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DOI: 10.1148/rg.262055041
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Malignant Transformation of Pelvic Endometriosis: MR Imaging Findings and Pathologic Correlation1

Mayumi Takeuchi, MD, PhD, Kenji Matsuzaki, MD, PhD, Hisanori Uehara, MD, PhD and Hiromu Nishitani, MD, PhD

1 From the Departments of Radiology (M.T., K.M., H.N.) and Molecular and Environmental Pathology (H.U.), University of Tokushima, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received March 4, 2005; revision requested June 6 and received June 23; accepted June 29. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  Malignant transformation of right-sided endometrioma in a 42-year-old woman. (a) Photomicrograph of a histopathologic specimen shows endometrial glands (*) outside the fibrous capsule of the cyst (FC), and hemorrhagic material inside the cystic lumen (L). (b) Photomicrograph of a histopathologic specimen shows clear cell carcinoma (C) and a cluster of hemosiderin-laden macrophages (arrows) within the thick fibrous capsule (FC).

 

Figure 1
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  		Figure 1b.  Malignant transformation of right-sided endometrioma in a 42-year-old woman. (a) Photomicrograph of a histopathologic specimen shows endometrial glands (*) outside the fibrous capsule of the cyst (FC), and hemorrhagic material inside the cystic lumen (L). (b) Photomicrograph of a histopathologic specimen shows clear cell carcinoma (C) and a cluster of hemosiderin-laden macrophages (arrows) within the thick fibrous capsule (FC).

 

Figure 2
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  		Figure 2a.  Bilateral endometriomas in a 21-year-old woman. (a) Axial T2-weighted fast spin-echo MR image (repetition time msec/echo time msec, 4000/105) shows bilateral adnexal masses with extensive shading, findings that represent endometriomas. (b) Axial T1-weighted spin-echo MR image (500/14) shows the endometriomas with high signal intensity. (c) Axial T1-weighted fat-saturated spin-echo MR image (500/14) shows no reduction of signal in the endometriomas. (d) Photograph of the resected specimen shows a cystic mass that contains chocolate-colored hemorrhagic material.

 

Figure 2
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  		Figure 2b.  Bilateral endometriomas in a 21-year-old woman. (a) Axial T2-weighted fast spin-echo MR image (repetition time msec/echo time msec, 4000/105) shows bilateral adnexal masses with extensive shading, findings that represent endometriomas. (b) Axial T1-weighted spin-echo MR image (500/14) shows the endometriomas with high signal intensity. (c) Axial T1-weighted fat-saturated spin-echo MR image (500/14) shows no reduction of signal in the endometriomas. (d) Photograph of the resected specimen shows a cystic mass that contains chocolate-colored hemorrhagic material.

 

Figure 2
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  		Figure 2c.  Bilateral endometriomas in a 21-year-old woman. (a) Axial T2-weighted fast spin-echo MR image (repetition time msec/echo time msec, 4000/105) shows bilateral adnexal masses with extensive shading, findings that represent endometriomas. (b) Axial T1-weighted spin-echo MR image (500/14) shows the endometriomas with high signal intensity. (c) Axial T1-weighted fat-saturated spin-echo MR image (500/14) shows no reduction of signal in the endometriomas. (d) Photograph of the resected specimen shows a cystic mass that contains chocolate-colored hemorrhagic material.

 

Figure 2
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  		Figure 2d.  Bilateral endometriomas in a 21-year-old woman. (a) Axial T2-weighted fast spin-echo MR image (repetition time msec/echo time msec, 4000/105) shows bilateral adnexal masses with extensive shading, findings that represent endometriomas. (b) Axial T1-weighted spin-echo MR image (500/14) shows the endometriomas with high signal intensity. (c) Axial T1-weighted fat-saturated spin-echo MR image (500/14) shows no reduction of signal in the endometriomas. (d) Photograph of the resected specimen shows a cystic mass that contains chocolate-colored hemorrhagic material.

 

Figure 3
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  		Figure 3a.  Malignant transformation of a left-sided ovarian endometrioma in a 40-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (3500/95) shows a left adnexal cystic mass with a slightly hyperintense mural nodule (arrow). (b) Sagittal T1-weighted spin-echo MR image (300/9) shows a hyperintense cystic mass with a hypointense mural nodule (arrow). (c) Sagittal contrast-enhanced T1-weighted gradient-echo MR image (100/1.6) shows enhancement of the mural nodule (arrow). Clear cell carcinoma was proved at surgery. (d) Axial T2-weighted fast spin-echo MR image (3600/90), obtained 2 years before a, b, and c, shows a left adnexal cystic mass with shading indicative of a benign endometrioma. (e) Axial T2-weighted fast spin-echo MR image (4800/88), obtained 2 years after a, shows a slightly hypointense mural nodule (arrow) and an absence of shading in the mass.

 

Figure 3
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  		Figure 3b.  Malignant transformation of a left-sided ovarian endometrioma in a 40-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (3500/95) shows a left adnexal cystic mass with a slightly hyperintense mural nodule (arrow). (b) Sagittal T1-weighted spin-echo MR image (300/9) shows a hyperintense cystic mass with a hypointense mural nodule (arrow). (c) Sagittal contrast-enhanced T1-weighted gradient-echo MR image (100/1.6) shows enhancement of the mural nodule (arrow). Clear cell carcinoma was proved at surgery. (d) Axial T2-weighted fast spin-echo MR image (3600/90), obtained 2 years before a, b, and c, shows a left adnexal cystic mass with shading indicative of a benign endometrioma. (e) Axial T2-weighted fast spin-echo MR image (4800/88), obtained 2 years after a, shows a slightly hypointense mural nodule (arrow) and an absence of shading in the mass.

 

Figure 3
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  		Figure 3c.  Malignant transformation of a left-sided ovarian endometrioma in a 40-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (3500/95) shows a left adnexal cystic mass with a slightly hyperintense mural nodule (arrow). (b) Sagittal T1-weighted spin-echo MR image (300/9) shows a hyperintense cystic mass with a hypointense mural nodule (arrow). (c) Sagittal contrast-enhanced T1-weighted gradient-echo MR image (100/1.6) shows enhancement of the mural nodule (arrow). Clear cell carcinoma was proved at surgery. (d) Axial T2-weighted fast spin-echo MR image (3600/90), obtained 2 years before a, b, and c, shows a left adnexal cystic mass with shading indicative of a benign endometrioma. (e) Axial T2-weighted fast spin-echo MR image (4800/88), obtained 2 years after a, shows a slightly hypointense mural nodule (arrow) and an absence of shading in the mass.

 

Figure 3
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  		Figure 3d.  Malignant transformation of a left-sided ovarian endometrioma in a 40-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (3500/95) shows a left adnexal cystic mass with a slightly hyperintense mural nodule (arrow). (b) Sagittal T1-weighted spin-echo MR image (300/9) shows a hyperintense cystic mass with a hypointense mural nodule (arrow). (c) Sagittal contrast-enhanced T1-weighted gradient-echo MR image (100/1.6) shows enhancement of the mural nodule (arrow). Clear cell carcinoma was proved at surgery. (d) Axial T2-weighted fast spin-echo MR image (3600/90), obtained 2 years before a, b, and c, shows a left adnexal cystic mass with shading indicative of a benign endometrioma. (e) Axial T2-weighted fast spin-echo MR image (4800/88), obtained 2 years after a, shows a slightly hypointense mural nodule (arrow) and an absence of shading in the mass.

 

Figure 3
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  		Figure 3e.  Malignant transformation of a left-sided ovarian endometrioma in a 40-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (3500/95) shows a left adnexal cystic mass with a slightly hyperintense mural nodule (arrow). (b) Sagittal T1-weighted spin-echo MR image (300/9) shows a hyperintense cystic mass with a hypointense mural nodule (arrow). (c) Sagittal contrast-enhanced T1-weighted gradient-echo MR image (100/1.6) shows enhancement of the mural nodule (arrow). Clear cell carcinoma was proved at surgery. (d) Axial T2-weighted fast spin-echo MR image (3600/90), obtained 2 years before a, b, and c, shows a left adnexal cystic mass with shading indicative of a benign endometrioma. (e) Axial T2-weighted fast spin-echo MR image (4800/88), obtained 2 years after a, shows a slightly hypointense mural nodule (arrow) and an absence of shading in the mass.

 

Figure 4
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  		Figure 4a.  Malignant transformation of a right-sided ovarian endometrioma in a 59-year-old woman. (a) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (550/9) shows a hyperintense right adnexal cystic mass with contrast-enhanced mural nodules. (b) Photograph of the resected specimen shows a cystic mass with nodular components. (c, d) Photomicrographs of histopathologic specimens show clear cell carcinoma with various morphologic features and cell types, including clear cells (c) and hobnail cells (arrows in d).

 

Figure 4
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  		Figure 4b.  Malignant transformation of a right-sided ovarian endometrioma in a 59-year-old woman. (a) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (550/9) shows a hyperintense right adnexal cystic mass with contrast-enhanced mural nodules. (b) Photograph of the resected specimen shows a cystic mass with nodular components. (c, d) Photomicrographs of histopathologic specimens show clear cell carcinoma with various morphologic features and cell types, including clear cells (c) and hobnail cells (arrows in d).

 

Figure 4
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  		Figure 4c.  Malignant transformation of a right-sided ovarian endometrioma in a 59-year-old woman. (a) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (550/9) shows a hyperintense right adnexal cystic mass with contrast-enhanced mural nodules. (b) Photograph of the resected specimen shows a cystic mass with nodular components. (c, d) Photomicrographs of histopathologic specimens show clear cell carcinoma with various morphologic features and cell types, including clear cells (c) and hobnail cells (arrows in d).

 

Figure 4
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  		Figure 4d.  Malignant transformation of a right-sided ovarian endometrioma in a 59-year-old woman. (a) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (550/9) shows a hyperintense right adnexal cystic mass with contrast-enhanced mural nodules. (b) Photograph of the resected specimen shows a cystic mass with nodular components. (c, d) Photomicrographs of histopathologic specimens show clear cell carcinoma with various morphologic features and cell types, including clear cells (c) and hobnail cells (arrows in d).

 

Figure 5
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  		Figure 5a.  Malignant transformation of a left-sided ovarian endometrioma in a 65-year-old woman. (a) Axial T1-weighted spin-echo MR image (466/14) shows a left adnexal, slightly hyperintense, large cystic mass with mural nodules. (b) Sagittal T2-weighted fast spin-echo MR image (4200/96) shows the cystic mass with high signal intensity and the mural nodules with heterogeneous signal intensity. The histologic diagnosis was poorly differentiated adenocarcinoma.

 

Figure 5
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  		Figure 5b.  Malignant transformation of a left-sided ovarian endometrioma in a 65-year-old woman. (a) Axial T1-weighted spin-echo MR image (466/14) shows a left adnexal, slightly hyperintense, large cystic mass with mural nodules. (b) Sagittal T2-weighted fast spin-echo MR image (4200/96) shows the cystic mass with high signal intensity and the mural nodules with heterogeneous signal intensity. The histologic diagnosis was poorly differentiated adenocarcinoma.

 

Figure 6
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  		Figure 6a.  Malignant transformation of a left-sided ovarian endometrioma in a 46-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (3400/120) shows a large left adnexal cystic mass with hypointense signal and shading and with a hyperintense mural nodule. (b) Sagittal T1-weighted spin-echo MR image (600/24) shows the cystic mass with high signal intensity. (c) Sagittal contrast-enhanced T1-weighted spin-echo MR image (600/24) shows enhancement of the mural nodule (arrow). The histologic diagnosis was endometrioid adenocarcinoma.

 

Figure 6
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  		Figure 6b.  Malignant transformation of a left-sided ovarian endometrioma in a 46-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (3400/120) shows a large left adnexal cystic mass with hypointense signal and shading and with a hyperintense mural nodule. (b) Sagittal T1-weighted spin-echo MR image (600/24) shows the cystic mass with high signal intensity. (c) Sagittal contrast-enhanced T1-weighted spin-echo MR image (600/24) shows enhancement of the mural nodule (arrow). The histologic diagnosis was endometrioid adenocarcinoma.

 

Figure 6
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  		Figure 6c.  Malignant transformation of a left-sided ovarian endometrioma in a 46-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (3400/120) shows a large left adnexal cystic mass with hypointense signal and shading and with a hyperintense mural nodule. (b) Sagittal T1-weighted spin-echo MR image (600/24) shows the cystic mass with high signal intensity. (c) Sagittal contrast-enhanced T1-weighted spin-echo MR image (600/24) shows enhancement of the mural nodule (arrow). The histologic diagnosis was endometrioid adenocarcinoma.

 

Figure 7
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  		Figure 7a.  Malignant transformation of a left-sided ovarian endometrioma in a 73-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (4000/120) shows a left adnexal cystic mass with a hypointense clot. (b) Sagittal contrast-enhanced T1-weighted fat-saturated spin-echo MR image (572/15) shows a hyperintense cystic mass with no enhanced mural nodules. A small mural nodule was found subsequently at surgery. The histologic diagnosis was clear cell carcinoma.

 

Figure 7
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  		Figure 7b.  Malignant transformation of a left-sided ovarian endometrioma in a 73-year-old woman. (a) Sagittal T2-weighted fast spin-echo MR image (4000/120) shows a left adnexal cystic mass with a hypointense clot. (b) Sagittal contrast-enhanced T1-weighted fat-saturated spin-echo MR image (572/15) shows a hyperintense cystic mass with no enhanced mural nodules. A small mural nodule was found subsequently at surgery. The histologic diagnosis was clear cell carcinoma.

 

Figure 8
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  		Figure 8a.  Right-sided ovarian endometriomas in a 26-year-old woman. (a) Axial T1-weighted spin-echo MR image (450/9) shows right adnexal cystic masses with high signal intensity that represent endometriomas. (b) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (550/9) shows intracystic high signal intensity sufficient to mask the contrast enhancement of any mural nodule that may be present. A large intracystic clot (arrow) shows no contrast enhancement. (c) Axial dynamic subtraction MR image synthesized from data obtained with both unenhanced MR imaging and with contrast-enhanced MR imaging with a dynamic sequence (gradient echo, 130/1.9) shows enhancement of the fibrous capsule around the cysts but no enhanced mural nodules.

 

Figure 8
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  		Figure 8b.  Right-sided ovarian endometriomas in a 26-year-old woman. (a) Axial T1-weighted spin-echo MR image (450/9) shows right adnexal cystic masses with high signal intensity that represent endometriomas. (b) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (550/9) shows intracystic high signal intensity sufficient to mask the contrast enhancement of any mural nodule that may be present. A large intracystic clot (arrow) shows no contrast enhancement. (c) Axial dynamic subtraction MR image synthesized from data obtained with both unenhanced MR imaging and with contrast-enhanced MR imaging with a dynamic sequence (gradient echo, 130/1.9) shows enhancement of the fibrous capsule around the cysts but no enhanced mural nodules.

 

Figure 8
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  		Figure 8c.  Right-sided ovarian endometriomas in a 26-year-old woman. (a) Axial T1-weighted spin-echo MR image (450/9) shows right adnexal cystic masses with high signal intensity that represent endometriomas. (b) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (550/9) shows intracystic high signal intensity sufficient to mask the contrast enhancement of any mural nodule that may be present. A large intracystic clot (arrow) shows no contrast enhancement. (c) Axial dynamic subtraction MR image synthesized from data obtained with both unenhanced MR imaging and with contrast-enhanced MR imaging with a dynamic sequence (gradient echo, 130/1.9) shows enhancement of the fibrous capsule around the cysts but no enhanced mural nodules.

 

Figure 9
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  		Figure 9a.  Malignant transformation of a left-sided ovarian endometrioma in a 40-year-old woman. (a) Unenhanced MR image obtained with a dynamic sequence (gradient echo, 130/1.9) shows a slightly hyperintense left adnexal mass. (b) Axial dynamic contrast-enhanced MR image obtained 90 seconds after the administration of contrast material shows an enhanced mural nodule (arrow). (c) Axial dynamic subtraction MR image synthesized from a and b shows the enhanced mural nodule (arrow) more clearly.

 

Figure 9
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  		Figure 9b.  Malignant transformation of a left-sided ovarian endometrioma in a 40-year-old woman. (a) Unenhanced MR image obtained with a dynamic sequence (gradient echo, 130/1.9) shows a slightly hyperintense left adnexal mass. (b) Axial dynamic contrast-enhanced MR image obtained 90 seconds after the administration of contrast material shows an enhanced mural nodule (arrow). (c) Axial dynamic subtraction MR image synthesized from a and b shows the enhanced mural nodule (arrow) more clearly.

 

Figure 9
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  		Figure 9c.  Malignant transformation of a left-sided ovarian endometrioma in a 40-year-old woman. (a) Unenhanced MR image obtained with a dynamic sequence (gradient echo, 130/1.9) shows a slightly hyperintense left adnexal mass. (b) Axial dynamic contrast-enhanced MR image obtained 90 seconds after the administration of contrast material shows an enhanced mural nodule (arrow). (c) Axial dynamic subtraction MR image synthesized from a and b shows the enhanced mural nodule (arrow) more clearly.

 

Figure 10
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  		Figure 10a.  Left-sided ovarian endometrioma in a 28-year-old woman. (a) Axial T1-weighted spin-echo MR image (500/14) shows a hyperintense left adnexal cystic mass with a hypointense crescent-shaped component (arrow). (b) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (800/14) shows no signal reduction in the cystic mass, while the signal is enhanced in the crescent-shaped component (arrow). (c) Axial T2-weighted fast spin-echo MR image (3500/105) shows heterogeneous signal intensity in the mass and a slightly hyperintense signal in the crescent-shaped component, which contains a follicle (arrow) and represents ovarian parenchyma.

 

Figure 10
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  		Figure 10b.  Left-sided ovarian endometrioma in a 28-year-old woman. (a) Axial T1-weighted spin-echo MR image (500/14) shows a hyperintense left adnexal cystic mass with a hypointense crescent-shaped component (arrow). (b) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (800/14) shows no signal reduction in the cystic mass, while the signal is enhanced in the crescent-shaped component (arrow). (c) Axial T2-weighted fast spin-echo MR image (3500/105) shows heterogeneous signal intensity in the mass and a slightly hyperintense signal in the crescent-shaped component, which contains a follicle (arrow) and represents ovarian parenchyma.

 

Figure 10
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  		Figure 10c.  Left-sided ovarian endometrioma in a 28-year-old woman. (a) Axial T1-weighted spin-echo MR image (500/14) shows a hyperintense left adnexal cystic mass with a hypointense crescent-shaped component (arrow). (b) Axial contrast-enhanced T1-weighted fat-saturated spin-echo MR image (800/14) shows no signal reduction in the cystic mass, while the signal is enhanced in the crescent-shaped component (arrow). (c) Axial T2-weighted fast spin-echo MR image (3500/105) shows heterogeneous signal intensity in the mass and a slightly hyperintense signal in the crescent-shaped component, which contains a follicle (arrow) and represents ovarian parenchyma.

 

Figure 11
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  		Figure 11a.  Bilateral ovarian endometriomas in a 36-year-old woman. (a) Axial T1-weighted spin-echo MR image (400/9) shows hyperintense pelvic cystic masses. (b) Axial T2-weighted fast spin-echo MR image (3600/89) shows a large heterogeneous masslike structure within one of the cysts (arrow). (c) Axial dynamic subtraction MR image synthesized from unenhanced MR image data and contrast-enhanced MR image data obtained with a dynamic sequence (gradient echo, 130/2.1) shows contrast enhancement of the fibrous capsule around the cyst but no enhancement of the masslike structure, which represents a blood clot.

 

Figure 11
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  		Figure 11b.  Bilateral ovarian endometriomas in a 36-year-old woman. (a) Axial T1-weighted spin-echo MR image (400/9) shows hyperintense pelvic cystic masses. (b) Axial T2-weighted fast spin-echo MR image (3600/89) shows a large heterogeneous masslike structure within one of the cysts (arrow). (c) Axial dynamic subtraction MR image synthesized from unenhanced MR image data and contrast-enhanced MR image data obtained with a dynamic sequence (gradient echo, 130/2.1) shows contrast enhancement of the fibrous capsule around the cyst but no enhancement of the masslike structure, which represents a blood clot.

 

Figure 11
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  		Figure 11c.  Bilateral ovarian endometriomas in a 36-year-old woman. (a) Axial T1-weighted spin-echo MR image (400/9) shows hyperintense pelvic cystic masses. (b) Axial T2-weighted fast spin-echo MR image (3600/89) shows a large heterogeneous masslike structure within one of the cysts (arrow). (c) Axial dynamic subtraction MR image synthesized from unenhanced MR image data and contrast-enhanced MR image data obtained with a dynamic sequence (gradient echo, 130/2.1) shows contrast enhancement of the fibrous capsule around the cyst but no enhancement of the masslike structure, which represents a blood clot.

 

Figure 12
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  		Figure 12.  Decidual change of the ectopic endometrium in a right-sided ovarian endometrioma in a 20-year-old pregnant woman. Sagittal T2-weighted fast spin-echo MR image (3300/102) shows a cystic mass with broad-based hyperintense mural nodules (arrow) behind the uterus.

 




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