The leading risk factor is familiarity; namely, history of ovarian cancer in a first-degree relative. Hereditary cases occur predominantly in premenopausal age, while the sporadic ones affect mostly older women. Dermoid cyst mature cystic teratoma is the most common benign ovarian neoplasm.
Sex cord-stromal neoplasms may produce hormones, both oestrogen and androgens, resulting in endocrinological symptoms. In addition, several benign lesions should also be considered, namely functional and haemorrhagic cyst, as well as endometriomas. Ovarian cancer may show direct extension to surrounding pelvic structures, as well as intraperitoneal, lymphatic and hematogenous spread.
Local invasion of uterus, fallopian tubes and contralateral adnexa can be found, while the involvement of bladder and rectum is less frequent. One of the most important features of ovarian cancer is intraperitoneal dissemination by exfoliation of cells, often associated with a variable amount of ascites: pouch of Douglas, greater omentum and subphrenic region are the most common sites of implantation, probably because of the preferential circulatory path of peritoneal fluid. Lymphatic dissemination is most common to para-aortic and paracaval lymph nodes, following the ovarian veins; pathologic lymph nodes can also be found in pelvic external iliac, hypogastric and obturatory and inguinal chains.
Hematogenous metastases are less frequent and most often tend to involve liver and lung; however spleen, bone, brain and other locations may be affected. The optimal assessment of an adnexal mass requires a multidisciplinary approach, based on physical examination, laboratory tests and imaging techniques. An important issue to consider in the management of ovarian masses is that they are very common, but most of them are benign and only a small part is borderline or malignant.
Preoperative biopsy should not be performed in ovarian masses, particularly if the mass appears to be surgically resectable at the moment, as this invasive procedure raises the risk of spreading cancer cells and potentially leads to iatrogenic upstaging worsening the prognosis. The most commonly used serum tumour marker for epithelial tumours is cancer antigen CA In postmenopausal women, CA has high sensitivity as well as high specificity, while in premenopausal women, it has an high sensitivity but low specificity, because it may also be elevated in other conditions e.
Human epididymis protein 4 HE4 is a recently added tumour marker and several studies have shown his usefulness in discriminating between benign and malignant adnexal masses in premenopausal women [ 5 , 6 ]. Diagnostic imaging plays a crucial role in detection, characterization and staging of adnexal masses.
- Medical history and physical exam.
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Regarding the vascularization, colour Doppler study is able to demonstrate both the presence and the localization of new tumour blood vessel: a predominantly central blood flow is more often associated with malignancy, while a peripheral one is more typical of a benign lesion [ 7 ]. Wu et al. However, unless morphological and vascularity features clearly indicate a benign lesion, further assessment is mandatory. Levine et al.
Computed Tomography CT of the abdomen and pelvis after contrast administration is important both in evaluation of spread of malignant lesions and in detection of recurrence after therapy, whereas it has a limited value in primary detection and characterization of an ovarian mass.
With CT scans, only lesions containing fat tissue and calcifications, like mature teratoma, can be easily characterized. CT is the imaging technique of choice in staging: looking for omental and peritoneal implants, ascites and lymphadenopathy is very important to assess the extension of the disease [ 8 ]. Therapy response evaluation is usually performed with CT, comparing pre-treatment with post-treatment scans preferably after six cycles of chemotherapy.
An interval between the CT scans of only three cycles of chemotherapy is indicated if serum markers are negative or their levels are not decreasing [ 11 ]. However, finding an increased FDG uptake in postmenopausal women has always to be considered an abnormality.
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Magnetic Resonance Imaging MRI is an essential problem solving tool to determine the site of origin of a pelvic mass and then to characterize an adnexal mass, especially in patients with indeterminate lesions [ 13 , 14 ]. MRI is also reliable in detecting local invasion. The main advantages of MRI are the high contrast resolution with excellent soft tissue contrast and lack of ionizing radiation exposure, which is particularly important in young female patients.
In order to obtain anatomic information and to study morphological and signal intensity characteristics of the mass, both T1- and T2-weighted sequences are needed. Fat-saturated T1-weighted images are helpful to detect haemorrhagic areas and fat tissue. The use of intravenous gadolinium improves detection of enhancing septa and solid components within the mass and of peritoneal and omental implants. Diffusion-weighted imaging DWI is a potentially useful technique in the assessment of adnexal masses; however, its role has been controversial in literature.
For Katayama et al. In , Thomassin-Naggara et al. Recently, other studies [ 18 , 19 ] have shown that high signal intensity on DWI is more frequent within malignant lesions and is useful for differentiating them from benign ones. It has to be considered that several benign lesions, namely endometriomas, teratomas and fibrothecomas, may also show restricted diffusion; however, a confident diagnosis of these lesions can usually be done with T1-weighted, T1-weighted fat-suppressed and T2-weighted standard sequences [ 20 ]. In a paper published in , Kyriazi et al.
In , Zhao et al. In our opinion, diffusion-weighted images should be included in MRI protocol. The role of 1.
Proton MR spectroscopy is a non-invasive diagnostic tool that may contribute to the differential diagnosis of subtypes in ovarian tumours. In addition to the 1. The various subtypes of malignant epithelial ovarian tumours serous, clear cell, endometrioid, and mucinous respond differently to chemotherapy. In particular, serous adenocarcinoma may have a good response to chemotherapy, whereas clear cell and mucinous adenocarcinomas may show poor response to chemotherapy.
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Proton MR spectroscopy may identify the presence of mucinous material containing N-acetyl mucinous compounds, and can provide helpful information in distinguishing mucinous and nonmucinous ovarian tumours. Therefore, MR spectroscopy helps to diagnose the subtypes of ovarian tumours and may contribute to the adequate treatment, thus improving management of these patients [ 25 ].
Compared with 1. In addition, in the study of complex adnexal masses, dynamic contrast-enhanced MRI is especially effective for increasing the conspicuity of findings that are predictive of malignancy. The MR imaging protocol we use in our institution to study patients with ovarian masses is as follows. MR imaging is performed with a closed-configuration superconducting 1. After i. MR imaging is performed with the patient lying in the supine position feet first.
Imaging in epithelial ovarian cancer
In case of voluminous ovarian masses that exceed the FOV of the above-mentioned sequences, we use the following MR protocol. All sequences are acquired in breath hold. Then we evaluated signal intensity features e. Unilocular cystic masses in the adnexal region are more likely benign and can have both non-ovarian or ovarian origin. Paraovarian cysts, hydrosalpinx, pyosalpinx and hematosalpinx are the most common extraovarian lesions, whereas ovarian lesions are usually represented by functional cysts and serous cystadenomas; less common unilocular ovarian cystic masses are cystadenofibromas and mucinous cystadenomas more often multilocular.
Most unilocular cystic masses have low signal intensity on T1-weighted images and high signal intensity on T2-weighted images.
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Paraovarian cysts or paratubal cysts or hydatid cysts of Morgagni arise from mesothelial, paramesonephric or mesonephric remnants. Hydrosalpinx is a fluid filled fallopian tube; it may assume a cystic appearance on some scans mimicking an ovarian lesion, but multiplanar visualization is usually able to demonstrate its sausage-like C-shape or S-shape tubular structure. Fallopian tubes can also be distended by pus or blood, respectively pyosalpinx high signal intensity on diffusion-weighted images and hematosalpinx high signal intensity on T1-weighted images [ 28 ].
The latter one may enlarge because of an internal bleeding, showing high signal on T1-weighted images: follow-up is able to differentiate haemorrhagic corpus luteum cysts from endometrioma considering complete resolution of the functional cyst.
Magnetic resonance imaging may aid ovarian cancer patients
Serous fluid shows low signal intensity on T1-weighted and high signal intensity on T2-weighted images Fig. They are usually smaller and more often bilateral than mucinous cystadenomas. Serous cystadenomas of borderline malignancy may show some small papillary projections. Serous cystadenoma in a year-old woman. On c sagittal and d axial contrast-enhanced fat-suppressed T1-weighted images, the cyst wall shows poor contrast enhancement white arrows without vegetations, nodularity, or solid components.
Cystadenofibroma is an uncommon benign epithelial ovarian tumour containing both epithelial and fibrous stromal components. This tumour may present as a purely cystic lesion, almost indistinguishable at MRI from a cystadenoma, although it more often shows a complex cystic appearance with thick septa and solid components.