Case Report

1
Radiological Category
Principal Modality (1) Principal Modality (2)
Genitourinary
CT
Ultrasound
Case Report 0016
Submitted by
Emma Ferguson, M.D.
Faculty reviewer
David Zelitt, M.D
Date accepted
20 June 2003
2
Case History

• 36 year old female with gradually increasing
  abdominal girth and four day history of severe
  left flank pain. Large mass in the mid left
  abdomen on physical exam.

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Radiological Presentations

Contrast Enhanced CT Abdomen
IMAGE 1
4
Radiological Presentations
Contrast Enhanced CT Pelvis
IMAGE 2
5
Radiological Presentations

IMAGE 3
Contrast Enhanced CT Pelvis
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Radiological Presentations

IMAGE 4
Transverse Ultrasound Image Left Adnexa
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Radiological Presentations
Longitudinal Ultrasound Left Adnexa with Doppler
IMAGE 5
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Test Your Diagnosis
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appropriate diagnosis of the left adnexal mass ?
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• Adenocarcinoma
• Pedunculated Fibroid
• Omental Implant
• Metastasis
• Fibroma
• Massive ovarian edema

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- Contrast enhanced CT scan of the
abdomen and pelvis shows a 10 x 10 x 7 cm, well
circumscribed solid mass in the left mid abdomen
(image 1) which connects to the uterus via the
broad ligament, consistent with a left adnexal
origin. A whirled appearance of the
mesenteric vessels suggests torsion (image 2,
arrow). The right ovary is normal, but no
normal left ovary is identified (image 3).
Small free fluid is seen in the pelvis.-
Ultrasound shows a large, heterogeneous but
mostly solid left adnexal mass (image 4). Only
minimal blood flow is visible in the periphery of
the mass (image 5).
Findings and Differentials
Findings
DDx for a predominantly solid ovarian mass

• Granulosa Cell Tumor
• Thecoma
• Fibroma
• Brenner Tumor
• Endometrioid Tumor
• Krukenberg Tumor
• Cystadenoma
• Cystadenocarcinoma

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Discussion

• Ovarian fibromas constitute 4 of all ovarian
  tumors and are composed of collagen producing
  spindle cells which resemble fibroblasts. These
  tumors usually arise in peri- or post- menopausal
  women, and the average size is six centimeters.
  Smaller tumors are frequently asymptomatic.
  Larger tumors cause abdominal enlargement, pain
  and urinary symptoms. Acute pain is associated
  with torsion. Fibromas may very rarely produce
  steroid hormones. Two unusual clinical syndromes
  are occasionally seen with ovarian fibromas.
  Meigs syndrome complicates 1-3 of ovarian
  fibromas and is accompanied by ascites and a
  hydrothorax, both of which remit after the tumor
  is removed. The hereditary basal cell nevus
  syndrome (Gorlins syndrome) usually involves
  bilateral fibromas which are calcified and occur
  in a younger population.
• Ovarian fibromas are almost always benign. This
  is important from an imaging standpoint because
  they may mimic malignant neoplasms given their
  solid appearance. Ultrasonographically, these
  tumors are generally hypoechoic and tend to
  attenuate the sound beam. CT scan typically
  shows a heterogeneous but predominantly solid
  mass which may have foci of edema, hemorrhage or
  necrosis, sometimes resulting in cyst formation,
  especially as the tumor increases in size. Most
  are unilateral. Less than ten percent show focal
  or diffuse calicification. Only rarely are
  benign implants seen in the peritoneum. Ascites
  is a fairly common finding and is believed to be
  a direct transudation from the tumor. It is seen
  in 40-50 of cases when the tumor is larger than
  five centimeters in diameter.
• The treatment for ovarian fibromas is excision,
  and the prognosis is excellent.

Haaga J, Lanzieri C, and Robert Gilkeson CT and
MR Imaging of the Whole Body 41782,
2002. Kurman R Pathology of the Female Genital
Tract 5923-5,2002. Robboy S, Anderson M, and
Peter Russell Patholgy of the Female
Reproductive Tract 619-22, 2002. Scully R, Young
R and Philip Clement Atlas of Tumor Pathology
Tumors of the ovary, maldeveloped gonads,
fallopian tube, and broad ligament 3, 194-7,
1996. Thurmond A, Jones M, and Deborah Cohen
Gynecologic, Obstetric, andBreast Radiology
259-64, 1996.
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Discussion

• The patient was taken to surgery and the left
  ovary was found to be torsed two times.
  Malignancy was suspected due to the solid
  appearance of the mass, and a TAH/BSO was
  performed.

Microscopically, the cells have small
spindle-shaped nuclei lacking atypia or
significant mitotic activity. The arrows point
to a region of hemorrhagic infarction.
The sectioned surface is gray-white and chalky
with hemorrhage.
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Ovarian fibroma with hemorrhagic
infarction.
Diagnosis