Clinical History
The patient complained of lower abdominal pain, discomfort and changes in bowel habit. A pelvic mass was discovered at transabdominal US examination. Other examinations were unremarkable.
Imaging Findings
The patient underwent a transabdominal US examination, to evaluate a large round mass, which was discovered at physical examination.
MRI of the pelvis was then requested, after the US examination, to evaluate a complex pelvic mass.
The MR examination shows a large mass (12 cm of maximum diameter) of the pelvis, arising from the left ovary, displacing the uterus and bladder, without a clear margin from the right ovary.
The most likely diagnosis is cystadenocarcinoma of the left ovary.
The patient underwent hystero-biannessiectomy, which confirmed the diagnosis.
Discussion
Malignant ovarian neoplasms may arise from all ovarian cell types and tissues. By far, the most frequent are those arising from the surface epithelium (mesothelium), and most of these are partially
cystic lesions. Annually in the United States, ovarian carcinomas are diagnosed in approximately 22,000 women, causing 16,000 deaths. Most malignant ovarian tumors are epithelial ovarian
cystadenocarcinomas. Mortality associated with malignant ovarian carcinoma is related to the stage at the time of diagnosis, and patients with ovarian carcinoma generally present late in the course
of disease. Malignant epithelial ovarian cystadenocarcinomas are associated with racial differences: women from northern and western Europe and North America are affected most frequently, whereas
women from Asia, Africa, and Latin America are affected least frequently. The incidence of epithelial ovarian cystadenocarcinomas rises exponentially with age until the sixth decade of life, at which
point it remains stable. Risk factors for ovarian cystadenocarcinoma include strong family history, advancing age, white race, infertility, nulliparity, a history of breast cancer, and BRCA gene
mutations. The majority of ovarian cystic tumors (both malignant and benign) are asymptomatic and they commonly do not cause symptoms until they reach an advanced stage. Patients may experience pain
or discomfort may occur in the lower abdomen, (also during intercourse), and having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate. Micturition may occur
frequently and is due to pressure on the bladder. Patients may experience abdominal fullness and bloating, indigestion, heartburn, or early satiety. Irregularity of the menstrual cycle and abnormal
vaginal bleeding may occur. No generalized screening test is available for ovarian cystadenocarcinoma, but women at high risk based on family history or previous history of breast cancer should
undergo an annual ultrasonographic examination and CA125 test. Mortality associated with malignant ovarian carcinoma is related to the stage at the time of diagnosis. The 5-year survival rate overall
is 41.6%, varying between 86.9% for FIGO stage Ia and 11.1% for stage IV. Authors (2, 3) stated that MRI is important to differentiate lesions deemed indeterminate after performing ultrasonography.
MRI images have better soft tissue contrast compared to CT scan images, particularly for identifying fat and blood products, and can give a better idea of the organ of origin of gynecologic masses.
As far as the papillary projections of ovarian neoplasms of cystic origin, the MR images correlate very well with the pathologic specimen (1). Outwater and colleagues stated that large papillary
projections had a distinctive structure of a fibrous stalk supporting clumps of edematous papillae with signal intensity similar to that of fluid on T2-weighted images; on the other hand smaller
papillae showed nondescript intracystic projections of intermediate signal intensity on T2-weighted images. All papillary projections (both large and smaller ones) in vivo enhanced after gadolinium
injection.
Differential Diagnosis List
Cystadenocarcinoma of the left ovary.
Final Diagnosis
Cystadenocarcinoma of the left ovary.
