Borderline Ovarian Tumours:MRI features to aid a challenging diagnosis

Transcription

1 Borderline Ovarian Tumours:MRI features to aid a challenging diagnosis Poster No.: R-0095 Congress: RANZCR ASM 2013 Type: Scientific Paper Authors: C. Shadbolt, S. Kouloyan-Ilic, A. Dobrotwir; Melbourne/AU Keywords: Genital / Reproductive system female, Oncology, MR, Observer performance, Education and training DOI: /ranzcr2013/R-0095 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 19

2 Purpose Ovarian cancer is the most lethal GYN malignancy. Epithelial neoplasms account for over 90% and are the most aggressive. Identifying precursor lesions is essential for an effective screening program. Borderline ovarian tumours (BOT) are thought to represent one of the precursor lesions. BOT occur in younger women (who may want to preserve fertility) and have a more favourable prognosis. BOT are difficult to diagnose preoperatively due to significant overlap with benign and malignant lesions both on imaging and histologic frozen section. To tailor the correct surgery (ovary preserving excision v full surgical staging) and appropriate referral to GYN Oncology service, more accurate pre-operative imaging assessment is needed. In order to assess the utility of MRI in differentiating these lesions from benign and malignant entities we have reviewed all women with a diagnosis of BOT referred to the Royal Women's Hospital (RWH) Tumour Board over a 5 year period who had a preoperative MRI. We have evaluated the most consistently demonstrated MRI features in BOT. Page 2 of 19

3 Methods and Materials Over a 5 year period, 169 women with BOT were referred to the RWH and 70 had multiplanar multisequence MRI obtained on 3T GE Signa Excite MRI scanner with 8 channel phased array pelvic coil. IV Buscopan antispasmodic and IV Gadolinium administered unless either was contra indicated (eg pregnant, low egfr or known allergy). MRI were images reviewed by 2 consultant radiologists with >10 yrs pelvic MRI experience and current MRI fellow. Features assessed: tumour size; unilaterality or bilaterality; number/ thickness of septations; number of cyst locules; type cyst fluid-simple/proteinaceous signal; presence/ number/size solid mural nodules/papillary excrescences; presence/not enhancement /diffusion restriction; presence/not ipsilateral normal ovarian stroma; presence/not ascites/omental cake / lymphadenopathy. Serum Ca125 and patient's age were also recorded. Page 3 of 19

4 Images for this section: Fig. 1: Ax T2w. Septated right ovary BOT with papillary excresences Page 4 of 19

5 Fig. 2: Ax C+T1FS. Enhancing papillary excrescences Page 5 of 19

6 Fig. 3: Ax DWI b1000. Diffusion restricting papillary excrescences. Page 6 of 19

7 Fig. 4: Sag T2w. Multiloculated "Murano glass" cysts containing fluid of varying signal Page 7 of 19

8 Fig. 5: Ax T1w. "Murano glass" appearance of varying precontrast T1 signal fluid. Page 8 of 19

9 Results 70 women diagnosed surgically with BOT had undergone pre-operative MRI. Age range: yrs with both mean and median age of 44yrs (90% <66yrs; 75% <58yrs). Pre-op Ca125 was available in 63/70 women ranging from ; mean of 64; median of 28 (90% < 105). 76 BOT (6 women had bilateral BOT; 38 unilateral left ovary; 26 right ovary). Size ranged from cc (mean 1626cc; medain 954cc). 39 mucinous, 34 serous; 3 seromucinous. Presence of T1 precontrast hyperintense fluid did not differentite between mucinous or serous tumours. Of the multiple imaging features assessed, the most commonly described appearances were: 1. Presence of ipsilateral normal ovarian stroma (93%) 2. BOT were most often multilocular (55% had >10 locules, only 12.5% were unilocular 3. In 80% of multicystic masses, septae were </=5mm thickness and the majority enhanced. 4. Mural "nodules" most often were clusters of daughter cysts/septae. In 48% true solid enhancing/diffusion restricting mural nodules occured. Low T2 signal frond-like projections were common and focal lowt1/t2 signal masses were found in 3 cases, confirmed histologically: 2 cystadenofibroma BOT and 1 BOT contained a Benign Brenner tumour. Not present in any BOT MRI studies: 1. Ascites (other than physiologic volume) 2. Omental cake/peritoneal implants 3. Lymphadenopathy (reactive nodes excluded) Page 9 of 19

10 Images for this section: Fig. 6: Sag T2w. Normal ipsilateral ovarian stroma (arrowed). Low T2 signal frond-like mural excresences. Page 10 of 19

11 Fig. 7: Sag T2w. Multicystic mural "nodules" Page 11 of 19

12 Fig. 8: Cor T2FS. BOT with heterogenous size multiple cystic locules and low T2 signal Brenner tumour. Page 12 of 19

13 Fig. 9: Ax C+T1FS. Left BOT solid enhancing mural nodules. Page 13 of 19

14 Conclusion While ovarian BOT are a heterogenous group of masses with diverse imaging appearances and histology, we found some common MRI features on review of 76 BOT tumors on MRI. Overall mass appearance could be generalised into 3 broad types: 1. Most common - Large mass with multiple heterogenously sized locules with innumerable thin enhancing septae/daughter mural cysts. Fluid T1/T2 signal variable including the "Murano glass" appearance. May contain solid enhancing mural nodules or focal low signal nodules (cystadenofibroma BOT, Brenner). 2. Less common - Smaller mass, unilocular/few locules with/without extensive low T2 signal minimally enhancing/diffusion restricting exuberant papillary excrescences 3. Infrequent - "Sponge-like" homogeneously microcystic mass. Page 14 of 19

15 Images for this section: Fig. 10: Type 1 Large multiloculated with thin septae. (Sag T2w). Page 15 of 19

16 Fig. 11: Type 2 Smaller mass, fewer locules, exuberant low T2 signal papillary excrescences. (Cor T2w) Page 16 of 19

17 Fig. 12: Type 3 "Sponge-like" microcystic homogeneous mass. (Cor T2FSw) Page 17 of 19

18 Personal Information C.L. Shadbolt, S. Kouloyan-Ilic, A. Dobrotwir. Department of Imaging, Royal Women's Hospital, Cnr Grattan Street & Flemington Rd, Parkville, VIC 3052, Australia. Page 18 of 19

19 References desouza NM, O'Neill R, McIndoe GA, et al. Borderline Tumors of the Ovary: CT and MRI Features and Tumor Markers in Differentiation from Stage I Disease. AJR 2005; 184:3), Bent CL, Sahdev A, Rockall AG et al. MRI appearances of borderline tumours. Clin Radiol 2009 Apr;64(4):430-8 Morotti M, Menada MV, Gillot DJ et al. The preoperative diagnosis of borderline ovarian tumours: a review of current literature. Arch Gynecol Obstet 2012 Apr;285(4): Bazot M, Haouy D, Darai E et al. Is MRI a useful tool to distinguish between serous and mucinous borderline ovarian tumours? Clin Radiol 2013 Jan;68(1):e1-8 Takemori M, Nishimura R, Hasegawa K. Clinical evaluation of MRI in the diagnosis of borderline ovarian tumours. Acta Obstet et Gynecol Scandinavica 2002;81: Lee EJ, Kim SH, Kim YH et al. Is Ca125 an additional help to radiologic findings for differentiation of borderline ovarian tumour from Stage I carcinoma? Acta Radiol 2011 May 1;52(4): Obermair A, Tang A, Ngan H et al. Nomogram to predict the probability of relapse in patients diagnosed with borderline ovarian tumours. Int J Gynecol Cancer 2013 Feb;23(2): Sala E, Rockall A, Freeman S et al. The added role of MR Imaging in Treatment Stratification of Patients with Gynecologic Malignancies: What the Radiologist Needs to Know. Radiology 2013 Mar;266: Page 19 of 19