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

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.

Radiological Presentations Contrast Enhanced CT Abdomen IMAGE #1

Radiological Presentations Contrast Enhanced CT Pelvis IMAGE #2

Radiological Presentations Contrast Enhanced CT Pelvis IMAGE #3

Radiological Presentations Transverse Ultrasound Image Left Adnexa IMAGE #4

Radiological Presentations Longitudinal Ultrasound Left Adnexa with Doppler IMAGE #5

Adenocarcinoma Pedunculated Fibroid Omental Implant Metastasis Fibroma Massive ovarian edema Which one of the following is your choice for the appropriate diagnosis of the left adnexal mass ? After your selection, go to next page. Test Your Diagnosis

- 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). Granulosa Cell Tumor Thecoma Fibroma Brenner Tumor Endometrioid Tumor Krukenberg Tumor Cystadenoma Cystadenocarcinoma Findings: DDx for a predominantly solid ovarian mass: Findings and Differentials

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. Meig’s 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 (Gorlin’s 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 % of cases when the tumor is larger than five centimeters in diameter. The treatment for ovarian fibromas is excision, and the prognosis is excellent. Discussion Haaga J, Lanzieri C, and Robert Gilkeson: CT and MR Imaging of the Whole Body: 4:1782, Kurman R: Pathology of the Female Genital Tract: 5:923-5,2002. Robboy S, Anderson M, and Peter Russell: Patholgy of the Female Reproductive Tract: , 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, Thurmond A, Jones M, and Deborah Cohen: Gynecologic, Obstetric, andBreast Radiology: , 1996.

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

Ovarian fibroma with hemorrhagic infarction. Diagnosis