Author: Inna Shyknevsky
Ultrasound CECT MRI - T1 MRI - T2 MRI - Postcontrast T1 Gross Histology Additional comments
Physiologic/Functional Cysts:

Follicle cyst

Ultrasound image 1 demonstrates several follicular cysts (arrows). These are usually unilocular, are anechoic, have a well defined posterior wall and demonstrate posterior acoustic enhancement (arrowheads). Overall, the ovary appears normal. Ultrasound image 2 demonstrates multiple small follicular cysts within the ovary. Axial contrast enhanced CT shows well-defined hypoattenuating adnexal mass which proved to be a simple cyst on US imaging. ;; Title: US and CT Evaluation of Acute Pelvic Pain of Gynecologic Origin in Nonpregnant Premenopausal Patients. Functional cyst on T2W image appears as hyperintense, cystic mass. Non-specific appearance. Axial T2W image shows unilocular hyperintense right ovarian mass (straight arrows). This mass regressed on follow-up imaging in 2 weeks, confirming diagnosis. Axial T1W post-contrast fat suppressed image shows smooth walled T1 hypointense right ovarian mass (straight arrows) with thin enhancing wall and no nodularity or vegetations. Image shows multiple follicular cysts (arrows) within the ovary. A type of functional cysts which results after an ovarian follicle fails to rupture or regress. These are usually simple cysts, have a thin wall, less than 3mm in thickness, and are usually less than 3cm in diameter.

Corpus luteum cyst

Ultrasound image shows hypoechoic cystic mass within an ovary, with posterior acoustic enhancement and thickened wall (arrow). It is filled with slightly echogenic material. Axial contrast-enhanced CT image shows enhancement of right corpus luteum wall (arrow) with a small amount of adjacent free fluid suggesting a ruptured cospus luteum cyst. Functional cyst on T2W image appears as hyperintense, cystic mass. Non-specific appearance. Axial T2W image shows unilocular hyperintense right ovarian mass (straight arrows).This mass regressed on follow-up imaging in 2 weeks, confirming diagnosis. Diagnosis confirmed by demonstrating resolution of cyst on 2 week follow-up imaging. Axial T1W post-contrast fat suppressed image shows smooth walled T1 hypointense right ovarian mass (straight arrows) with thin enhancing wall and no nodularity or vegetations. Image of gross specimen that has been separated in half. This demonstrates a well-circumscribed cyst containing hemorrhage and a rim of luteinized tissue (arrows). This is a type of functional cyst that occurs from hemorrhage into a corpus luteum. If a functional cyst is more than 1cm in size, it is more likely a corpus luteum cyst rather than follicular cyst.

Theca-lutein cyst

Transabdominal ultrasound images demonstrate multiseptated cystic structures in the adnexa in different patients. These were bilateral in one of the two cases. Gross specimen from a hysterectomy and bilateral oophorectomy in a patient with choriocarcinoma demonstrates bilateral theca lutein cysts. These are the largest of the physiologic cysts. They usually occur with abnormally elevated levels of beta hCG, such as in gestational trophoblastic disease (up to 50% of patients with theca lutein cysts) or with ovarian hyperstimulation syndrome in a setting of infertility treatment. When associated with gestational trophoblastic disease, these usually resolve within about 4 months following resolution of the primary disease. Theca lutein cysts are usually bilateral and multilocular.

Benign Primary Ovarian Neoplasms:

Germ cell tumor: Teratoma

US appearance is variable. There several common pattens: (a) Most common is a cystic mass with echogenic nodule. (b) Diffusely or partially echogenic mass. The echogenic area usually demonstrates sound attenuation due to sebaceous material and hair within the cyst cavity. (c) multiple thin, echogenic bands caused by hair in the cyst cavity. On occasion, sebaceous material can be hypo or anechoic.
Image 1 is a longitudinal pelvic US image demonstrating, centrally echogenic focus (arrowheads) representing fat within ovarian dermoid (arrow).


Image 2 is a transvaginal US image demonstrating a fat-fluid level (arrow) and an echogenic mural nodule (cursors), which can be seen in some cases.

Image 3 shows a transabdominal US image with a heterogeneous mass containing echogenic reflectors representing hair. There is no evidence of calcification or fat.
On CT, fat attenuation within a cyst, with or without calcification in the wall, is diagnostic for mature cystic teratoma. Image 1: Axial CT image of the pelvis shows bilateral ovarian masses (open arrows) of mixed attenuation containing fat (straight arrows), soft tissue (arrow heads), and calcium (curved arrow).

Image 2: Axial contrast enhanced CT image with cyst cavity demonstrates fat attenuation (F). A round Rokitansky nodule is seen (arrow) and has a feathery appearance at the fatty interface where the hair arises from it (arrowhead).
Image 1 shows Axial T1-weighted spin-echo MR image with a high-signal-intensity mass of the right ovary (arrow). ;; Title: Ovarian teratomas: Tumor types and imaging characteristics

Image 2: Axial fat-saturated T1-weighted gradi- ent-echo MR image (290/2.1) demonstrates saturation of the cyst contents (arrow).

Image 3: Axial T1-weighted spin-echo MR image shows a high- signal-intensity nodule in the wall of the mass.

Image 4: Axial fat-saturated T1-weighted gradient-echo MR image demonstrates saturation of the fatty nodule (arrow).
Image 1: T2-weighted fast spin-echo MR image shows right pelvic mass which demonstrates heterogeneous internal signal intensity with punctate high signal intensity (arrow). Photograph of the bisected tumor shows the Rokitansky nodule (thick arrow), which has the yellowish appearance of adipose tissue, and sebaceous components (F). Teeth are seen in the center of the Rokitansky nodule. Germ cell tumors are a category of ovarian neoplasm. This group make up about 15-20% of all ovarian neoplasms. About 95% of these are Benign Cystic Teratomas. Of the teratomas, most are mature teratomas (benign teratomas) or immature teratomas (malignant teratomas). Mature/benign teratomas are most commonly cystic, and are referred to as Benign Cystic Teratomas or Dermoid Cysts. Mature cystic teratomas make up the majority of mature teratomas. They affect young patients (mean pt age 30yrs) and are the most common mass of the ovary found in children. These tumors contain at least two of three germ cell layers, are slow-growing, and can be bilateral in approximately 10% of patients. Average tumor size is 7cm. They are usually unilocular, contain sebaceous material and various other tissue (ectodermal, mesodermal and endodermal origin). They often have a nodule (Rokitansky nodule) which can contain hair and teeth.

Epithelial tumor: Serous cystadenoma

Transabdominal longitudinal US image of left adnexa shows predominantly cystic adnexal mass (arrows) with a this septation (arrowhead). unilocular cystic mass in the right lower quadrant (arrows). The wall of the mass is not delineated, and there is no evidence of any excrescence within it. homogeneous low signal intensity with no solid components. homogenous high signal intensity, no septations or wall irregularity. large cyst with a rim of ovarian tissue (arrows). Belongs to epithelial category of ovarian neoplasms. Benign serous cystadenomas comprise up to 60% of serous type of epithelial ovarian neoplasms. This is unilocular or multilocular cystic mass with homogeneous attenuation on CT, homogeneous signal intensity of the locules on MRI, contains thin, regular wall, thin septations and no vegetations.

Epithelial tumor: Mucinous cystadenoma

Mucinous cystadenoma in 21 year old woman who is 24-weeks pregnant. Longitudinal pelvic US image shows complex left adnexal mass which extends into the abdomen. The mass demonstrates cystic component (arrows) with low-level internal echoes and multiple tubular cystic structures (arrowheads). Image 1: Benign mucinous cystadenoma in a 26- year-old woman. Contrast-enhanced CT scan shows a large, multilocular cystic mass (arrows) with a smooth contour, honeycomb appearance, and heterogeneous attenuation in the locules.

Image 2 shows mucinous cystadenoma in a 40 year old woman. The axial CT image demonstrates very large, homogenous, mass with several septations. The fluid within the left-sided locules is slightly greater in attenuation.
mass of homogeneous intermediate signal intensity without septation, anterior and superior to the gravid uterus. Mucinous cystadenoma. Photomicrograph (original magnification, xlOO; H-E stain) shows a single layer of benign columnar mucinous cells (arrows). Belongs to epithelial category of ovarian neoplasms. Benign mucinous cystadenomas comprise up to 80% of mucinous type of epithelial ovarian neoplasms. This neoplasm usually presents as a multilocular cystic mass, can have a honeycomb appearance, and is usually larger than serous ovarian neoplasms. Fluid within locules can have heterogenous attenuation on CT and heterogeneous signal on MRI. There should be no vegetations present.

Epithelial tumor: Brenner tumor

Incidentally discovered Brenner tumor in a 68-year-old woman. Contrast-enhanced CT scan shows a small, ovoid solid mass with homogeneous en- hancement (arrows), a finding that is nonspecific for a solid tumor. Almost always benign, represent about 2-3% of ovarian tumors, are usually less than 2cm in size, and are commonly diagnosed incidentally. These tumors are made of transitional cells and dense stroma. They can be associated with other ovarian neoplasms in 1/3 of cases.Imaging findings are non-specific.

Sex cord-stromal tumor: Fibroma

Although US appearance can be variable, these tumors often appear as a hypoechoic, solid mass which can have posterior acoustic shadowing. Image: transverse transabdominal US image shows a hypoechoic mass (M) with sound attenuation (arrows). On CT, this mass is slightly hypodense, and can be non-enhacing or slowly-enhancing on post-contrast imaging. Image shows axial CT scan which demonstrates a mass (M) with a solid appearance and no distinguishing characteristics. On T1W imaging, this mass usually shows homogeneous relatively low signal intensity. Image: T1-weighted spin-echo MR. M=mass. On T2W imaging, fibromas appear as well-defined masses with low signal intensity. These masses can have T2 hyperintense foci due to cystic degeneration or edema. Image: T2-weighted fast spin-echo MR shows the mass (M) with very low signal intensity similar to that of muscle, a finding that is character-istic of an ovarian fibroma. Small ovarian cysts at the margin of the mass (arrow) help identify the mass as ovarian. Gross specimen demonstrates an enlarged ovarian mass with a smooth, bosselated surface. On cut section, these tumors appear dense and white, accounting for the solid appearance seen at US. Belongs to the sex cord-stromal category of tumors. accounts for approximately 4% of ovarian neoplasms. These masses typically occur in middle aged women, can be asymptomatic, and are associated with ascites in up to approximately 40% of cases. When ovarian fibroma is associated with ascites and a pleural effusion, it is referred to as Meigs Syndrome. Histologically, these tumors are composed of fibrous tissue and lipid rich theca cells. Pathologically, fibrotic ovarian tumors can be classified as a fibroma, thecoma, fibrothecoma, or fibrosed thecoma.

Borderline Epithelial Ovarian Neoplasms:

Borderline papillary serous tumor in a 48-year-old woman with an elevated serum CA-125 level. Longitudinal US image of the right adnexa shows a cystic mass (cursors) containing a mural excrescence (arrow). Cystadenofibroma with borderline features in a 69-year-old woman. T1-weighted MR image shows a large mass containing slightly hyperintense cyst fluid.

Borderline papillary serous tumor in a 48-year-old woman with an elevated serum CA-125 level. Fat-saturated T1-weighted gradient-echo MR image shows excrescences (arrow) as fronds that have lower signal intensity than the cyst fluid.

Borderline mucinous ovarian tumor in a 59-year-old woman. Axial T1-weighted spin-echo MR image shows a large, multiloculated ovarian tumor (t) with variable signal intensities among the loculi.
Cystadenofibroma with borderline features in a 69-year-old woman. T2-weighted fast spin-echo MR image shows papillary projections (arrowheads) consisting of a low- signal-intensity fibrous core and barely visible edematous stroma. A prominent fibrous component with very low signal intensity is seen in the wall (arrow).

Borderline papillary serous tumor in a 48-year-old woman with an elevated serum CA-125 level. T2-weighted MR image shows papillary projections (thick arrow) with a low-signal-intensity core (thin arrow).

Borderline mucinous ovarian tumor in a 59-year-old woman.Sagittal T2-weighted fast spin-echo MR image shows the tumor (t) with predominantly high signal intensity similar to that of urine in the bladder (b).
Cystadenofibroma with borderline features in a 69-year-old woman. Fat-suppressed T1-weighted gradient-echo MR image obtained after the administration of gadopentetate dimeglumine demonstrates marked enhancement of the papillary projections (arrow- heads) but less enhancement of the fibrous component (arrow). Borderline papillary serous tumor in a 48-year-old woman with an elevated serum CA-125 level. Photomicrograph (original magnification, 40; hematoxylin-eosin stain) shows the papillary projections with a low-signal-intensity core (Cr) and edematous papillae (P). Borderline ovarian neoplasms are part of the epithelial group of ovarian tumors. Most borderline neoplasms are either serous or mucinous. These are also referred to as tumors of low malignant potential and differ from malignant epithelial ovarian neoplasms clinically and histologically. Histologically, these tumors do not have stromal invasion. They demonstrate soft tissue proliferation and papillary projections, and can metastasize throughout the peritoneum. Borderline tumors usually occur in young patients and have a better prognosis than malignant epithelial neoplasms.

Malignant Primary Ovarian Neoplasms:

Epithelial tumor: Serous carcinoma

Poorly differentiated papillary serous ovarian carcinoma in a 67-year-old woman. Longitudinal endovaginal US image through the right adnexa shows a heterogeneous, moderately echogenic solid mass (m) that is not clearly distinguishable from the uterus (u). Papillary serous cystadenocarcinoma in a 62-year-old woman. CT scan shows the mass with a bilobed appearance and calcification (solid arrow). Faint areas of increased attenuation (open arrows) indicate the complex nature of the mass. Papillary serous cystadenocarcinoma in a 62-year-old woman. Axial T2-weighted spin-echo MR image obtained at about the same level as the CT scan fails to show the calcification but demonstrates septation (open arrow) not seen on the CT scan. Solid tissue (solid arrow) is also seen.

Papillary serous carcinoma in a 41-year-old woman. Sagittal T2-weighted MR image shows a right ovarian mass with irregular solid components (arrow) and florid intracystic papillary projections (arrowheads). Ascites is also present (A), with implants in the cul-de-sac.
Papillary serous carcinoma in a 41-year-old woman. T1-weighted gradient-echo MR image obtained after the administration of gadopentetate dimeglumine shows enhancement of the papillary projections (arrowheads) and solid components (thick arrow) as well as implants (thin arrow). Photograph of the gross specimen shows the smooth external surface of the bilateral tumors seen on CT and MR. Epithelial neoplasms make up about 85% of malignant ovarian tumors. The majority of these are serous and mucinous, with serous being most common. These are usually cystic, can be uni- or multi-locular, and will have varying amounts of solid tissue or papillary projections. Distinguishing between serous and mucinous is usually not possible by imaging. Presence of non-fat, non-fibrous solid components is suspicious for malignancy. Serous carcinoma can have calcifications resulting in high attenuation of the primary mass and any tumor deposits.

Epithelial tumor: Mucinous carcinoma

Elderly patient with longitudinal sonogram image which shows a multi-septated complex adnexal mass that is predominantly cystic in nature. Large amounts of ascites were noted on additional images. Because of the patient’s age, a primary malignant ovarian neoplasm was strongly suspected. Ruptured mucinous cystadenocarcinoma in a 36-year-old woman. Sagittal turbo spin-echo T1-weighted MR image shows a large, multilocular mass with heterogeneous high signal intensity but with variable signal intensity in the locules. Ruptured mucinous cystadenocarcinoma in a 36-year-old woman. On an axial turbo spin-echo T2-weighted MR image the mass demonstrates high signal intensity, and there are multiple locules with a honeycomb appearance. The tumor wall is disrupted by spillage of the mucinous material (arrows). Ruptured mucinous cystadenocarcinoma in a 36-year-old woman. Gadolinium- enhanced fat-suppressed turbo spin-echo T1- weighted MR image demonstrates marked enhancement of the tumor wall and septa. Gross specimen of the excised mass, which proved to be mucinous cystadenocarcinoma. Image shows large multiloculated cystic structure containing thick, viscid fluid (arrows). Some areas within the tumor are more solid (arrowheads); these represented more cellular areas microscopically. Photomicrograph (original magnification, x 150; H-E stain) of a specimen from a patient with mucinous adenocarcinoma shows large amounts of mucin, including extrusion through a defect in the neoplastic epithelium (arrow). Epithelial neoplasms make up about 85% of malignant ovarian tumors. The majority of these are serous and mucinous. Mucinous carcinoma is less common than serous. These masses are usually cystic, can be uni- or multi-locular, and will have varying amounts of solid tissue or papillary projections. Distinguishing between serous and mucinous is usually not possible by imaging.On MRI, signal intensity of cystic components of the mass can be variable, depending on amount of mucinous, proteinaceous, or hemorrhagic material.

Epithelial tumor: Endometrioid ovarian cancer

Endometrioid carcinoma of the left ovary associated with uterine endometrial carcinoma in a 65 year old woman. Longitudinal US image (left) shows enlarged and heterogenous endometrium. Transverse US image (right) shows solid left adnexal mass (arrow). Endometrioid carcinoma of the ovary and endometrial carcinoma of the uterus in a 38-year-old woman. RIGHT: contrast-enhanced lower abdominal CT scan shows a complex cystic and solid tumor with enhancement of the solid-tissue elements and a thick, irregular wall. LEFT: contrast-enhanced pelvic CT scan shows a widened endometrial cavity with a nodular enhancing solid mass (arrowheads). Endometrioid carcinoma of left ovary associated with uterine endometrial carcinoma in a 65 year old woman. COronal T2W MR image shows an intermediate signal intensity mass (M) in left adnexa, inferior to a loop of bowel (black arrows). Also noted it irregularity and heterogeneity of the endometrium (white arrow). Endometrioid carcinoma of the ovary in a 50-year-old woman. Gross specimen photograph of a section through the solid portion of the tumor. Represents about 10%–15% of all ovarian carcinomas, can be associated with synchronous endometrial carcinoma or endometrial hyperplasia, and can be bilateral in up to half of cases. Rarely, these can arise from endometriosis. This mass has non-specific imaging findings.

Epithelial Tumor: Clear cell

Clear cell adenocarcinoma in a 78-year-old woman with weight loss and abdominal pain. CT scan shows a thick-walled mass with a markedly irregular, solid-tissue component (arrows). Clear cell carcinoma in a 42-year-old woman.Sagittal turbo spin-echo T2-weighted MR image demonstrates a large cystic mass (M) with hypointense, irregular solid protrusions peripherally. U=uterus. Clear cell carcinoma in a 42-year-old woman. Gadolinium enhanced fat-suppressed T1- weighted MR image demonstrates marked enhancement of the solid portions of the mass. Clear cell carcinoma. RIGHT: Photomicrograph (original magnification, xlOO; H-E stain) shows predominantly clear cells (polygonal cells with a large amount of clear cytoplasm) (arrows). LEFT: Photomicrograph (original magnification, x 100; H-E stain) of a specimen from a different patient demonstrates characteristic hobnail cells (apical hyperchromatic nuclei that project into the central glandular elements) (arrows). Both types (clear and hobnail) ofcellular morphology are typically present in this neoplasm. Approximately 5% of ovarian carcinomas. Over 3/4 of the cases present at an early stage. Thus, the prognosis is often better. Imaging findings are not specific. The mass often presents as a cystic mass with solid components.

Malignant germ cell tumor: Dysgerminoma

US features are non-specific. Sonogram shows a large echogenic mass arising from the pelvis. Dysgerminoma in an 18-year-old woman. Contrast-enhanced CT scan shows a large, multilobulated solid mass with highly enhancing fibrovascular septa (arrows) and cystic change (arrowheads). Dysgerminoma in a 17-year-old girl. Axial turbo spin-echo T2-weighted MR image shows a large, multilobulated mass with intermediate signal intensity and persistent low signal intensity of the septa (arrows). The irregular high-signal-intensity areas (arrowheads) indicate necrosis. Dysgerminoma in a 17-year-old girl. Axial gadolinium-enhanced turbo spin-echo T1-weighted MR image demonstrates relatively homogeneous enhancement with persistent low signal intensity of the septa (arrows) and unenhanced necrotic areas (arrowheads). gross specimen shows an nearly completely solid mass. Fine fibrous septa are seen running through the tumor ,which are not visible on the radiologic images. Make up about 50% of malignant germ cell tumors and up to 2% of ovarian cancers. Up to 3/4 of these occur in the 2nd and 3rd decade. Approximately 1/3 are aggressive and break through their capsule. Most of these tumors are not associated with hormone production. These are usually multilobulated solid masses with prominent fibrovascular septa.

Malignant germ cell tumor: Immature teratoma

Non specific US appearance. An example is an immature teratoma associated with contralateral mature cystic teratoma in a 27-year-old woman. Transverse transabdominal US image (right) shows a heterogenous mass in the cul-de-sac (arrowheads).Transverse transabdominal US image through the mid abdomen (left) shows a larger mass containing calcifications (arrowheads). Foci of fat are difficult to appreciate. Immature teratoma associated with contralateral mature cystic teratoma in a 27-year-old woman. Image shows two axial CT slices at the level of the abdomen and pelvis. CT slice through the pelvis shows a mature cystic teratoma in the cul-de-sac with fat attenuation and central calcification (arrowheads). CT slice through the abdominal mass shows an immature teratoma (arrowheads) with foci of fat (arrow) and scattered calcifications. Immature teratoma associated with ipsilateral mature cystic teratoma in a 27-year-old woman. (Top): Axial T1-weighted MR image shows a large mass of the left ovary with multiple high-signal-intensity foci (arrowheads). A lesion with the typical appearance of a mature cystic teratoma lies adjacent to the mass (arrow).(Bottom): Fat-suppressed T1-weighted MR image shows that some of the high-signal-intensity foci in the top image are hemorrhagic and retain their high signal intensity (open arrowhead), whereas others represent foci of fat (solid arrowheads). The ipsilateral mature cystic teratoma demonstrates suppression of the signal of the cyst contents (arrow). Immature teratoma associated with ipsilateral mature cystic teratoma in a 27-year-old woman. Axial T2-weighted fast spin-echo MR image shows the large fluid (F) and solid (S) components of the mass. These masses are composed of tissues derived from the three germ layers. They are rare, occur in young patients who are usually in the second decade of life, and have clinically malignant features. On presentation, they are large (average tumor size of 14-25cm). They may be solid or contain cystic components, and may contain serous, mucinous or sebaceous fluid. On histological exam, they contain immature or embryonic tissue elements. The amount of yolk sac tumor within the immature teratomas is a source of alpha-fetoprotein in affected patients. It is also used as a major predictor of stage, grade, and rate of tumor recurrence. Ipsilateral mature cystic teratomas are seen in 26% of cases of immature teratoma. Immature teratomas are bilateral in 10% of cases. These masses have characteristic CT and MRI appearance, which show a large, irregular solid component containing coarse calcifications and small foci of fat. Hemorrhage is also often seen.

Malignant germ cell tumor: Endodermal sinus tumor (also called yolk sac tumor)

Non specific US appearance. Image shows longitudinal sonogram through the middle of the pelvis with large mass above the urinary bladder and ascites (A) in the cul-de-sac. The mass is predominantly solid, but several cystic areas are seen within it. Endodermal sinus tumor in a 29-year-old woman. Contrast-enhanced CT scan shows a large, complex pelvic mass with solid and cystic components (arrows). Associated ascites is also seen (asterisk). The patient had an elevated serum alpha-fetoprotein level. Cut gross specimen shows the minor cystic component (C). This is a rare tumor type, which is rapidly growing, associated with elevated alpha-fetoprotein, carries a poor prognosis, and usually affects patients in the second decade of like. They usually present as a a large complex mass with both cystic and solid components.

Malignant germ cell tumor: Choriocarcinoma

Non specific imaging findings. Right ovarian choriocarcinoma in a 45-year-old woman with elevated levels of hCG in serum and urine. Axial contrast- enhanced CT image shows a solid, enhancing mass arising from the right ovary (arrow). At pathologic analysis after surgical excision, the mass was found to be a primary ovarian choriocarcinoma. Coexistent ovarian luteoma and endometrial hyperplasia secondary to hy- perestrogenism also were seen at surgery.

Other Primary Ovarian Neoplasms:

Granulosa-stromal cell tumors: Granulosa Cell Tumor

Stage I juvenile GCT in a 10-year-old girl with abdominal pain. Computed tomographie (CT) scan shows a multicystic mass filling most of the abdomen. Enhancing solid tumor (arrowheads) appears on the right and left sides of the mass.

Adult GCT in a 38-year-old woman with amenorrhea for 12 years. CT scan obtained after intra- venous and oral contrast material administration shows a large, cystic and solid mass without ascites.
Stage I juvenile GCT in a 10-year-old girl with abdominal pain. Ti-weighted spin-echo magnetic resonance image shows the mass with slightly high-signal-intensity components. Stage I juvenile GCT in a 10-year-old girl with abdominal pain. T2- weighted fast spin-echo MR image shows varying signal intensity of the mass, which appears mostly solid in this image.

Adult GCT in a 38-year-old woman with amenorrhea for 12 years. Axial T2-weighted MR image shows the large solid component with numerous cystic spaces, produc- ing a spongelike appearance (arrowheads).
Stage I juvenile GCT in a 10-year-old girl with abdominal pain. Photograph of the bisected surgical specimen shows large solid components of the mass. Bar = 3 cm. Can be Adult type (about 95%) or Juvenile Type. Usually found in peri-menopausal or postmenopausal women. They are associated with estrogen production. Can be associated with endometrial carcinoma in up to 1/4 of cases.

Granulosa-stromal cell tumors: Thecoma

Right ovarian thecoma in a 21-year-old woman with a 22-week gestation. Transverse transabdominal US image shows the fetus (U) and uterine wall adjacent to the mass (M), which has mixed echogenicity. Right ovarian thecoma in a 21-year-old woman with a 22-week gestation. Coronal T1-weighted MR image shows the gravid uterus (U) and a right adnexal mass (M) that is separate from the uterus. Right ovarian thecoma in a 21-year-old woman with a 22-week gestation. Axial T2-weighted image shows that the tumor (M) has high signal intensity but appears solid. The signal intensity is higher than that expected for a fibroma or fibrothecoma. Right ovarian thecoma in a 21-year-old woman with a 22-week gestation. Photograph of the bisected gross specimen shows the characteristic yellow color of a thecoma resulting from lipid deposition in the steroid-secreting cells. Part of a group of tumors that range from pure thecomas to pure fibromas. Thecal components are lipid-containing and produce estrogen.

Granulosa-stromal cell tumors: Fibroma (SEE "FIBROMA" UNDER BENIGN LESIONS ABOVE)

Sertoli-stromal cell tumors: Sertoli-Leydig Tumor

Sertoli-Leydig cell tumor with intermediate differentiation in a 42-year-old woman with irregular menses for 4 years. Transverse sonogram shows a hypoechoic well-defined mass (arrow) in the left adnexa. U = uterus. Sertoli-Leydig cell tumor with intermediate differentiation in a 42-year-old woman with irregular menses for 4 years. Axial CT scan obtained after intravenous administration of contrast material shows the mass (arrow) with homogeneous attenuation less than that of the enhanced uterus (U). Sertoli-Leydig cell tumor with heterologous elements in a 14-year-old girl with irregular menses. Axial T1-weighted MR image shows a large right ovarian mass anterior to the uterus (U). Sertoli-Leydig cell tumor with intermediate differentiation in a 42-year-old woman with irregular menses for 4 years. Axial T2-weighted MR image shows the solid mass (arrow) with low-intermediate signal intensity, similar to that of normal ovarian stroma or the uterine leiomyoma (arrowhead).

Sertoli-Leydig cell tumor with heterologous elements in a 14-year-old girl with irregular menses. Axial T2-weighted MR image shows the mass with cystic and solid components. The left ovary (arrow) is normal.
Sertoli-Leydig cell tumor with heterologous elements in a 14-year-old girl with irregular menses. Gadolinium-enhanced T1 weighted gradient-echo MR image shows enhancement of the solid portions of the tumor. Sertoli-Leydig cell tumor with heterologous elements in a 14-year-old girl with irregular menses. Photograph of cut surface of the tumor shows its cystic and solid areas. Sertoli-Leydig cell tumors are most common subtype, and about 3/4 of cases occur in patients less than 30 years of age. Hormone producing and associated with hormone production and virilization. Can demonstrate malignant behavior in up to 18% of patients.

Steroid cell tumors

Steroid cell tumor in a 7-year-old girl with pseudoprecocious puberty. Longitudinal sonogram (LEFT) shows the uterus, which is enlarged for the patient’s age. Transverse sonogram (RIGHT) shows a heterogeneous mass (M) replacing the right ovary. Steroid cell tumor in a 7-year-old girl with pseudoprecocious pubertyCoronal T2-weighted MR image shows the intermediate- signal-intensity solid mass (M) surrounded by ascites (arrowheads). These are rare tumors (less that 1 % of ovarian neoplasms) containing steroid secreting cells, which often contain intracellular lipid. They can cause virilization. Up to 1/3 cases can demonstrate malignant behavior. ;

Infection:

Tubo-ovarian abscess

Bilateral tubo-ovarian abscesses in a 38-year-old woman who presented with fever and pelvic pain. LEFT: Axial contrast-enhanced CT scan shows bilateral, peripherally enhancing, thick-walled complex cystic structures with an adjacent serpiginous component (arrow). RIGHT: Coronal oblique reformatted image helps confirm the tubular nature of these structures, which proved to be bilateral tubo-ovarian abscesses at surgery. u=uterine fundus.

Fitz-Hugh–Curtis syndrome in a 28-year-old woman with PID and abnormal LFTs. Contrast-enhanced CT scan through the pelvis shows a complex right adnexal mass (arrows) with a thick enhancing rim and surrounding inflammation, findings that are compatible with a TOA. Contrast-enhanced CT scan through the upper abdomen shows subcapsular and periportal perfusional variation (white arrowheads) and periportal edema (black arrowhead) due to perihepatitis from peritoneal spread of infection.

Other:

Endometrioma

Image 1: Endometrioma in a 40-year-old woman. US reveals a cystic mass with diffuse internal low level echoes.

Image 2: Transvaginal US image shows a cys- tic mass with diffuse low-level homogeneous ech- oes, findings typical of endometrioma.

Image 3: Transvaginal US image shows an ovarian endometrioma with low-level echogenicity, thick septations, and a soft-tissue component caused by clot formation (arrow).

Image 4: Transvaginal US image of a 37-year-old woman with cyclic pain shows a cystic mass with a fluid-debris level. Color Doppler US image depicts blood flow in the thick septation because of an organizing hematoma in a recurrent hemorrhage.
Specific MR imaging findings: Multiple cystic masses with high T1 signal intensity and low T2 signal intensity. . Endometrioma in a 40-year-old woman. T1-weighted spin-echo MR image reveals a mass in the right ovary with high signal intensity and a discrete wall (arrow) Specific MR imaging findings: Cystic mass(s) with high T1 signal intensity and low T2 signal intensity. . Endometrioma in a 40-year-old woman. T2-weighted MR image shows the mass is very low signal intensity (referred to as “shading”) (arrow). Approximately 80% of pelvic endometriosis is found in the ovary. Can have fluid-fluid levels or debris-fluid levels. CT is not a useful modality for evaluation.

Hemorrhagic cyst

Image 1: Hemorrhagic cyst in a 41-year-old woman. Transverse and sagittal endovaginal US images show a right ovarian cyst with lacelike internal echoes, a finding that is suggestive of hemorrhagic cyst.

Image 2: US image shows a cyst containing a solid appearing nodule in a non-dependent portion. The nodule disintegrated with movement of the cyst, confirming that it was adherent debris.

Image 3: US image shows an ovarian cyst that contains multiple echogenic bands against a hypoechoic background. This fishnet appearance represents residual fibrin strands.

Polycystic ovarian syndrome

US image 1 demonstrated transvaginal US image of typical appearance of polycystic ovary with multiple subcapsular follicular cysts (arrows).

US Image 2 shows a hypoechoic appearance of the ovary without discrete cysts, a finding seen in upto 25% of patients with polycystic ovaries.
Coronal T2-weighted MR image shows that both ovaries are slightly enlarged and have many follicles at the periphery (arrowheads). This is an image from a 27yo patient with PCOS and endometrial carcinoma. Gross Specimen photo demonstrates bilateral ovarian enlargement, a typical finding in PCOS. Incidentally noted is a uterine leiomyoma. Histologic section (H-E stain) shows multiple cysts situated superficially beneath the outer cortex, whereas the central portion of the ovary is composed of homogeneous stroma. Endocrine disorder with chronic anovulation, diagnosed with clinical and laboratory findings or pathologic examination of the ovaries. On laboratory analysis there is elevted LH, LH/FSH ratio and elevated androgen levels. Both ovaries are affected. Ovaries contain multiple tiny subcapsular follicular cysts, usually more than 5 cysts in each ovary, which are usually 5-8mm in size. The ovaries may be enlarged or be normal in size. Ovaries are normal in volume in about 30% of cases.

Ovarian Hyperstimulation Syndrome

Ovarian hyperstimulation Syndrome in a woman being treated for infertility. Sagittal US image shows an enlarged ovary with multiple large cysts. Color Doppler image shows central blood flow. Ovarian hyperstimulation syndrome in a 37-year-old woman who was undergoing ovulation induction. CT scan of the pelvis shows massive enlargement of the ovaries by multiple corpus luteum cysts surrounding a core of central ovarian stroma with relatively higher attenuation (*). More cephalad images (not shown) demonstrated a large amount of intraabdominal ascites. Ovarian torsion in ovarian hyperstimulation syndrome, who was also 11 weeks pregnant and presented with RLQ pain. Axial fat-saturated T2-weighted image of the lower pelvis shows the cervix (white arrowhead) and rectum (R). Both ovaries are enlarged and contain multiple follicles (black arrowheads). These findings are consistent with ovarian hyperstimulation syndrome. Note the asymmetrical enlargement of the right ovary, which also demonstrates a subtle increase in signal intensity of the stroma (*). A small amount of fluid is seen between the two ovaries (arrow). Although the right ovary had arterial and venous flow at Doppler imaging, the MR findings were consistent with right ovarian torsion, which was confirmed at laparotomy. Also see section on Theca-lutein cyst above.

Torsion

Unilateral ovarian enlargement, above 4cm, is most commonly seen. This can be seen before infarction occurs. Longitudinal sonogram shows an enlarged 7-cm ovary (between cursors labeled A) with peripheral cysts. Power Doppler sonogram shows complete absence of blood flow in the ovary.The pinpoint foci of color in the center of the ovary are secondary to motion artifact. Surgically proved ovarian torsion in a 31-year-old woman. Contrast-enhanced CT image shows enlarged right adnexa, which displaces the uterus (U) anteriorly, and lack central enhancement. In addition, a hypoattenuating peripheral cystic structure can be seen (arrow). The enlarged ovary (O) was mistaken for a fibroid uterus. Ovarian torsion in ovarian hyperstimulation syndrome, who was also 11 weeks pregnant and presented with RLQ pain. Axial fat-saturated T2-weighted image of the lower pelvis shows the cervix (white arrowhead) and rectum (R). Both ovaries are enlarged and contain multiple follicles (black arrowheads). These findings are consistent with ovarian hyperstimulation syndrome. Note the asymmetrical enlargement of the right ovary, which also demonstrates a subtle increase in signal intensity of the stroma (*). A small amount of fluid is seen between the two ovaries (arrow). Although the right ovary had arterial and venous flow at Doppler imaging, the MR findings were consistent with right ovarian torsion, which was confirmed at laparotomy.

Ovarian torsion in a 31-year-old woman who was 30 weeks pregnant and had RLQ pain and nausea. Axial fat-saturated T2-weighted MR image shows high signal intensity within the right ovarian stroma (*) caused by edema. Note the peripherally located follicles, which appear prominent due to the stromal edema. A small amount of fluid is also present surrounding the ovary (arrowheads); this fluid was not appreciated without fat saturation. These MR imaging findings are characteristic of ovarian torsion, and the diagnosis was confirmed at surgery.
Gross specimen demonstrates massive ovarian enlargement with edema and hemorrhage. Vascular pedicle twists resulting in obstruction of venous and lymphatic flow. Arterial inflow is maintained initially. Next, there occurs diffuse ovarian edema/enlargement, which causes increase pressure within the ovary. This leads to ischemia and infarction. Predisposing factors include large ovarian cysts, masses, and ovarian enlargement in the setting of ovarian hyperstimulation syndrome.