Malignant Transformation of Endometriosis: Magnetic Resonance Imaging Aspects

Transcription

1 Malignant Transformation of Endometriosis: Magnetic Resonance Imaging Aspects Poster No.: C-0084 Congress: ECR 2014 Type: Scientific Exhibit Authors: E. A. Yukhno, I. Trofimenko, G. Trufanov; St. Petersburg/RU Keywords: Genital / Reproductive system female, Oncology, MR, Diagnostic procedure, Cancer, Cysts DOI: /ecr2014/C-0084 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 46

2 Aims and objectives Malignant transformation of endometriosis is a rare and still unsolved problem for both researchers and clinicians. The mean age of the patients is years that is 10 to 20 years less comparing with mean age of patients with primary ovarian cancer. So the objective of our study was the assessment of the evaluation of magntic resonance imaging in malignant transformation of endometrioid ovarian cysts, and the search for the diagnostic significant signs and symptoms to enable differential diagnosis between malignant transformation and benign neoplasm. Page 2 of 46

3 Methods and materials 15 patients with malignant transformation of endometrioid cysts that had been followed up since 2009 till 2013 were enrolled in the study, mean age at the baseline was 36±6 years. The follow-up lasted from 6 to 36 months. All the patients underwent MR scanning at 1.5 Tesla system with standard protocol, included T2 and T1 weighted images (as well as T1 fat suppressed images), diffusion-weighted and dynamic contrast-enhanced series. All patients underwent surgical treatment, and the diagnosis was confirmed by pathomorphological and histological analysis. Page 3 of 46

4 Results The main signs of a malignant cyst transformation included size increase and wall thickening of the endometrioma, the disappearance of shading sign (i.e. an intensification of the MRI: spin-echo T2-weighted MR scans showed signal intensification, solid component at the site of papillary excrescences that were isointensive compared to outer myometrium). In all patients postcontrast T1-weighted FS (with fat suppression) MR scans showed a fast uptake of the contrast agent (since the first minute) by the thickened wall and solid component with the comparable intensity to that of myometrium, and a fast washout, which indicates hypervascularity. High b-value diffusion-weighted MRI scans (b=800) provided high signal intensity images of tumor tissue with limited diffusion at the apparent diffusion coefficient map (0,88±0,16 2 mm /sec). The presence of solid (T1 and T2 hypointense) component in the cyst was not a reliable factor of malignancy and needed to be differentiated between malignant tumor growth, decidualization and inflammatory tissue. Fig.1-3. A 25-year-old patient with an endometrial cyst on left ovary. Fig.4-6. A 35-year-old patient with a large endometrial cyst with the septum. Fig A 41-year-old patient with an endometrioma of the right ovary. Fig The same patient at 18-month follow-up. Fig A 37-year-old patient with endometrial cyst of left ovary. Fig The same patient at 36-month follow-up. Fig A 29-year-old patient with an endometrial cyst of left ovary. Fig The same patient at 12-month follow-up. Fig A cyst of the yellow body of ovary appears as a neoplasm with thick (up to 4 mm) wall containing a moderately heterogenous fluid on #2-weighted MR scans. Fig Teratoma with the hemorrhage. Fig Right-sided hydrosalpinx and endometrial cyst of right ovary. Fig Endometrial ovarian cysts. Page 4 of 46

5 Images for this section: Fig. 1: A 25-year-old patient with an endometrial cyst on left ovary. Axial T2-weighted MR scan shows low-signal-intensity cyst content. Page 5 of 46

6 Fig. 2: A 25-year-old patient with an endometrial cyst on left ovary. Axial T2-weighted MR scan shows low-signal-intensity cyst content. Page 6 of 46

7 Fig. 3: A 25-year-old patient with an endometrial cyst on left ovary. Axial T1-weighted MR scan with fat suppression. Page 7 of 46

8 Fig. 4: A 35-year-old patient with a large endometrial cyst with the septum. Sagittal T2weighted MR scan shows a large neoplasm located in the retrouterine space with the thick wall (up to 4 mm) and heterogeneous, mostly hypointense content with the hyperintense components of irregular shape. The ovarian tissue with single follicles is spread on its anterior wall. Page 8 of 46

9 Fig. 5: A 35-year-old patient with a large endometrial cyst with the septum. Cyst content appears high intense on sagittal T1-weighted MR scan and a septum of regular thickness located on it's anterior-inferior surface. Page 9 of 46

10 Fig. 6: A 35-year-old patient with a large endometrial cyst with the septum. Postcontrast T1-weighted FS MR scan shows non-specific contrast-enhancement of the wall and septum and an uptake of the contrast agent by the ovarian tissue. Page 10 of 46

11 Fig. 7: A 41-year-old patient with an endometrioma of the right ovary. Axial T1-weighted show a cystic neoplasm with the regularly thickened hypointense smooth wall located in front of the right tube angle. The cyst content is iso-hyperintense. Preserved ovarian tissue is adjacent to the upper pole of the neoplasm. Page 11 of 46

12 Fig. 8: A 41-year-old patient with an endometrioma of the right ovary. Sagittal T2weighted show a cystic neoplasm with the regularly thickened hypointense smooth wall located in front of the right tube angle. The cyst content is hyperintense. Page 12 of 46

13 Fig. 9: A 41-year-old patient with an endometrioma of the right ovary. Sagittal #1weighted FS MR scans show a cystic neoplasm with the regularly thickened hypointense smooth wall located in front of the right tube angle. The cyst content is iso-hyperintense on T1-weighted MR images. Page 13 of 46

14 Fig. 10: A 41-year-old patient with an endometrioma of the right ovary. Sagittal #1weighted FS. On postcontrast #1-weighted MR scan there is a delayed moderate contrast enhancement, and the uptake is lower than in the ovarian stroma. Page 14 of 46

15 Fig. 11: A 41-year-old patient with an endometrioma of the right ovary. Sagittal #1weighted FS. At subtraction there is a delayed moderate contrast enhancement, and the uptake is lower than in the ovarian stroma. Page 15 of 46

16 Fig. 12: The 41-year-old patient with an endometrioma of the right ovary at 18-month follow-up. Axial #1-weighted show an increase and thickening of the cyst wall. Page 16 of 46

17 Fig. 13: The 41-year-old patient with an endometrioma of the right ovary at 18-month follow-up. Sagittal #2-weighted MR scan show an increase and thickening of the cyst wall, increase of signal intensity. There are numerous isointense papillary excrescences on the inner surface of the cyst. Page 17 of 46

18 Fig. 14: The 41-year-old patient with an endometrioma of the right ovary at 18-month follow-up. Sagittal #1-weighted FS MR scans show an increase and thickening of the cyst wall. Page 18 of 46

19 Fig. 15: The 41-year-old patient with an endometrioma of the right ovary at 18-month follow-up. Sagittal postcontrast #1-weighted FS MR scan shows thickened wall and solid component of the neoplasm with early homogenous enhancement. Page 19 of 46

20 Fig. 16: A 37-year-old patient with endometrial cyst of left ovary. Axial #1-weighted images demonstrate a cystic neoplasm with smooth wall in the left ovary. Hemorrhagic content appears isointense. Preserved ovarian tissue is adjacent to the lower pole of the neoplasm. Page 20 of 46

21 Fig. 17: A 37-year-old patient with endometrial cyst of left ovary. Axial #1-weighted FS MR images demonstrate a cystic neoplasm with smooth wall in the left ovary. Hemorrhagic content appears hyperintense. Page 21 of 46

22 Fig. 18: A 37-year-old patient with endometrial cyst of left ovary. Coronal #2-weighted MR scan. Hemorrhagic content appears isointense on #2-weighted MRI scans. Preserved ovarian tissue is adjacent to the lower pole of the neoplasm. Page 22 of 46

23 Fig. 19: A 37-year-old patient with endometrial cyst of left ovary at 36-month follow-up. Axial #1-weighted show increased size and irregular thickening of the walls of the cyst. Page 23 of 46

24 Fig. 20: A 37-year-old patient with endometrial cyst of left ovary at 36-month follow-up. Axial #1-weighted FS MR scans show increased size and irregular thickening of the walls of the cyst. Page 24 of 46

25 Fig. 21: A 37-year-old patient with endometrial cyst of left ovary at 36-month follow-up. Coronal #2-weighted MR scans show the disappearance of the shading sign. Numerous isointense papillary excrescences are visualized on the inner surface. Page 25 of 46

26 Fig. 22: A 37-year-old patient with endometrial cyst of left ovary at 36-month follow-up. Axail postcontrast #1-weighted FS MR scan show thickened wall and solid component with an early intense homogenous enhancement. Page 26 of 46

27 Fig. 23: A 37-year-old patient with endometrial cyst of left ovary at 36-month followup. Axial high b-value diffusion-weighted MRI scans (b=800) demonstrate high-signalintense tumor tissue with the limited diffusion at the at the apparent diffusion coefficient map (0,65 mm2/sec). Page 27 of 46

28 Fig. 24: A 29-year-old patient with an endometrial cyst of left ovary. Axial #2-weighted images show a cyst neoplasm with smooth wall in the left ovary. Its hemorrhagic content appears isointense on #2-weighted MRI scans. (arrow). Page 28 of 46

29 Fig. 25: A 29-year-old patient with an endometrial cyst of left ovary. Axial #1-weighted FS MR scans show a cyst neoplasm with smooth wall in the left ovary. Its hemorrhagic content appears hyperintense on #1-weighted. Page 29 of 46

30 Fig. 26: A 29-year-old patient with an endometrial cyst of left ovary at 12-month followup. Axial #2-weighted show an increased cyst neoplasm with the solid component on the medial wall. Page 30 of 46

31 Fig. 27: A 29-year-old patient with an endometrial cyst of left ovary at 12-month follow-up. Axial #1-weighted MR scans show an increased cyst neoplasm with the solid component on the medial wall. Page 31 of 46

32 Fig. 28: A 29-year-old patient with an endometrial cyst of left ovary at 12-month followup. High b-value diffusion-weighted MRI scans (b=800) demonstrate tumor of high signal intensity with limited diffusion at the apparent diffusion coefficient map (0,83 mm2/sec). Page 32 of 46

33 Fig. 29: Axial T2-weighted image. The endometrial cysts of both ovaries. A cyst of the yellow body of the right ovary appears as a neoplasm with thick (up to 4 mm) wall containing a moderately heterogenous fluid on #2-weighted MR scans. Page 33 of 46

34 Fig. 30: Axial T1-weighted image with fs.the endometrial cysts of both ovaries hyperintense sygnal. A cyst of the yellow body of the right ovary appears as a neoplasm with thick (up to 4 mm) wall containing hypointense fluid. Page 34 of 46

35 Fig. 31: Axial T1-weighted image with fs 2 min after contrast injection. After bolus injection of a contrast agent it is quickly accumulated by the cyst wall (up to 89%), its signal intensity is compared to the one of contrast-enhanced myometrium (118%) and is higher than the one of ovarian stroma (48%) Page 35 of 46

36 Fig. 32: Teratoma with the hemorrhage. Sagittal #2-weighted image show teratoma. The high-signal-intensity fatty component of the dermoid cyst is shown. Page 36 of 46

37 Fig. 33: Teratoma with the hemorrhage. Sagittal #1-weighted MR scan. The high-signalintensity fatty component of the dermoid cyst is shown. Page 37 of 46

38 Fig. 34: Teratoma with the hemorrhage. Sagittal #2-weighted with fat suppression MR scan. The high-signal-intensity fatty component of the dermoid cyst is removed by the fat suppression technique, and the intense hemorrhage component is visualized Page 38 of 46

39 Fig. 35: Right-sided hydrosalpinx and endometrial cyst of right ovary. Coronal #2weighted MR scans show an elongated mass containing cysts with heterogenous walls and incomplete septa. There is a caudal unilocular cyst with smooth walls, thick capsule and hemorrhagic content. A suggested diagnosis is the following: external genital endometriosis, endometrial cyst and chronic right-sided hydrosalpinx. Regarding the increased serum level of tumor marker ##-125 (98,5 IU/ml) and elevated erythrocyte sedimentation rate panhysterectomy was performed, and diagnosis was histologically and pathomorphologically confirmed. Page 39 of 46

40 Fig. 36: Right-sided hydrosalpinx and endometrial cyst of right ovary. Axial #2-weighted FS MR scans show an elongated mass containing cysts with heterogenous walls and incomplete septa (arrows). There is a caudal unilocular cyst with smooth walls, thick capsule and hemorrhagic content. Page 40 of 46

41 Fig. 37: Right-sided hydrosalpinx and endometrial cyst of right ovary. Axial #1-weighted FS MR scans. There is a caudal unilocular cyst with smooth walls, thick capsule and hemorrhagic content (hyperintense on T1). Page 41 of 46

42 Fig. 39: Endometrial ovarian cysts. coronal #2-weighted MR images.there are hemorrhagic cysts with thick walls and intraluminal thrombi of very low signal intensity in both ovaries. Page 42 of 46

43 Fig. 38: Endometrial ovarian cysts. coronal #1-weighted FS MR images. Haemorrhagic cysts with thick walls and intraluminal thrombi of very low signal intensity in both ovaries. Page 43 of 46

44 Conclusion Therefore, magnetic resonance imaging is a informative technique for diagnosis of malignant transformation of endometrioid ovarian cyst. Page 44 of 46

45 Personal information Dr. Elena A. Yukhno radiologist, MRI specialist in Medical Millitary Academy and Perinatology and Pediatrics University Heart, Blood and Endocrinology Almazov's Center, Saint-Petersburg, Russia Dr. Irina A. Trofimenko radiologist, MRI specialist in City Hospital #40, Saint-Petersburg, Russia Prof. G. E. Trufanov head of radiology department in Medical Millitary Academy, professor in Perinatology and Pediatrics University Heart, Blood and Endocrinology Almazov's Center, Saint-Petersburg, Russia Dr. Evgenia A. Pavlovskaya, radiologist, MRI specialis in Medical Millitary Academy, Saint-Petersburg, Russia. Page 45 of 46

46 References Page 46 of 46