Answer for BIR CoW 06 Mar 2022
Ovarian CA
Findings
MRI Abdomen & Pelvis: •Irregular mixed intensity lesion with restricted diffusion in right adnexal region. •Nodular thickening of omentum with restricted diffusion. •Nodular soft tissue thickening with restricted diffusion in Pouch of Douglas. •Multiple peritoneal nodules with restricted diffusion. HPE – Serous cystadenocarcinoma with omental deposits.
Discussion
Ovarian cancer is the second most common gynecologic malignancy. Ovarian tumors can be categorized as epithelial, germ cell, sex cord–stromal, or metastatic. Epithelial tumors are the most common histopathologic type of malignant ovarian tumor (85% of cases). Subtypes of epithelial tumors include serous, mucinous, endometrioid, clear cell, and Brenner tumors. Epithelial tumors are rare before puberty; their prevalence increases with age and peaks in the 6th and 7th decades of life. The most common type of ovarian malignancy is serous carcinoma (approximately 40% of cases). Imaging Evaluation: Ultrasound – US remains the study of choice in the initial evaluation of suspect adnexal masses because it is relatively inexpensive, noninvasive, and widely available. Transabdominal US, endovaginal US, or both should be performed for the evaluation of adnexal masses. Certain findings can be used to distinguish between benign and malignant disease. Morphologic features including thick, irregular walls and septa, papillary projections, and solid, moderately echogenic loculi have been described as suggestive of malignant tumor. Color Doppler US of ovarian masses helps identify vascularized tissue and can assist in differentiating solid tumor tissue from nonvascularized structures. Benign lesions tend to initiate new tumor blood vessel formation peripherally from preexisting host vessels, whereas malignant tumors tend to initiate new tumor blood vessel formation centrally. It is also used in conjunction with pulsed Doppler US to identify vessels for waveform analysis. malignant tumor vessels generally have low impedance, which causes high diastolic flow and low systolic-diastolic variation. CT – CT is most useful for evaluating the extent of disease in the abdomen and pelvis. CT of the abdomen or pelvis allows comprehensive evaluation of all potential sites of peritoneal implants or lymphadenopathy as well as of the primary tumor site. CT allows use of oral contrast agent to distend and mark the bowel and help differentiate bowel from peritoneal implants. MRI – MRI can identify different types of masses using tissue characterization based on magnetic resonance properties. Acquisition of both T1- and T2-weighted images is fundamental in the delineation of pelvic anatomy and in tissue characterization. Fat-saturated T1-weighted images help distinguish fatty from hemorrhagic masses. Administration of gadolinium chelates allows better depiction of internal architecture and is useful in differentiating cystic from solid lesions and malignant from benign lesions. Adding DWI and ADC maps to the conventional MR images provides quantitative and qualitative analysis of the ovarian masses, lymph nodes, and peritoneal deposits and hence, increasing the sensitivity, specificity, and accuracy of the non-contrast conventional images. Solid components restrict diffusion and metastases may also exhibit restricted diffusion. Epithelial neoplasms – The two most common types of epithelial neoplasms are serous and mucinous tumors. Epithelial ovarian neoplasms can be classified as benign, borderline (ie, having a low potential for malignancy), or malignant (carcinomas). Features that are more suggestive of benign cystic neoplasm include unilocularity of cysts, thin walls, minimal septations, and absence of papillary projections. Borderline tumors show more proliferation (papillary projections) than cystadenomas and may metastasize throughout the peritoneum but are not true malignancies. Malignant varieties are associated with varying proportions of a solid component. Serous tumors are the most common neoplasms in both the benign and malignant category. Approximately 60% are benign and ~15% of borderline malignancy; These occur most commonly in women of reproductive age. The malignant tumors comprise of 25% of cases and tend to occur in older patients. Cystadenomas are usually unilocular, whereas malignancies demonstrate solid components and multilocularity. The signal intensity of the cyst contents of these tumors is variable but is usually low to intermediate on T1-weighted MR images and high on T2-weighted images. At CT, diffuse psammomatous calcifications may cause these tumors or their implants to have very high attenuation. Features that suggest a malignant over a benign cystic neoplasm include: • large cystic mass • thick irregular walls and septa • papillary projections • large soft tissue component • ascites • evidence of invasive spread or adenopathy
References:
•Russell P. Surface epithelial-stromal tumors of the ovary. In: Kurman RJ, eds. Blaustein's pathology of the female genital tract. 4th ed. New York, NY: Springer-Verlag, 1994; 705-782. •Franchi M, Beretta P, Ghezzi F, Zanaboni F, Goddi A, Salvatore S. Diagnosis of pelvic masses with transabdominal color Doppler, CA 125 and ultrasonography. Acta Obstet Gynecol Scand 1995; 74:734-739. •Troiano RN, McCarthy S. Magnetic resonance imaging evaluation of adnexal masses. Semin Ultrasound CT MR 1994; 15:38-48. •Ghossain MA, Buy JN, Ligneres C, et al. Epithelial tumors of the ovary: comparison of MR and CT findings. Radiology 1991; 181:863-870.
Findings
MRI Abdomen & Pelvis: •Irregular mixed intensity lesion with restricted diffusion in right adnexal region. •Nodular thickening of omentum with restricted diffusion. •Nodular soft tissue thickening with restricted diffusion in Pouch of Douglas. •Multiple peritoneal nodules with restricted diffusion. HPE – Serous cystadenocarcinoma with omental deposits.
Discussion
Ovarian cancer is the second most common gynecologic malignancy. Ovarian tumors can be categorized as epithelial, germ cell, sex cord–stromal, or metastatic. Epithelial tumors are the most common histopathologic type of malignant ovarian tumor (85% of cases). Subtypes of epithelial tumors include serous, mucinous, endometrioid, clear cell, and Brenner tumors. Epithelial tumors are rare before puberty; their prevalence increases with age and peaks in the 6th and 7th decades of life. The most common type of ovarian malignancy is serous carcinoma (approximately 40% of cases). Imaging Evaluation: Ultrasound – US remains the study of choice in the initial evaluation of suspect adnexal masses because it is relatively inexpensive, noninvasive, and widely available. Transabdominal US, endovaginal US, or both should be performed for the evaluation of adnexal masses. Certain findings can be used to distinguish between benign and malignant disease. Morphologic features including thick, irregular walls and septa, papillary projections, and solid, moderately echogenic loculi have been described as suggestive of malignant tumor. Color Doppler US of ovarian masses helps identify vascularized tissue and can assist in differentiating solid tumor tissue from nonvascularized structures. Benign lesions tend to initiate new tumor blood vessel formation peripherally from preexisting host vessels, whereas malignant tumors tend to initiate new tumor blood vessel formation centrally. It is also used in conjunction with pulsed Doppler US to identify vessels for waveform analysis. malignant tumor vessels generally have low impedance, which causes high diastolic flow and low systolic-diastolic variation. CT – CT is most useful for evaluating the extent of disease in the abdomen and pelvis. CT of the abdomen or pelvis allows comprehensive evaluation of all potential sites of peritoneal implants or lymphadenopathy as well as of the primary tumor site. CT allows use of oral contrast agent to distend and mark the bowel and help differentiate bowel from peritoneal implants. MRI – MRI can identify different types of masses using tissue characterization based on magnetic resonance properties. Acquisition of both T1- and T2-weighted images is fundamental in the delineation of pelvic anatomy and in tissue characterization. Fat-saturated T1-weighted images help distinguish fatty from hemorrhagic masses. Administration of gadolinium chelates allows better depiction of internal architecture and is useful in differentiating cystic from solid lesions and malignant from benign lesions. Adding DWI and ADC maps to the conventional MR images provides quantitative and qualitative analysis of the ovarian masses, lymph nodes, and peritoneal deposits and hence, increasing the sensitivity, specificity, and accuracy of the non-contrast conventional images. Solid components restrict diffusion and metastases may also exhibit restricted diffusion. Epithelial neoplasms – The two most common types of epithelial neoplasms are serous and mucinous tumors. Epithelial ovarian neoplasms can be classified as benign, borderline (ie, having a low potential for malignancy), or malignant (carcinomas). Features that are more suggestive of benign cystic neoplasm include unilocularity of cysts, thin walls, minimal septations, and absence of papillary projections. Borderline tumors show more proliferation (papillary projections) than cystadenomas and may metastasize throughout the peritoneum but are not true malignancies. Malignant varieties are associated with varying proportions of a solid component. Serous tumors are the most common neoplasms in both the benign and malignant category. Approximately 60% are benign and ~15% of borderline malignancy; These occur most commonly in women of reproductive age. The malignant tumors comprise of 25% of cases and tend to occur in older patients. Cystadenomas are usually unilocular, whereas malignancies demonstrate solid components and multilocularity. The signal intensity of the cyst contents of these tumors is variable but is usually low to intermediate on T1-weighted MR images and high on T2-weighted images. At CT, diffuse psammomatous calcifications may cause these tumors or their implants to have very high attenuation. Features that suggest a malignant over a benign cystic neoplasm include: • large cystic mass • thick irregular walls and septa • papillary projections • large soft tissue component • ascites • evidence of invasive spread or adenopathy
References:
•Russell P. Surface epithelial-stromal tumors of the ovary. In: Kurman RJ, eds. Blaustein's pathology of the female genital tract. 4th ed. New York, NY: Springer-Verlag, 1994; 705-782. •Franchi M, Beretta P, Ghezzi F, Zanaboni F, Goddi A, Salvatore S. Diagnosis of pelvic masses with transabdominal color Doppler, CA 125 and ultrasonography. Acta Obstet Gynecol Scand 1995; 74:734-739. •Troiano RN, McCarthy S. Magnetic resonance imaging evaluation of adnexal masses. Semin Ultrasound CT MR 1994; 15:38-48. •Ghossain MA, Buy JN, Ligneres C, et al. Epithelial tumors of the ovary: comparison of MR and CT findings. Radiology 1991; 181:863-870.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!