Characterizing Adnexal Masses: Pearls and Pitfalls 20 th Annual Summer Practicum SCBT-MR Jackson Hole August 11, 2010

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1 Characterizing Adnexal Masses: Pearls and Pitfalls 20 th Annual Summer Practicum SCBT-MR Jackson Hole August 11, 2010 Evan S. Siegelman MD University of Pennsylvania Medical Center

2 Adnexal Masses: Pearls T1 Hyperintensity T2 Hypointensity Tubular Configuration Papillary Projections Mucinous Cystadenoma Peritoneal Implants

3 Adnexal Masses: Pitfalls Lipid Poor Mature Cystic Teratoma Peritoneal Inclusion Cyst

4 T1 Hyperintensity: DDX Fat Hemorrhage Protein Flow Paramagnetic Effects

5 T1 Hyperintensity: DDX Mature Cystic Teratoma Endometrioma Functional Cyst

6 High Signal Intensity on T1 Loss of Signal Intensity with Fat Saturation Tissue is Characterized as Fat Dx: Mature Cystic Teratoma

7 T1 SI with / without Fat Saturation Hemorrhage or Protein Multiple or Bilateral: Specific for Endometriomas Single Lesion T2 SI Endometrioma T2 SI Functional Cyst

8 T2 Hypointensity: DDX Fibrosis Smooth Muscle Concentrated Protein / Blood

9 T2 Hypointensity: DDX Exophytic Leiomyoma Fibroma / Fibrothecoma Brenner Tumor Endometrioma

10 Exophytic Leiomyoma Separate Ipsilateral Ovary Bridging Vessel Sign

11 Fibroma-Fibrothecoma Fibrothecoma 50% of Sex Cord Stromal Tumors > 95% Benign Fibrothecoma: Endometrial Hyperplasia in Postmenopausal Woman Large Fibroma: Meig s s Syndrome

12 Brenner Tumor < 1% Epithelial Ovarian Neoplasms >98% Benign Ovarian Transitional Cells Surrounds by Fibrosis 30% Ipsilateral or Contralateral Benign Ovarian Tumor

13 Tubular Configuration Radiography: One View is No View MR: One Plane is No Plane Three Orthogonal Planes? 3D isotropic voxel T2 WI? Tube Revealed on 1 of the 3 Orthogonal Planes

14 Dilated Fallopian Tube Endometriosis T1 SI Content Other Findings of Endometriosis Pelvic Inflammatory Disease Prior Hysterectomy

15 Papillary Projections QED: Epithelial Ovarian Neoplasm Not Specific for Malignancy T2 Zonal Anatomy Inner SI Fibrous Core Outer SI Edematous Stroma

16 Serous Ovarian Neoplasms Serous Cystadenoma Serous Borderline Tumor (BOT) Low Grade Serous Cystadenocarcinoma (LGSC) High Grade Serous Cystadenocarcinoma (HGSC) New frontiers for ovarian cancer risk evaluation: proteomics and contrastenhanced ultrasound." AJR Am J Roentgenol 2010: 194(2): An immunohistochemical comparison between low-grade and high-grade ovarian serous carcinomas: significantly higher expression of p53, MIB1, BCL2, HER- 2/neu, and C-KIT in high-grade neoplasms Am J Surg Pathol 29(8):

17 Mucinous Cystadenoma Huge Adnexal Neoplasms Large Size Malignancy MR Imaging Features Multiple Locules No Ascites, Papillary Projections Minimal T1 and T2 Shortening from Viscous Mucin

18 Peritoneal Implants Specific* (< 100%) for Malignancy In Setting of Ovarian Mass Refer to Gyn Oncologist Neoadjuvant Chemotherapy *Radiographics 2005;25: Best Cases from the AFIP: Borderline Papillary Serous Tumor of the Right Ovary.

19 Pitfall: Lipid Poor Teratoma < 5 % of Mature Cystic Teratoma In Phase and Opposed Phase Chemical Shift Imaging Specific Gravity

20 Pitfall: Peritoneal Inclusion Cyst Non-Pancreatic Pseudocyst Loculated Peritoneal Fluid Surrounds One or Both Ovaries Borders: Pelvic Peritoneal Cavity Not a Cystic Ovarian Neoplasm

21 Peritoneal Inclusion Cyst: Clinical Features Premenopausal Women Prior Surgery, Endometriosis Mesothelial Lining Cells Lose Ability to Absorb Fluid Rx: Aspirate, Sclerosing Agents

23 Samuel Clemens: Mark Twain Born: 175 years ago Died: 100 years ago: 1910 Huck Finn: Published 125 years ago: 1885

24 Samuel Clemens: Mark Twain I I was gratified to be able to answer promptly and I did I I said I didn t t know

25 CME Question: Comparing T1 weighted images with and without fat suppression is most useful in differentiating what two conditions A. Benign and Malignant serious neoplasms B. Hemorrhagic functional cysts and endometriomas C. Mature and immature teratomas D. Endometriomas and Mature cystic teratomas E. Lipoleiomyomas and Mature cystic teratomas (Answer = D)

Value of MRI in Characterizing Adnexal Masses

The Journal of Obstetrics and Gynecology of India (July August 2015) 65(4):259 266 DOI 10.1007/s13224-015-0730-9 PHOTO ESSAY Value of MRI in Characterizing Adnexal Masses Alpana Karnik 1 Raina Anil Tembey