Ovarian Lesion Benign vs Malignant? Michele Keenan 1,2 Bernice Dunne 2 Mary Moran 1 Therese Herlihy 1 1. Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Ireland 2. Midland Regional Hospital, Portlaoise, County Laois, Ireland Midland Regional Hospital Portlaoise
Patient presentation -57yr old -GP visit -Bloating -Virgin intacta
Ultrasound findings Ascites Right ovary? Uterus Right ovary Ascites
Ultrasound Findings Doppler flow of right ovary. Some internal vascularity noted Right ovary measures 8.6cm x 5.5cm
Ultrasound findings Ascites in RUQ Ascites around liver Ascites GB Liver
Radiology report There is diffuse huge abdominal and pelvic ascites making the examination difficult to evaluate. There is a 8.6 cm x 5.5cm mildly heterogenous predominantly solid mass-like lesion seen posterior to the uterus?right adnexal region, suspicious for ovarian mass lesion. There in internal vascularity but no gross hyperaemia throughout is appreciated. The uterus measures 5.2 x 2 cm. Endometrial stripe thickness 5mm No definite hepatic focal lesion is seen. Kidneys are normal in size. The corticomedullary differentiation is preserved. No hydronephrosis identified. The spleen is normal in size. CT scan for further assessment is advised.
IOTA group ultrasound rules.benign or Malignant? Unilocular cyst B-rules Presence of solid components where the largest is <7mm Acoustic shadowing present Smooth multilocular tumor with largest diameter <10cm No blood flow Sensitivity 95%, sensitivity 91% M-rules Irregular solid tumor Ascites At least 4 papillary structures Irregular multilocular solid tumor with largest diameter <10cm Very strong blood flow Table 1. IOTA guidelines re ultrasound characteristics benign vs. malignant ovarian masses
CT Images Liver Liver surrounded with ascites Gross ascites Right ovary Axial image upper abdomen Right ovary Coronal image of abdomen Axial image of pelvis
CT Scan Report There is a 8.5cm x 5 cm heterogenous lesion noted in the right adnexal region with enhancing mural nodule and area of calcification likely malignant. Extensive free fluid in the abdomen and pelvis. The anteverted uterus and Lt adnexa are unremarkable. No obvious hilar or mediastinal adenopathy. No para-aortic or pelvic adenopathy. Minor atelectasis in the lower lobes bilaterally. No pulmonary metastases or pleural effusions. Liver, gallbladder, spleen, pancreas and both kidneys appear normal.
MRI images Right ovary Sacrum Right ovary Bowel Uterus Uterus Urinary bladder Ascites T2 sagittal view pelvis Urinary bladder T1 axial view pelvis Urinary bladder
MRI Scan Report There is a heterogenous 8.0 x 5.5x 6.4cm lobulated, solidcystic mass within the right hemi-pelvis in continuity with right adnexa, medial to the common iliac vessels. The irregular, peripheral nodular component of the lesion demonstrates post contrast enhancement and restricted diffusion. Concerning for malignancy. There is a significant volume of ascites in the pelvis and both lower abdominal quadrants. The uterus and left adnexa are unremarkable. No pelvic or visualised retroperitoneal lymphadenopathy. No destructive bone lesion.
Patient management Bilateral salpingooophrectom Omenectomy Appendectomy Lymphadenectomy TAH Patient admitted Proliferative oxyphilic struma ovarii of right ovary CA125= 1145u/ml Normal range 0 35 u/ml Pigtail catheter inserted No evidence of stromal carcinoid or typical stroma derived thyroid carcinoma. Struma ovarii is a rare ovarian neoplasm consisting almost exclusively of mature thyroid tissue(>50%) derived from germ cell in a mature teratoma.
Take home message sometimes things aren't always as they seem!!!
References 1. Timmerman D, Testa A, Bourne T, Ameye L, Jurkovic D, Van Holsbeke C et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound in Obstetrics and Gynecology. 2008;31(6):681-690. 2. Jin C, Dong R, Bu H, Yuan M, Zhang Y, Kong B. Coexistence of benign struma ovarii, pseudo-meigs'syndrome and elevated serum CA125: Case report and review of the literature. Oncology Letters. 2015. 3. Diavatis SPapanikolaou A. Level of HE4 is Correlated with Diagnosis of Struma Ovarii: A Case Report. American Journal of Case Reports. 2016;17:459-461. 4. Inkollu S, Kanumury V, Dasharatha M, Adusumilli P. A rare ovarian tumour, struma ovarii. International Journal of Research in Medical Sciences. 2016;:1292-1294. 5. 5.Timmerman D, Van Calster B, Testa A, Savelli L, Fischerova D, Froyman W et al. Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group. American Journal of Obstetrics and Gynecology. 2016;214(4):424-437.