urology gynecology anapath et imagerie c balleyguier
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Corinne Balleyguier, Radiology
Pierre Duvillard, Pathology
Gustave Roussy, Villejuif
From Imaging to Pathology : How to assess Benignity in Rare Ovarian Tumors?
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How to assess Benignity in Rare Ovarian Tumors?
� Imaging ?? � Nearly never… � Excepted for some functional ovarian lesions
� Simple functional cyst � Haemorraghic functional cyst � ..
� Some common benign ovarian lesions � Endometrioma � Ovarian fibroma
� Pathology?? � Nearly ever… � To avoid for functional lesions …
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Functional Ovarian Lesions
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Functional ovarian cyst: YES
� Ultrasound may assess the content of a liquid cyst
� Harmonic imaging may be useful to better define cystic content
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Color Döppler?
� Color Döppler is not accurate: � In 30 % of cases, arterial
flow is found in cystic wall
� Usually with a low resistive index
� Be careful to misunderstanding with a malignant lesion !!!
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Haemorrhagic functional cyst: YES
Internal content with thin walls
No blood flow inside thin walls
The cyst must disappeared on short time follow-up at D6
NO MRI !!
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Endometrioma: YES
� Ultrasound is usually enough
� Typical features: � Thin echoes,
homogeneous blood cyst
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Complex endometrioma: US/MRI
� Rarely, clots may simulate papillary projections
� Additional MRI is useful
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T1
T1 + Fat Sat
T2
Endometrioma Hyperintense T1w Hyper / Hypointensity T2w Hyperintense T1+ FS
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And Rare Ovarian Tumors ??
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What are Rare Ovarian Tumors ?
Germ cell ovarian tumors
Immature teratoma
Monodermal teratoma (struma ovarii)
Carcinoid T Neuroectodermic T
Non teratomatous T (Dysgerminoma)
Yolk sac T Embryonnary carcinoma
Non gravidic choriocarcinoma Polyembryoma
Mixed germ cell Tumeurs
Ovarian tumor classification OMS 2003
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Stromal Tumors
Fibroma Thecoma
Fibrosarcoma Stromal T with minor
sex-cord differenciation
Sclerosing stromal T
Sex cord ovarian T
Granulosa stroma cell T
Sertoli stromal cell T
Sex cord of mixed or unclassified cell
type Gynandroblastoma
Indifferenciated sex cord T
Steroïd T
Stromal Luteoma Leydig cell T Steroid cell T
Ovarian tumor classification OMS 2003
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To play in defence or
what are the findings for benign?
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Pure solid ovarian tumor on
ultrasound
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Ovarian Fibroma � Diagnosis of ovarian fibroma may nearly be assess on
imaging : US + MRI � Ultrasound findings:
� Solid ovarian mass � Homogeneous content � Arterial flow
� Ultrasound may be doubtful in case of old ovarian fibroma: � Heterogenous � Posterior attenuation � Low blood flow
� èMRI
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Ovarian Fibroma
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Ovarian Fibroma : MRI
� MRI is the best imaging examination to assess fibrous content � Hypointense signal : T1w and
T2w � Moderate to high intense uptake
� Enhancing curves lesion / myometrium may be useful
� Fibrothecoma : � Hypointense signal : T2w � Intense uptake after injection
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Ovarian Fibroma
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Thomassin-Naggara, I. et al. Radiology 2008;0:2481071120
Serous Borderline Cystadenoma
Bénin
Borderline
Benign
Malignant
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Right Fibroma Left Fibrothecoma
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Stromal Ovarian Tumors (Fibroma, Thecoma)
� Unilateral tumors nearly always benign � Solid content, white/yellow colour, homogenous � Medium size : 6 cm � Histologically, architecture is fasciculated without any
atypia or mitoses � Good prognosis allows conservative surgery,
especially for young women
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Homogenous, echoic Cyst on
Ultrasound
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Mature Teratoma
Echoic, homogenous cyst
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Teratoma : Germ Cell Tumour
� Ultrasound features can vary according internal content : cyst, fat, calcification.
� Ultrasound diagnosis may be difficult : � A dermoïd cyst may mimic intestinal loops
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Cystic Mature Teratoma
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MRI may assess fatty content � Fat signal characterization: � Hyperintense signal : T1w � Hyperintense signal : T2w � Hypointense signal: T1w with fat
suppression
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T1w T2w
T1 FS
Cystic mature teratoma
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Benign Teratoma : Pathology
� Polydermal teratoma: � Solid (15-20 % of solid teratoma) � Cystic (dermoïd cyst)
� 27-44% of all ovarian tumors � Non specific clinical symptoms � Diameter usually < 15 cm � Bilateral in15% of cases, sometime multiple � External wall smooth, half-solid, half-cystic with pilo-
sebaceous tissue � Very heterogenous on pathology including components of
the 3 primitive mature tissues.
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Benign Teratoma
� Monodermal dedicated � Struma Ovarii � Ovarian carcinoïd T
� Insulet carcinoïds � Trabecular carcinoïds � Mucinous carcinoïds (globlet cell carcinoïds)
� Strumal carcinoïds
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Attacking Game or How to find Malignant Features …
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Most common rare malignant Ovarian Tumors…
Immature Teratoma Granulosa cell Tumor
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Immature Teratoma?
� Immature teratoma is rare � Difficult diagnosis on imaging � Imaging :
� Heterogenous internal content � Haemorrhagic content (MRI++) � Heterogenous, intense uptake � Large size � Multiple irregular calcifications � Tissue thickening within Rokitansky’s
protuberance
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Immature Teratoma
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Pathologist : Referee
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Immature Teratoma � Clinical features :
� 3% of ovarian teratoma (nearly 20% of primary malignant germ cell tumors and 10-20% of malignant ovarian tumors occuring before 20 yo).
� Usually revealed with an abdominal mass and abdominal pain.
� Extra ovarian lesions in 33% of cases (peritoneal implants).
� Large tumors (18 cm medium size), usually unilateral with rupture or break of capsula in 50% of cases.
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Immature Teratoma � Microscopic features:
� Polymorphous lesions including variable amount of mainly neurectodermal immature tissue.
� Other immature content are possible : ◆ Embryologic epithelial tissue (endodermal,
ectodermal..). ◆ Immature mesenchymatous tissue (cartilage,
striated muscle…). ◆ Liver, renal, vitellin tissue...
� Mature tissue may be associated.
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Immature Teratoma
� Treatment and prognosis: � According tumor stage and tumor grade. � Conservative surgery if possible + chemotherapy (BEP)
for tumors grade 2 and 3 and stage II and III. � Clinical complete response is obtained in nearly all
cases after CT (77% of 5 years remission). � Residual peritoneal lesions may be detected (fibrous
nodule). � Growing teratoma syndroma is exceptionnal.
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Pitfall: Growing Teratoma � Multifocal peritoneal
extension of an immature teratoma after complete response with CT : � Benign lesion � Surgery may be complete to
remove all peritoneal implants � Nimkin K, Pediatr Radiol.
2004 Mar;34(3):259-62.
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Granulosa Cell Tumor � Rare ovarian T (0.6-3% of all ovarian T)
� 5% of malignant lesions � Mesenchymatous and sex-cord like
tumors � Two types:
� Adult (AGT) � Juvenile (JGT) : malignancy risk is higher
� Medium size : 10 cm � Hormonal clinical symptoms � Partly cystic, haemorrhagic content
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Adult Granulosa Cell T 35 yo
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15 yo Juvenile Granulosa Cell T
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Pathologist : Referee
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Adult Granulosa Cell Tumors � Clinical features :
� 6% of malignant ovarian tumors � Usually diagnosed after menopause � Associated to hyperestrogenic features in 75% of
cases � Diagnosed at stage 1 in 90% of cases � Unilateral in 85% of cases, variable size,
heterogenous with capsule rupture in 10 -12% of cases
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Juvenile Granulosa Cell Tumors
� Clinics: � 5% of granulosa cell tumors and 97% are
diagnosed before 30 years � Hormonal features in a child � Unilateral in 98% for stage I cases � Macroscopic features are similar to those of Adult
form tumors
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Granulosa Cell Tumors
� Prognostic factors : � Stage at diagnosis
� Evolution and treatment: � Malignant lesions with low progression, late
recurrence in adult (20% at 5 years) � Death rate : 12.5% � Surgical treatment :
� Conservative for juvenile form stage IA
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Across the Line… Very rare Ovarian Tumors…
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Does Imaging help to diagnose a rare malignant Ovarian Tumor?
� Common features to detect : � Size > 10 cm � Haemorrhagic content : ultrasound, MRI (++) � Irregular calcifications � Central necrosis: MRI (hyperT2, hypoT1, peripheral
heterogenous enhancement) � Jung SE, Radiographics. 2002
� Ascitis � Peritoneal carcinomatosis � Lymph node
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Endodermal sinus Tumor : Yolk sac T
� Rare malignant germ cell tumor (< 1 % malignant T) � 20-30 yo
� Variable feature (cystic to solid) � Imaging features:
� Haemorrhagic content � Hyperintense uptake � Heterogenous
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Yolk Sac Tumor � Clinics:
� 20% of malignant germ cell ovarian tumors (medium age 16-19 yo) (10% before10 yo)
� Fast growing tumors : abdominal mass, pelvic pain. Emergency for surgery : risk of ovarian torsion or tumor rupture.
� α-foetoprotein synthesis (high level (>1000 ng/ml).
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Yolk sac Tumor � Macroscopic features:
� Large tumor (15 cm), unilateral, sometimes peritoneal carcinomatosis.
� External wall smooth, rupture in 25% of cases. � Solid and cystic, bloody content, necrosis � Other germ cell tumor may be associated (15% of
dermoïd cyst).
� Prognostic factors � Clinical stage : 5 years survival 70-90% for stage 1
� 30 à 50% for other stage. � Residual lesions after surgery � Liver lesions.
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Choriocarcinoma � < 1 % malignant T � 15 yo � Imaging features :
� Necrosis � Hypervascularization � Peripheral calcifications
� Biology : � βHCG serous elevation with a non gravid uterus
� Treatment and prognosis: � Very aggressive tumors with peritoneal extension � Same treatment as other malignant germ cell tumors.
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Conclusion � To assess benignity in rare ovarian
tumors ……. � With pathology: YES, usually � With surgery…
� Imaging : NO � Exception :
� Functional lesions � Fibrous tumors � Mature teratoma : +/-
� Imaging as an adjunct tool : � Necrosis, calcifications, blood