DOI: 10.1148/rg.265045206
Developing an MR Imaging Strategy for Diagnosis of Ovarian Masses1
Izumi Imaoka, MD,
Akihiko Wada, MD,
Yasushi Kaji, MD,
Takafumi Hayashi, MD,
Michiharu Hayashi, MD,
Michimasa Matsuo, MD and
Kazuro Sugimura, MD
1 From the Departments of Radiology (I.I., A.W., T.H., M.M.) and Obstetrics and Gynecology (M.H.), Tenri Hospital, Tenri, Nara, Japan; the Department of Radiology, Shimane University School of Medicine, Izumo, Shimane, Japan (A.W., T.H.); the Department of Radiology, Dokkyo Medical University School of Medicine, Shimotsuga-gun, Tochigi, Japan (Y.K.); and the Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan (K.S.). Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received November 26, 2004; revision requested January 24, 2005; final revision received March 2, 2006; accepted March 17. All authors have no financial relationships to disclose.
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Figure 1a. Hemorrhagic functional cyst in a 33-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a solitary cyst (arrows) in the right ovary. The cyst has a high-signal-intensity rim on both images, which is suggestive of a subacute hematoma. M = uterine leiomyoma.
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Figure 1b. Hemorrhagic functional cyst in a 33-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a solitary cyst (arrows) in the right ovary. The cyst has a high-signal-intensity rim on both images, which is suggestive of a subacute hematoma. M = uterine leiomyoma.
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Figure 2a. Functional cyst in an 18-year-old woman. U = uterus, curved arrow = left ovary. (a) Axial T2-weighted image shows a unilocular cystic mass (straight arrows) in the right ovary. (b) On a contrast-enhanced fat-suppressed T1-weighted image, the cyst wall appears smooth without vegetations or nodularity (straight arrows). Transvaginal US was performed 2 weeks after MR imaging, and the mass was definitely diagnosed as a functional cyst because of its regression.
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Figure 2b. Functional cyst in an 18-year-old woman. U = uterus, curved arrow = left ovary. (a) Axial T2-weighted image shows a unilocular cystic mass (straight arrows) in the right ovary. (b) On a contrast-enhanced fat-suppressed T1-weighted image, the cyst wall appears smooth without vegetations or nodularity (straight arrows). Transvaginal US was performed 2 weeks after MR imaging, and the mass was definitely diagnosed as a functional cyst because of its regression.
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Figure 3a. Paraovarian cyst in a 23-year-old woman. (a) Coronal T2-weighted image (half-Fourier acquisition single-shot turbo spin echo) shows a pelvic mass (arrows) that is cystic and unilocular. Normal bilateral ovaries (arrowheads) are demonstrated separately from the mass. B = bladder. (b) On an axial contrast-enhanced fat-suppressed T1-weighted image, the mass (short straight arrows) abuts the right round ligament (long straight arrow). At surgery, a right paraovarian cyst was found. U = uterus, curved arrow = left ovary. (Fig 3b reprinted, with permission, from reference 5.)
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Figure 3b. Paraovarian cyst in a 23-year-old woman. (a) Coronal T2-weighted image (half-Fourier acquisition single-shot turbo spin echo) shows a pelvic mass (arrows) that is cystic and unilocular. Normal bilateral ovaries (arrowheads) are demonstrated separately from the mass. B = bladder. (b) On an axial contrast-enhanced fat-suppressed T1-weighted image, the mass (short straight arrows) abuts the right round ligament (long straight arrow). At surgery, a right paraovarian cyst was found. U = uterus, curved arrow = left ovary. (Fig 3b reprinted, with permission, from reference 5.)
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Figure 4a. Hydrosalpinx in a 48-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a large unilocular cystic mass (arrows). The preoperative diagnosis was a serous cystadenoma of the ovary; however, a huge left hydrosalpinx was found at surgery. U = uterus.
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Figure 4b. Hydrosalpinx in a 48-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a large unilocular cystic mass (arrows). The preoperative diagnosis was a serous cystadenoma of the ovary; however, a huge left hydrosalpinx was found at surgery. U = uterus.
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Figure 5a. Serous cystadenoma in a 27-year-old woman. U = uterus. (a) Sagittal T2-weighted image shows a hyperintense mass that is cystic and unilocular (arrows). (b) On a contrast-enhanced fat-suppressed T1-weighted image, the cyst wall appears smooth without vegetations, nodularity, or a solid component (arrows).
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Figure 5b. Serous cystadenoma in a 27-year-old woman. U = uterus. (a) Sagittal T2-weighted image shows a hyperintense mass that is cystic and unilocular (arrows). (b) On a contrast-enhanced fat-suppressed T1-weighted image, the cyst wall appears smooth without vegetations, nodularity, or a solid component (arrows).
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Figure 6a. Endometriotic cysts (chocolate cysts) in a 30-year-old woman. U = uterus, curved arrow = left ovary. (a) Axial T1-weighted image shows multiple chocolate cysts (multiplicity) in the right ovary. All three cysts are hyperintense (straight arrows, arrowhead). (b) On an axial T2-weighted image, one of the cysts is hyperintense (arrowhead) and the other two are hypointense (ie, shading) (straight arrows). The largest cyst demonstrates extensive shading.
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Figure 6b. Endometriotic cysts (chocolate cysts) in a 30-year-old woman. U = uterus, curved arrow = left ovary. (a) Axial T1-weighted image shows multiple chocolate cysts (multiplicity) in the right ovary. All three cysts are hyperintense (straight arrows, arrowhead). (b) On an axial T2-weighted image, one of the cysts is hyperintense (arrowhead) and the other two are hypointense (ie, shading) (straight arrows). The largest cyst demonstrates extensive shading.
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Figure 7a. Clear cell carcinoma in a 59-year-old woman. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large hyperintense cystic mass (short arrows) with a nodular solid component (arrowhead). Note that an endometriotic cyst (long arrow) abuts the tumor, despite the postmenopausal age of the patient. (c) Contrast-enhanced fat-suppressed T1-weighted image shows strong enhancement of the mural nodule (arrowhead). Short arrows = large mass, long arrow = endometriotic cyst. At surgery, a clear cell carcinoma of the left ovary and an endometriotic cyst of the right ovary that contained chocolate-colored hemorrhagic material were found.
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Figure 7b. Clear cell carcinoma in a 59-year-old woman. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large hyperintense cystic mass (short arrows) with a nodular solid component (arrowhead). Note that an endometriotic cyst (long arrow) abuts the tumor, despite the postmenopausal age of the patient. (c) Contrast-enhanced fat-suppressed T1-weighted image shows strong enhancement of the mural nodule (arrowhead). Short arrows = large mass, long arrow = endometriotic cyst. At surgery, a clear cell carcinoma of the left ovary and an endometriotic cyst of the right ovary that contained chocolate-colored hemorrhagic material were found.
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Figure 7c. Clear cell carcinoma in a 59-year-old woman. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large hyperintense cystic mass (short arrows) with a nodular solid component (arrowhead). Note that an endometriotic cyst (long arrow) abuts the tumor, despite the postmenopausal age of the patient. (c) Contrast-enhanced fat-suppressed T1-weighted image shows strong enhancement of the mural nodule (arrowhead). Short arrows = large mass, long arrow = endometriotic cyst. At surgery, a clear cell carcinoma of the left ovary and an endometriotic cyst of the right ovary that contained chocolate-colored hemorrhagic material were found.
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Figure 8a. Mucinous cystadenoma in an 18-year-old woman. U = uterus. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large multilocular cystic mass (arrows). The loculi show various signal intensities on both images (stained glass appearance). The examination was performed with a body coil because the tumor extended to just below the liver. (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Note that some loculi show high signal intensity on both the pre- and post-contrast images (arrowheads in b and c); these may mimic an enhancing solid component.
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Figure 8b. Mucinous cystadenoma in an 18-year-old woman. U = uterus. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large multilocular cystic mass (arrows). The loculi show various signal intensities on both images (stained glass appearance). The examination was performed with a body coil because the tumor extended to just below the liver. (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Note that some loculi show high signal intensity on both the pre- and post-contrast images (arrowheads in b and c); these may mimic an enhancing solid component.
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Figure 8c. Mucinous cystadenoma in an 18-year-old woman. U = uterus. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large multilocular cystic mass (arrows). The loculi show various signal intensities on both images (stained glass appearance). The examination was performed with a body coil because the tumor extended to just below the liver. (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Note that some loculi show high signal intensity on both the pre- and post-contrast images (arrowheads in b and c); these may mimic an enhancing solid component.
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Figure 9a. Mucinous cystic tumor of borderline malignancy in a 22-year-old woman. U = uterus. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large multilocular cystic mass (arrows). Multiple small loculi are seen, some of which have a back-to-back appearance (arrowheads in a). (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Arrowheads = back-to-back loculi. At surgery, a mucinous cystic tumor of borderline malignancy was found in the right ovary. It is impossible to distinguish borderline malignant tumors from cystadenomas at preoperative MR imaging (cf Fig 8).
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Figure 9b. Mucinous cystic tumor of borderline malignancy in a 22-year-old woman. U = uterus. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large multilocular cystic mass (arrows). Multiple small loculi are seen, some of which have a back-to-back appearance (arrowheads in a). (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Arrowheads = back-to-back loculi. At surgery, a mucinous cystic tumor of borderline malignancy was found in the right ovary. It is impossible to distinguish borderline malignant tumors from cystadenomas at preoperative MR imaging (cf Fig 8).
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Figure 9c. Mucinous cystic tumor of borderline malignancy in a 22-year-old woman. U = uterus. (a, b) Sagittal T2-weighted (a) and fat-suppressed T1-weighted (b) images show a large multilocular cystic mass (arrows). Multiple small loculi are seen, some of which have a back-to-back appearance (arrowheads in a). (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Arrowheads = back-to-back loculi. At surgery, a mucinous cystic tumor of borderline malignancy was found in the right ovary. It is impossible to distinguish borderline malignant tumors from cystadenomas at preoperative MR imaging (cf Fig 8).
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Figure 10a. Serous papillary carcinoma in a 56-year-old woman. (a) Axial T2-weighted image shows a cystic and solid mass (arrows). (b) Contrast-enhanced fat-suppressed T1-weighted image shows the exophytic papillary projections of the tumor (arrows). This is the typical appearance of a serous papillary adenocarcinoma.
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Figure 10b. Serous papillary carcinoma in a 56-year-old woman. (a) Axial T2-weighted image shows a cystic and solid mass (arrows). (b) Contrast-enhanced fat-suppressed T1-weighted image shows the exophytic papillary projections of the tumor (arrows). This is the typical appearance of a serous papillary adenocarcinoma.
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Figure 11a. Mucinous cystadenocarcinoma in a 72-year-old woman. Axial T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a cystic and abundantly solid mass (arrows). The postoperative diagnosis was a stage IC mucinous cystadenocarcinoma of the left ovary.
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Figure 11b. Mucinous cystadenocarcinoma in a 72-year-old woman. Axial T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a cystic and abundantly solid mass (arrows). The postoperative diagnosis was a stage IC mucinous cystadenocarcinoma of the left ovary.
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Figure 12a. Metastatic ovarian carcinoma in a 46-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a multicystic mass (short arrows) with a solid component. The irregular thick septa and solid component enhance on the postcontrast image (arrowheads in b). A rectal tumor is also seen (long arrow). At surgery, a rectal carcinoma and a metastatic tumor of the right ovary were found.
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Figure 12b. Metastatic ovarian carcinoma in a 46-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a multicystic mass (short arrows) with a solid component. The irregular thick septa and solid component enhance on the postcontrast image (arrowheads in b). A rectal tumor is also seen (long arrow). At surgery, a rectal carcinoma and a metastatic tumor of the right ovary were found.
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Figure 13a. Mature cystic teratoma in a 23-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a well-defined hyperintense mass (short arrows). A typical fat (Fa)–fluid (Flu) level is seen with floating debris (D). There is chemical shift artifact (arrowheads) at the boundary between the floating debris and the fatty component. The hypointense nodule (long arrow) represents a tooth within the tumor.
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Figure 13b. Mature cystic teratoma in a 23-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a well-defined hyperintense mass (short arrows). A typical fat (Fa)–fluid (Flu) level is seen with floating debris (D). There is chemical shift artifact (arrowheads) at the boundary between the floating debris and the fatty component. The hypointense nodule (long arrow) represents a tooth within the tumor.
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Figure 14a. Mature cystic teratoma and endometriotic cyst in a 34-year-old woman. (a) Axial T1-weighted image shows bilateral hyperintense ovarian cysts (arrow, arrowhead). U = uterus. (b) Sagittal T1-weighted image obtained with selective chemical fat suppression shows that the right ovarian cyst has decreased in signal intensity (arrowhead). This finding is diagnostic for a mature cystic teratoma (dermoid cyst). B = bladder. (c) Sagittal T1-weighted image obtained with selective chemical fat suppression shows that the left ovarian cyst remains hyperintense (arrow). This finding is diagnostic for an endometriotic cyst. B = bladder, U = uterus.
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Figure 14b. Mature cystic teratoma and endometriotic cyst in a 34-year-old woman. (a) Axial T1-weighted image shows bilateral hyperintense ovarian cysts (arrow, arrowhead). U = uterus. (b) Sagittal T1-weighted image obtained with selective chemical fat suppression shows that the right ovarian cyst has decreased in signal intensity (arrowhead). This finding is diagnostic for a mature cystic teratoma (dermoid cyst). B = bladder. (c) Sagittal T1-weighted image obtained with selective chemical fat suppression shows that the left ovarian cyst remains hyperintense (arrow). This finding is diagnostic for an endometriotic cyst. B = bladder, U = uterus.
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Figure 14c. Mature cystic teratoma and endometriotic cyst in a 34-year-old woman. (a) Axial T1-weighted image shows bilateral hyperintense ovarian cysts (arrow, arrowhead). U = uterus. (b) Sagittal T1-weighted image obtained with selective chemical fat suppression shows that the right ovarian cyst has decreased in signal intensity (arrowhead). This finding is diagnostic for a mature cystic teratoma (dermoid cyst). B = bladder. (c) Sagittal T1-weighted image obtained with selective chemical fat suppression shows that the left ovarian cyst remains hyperintense (arrow). This finding is diagnostic for an endometriotic cyst. B = bladder, U = uterus.
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Figure 15a. Fibroma in a 52-year-old woman. (a) Sagittal T2-weighted image shows a hypointense solid mass (arrows). U = uterus. (b, c) Unenhanced (b) and contrast-enhanced (c) fat-suppressed T1-weighted images show weak enhancement of the mass (arrows) compared with that of the uterine myometrium (U). No vascular signal void is seen between the uterus and the mass.
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Figure 15b. Fibroma in a 52-year-old woman. (a) Sagittal T2-weighted image shows a hypointense solid mass (arrows). U = uterus. (b, c) Unenhanced (b) and contrast-enhanced (c) fat-suppressed T1-weighted images show weak enhancement of the mass (arrows) compared with that of the uterine myometrium (U). No vascular signal void is seen between the uterus and the mass.
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Figure 15c. Fibroma in a 52-year-old woman. (a) Sagittal T2-weighted image shows a hypointense solid mass (arrows). U = uterus. (b, c) Unenhanced (b) and contrast-enhanced (c) fat-suppressed T1-weighted images show weak enhancement of the mass (arrows) compared with that of the uterine myometrium (U). No vascular signal void is seen between the uterus and the mass.
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Figure 16. Fibrothecoma in a 72-year-old woman. Axial T2-weighted image shows a heterogeneous solid mass (arrows) with intermediate to high signal intensity. Ascites is seen in the cul-de-sac. The uterus (U) is enlarged, an abnormal finding in a postmenopausal woman.
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Figure 17a. Subserosal leiomyoma in a 44-year-old woman. Sagittal fat-suppressed T1-weighted (a) and T2-weighted (b) images show a well-defined mass (arrows) at the posterior aspect of the uterus (U). The mass has intermediate signal intensity on the T1-weighted image and low signal intensity on the T2-weighted image. There are extensive vascular flow voids (arrowheads) between the mass and the myometrium (the flow void sign). This finding is a reliable indicator of a subserosal uterine leiomyoma.
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Figure 17b. Subserosal leiomyoma in a 44-year-old woman. Sagittal fat-suppressed T1-weighted (a) and T2-weighted (b) images show a well-defined mass (arrows) at the posterior aspect of the uterus (U). The mass has intermediate signal intensity on the T1-weighted image and low signal intensity on the T2-weighted image. There are extensive vascular flow voids (arrowheads) between the mass and the myometrium (the flow void sign). This finding is a reliable indicator of a subserosal uterine leiomyoma.
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Figure 18a. Brenner tumor in a 79-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a low-signal-intensity solid mass (arrows) that is sharply demarcated. In addition, a multicystic mass (arrowheads) is seen beside the solid mass. At surgery, a Brenner tumor (solid mass) and an associated mucinous cystadenoma (multicystic mass) were found.
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Figure 18b. Brenner tumor in a 79-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a low-signal-intensity solid mass (arrows) that is sharply demarcated. In addition, a multicystic mass (arrowheads) is seen beside the solid mass. At surgery, a Brenner tumor (solid mass) and an associated mucinous cystadenoma (multicystic mass) were found.
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Figure 19a. Granulosa cell tumor in a 55-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a mass with a predominantly solid appearance (arrows). Cystic components are seen in the tumor; some of them are hemorrhagic, thus appearing hyperintense on both images (arrowheads).
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Figure 19b. Granulosa cell tumor in a 55-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a mass with a predominantly solid appearance (arrows). Cystic components are seen in the tumor; some of them are hemorrhagic, thus appearing hyperintense on both images (arrowheads).
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Figure 20a. Dysgerminoma in a 16-year-old girl. U = uterus. (a) Sagittal T2-weighted image shows a huge solid tumor (arrows). Hypointense septa with vascular signal voids (arrowheads) are seen within the tumor. (b) Contrast-enhanced fat-suppressed T1-weighted image shows strong enhancement of the tumor (arrows) and the septa (arrowheads).
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Figure 20b. Dysgerminoma in a 16-year-old girl. U = uterus. (a) Sagittal T2-weighted image shows a huge solid tumor (arrows). Hypointense septa with vascular signal voids (arrowheads) are seen within the tumor. (b) Contrast-enhanced fat-suppressed T1-weighted image shows strong enhancement of the tumor (arrows) and the septa (arrowheads).
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Figure 21a. Serous carcinoma in a 40-year-old woman. Axial T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a solid nodular mass (arrows). The tumor has nonspecific high signal intensity on the T2-weighted image and demonstrates enhancement on the contrast-enhanced image. In addition, there is enlargement of bilateral external iliac lymph nodes (arrowheads), which is a strong indicator of malignancy.
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Figure 21b. Serous carcinoma in a 40-year-old woman. Axial T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a solid nodular mass (arrows). The tumor has nonspecific high signal intensity on the T2-weighted image and demonstrates enhancement on the contrast-enhanced image. In addition, there is enlargement of bilateral external iliac lymph nodes (arrowheads), which is a strong indicator of malignancy.
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Copyright © 2006 by the Radiological Society of North America.
