (arrowheads in a). The patient presented with atypical genital bleeding, and the endometrium has higher signal intensity than that normally seen in postmenopausal women on the T2-weighted image (a). This appearance is similar to that of a GCT with a macrofollicular pattern. (c) Photomicrograph (original magnification, x10; H-E stain) reveals that the tumor is composed of cysts, the epithelial lining of which is mucin-filled columnar cells (arrows). The histopathologic diagnosis was mucinous cystadenoma. Conversely, this tumor has relatively rich stroma, which can contain testosterone-aromatizing enzymes. The increased serum estradiol level returned to normal after surgery. (Reprinted, with permission, from reference 36.)
|
|
View larger version (147K):
[in a new window]
|
Figure 13c. Mucinous cystadenoma with stromal hyperplasia in a 65-year-old woman. (a, b) Coronal T2-weighted (a) and contrast-enhanced fat-saturated T1-weighted (b) MR images show a multilocular cystic mass (arrows) containing fluid with varying signal intensities on the right cranial side of the enlarged uterus (arrowheads in a). The patient presented with atypical genital bleeding, and the endometrium has higher signal intensity than that normally seen in postmenopausal women on the T2-weighted image (a). This appearance is similar to that of a GCT with a macrofollicular pattern. (c) Photomicrograph (original magnification, x10; H-E stain) reveals that the tumor is composed of cysts, the epithelial lining of which is mucin-filled columnar cells (arrows). The histopathologic diagnosis was mucinous cystadenoma. Conversely, this tumor has relatively rich stroma, which can contain testosterone-aromatizing enzymes. The increased serum estradiol level returned to normal after surgery. (Reprinted, with permission, from reference 36.)
|
|
View larger version (111K):
[in a new window]
|
Figure 14a. PCOS in a 27-year-old woman with endometrial carcinoma. The patient was slightly obese (height, 156.8 cm; weight, 74.6 kg; body mass index, 30) and had an irregular menstrual cycle. In this case, the serum testosterone level was within the normal range (44.3 ng/dL [1.5 nmol/L]). (a) Coronal T2-weighted MR image shows that both ovaries are slightly enlarged and have many follicles at the periphery (arrowheads). Total hysterectomy and bilateral salpingooophorectomy were performed to treat the advanced endometrial carcinoma. (b) Loupe image of a histologic section (H-E stain) shows multiple cysts situated superficially beneath the outer cortex, whereas the central portion of the ovary is composed of homogeneous stroma.
|
|
View larger version (100K):
[in a new window]
|
Figure 14b. PCOS in a 27-year-old woman with endometrial carcinoma. The patient was slightly obese (height, 156.8 cm; weight, 74.6 kg; body mass index, 30) and had an irregular menstrual cycle. In this case, the serum testosterone level was within the normal range (44.3 ng/dL [1.5 nmol/L]). (a) Coronal T2-weighted MR image shows that both ovaries are slightly enlarged and have many follicles at the periphery (arrowheads). Total hysterectomy and bilateral salpingooophorectomy were performed to treat the advanced endometrial carcinoma. (b) Loupe image of a histologic section (H-E stain) shows multiple cysts situated superficially beneath the outer cortex, whereas the central portion of the ovary is composed of homogeneous stroma.
|
|
View larger version (146K):
[in a new window]
|
Figure 15a. Polycystic ovary in a 19-year-old woman with Cushing syndrome. The patient was markedly obese (height, 168.6 cm; weight, 106.9 kg; body mass index, 37.6) and had hirsutism. She had had secondary amenorrhea for 1 year. Results of an endocrinologic survey revealed increased levels of serum cortisol (26.9 µg/dL [742 nmol/L]; normal range, 6-18 µg/dL [166-497 nmol/L]) and corticotropin (88.7 pg/mL [20 pmol/L]; normal range, 7-54 pg/mL [1.5-12 pmol/L]). A slight increase in the serum testosterone level was also noted (63.0 ng/dL [2.2 nmol/L]). (a) Coronal fat-saturated T1-weighted MR image of the sella turcica reveals a pituitary adenoma (arrows), which has weaker enhancement than the normal pituitary gland (arrowheads). (b) Coronal T2-weighted MR image of the pelvis demonstrates a slightly enlarged ovary with an increased number of follicles (arrows). Although this is not a typical ovarian finding of PCOS, it is similar to one. Because it has been reported that the morphologic characteristics of ovaries in patients with Cushing syndrome and increased cortisol secretion are suggestive of PCOS, we speculate that the secondary amenorrhea in this patient was due to secondary PCOS.
|
|
View larger version (168K):
[in a new window]
|
Figure 15b. Polycystic ovary in a 19-year-old woman with Cushing syndrome. The patient was markedly obese (height, 168.6 cm; weight, 106.9 kg; body mass index, 37.6) and had hirsutism. She had had secondary amenorrhea for 1 year. Results of an endocrinologic survey revealed increased levels of serum cortisol (26.9 µg/dL [742 nmol/L]; normal range, 6-18 µg/dL [166-497 nmol/L]) and corticotropin (88.7 pg/mL [20 pmol/L]; normal range, 7-54 pg/mL [1.5-12 pmol/L]). A slight increase in the serum testosterone level was also noted (63.0 ng/dL [2.2 nmol/L]). (a) Coronal fat-saturated T1-weighted MR image of the sella turcica reveals a pituitary adenoma (arrows), which has weaker enhancement than the normal pituitary gland (arrowheads). (b) Coronal T2-weighted MR image of the pelvis demonstrates a slightly enlarged ovary with an increased number of follicles (arrows). Although this is not a typical ovarian finding of PCOS, it is similar to one. Because it has been reported that the morphologic characteristics of ovaries in patients with Cushing syndrome and increased cortisol secretion are suggestive of PCOS, we speculate that the secondary amenorrhea in this patient was due to secondary PCOS.
|
|
Copyright © 2004 by the Radiological Society of North America.
