1. Developing an MR Imaging Strategy for Diagnosis of Ovarian Masses
RadioGraphics 2006; 26:1431–1448
Presented by Int 蘇春梅
Supervised by Dr.順星橋

2. Use of MRI for diagnosis of ovarian masses
Morphologic characteristics
(cystic masses, cystic and solid masses, and solid masses)
Signal intensity characteristics on T1-and T2-weighted images
High signal on T1: Endometriotic cyst
Low signal on T2: Fibrothecomas
Adequate use of intravenous contrast material

3. WHO Histologic Classification of Ovarian Tumors

4. MR Imaging criteria for malignant ovarian tumors
Primary criteria
A solid mass or large solid component
Wall thickness greater than 3 mm
Septal thickness greater than 3mm
and/or vegetations or nodularity
Necrosis

5. MR Imaging criteria for malignant ovarian tumors
Ancillary criteria
Involvement of pelvic organs or the sidewall
Peritoneal, mesenteric, or omental disease
Ascites
Adenopathy

6. Sensitivity for malignancy: 91%–100%
Specificity : 91%-92%

7. Three groups of ovarian tumors
Cystic masses
Cystic and solid masses
Predominantly solid masses

8. Cystic Masses Unilocular Cystic Masses
( Functional cysts, paraovarian cysts,
hydrosalpinx, serous cystadenomas)
Multilocular Cystic Masses
( Endometriotic cysts, mucinous
cystadenomas, mucinous cystic tumors)

9. Unilocular Cystic Masses
Well-circumscribed cystic masses
Low signal intensity on T1-weighted images
High signal intensity on T2-weighted images

10. Unilocular Functional Cysts
Solitary follicle cysts and
Corpus luteum cysts
Smooth linings that contain serous or
bloody fluid
Regress within 2 months
Complicated by rupture and cause
abdominal pain and hemoperitoneum.

11. Hemorrhagic functional cyst (Axial T1-weighted image)
High-signal-intensity rim
Solitary cyst
( Right ovary)
Hemorrhagic functional cyst in a 33-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a solitary cyst (arrows) in the right ovary. The cyst has a high-signal-intensity rim on both images, which is suggestive of a subacute hematoma. M uterine leiomyoma.
Uterine leiomyoma

12. Hemorrhagic functional cyst ( T2-weighted image)
High-signal-intensity rim

13. Functional cyst (Axial T2-weighted image)
Unilocular cystic mass
(Right ovary)
Uterus
Left ovary
Functional cyst in an 18-year-old woman. U uterus, curved arrow left ovary. (a) Axial T2-weighted
image shows a unilocular cystic mass (straight arrows) in the right ovary. (b) On a contrast-enhanced fat-suppressed T1-weighted image, the cyst wall appears smooth without vegetations or nodularity (straight arrows). Transvaginal US was performed 2 weeks after MR imaging, and the mass was definitely diagnosed as a functional cyst because of its regression

14. Functional cyst (Contrast-enhanced fat-suppressed T1-weighted image)
Smooth cyst wall
(without vegetations
or nodularity)
Uterus
Left ovary

15. Unilocular Paraovarian cysts
Not ovarian masses
Arise from mesothelial, paramesonephric or mesonephric (wolffian) structures
Mesosalpinx between the ovary and fallopian tube, and close to the ipsilateral round ligament
Contain serous fluid with a thin wall

16. Paraovarian cyst (Coronal T2-weighted image )
Left ovary
Pelvic mass
(cystic and unilocular)
Paraovarian cyst in a 23-year-old woman. (a) Coronal T2-weighted image (half-Fourier acquisition
single-shot turbo spin echo) shows a pelvic mass (arrows) that is cystic and unilocular. Normal bilateral ovaries (arrowheads) are demonstrated separately from the mass. B bladder. (b) On an axial contrast-enhanced fat-suppressed T1-weighted image, the mass (short straight arrows) abuts the right round ligament (long straight arrow). At surgery, a right paraovarian cyst was found. U uterus, curved arrow left ovary
Bladder

17. Paraovarian cyst (Axial contrast-enhanced fat-suppressed T1-weighted image)
Right paraovarian cyst
Left ovary
Uterus
Right round ligament

18. Unilocular Hydrosalpinx
Dilated fallopian tubes appear as fluid-filled structures that are sausage-shaped and/or C- or S-shaped
Salpingitis and pelvic endometriosis are common

19. Hydrosalpinx ( Sagittal T2-weighted )
Large unilocular cystic mass
(Left)
Figure(4).Hydrosalpinx in a 48-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced
fat-suppressed T1-weighted (b) images show a large unilocular cystic mass (arrows). The
preoperative diagnosis was a serous cystadenoma of the ovary; however, a huge left hydrosalpinx
was found at surgery. U uterus.

20. Hydrosalpinx (contrast-enhanced fat-suppressed T1-weighted )

21. Unilocular Serous tumors
25% of benign ovarian neoplasms
12-23% ~ Bilateral involvement
Serous cystadenomas are unilocular or multilocular cysts filled with clear watery fluid
Lining of the cyst is flat or may have small papillary projections
MRI: Unilocular cyst with a thin wall

22. Serous cystadenoma ( Sagittal T2-weighted )
Hyperintense unilocular cyst
Figure 5. Serous cystadenoma in a 27-year-old woman. U uterus. (a) Sagittal T2-weighted
image shows a hyperintense mass that is cystic and unilocular (arrows). (b) On a contrast-enhanced
fat-suppressed T1-weighted image, the cyst wall appears smooth without vegetations,
nodularity, or a solid component (arrows).

23. Serous cystadenoma ( Contrast-enhanced fat-suppressed T1-weighted )

24. Multilocular Cystic Masses
(1) Endometriotic cysts
(2) Mucinous cystadenomas
(3) Mucinous cystic tumors of borderline
malignancy

25. MRI findings for ovarian endometriotic cysts
Both T1- and T2-: High signal (OR)
T1 : High and T2 : Low signal (shading)
Methemoglobin : T1 shortening(亮)
Chronic cyclic hemorrhage and high viscosity : T2 shortening (shading)
Multicentric growth cysts and associated with fibrous adhesions
Sensitivity: 82-90%; Specificity: 91-98%
Methemoglobin causes T1 shortening. Chronic cyclic hemorrhage and high viscosity of the contents in the
endometriotic cysts cause T2 shortening and produce shading. The cysts show a tendency for multicentric
growth (multiplicity) (Fig 6) and are often associated with fibrous adhesions.

26. Endometriotic cysts (Axial fat-suppressed T1-weighted )
Left ovary
Hyperintense cysts
Figure6. Endometriotic cysts (chocolate cysts) in a 30-year-old woman. U uterus, curved arrow left ovary.
(a) Axial T1-weighted image shows multiple chocolate cysts (multiplicity) in the right ovary. All three cysts are hyperintense (straight arrows, arrowhead). (b) On an axial T2-weighted image, one of the cysts is hyperintense (arrowhead) and the other two are hypointense (ie, shading) (straight arrows). The largest cyst demonstrates extensive shading.

27. Endometriotic cysts (Axial T2-weighted )
Left ovary
Hypointense cyst

28. Mucinous cystadenoma 41% of benign ovarian neoplasms 2-5% : Bilateral
Large multilocular cysts containing gelatinous material or fluid of various viscosity
Various signal intensities on both T1 and T2 (stained glass appearance)

29. Mucinous cystadenoma ( Sagittal T2-weighted )
Large multilocular cystic mass
Figure 8. Mucinous cystadenoma in an 18-year-old woman. U uterus. (a, b) Sagittal T2-weighted (a) and fatsuppressedT1-weighted (b) images show a large multilocular cystic mass (arrows). The loculi show various signal intensities on both images (stained glass appearance). The examination was performed with a body coil because the tumor extended to just below the liver. (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Note that some loculi show high signal intensity on both the pre- and postcontrast images (arrowheads in b and c); these may mimic an enhancing solid component.

30. Mucinous cystadenoma ( Fat suppressedT1-weighted )
High signal intensity
Figure 8. Mucinous cystadenoma in an 18-year-old woman. U uterus. (a, b) Sagittal T2-weighted (a) and fatsuppressedT1-weighted (b) images show a large multilocular cystic mass (arrows). The loculi show various signal intensities on both images (stained glass appearance). The examination was performed with a body coil because the tumor extended to just below the liver. (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Note that some loculi show high signal intensity on both the pre- and postcontrast images (arrowheads in b and c); these may mimic an enhancing solid component.

31. Mucinous cystadenoma ( Contrast-enhanced fat-suppressed T1-weighted )
Figure 8. Mucinous cystadenoma in an 18-year-old woman. U uterus. (a, b) Sagittal T2-weighted (a) and fatsuppressedT1-weighted (b) images show a large multilocular cystic mass (arrows). The loculi show various signal intensities on both images (stained glass appearance). The examination was performed with a body coil because the tumor extended to just below the liver. (c) Contrast-enhanced fat-suppressed T1-weighted image shows no solid component within the tumor (arrows). Note that some loculi show high signal intensity on both the pre- and postcontrast images (arrowheads in b and c); these may mimic an enhancing solid component.

32. Cystic and Solid Masses
Ovarian malignancy
Includes primary epithelial carcinomas and metastatic tumors
Surface epithelial-stromal tumors :90%
Serous, Mucinous, Endometrioid, Clear
cell and transitional cell (Brenner) tumors

33. Cystic and Solid Masses
(1) Serous papillary adenocarcinoma
(2) Mucinous cystadenocarcinoma
(3) Metastatic ovarian carcinoma
(4) Mature cystic teratoma

34. Serous papillary adenocarcinoma
Most common and 50% of all ovarian malignancies
90% of patients : elevation of CA-125
Intracystic or exophytic papillae are sometimes present

35. Serous papillary adenocarcinoma ( Axial T2-weighted image )
Cystic and solid mass
Figure 10. Serous papillary carcinoma in a 56-year-old woman. (a) Axial T2-weighted image shows a cystic and solid mass (arrows). (b) Contrast-enhanced fat-suppressed T1-weighted image shows the exophytic papillary projections of the tumor (arrows). This is the typical appearance of a serous papillary adenocarcinoma.

36. Serous papillary adenocarcinoma ( Contrast-enhanced fat-suppressed T1-weighted )
Exophytic papillary
projections of the tumor
Figure 10. Serous papillary carcinoma in a 56-year-old woman. (a) Axial T2-weighted image shows a cystic and solid mass (arrows). (b) Contrast-enhanced fat-suppressed T1-weighted image shows the exophytic papillary projections of the tumor (arrows). This is the typical appearance of a serous papillary adenocarcinoma.

37. Mucinous cystadenocarcinoma
11% of ovarian carcinomas
>50% have stage I disease
Mimic metastases to the ovary from the colon or appendix

38. Mucinous cystadenocarcinoma ( Axial T2-weighted )
Cystic and
abundantly solid mass
Figure 11. Mucinous cystadenocarcinoma in a 72-year-old woman. Axial T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a cystic and abundantly solid mass (arrows). The postoperative diagnosis was a stage IC mucinous cystadenocarcinoma of the left ovary.

39. Mucinous cystadenocarcinoma (Contrast-enhanced fat-suppressed T1-weighted )
Figure 11. Mucinous cystadenocarcinoma in a 72-year-old woman. Axial T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a cystic and abundantly solid mass (arrows). The postoperative diagnosis was a stage IC mucinous cystadenocarcinoma of the left ovary.

40. Metastatic ovarian carcinoma
Extragenital tumors of the intestines, stomach, and breast
Spread via blood vessels and lymphatics
More common than primary ovarian
mucinous carcinomas
Metastatic carcinomas: Bilateral
Primary mucinous carcinomas:Unilateral

41. Metastatic ovarian carcinoma ( Sagittal T2-weighted )
Multicystic mass
Rectal tumor
Figure 12. Metastatic ovarian carcinoma in a 46-year-old woman. Sagittal T2-weighted (a) and
contrast-enhanced fat-suppressed T1-weighted (b) images show a multicystic mass (short arrows)
with a solid component. The irregular thick septa and solid component enhance on the postcontrast
image (arrowheads in b). A rectal tumor is also seen (long arrow). At surgery, a rectal carcinoma
and a metastatic tumor of the right ovary were found.

42. Metastatic ovarian carcinoma ( Contrast-enhanced fat-suppressed T1-weighted )
Irregular thick septa and
solid component
Figure 12. Metastatic ovarian carcinoma in a 46-year-old woman. Sagittal T2-weighted (a) and
contrast-enhanced fat-suppressed T1-weighted (b) images show a multicystic mass (short arrows)
with a solid component. The irregular thick septa and solid component enhance on the postcontrast
image (arrowheads in b). A rectal tumor is also seen (long arrow). At surgery, a rectal carcinoma
and a metastatic tumor of the right ovary were found.
Rectal tumor

43. Mature cystic teratoma
20% of all ovarian neoplasms
Mesodermal, endodermal, and
ectodermal derivatives are present in the tumor
Benign tumor includes ectodermal derivatives (sebaceous contents)
Fatty tissue: High-signal-intensity on
T1 and T2

44. Mature cystic teratoma ( Axial T1-weighted )
Fat
Tooth
Debris
Figure 13. Mature cystic teratoma in a 23-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a well-defined hyperintense mass (short arrows). A typical fat (Fa)–fluid (Flu) level is seen with floating debris (D). There is chemical shift artifact (arrowheads) at the boundary between the floating debris and the fatty component. The hypointense nodule (long arrow) represents a tooth within the tumor.
Fluid

45. Mature cystic teratoma ( Axial T2-weighted )
Figure 13. Mature cystic teratoma in a 23-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a well-defined hyperintense mass (short arrows). A typical fat (Fa)–fluid (Flu) level is seen with floating debris (D). There is chemical shift artifact (arrowheads) at the boundary between the floating debris and the fatty component. The hypointense nodule (long arrow) represents a tooth within the tumor.

46. Solid Masses Benign, borderline and malignant tumors
Fibroma and Fibrothecoma : solid benign tumors

47. Fibroma ( Sagittal T2-weighted )
Hypointense solid mass
Uterus
Figure 15. Fibroma in a 52-year-old woman.
(a) Sagittal T2-weighted image shows a hypointense solid mass (arrows). U uterus. (b, c) Unenhanced (b) and contrast-enhanced (c) fat-suppressed T1-weighted images show weak enhancement of the mass (arrows) compared with that of the uterine myometrium (U). No vascular signal void is seen between the uterus and the mass.

48. Fibroma ( Unenhanced fat-suppressed T1)
Figure 15. Fibroma in a 52-year-old woman.
(a) Sagittal T2-weighted image shows a hypointense solid mass (arrows). U uterus. (b, c) Unenhanced (b) and contrast-enhanced (c) fat-suppressed T1-weighted images show weak enhancement of the mass (arrows) compared with that of the uterine myometrium (U). No vascular signal void is seen between the uterus and the mass.

49. Fibroma ( Contrast-enhanced fat-suppressed T1)
Weak enhancement of the mass
Figure 15. Fibroma in a 52-year-old woman.
(a) Sagittal T2-weighted image shows a hypointense solid mass (arrows). U uterus. (b, c) Unenhanced (b) and contrast-enhanced (c) fat-suppressed T1-weighted images show weak enhancement of the mass (arrows) compared with that of the uterine myometrium (U). No vascular signal void is seen between the uterus and the mass.

50. Fibrothecoma Most common solid benign tumors Sex cord-stromal tumors
Composed of spindle, oval, or round cells forming various collagen
Edema and cyst formation
T2 : Mixed low to high signal
Estrogenic and uterine enlargement

51. Fibrothecoma ( Axial T2-weighted )
Heterogeneous solid mass
Enlarged Uterus
Figure 16. Fibrothecoma in a 72-year-old woman. Axial T2-weighted image shows a heterogeneous solid mass (arrows) with intermediate to high signal intensity. Ascites is seen in the cul-de-sac. The uterus (U) is enlarged, an abnormal finding in a postmenopausal woman.
72 y/o, postmenopausal woman

52. Brenner tumor ( Axial T1-weighted )
Low-signal solid mass
Multicystic mass
Figure 18. Brenner tumor in a 79-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a low-signal-intensity solid mass (arrows) that is sharply demarcated. In addition, a multicystic mass (arrowheads) is seen beside the solid mass. At surgery, a Brenner tumor (solid mass) and an associated mucinous cystadenoma (multicystic mass) were found.

53. Brenner tumor ( Axial T2-weighted )
low-signal-intensity
solid mass
Multicystic mass
(mucinous cystadenoma)
Figure 18. Brenner tumor in a 79-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a low-signal-intensity solid mass (arrows) that is sharply demarcated. In addition, a multicystic mass (arrowheads) is seen beside the solid mass. At surgery, a Brenner tumor (solid mass) and an associated mucinous cystadenoma (multicystic mass) were found.

54. Granulosa cell tumor ( Axial T1-weighted )
Solid mass
Cyst
Hemorrhagic cyst
(Hyperintense)
Figure 19. Granulosa cell tumor in a 55-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a mass with a predominantly solid appearance (arrows). Cystic components are seen in the tumor; some of them are hemorrhagic, thus appearing hyperintense on both images (arrowheads).

55. Granulosa cell tumor ( Axial T2-weighted )
Figure 19. Granulosa cell tumor in a 55-year-old woman. Axial T1-weighted (a) and T2-weighted (b) images show a mass with a predominantly solid appearance (arrows). Cystic components are seen in the tumor; some of them are hemorrhagic, thus appearing hyperintense on both images (arrowheads).

56. Serous carcinoma ( Axial T2-weighted )
Solid nodular mass
Bilateral external
iliac lymph nodes
Figure 21. Serous carcinoma in a 40-year-old woman. Axial T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a solid nodular mass (arrows). The tumor has nonspecific high signal intensity on the T2-weighted image and demonstrates enhancement on the contrast-enhanced image. In addition, there is enlargement of bilateral external iliac lymph nodes (arrowheads), which is a strong indicator of malignancy.

57. Serous carcinoma ( Contrast-enhanced fat-suppressed T1-weighted )
Figure 21. Serous carcinoma in a 40-year-old woman. Axial T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) images show a solid nodular mass (arrows). The tumor has nonspecific high signal intensity on the T2-weighted image and demonstrates enhancement on the contrast-enhanced image. In addition, there is enlargement of bilateral external iliac lymph nodes (arrowheads), which is a strong indicator of malignancy.

58. Diagnosis of Ovarian Masses with MRI