1. From Imaging to Pathology :
How to assess Benignity in Rare Ovarian Tumors?
Corinne Balleyguier, Radiology
Pierre Duvillard, Pathology
Gustave Roussy, Villejuif

2. How to assess Benignity in Rare Ovarian
Tumors?
— Imaging ??
— Nearly never…
— Excepted for some functional ovarian lesions
— Simple functional cyst
— Haemorraghic functional cyst
— ..
— Some common benign ovarian lesions
— Endometrioma
— Ovarian fibroma
— Pathology??
— Nearly ever…
— To avoid for functional lesions …

3. Functional Ovarian Lesions

4. Functional ovarian
cyst: YES
— Ultrasound may
assess the content
of a liquid cyst
— Harmonic imaging
may be useful to
better define cystic
content

5. Color Döppler?
— Color Döppler is not
accurate:
— In 30 % of cases, arterial
flow is found in cystic
wall
— Usually with a low
resistive index
— Be careful to
misunderstanding with a
malignant lesion !!!

6. Haemorrhagic functional
cyst: YES
Internal content with thin
walls
No blood flow inside thin
walls
The cyst must disappeared
on short time follow-up at D6
NO MRI !!

7. Endometrioma: YES
— Ultrasound is usually
enough
— Typical features:
— Thin echoes,
homogeneous blood
cyst

9. Complex endometrioma: US/MRI
— Rarely, clots may
simulate papillary
projections
— Additional MRI is useful

10. T2
T1
Endometrioma
Hyperintense T1w
Hyper / Hypointensity T2w
Hyperintense T1+ FS
T1 + Fat Sat

11. And Rare Ovarian Tumors ??

12. What are Rare Ovarian Tumors ?
Germ cell
ovarian tumors
Immature teratoma
Monodermal teratoma
(struma ovarii)
Carcinoid T
Neuroectodermic T
Non teratomatous T
(Dysgerminoma)
Yolk sac T
Embryonnary carcinoma
Non gravidic
choriocarcinoma
Polyembryoma
Ovarian tumor classification
OMS 2003
Mixed germ cell Tumeurs

13. Stromal Tumors
Fibroma
Thecoma
Fibrosarcoma
Stromal T with minor
sex-cord
differenciation
Sclerosing stromal T
Sex cord
ovarian T
Granulosa stroma
cell T
Sertoli stromal cell
T
Sex cord of mixed
or unclassified cell
type
Gynandroblastoma
Indifferenciated
sex cord T
Ovarian tumor classification
OMS 2003
Steroïd T
Stromal Luteoma
Leydig cell T
Steroid cell T

14. To play in defence
or
what are the findings for benign?

15. Pure solid ovarian tumor on
ultrasound

16. Ovarian Fibroma
— Diagnosis of ovarian fibroma may nearly be assess on
imaging : US + MRI
— Ultrasound findings:
— Solid ovarian mass
— Homogeneous content
— Arterial flow
— Ultrasound may be doubtful in case of old ovarian fibroma:
— Heterogenous
— Posterior attenuation
— Low blood flow
— èMRI

17. Ovarian Fibroma

19. Ovarian Fibroma : MRI
— MRI is the best imaging
examination to assess fibrous
content
— Hypointense signal : T1w and
T2w
— Moderate to high intense uptake
— Enhancing curves lesion / myometrium
may be useful
— Fibrothecoma :
— Hypointense signal : T2w
— Intense uptake after injection

20. Ovarian Fibroma

21. Serous Borderline Cystadenoma
Benign
Malignant
Bénin
Borderline
Thomassin-Naggara, I. et al. Radiology
2008;0:2481071120

22. Right Fibroma
Left Fibrothecoma

23. Stromal Ovarian Tumors
(Fibroma, Thecoma)
— Unilateral tumors nearly always benign
— Solid content, white/yellow colour, homogenous
— Medium size : 6 cm
— Histologically, architecture is fasciculated without any
atypia or mitoses
— Good prognosis allows conservative surgery,
especially for young women

26. Homogenous, echoic Cyst on
Ultrasound

27. Echoic, homogenous cyst
Mature
Teratoma

29. Teratoma : Germ Cell Tumour
— Ultrasound features can vary according
internal content : cyst, fat, calcification.
— Ultrasound diagnosis may be difficult :
— A dermoïd cyst may mimic intestinal loops

30. Cystic Mature
Teratoma

31. MRI may assess fatty content
— Fat signal characterization:
— Hyperintense signal : T1w
— Hyperintense signal : T2w
— Hypointense signal: T1w with fat
suppression

32. T1w
T2w
Cystic
mature
teratoma
T1 FS

33. Benign Teratoma : Pathology
— Polydermal teratoma:
— Solid (15-20 % of solid teratoma)
— Cystic (dermoïd cyst)
— 27-44% of all ovarian tumors
— Non specific clinical symptoms
— Diameter usually < 15 cm
— Bilateral in15% of cases, sometime multiple
— External wall smooth, half-solid, half-cystic with pilosebaceous tissue
— Very heterogenous on pathology including components of
the 3 primitive mature tissues.

36. Benign Teratoma
— Monodermal dedicated
— Struma Ovarii
— Ovarian carcinoïd T
— Insulet carcinoïds
— Trabecular carcinoïds
— Mucinous carcinoïds (globlet cell carcinoïds)
— Strumal carcinoïds

38. Attacking Game or How to find Malignant
Features …

39. Most common rare malignant
Ovarian Tumors…
Immature Teratoma
Granulosa cell Tumor

40. Immature Teratoma?
— Immature teratoma is rare
— Difficult diagnosis on imaging
— Imaging :
— Heterogenous internal content
— Haemorrhagic content (MRI++)
— Heterogenous, intense uptake
— Large size
— Multiple irregular calcifications
— Tissue thickening within Rokitansky’s
protuberance

41. Immature Teratoma

42. Pathologist : Referee

43. Immature Teratoma
— Clinical features :
— 3% of ovarian teratoma (nearly 20% of primary
malignant germ cell tumors and 10-20% of malignant
ovarian tumors occuring before 20 yo).
— Usually revealed with an abdominal mass and
abdominal pain.
— Extra ovarian lesions in 33% of cases (peritoneal
implants).
— Large tumors (18 cm medium size), usually unilateral
with rupture or break of capsula in 50% of cases.

45. Immature Teratoma
— Microscopic features:
—
—
—
Polymorphous lesions including variable amount of
mainly neurectodermal immature tissue.
Other immature content are possible :
◆ Embryologic epithelial tissue (endodermal,
ectodermal..).
◆ Immature mesenchymatous tissue (cartilage,
striated muscle…).
◆ Liver, renal, vitellin tissue...
Mature tissue may be associated.

47. Immature Teratoma
— Treatment and prognosis:
— According tumor stage and tumor grade.
— Conservative surgery if possible + chemotherapy (BEP)
for tumors grade 2 and 3 and stage II and III.
— Clinical complete response is obtained in nearly all
cases after CT (77% of 5 years remission).
— Residual peritoneal lesions may be detected (fibrous
nodule).
— Growing teratoma syndroma is exceptionnal.

48. Pitfall: Growing Teratoma
— Multifocal peritoneal
extension of an immature
teratoma after complete
response with CT :
— Benign lesion
— Surgery may be complete to
remove all peritoneal
implants
— Nimkin K, Pediatr Radiol.
2004 Mar;34(3):259-62.

49. Granulosa Cell Tumor
— Rare ovarian T (0.6-3% of all ovarian T)
— 5% of malignant lesions
— Mesenchymatous and sex-cord like
tumors
— Two types:
— Adult (AGT)
— Juvenile (JGT) : malignancy risk is higher
— Medium size : 10 cm
— Hormonal clinical symptoms
— Partly cystic, haemorrhagic content

50. Adult Granulosa Cell T
35 yo

51. 15 yo
Juvenile Granulosa Cell T

52. Pathologist : Referee

53. Adult Granulosa Cell Tumors
— Clinical features :
— 6% of malignant ovarian tumors
— Usually diagnosed after menopause
— Associated to hyperestrogenic features in 75% of
cases
— Diagnosed at stage 1 in 90% of cases
— Unilateral in 85% of cases, variable size,
heterogenous with capsule rupture in 10 -12% of
cases

54. Juvenile Granulosa Cell Tumors
— Clinics:
— 5% of granulosa cell tumors and 97% are
diagnosed before 30 years
— Hormonal features in a child
— Unilateral in 98% for stage I cases
— Macroscopic features are similar to those of Adult
form tumors

58. Granulosa Cell Tumors
— Prognostic factors :
— Stage at diagnosis
— Evolution and treatment:
— Malignant lesions with low progression, late
recurrence in adult (20% at 5 years)
— Death rate : 12.5%
— Surgical treatment :
— Conservative for juvenile form stage IA

59. Across the Line…
Very rare Ovarian Tumors…

60. Does Imaging help to diagnose a
rare malignant Ovarian Tumor?
— Common features to detect :
— Size > 10 cm
— Haemorrhagic content : ultrasound, MRI (++)
— Irregular calcifications
— Central necrosis: MRI (hyperT2, hypoT1, peripheral
heterogenous enhancement)
— Jung SE, Radiographics. 2002
— Ascitis
— Peritoneal carcinomatosis
— Lymph node

61. Endodermal sinus Tumor : Yolk sac T
— Rare malignant germ cell tumor (< 1 % malignant T)
— 20-30 yo
— Variable feature (cystic to solid)
— Imaging features:
— Haemorrhagic content
— Hyperintense uptake
— Heterogenous

63. Yolk Sac Tumor
— Clinics:
— 20% of malignant germ cell ovarian tumors (medium
age 16-19 yo) (10% before10 yo)
— Fast growing tumors : abdominal mass, pelvic pain.
Emergency for surgery : risk of ovarian torsion or tumor
rupture.
— α-foetoprotein synthesis (high level (>1000 ng/ml).

64. Yolk sac Tumor
— Macroscopic features:
— Large tumor (15 cm), unilateral, sometimes
peritoneal carcinomatosis.
— External wall smooth, rupture in 25% of cases.
— Solid and cystic, bloody content, necrosis
— Other germ cell tumor may be associated (15% of
dermoïd cyst).
— Prognostic factors
— Clinical stage : 5 years survival 70-90% for stage 1
— 30 à 50% for other stage.
— Residual lesions after surgery
— Liver lesions.

67. Choriocarcinoma
— < 1 % malignant T
— 15 yo
— Imaging features :
— Necrosis
— Hypervascularization
— Peripheral calcifications
— Biology :
— βHCG serous elevation with a non gravid uterus
— Treatment and prognosis:
— Very aggressive tumors with peritoneal extension
— Same treatment as other malignant germ cell tumors.

70. Conclusion
— To assess benignity in rare ovarian
tumors …….
— With pathology: YES, usually
— With surgery…
— Imaging : NO
— Exception :
— Functional lesions
— Fibrous tumors
— Mature teratoma : +/— Imaging as an adjunct tool :
— Necrosis, calcifications, blood