Ovarian borderline tumors of MRI: Imaging findings and
radiologic-pathologic correlation
Poster No.:
C-317
Congress:
ECR 2009
Type:
Educational Exhibit
Topic:
Genitourinary
Authors:
R. N. Matsubayashi , Y. Matsuo , T. Nakazono , Y. Okajima , T.
1
1 1
2
2
3
2
3
Muranaka ; Fukuoka/JP, Tokyo/JP, Saga/JP
Keywords:
Ovary, Imaging findings, borderline tumor
DOI:
10.1594/ecr2009/C-317
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Page 1 of 48
Learning objectives
Learning Objectives
n To illustrate the MR imaging features of ovarian borderline tumors.
n To learn the essential diagnostic clues based on the histologic features of
borderline tumors.
Background
Background
n Ovarian tumors are classified as benign, borderline, and malignant.
n Borderline tumors have a relatively good prognosis and originate in younger
patients compared with malignant tumors, and it is important to diagnose them
correctly to ensure adequate treatment.
n We present the MR images of surface epithelial-stromal borderline tumors and
correlate the findings with histologic features. Additionally, granulosa cell and
carcinoid tumors are also shown.
Imaging findings OR Procedure details
Imaging findings
Surface Epithelial Borderline Tumors
1. Serous Borderline Tumor (SBT)
n Definition: An ovarian tumor of low malignant potential exhibiting an atypical
epithelial proliferation of serous type cells greater than that seen in their benign
counterparts but without destructive stromal invasion.
n Epidemiology: Patients with SBT are approximately 10-15 years younger than
those with serous carcinoma. About 30-50% of SBT are bilateral.
n Macroscopy: May be cystic with a variable number of excrescences, form a solid
purely surface papillary growth or have a combination of these appearances. SBTs
Page 2 of 48
generally lack areas of necrosis and hemorrhage. The cysts usually contain serous
fluid, but can occasionally be mucinous.
Serous surface borderline tumor is the variant; polypoid excrescences formed by
fine papillae with features of SBT occupy the outer surface of the ovary.
n Histopathology: The hallmarks of SBT that distinguish it from a cystadenoma are
the presence of epithelial hyperplasia forming papillae, micropapillae associated
with "detached" or "floating" cell clusters and mild to moderate nuclear atypia. The
epithelial hyperplasia exhibits "hierarchical branching". There is no destructive
stromal invasion.
n The micropapillary type (5-10%) more frequently involves the ovarian surface.
Fig.: Serous borderline cystic tumor exhibiting polypoid excrescences in the
cyst.
Page 3 of 48
Fig.: On T2-weighted images (T2WI), the excrescence exhibited a "broccoli"-like
appearance, and had low signal-intensity (SI) stalk with delicate branching. This
reflects the histologic hierarchical branching.
Page 4 of 48
Fig.: Histologically, the stroma exhibits dense collagen and hyalinization (a), and
severe edematous change in the surface (b). Macroscopically, this edematous
region appears as many cyst-like nodules (arrows).
Page 5 of 48
Fig.: A serous tumor can be confined to the right ovarian surface (arrows), and
typical cystic mass with excrescences in the contralateral ovary. Serous tumors
are often bilateral with different growth pattern and grade.
Imaging Findings of SBT:
n Serous borderline cystic tumor exhibiting polypoid excrescences in the cyst.
n On T2-weighted images (T2WI), the excrescence shows a "broccoli"-like
appearance, and has low signal-intensity (SI) stalk with delicate branching. This
reflects the histologic "hierarchical branching".
2. Mucinous borderline tumor (MBT), intestinal-type
n Definition: Ovarian tumors of low malignant potential exhibiting an epithelial
proliferation of mucinous type cells greater than that seen in their benign
counterparts but without evidence of stromal invasion. The epithelial component
resembles intestinal epithelium and almost always contains goblet cells.
n Epidemiology: The intestinal-type account for 85-90% of mucinous borderline
tumors.
Page 6 of 48
n Macroscopy: The tumors are bilateral in approximately 5% of cases and usually
large, multilocular and rarely unilocular cystic masses containing watery or
viscous mucoid material. Velvety excrescences may line the cysts. Hemorrhage,
necrosis, solid and papillary areas are occasionally seen.
n Histopathology: Areas resembling mucinous cystadenomas are common. In the
borderline areas, the cells lining the cysts are stratified (usually to no more than
3 layers).
n Borderline tumors tend to have a larger number of loculi than adenomas
(Okamoto, et al. 2007).
Fig.: A large, multilocular cystic mass exhibits a typical, "stained-glass" appearance.
In particular, the central part exhibits many tiny loculi with thickening of the walls. This
part shows a high SI on DWI.
Page 7 of 48
Fig.: The slightly thickened walls of the central part show enhancement on Gd-T1WI
Page 8 of 48
Fig.: Pathologically, the thickened walls show many glands lined by intestinal-type
epithelia that exhibit nuclear stratification and goblet cells are noted.
Page 9 of 48
Fig.: Mucinous cystic tumor with a mural nodule (arrows). This part exhibits slight to
very low SI and homogenous enhancement. This part is an adenofibroma (It is not a
typical "black sponge", but a report showed that typical findings are found in only 43%
of the tumors (Jung et al. 2006)).
Imaging Findings of MBT:
n MBT exhibits a multilocular cystic mass (stained-glass appearance) with partially
thickened walls.
n On contrast-enhanced MR imaging, the wall exhibits enhancement.
n Borderline tumors tend to have a larger number of loculi than adenomas.
3. Mullerian mucinous borderline tumor, MMBT (mucinous borderline tumor,
endocervical-like)
n MMBT was first described in 1988 by Rutgers and Scully.
n Definition: Borderline tumors of low malignant potential exhibiting an epithelial
proliferation of mucinous type cells greater than that observed in their benign
Page 10 of 48
counterparts but without destructive stromal invasion. The mucinous epithelial
cells resemble endocervical epithelium.
n Epidemiology: 10-15% of MBT. The average patient's age is 34 years.
n Macroscopy: MMBT are bilateral in approximately 40% of cases. MMBT are more
often unilocular with intracystic papillae. The papillae that architecturally resemble
those of SBT.
n Histopathology: They differ from intestinal-type tumors in that the intracystic
growth is composed of bulbous papillae similar to those of SBT.
n 30% of the cases show endometriosis. 20% of the cases show endometriosis in
the ipsilateral ovary, and these endometrioses undergo transition to the neoplastic
epithelium.
Fig.: An MMBT exhibits polypoid papilla in the endometriotic cyst. The papilla
exhibits very high SI with delicate branching core on T2WI (cotton ball-like) and weak
enhancement on dynamic contrast study.
Page 11 of 48
Fig.: This MMBT exhibits a large papilla in the endometriotic cyst. The papilla exhibits
very high SI on T2WI with low SI core, and weak enhancement on dynamic contrast
study. Histologically, branching edematous papillae lined by endocervical type
mucinous cells are revealed.
4. Mullerian mixed-epithelial borderline tumor, MEBT (Borderline mixed epithelial
tumor)
n MEBT was first well characterized in 1988 by Rutgers and Scully.
n Definition: Borderline tumor composed of an admixture of two or more of the
following cell types: endocervical-like mucinous, ciliated serous, endometrioid,
and squamous. The second or second and third cell types must comprise alone or
together at least 10% of the neoplastic lining.
n Epidemiology: MEBT account for 5% of borderline tumors. The average patient's
age is 35 years. MEBT are more often seen in premenoposal woman.
n Macroscopy: MEBT are bilateral in approximately 22% of cases. MEBT are more
often unilocular with intracystic papillae. The papillae architecturally resemble
those of SBT.
Page 12 of 48
n Histopathology: They exhibit papillae with detached cell clusters reminiscent of
SBT, but they generally contain a mixture of endocervical-like cells and indifferent
eosinophilic epithelium.
n 53% of the cases exhibit endometriosis. 33% of the cases exhibit endometriosis
in the ipsilateral ovary.
Fig.: An MEBT exhibits polypoid papilla in the endometriotic cyst. This papilla exhibits
very high SI in the periphery with low SI core on T2WI. These features resemble those
of MMBT. Weak enhancement of this papilla in the periphery is observed on dynamic
contrast-enhanced study.
Page 13 of 48
Fig.: This MEBT exhibits polypoid papilla in the endometriotic cyst, and these imaging
features are similar to MEBT-1; however, the surface of the lesion exhibits high SI on
T1WI. Histologically, this portion reflects clots on the surface of the lesion (There is no
contrast-enhanced image).
Page 14 of 48
Fig.: The papilla exhibits high intensity on T2WI with a low intensity core.
Histologically, a severely edematous branching papillae with fibrous core is noted. The
high intensity on T2WI may reflect the edematous stroma.
Page 15 of 48
Fig.: Histologically, they exhibit finely branching complex papillae with detached cell
clusters reminiscent of SBT, but they generally contain a mixture of endocervical-like
cells (mucinous, serous and endometrioid) and indifferent eosinophilic epithelium.
Imaging findings of MMBT/MEBT
n MMBT/MEBT exhibit polypoid papilla in the endometriotic cysts. The papilla
exhibits very high SI with delicate branching core on T2WI (cotton ball-like) and
weak enhancement on dynamic contrast-enhanced study.
n The high SI on T2WI may reflect the edematous stroma.
n The imaging findings of MMBT and MEBT are resemble.
5. Endometrioid Borderline Tumor
n Definition: An ovarian tumor of low malignant potential composed of atypical or
histologically malignant endometrioid type glands or cysts, often set in a dense
fibrous stroma with absence of stromal invasion.
n Epidemiology: Rare (they account for 3-18% of malignant ovarian neoplasms)
Page 16 of 48
n More than 15-50% have endometriosis in the ipsilateral ovary. Often unilateral.
n Histopathology: Adenofibromatous (common) Villoglandular or papillary
Combination of villoglandular and adenofibromatous
Fig.: A large solid mass in the endometriotic cyst is observed. The mass primarily
exhibits intermediate homogenous SI on both T1 and T2WI, but the central portion
exhibits high SI on both T1 and T2WI.
Page 17 of 48
Fig.: The mass exhibits gradual enhancement on dynamic study. On early image,
reticular linear enhancement is seen. The central portion exhibits no enhancement.
Page 18 of 48
Fig.: Histologically, atypical or malignant endometrioid type glands set in a dense
fibrous stroma with absence of stromal invasion. The central portion contains
hematoma.
6. Borderline Brenner Tumor
n Definition: An ovarian transitional cell tumor of low malignant potential with
atypical or malignant features of the epithelium but lacking obvious stromal
invasion.
n Epidemiology: Only 3-5% of Brenner tumors. They are confined to the ovary and,
with rare exceptions, have been unilateral. The average patient's age is 59 years.
n Brenner tumors are associated with another tumor type, usually mucinous
cystadenoma (25%).
n Macroscopy: Typically large (median; 16-20cm). They usually have a solid
component resembling benign Brenner tumor as well as a cystic component
containing a papillary or polypoid mass.
Page 19 of 48
n Histopathology: Borderline Brenner tumors exhibit a greater degree of
architectural complexity than benign Brenner tumors. Typically, a benign Brenner
tumor component is also present.
n Imaging Findings: Higher SI than benign counter part on T2WI (Takeuchi, et al.
2008).
Fig.: A solid and cystic mass is shown. The solid portion exhibits calcification on CT.
On T2WI, the upper part of the solid portion exhibits intermediate SI (arrows) and the
lower part exhibits very low SI. Typical benign Brenner tumors exhibit very low SI on
T2WI.
Page 20 of 48
Fig.: The solid portion exhibits gradual enhancement on dynamic study.
Diagnostic clues of surface epithelial borderline tumors
n Prominent papillary projection than their benign counterpart (especially SBT)
n No invasive extension, ascites and lymphadenopathy
n Relatively younger than cases with malignant tumor
n Borderline Brenner tumor exhibits higher SI on T2WI
Sexcord-Stromal Tumor
7. Granulosa cell tumor
n Account for 1.5% (range, 0.6-3%) of all ovarian tumors. The tumor occurs in a
wide age range.
Page 21 of 48
n The tumors produce or store a variety of steroid hormones (most are
estrogenic, but rarely androgenic activity may occur). The tumor can induce
pseudoprecocious puberty, menstrual disorders and irregular uterine bleeding.
n Two major subtypes are recognized: adult type (more than 95%) and juvenile type
n Adult type exhibits admixture of cystic and solid areas. The tumor cells have a
nuclear groove (juvenile type lacks of nuclear groove).
n Imaging findings: multilocular or solid and cystic mass with hemorrhage.
Fig.: Case 1. A large multilocular mass. This case is a postmenopausal woman, but a
large uterus is noted (arrow).Case 2. Mainly, the mass exhibits low SI on both T1 and
T2WI with cystic parts. High SI, which reflects the hemorrhage, is observed on T1WI.
Germ Cell Tumor
8. Carcinoid
Page 22 of 48
n These tumors contain
neuroendocrine cells.
extensive
components
of
well-differentiated
n They may occur in pure form or within a dermoid cyst, a mucinous cystic tumor
or a Brenner tumor.
n Subtypes: Insular, trabecular, mucinous and strumal.
n Carcinoid syndrome occurs in 3.2-30%
n Peptide YY production by the tumor cells causes severe constipation in
trabecular carcinoids.
n Carcinoids are immunoreactive to the neuroendocrine markers (chromogranin
A, synaptophysin, Leu-7, grimelius stain) .
Fig.: A large multilocular mass exhibits a solid portion. The solid portion exhibits
relatively high SI on T1WI, low SI on T2WI and homogeneous enhancement on FS-GdT1WI.A fatty component is noted (arrow).
Page 23 of 48
Fig.: The solid portion of this case exhibits low SI on T2WI and high SI on T2WI: We
speculate that the stromal fibrosis, hemorrhage and neuroendocrine granules may
affect the SI.
Images for this section:
Page 24 of 48
Fig. 1: Serous borderline cystic tumor exhibiting polypoid excrescences in the cyst.
Page 25 of 48
Fig. 2: On T2-weighted images (T2WI), the excrescence exhibited a "broccoli"-like
appearance, and had low signal-intensity (SI) stalk with delicate branching. This reflects
the histologic hierarchical branching.
Page 26 of 48
Fig. 3: Histologically, the stroma exhibits dense collagen and hyalinization (a), and severe
edematous change in the surface (b). Macroscopically, this edematous region appears
as many cyst-like nodules (arrows).
Page 27 of 48
Fig. 4: A serous tumor can be confined to the right ovarian surface (arrows), and
typical cystic mass with excrescences in the contralateral ovary. Serous tumors are often
bilateral with different growth pattern and grade.
Page 28 of 48
Fig. 5: A large, multilocular cystic mass exhibits a typical, "stained-glass" appearance.
In particular, the central part exhibits many tiny loculi with thickening of the walls. This
part shows a high SI on DWI.
Page 29 of 48
Fig. 6: The slightly thickened walls of the central part show enhancement on Gd-T1WI
Page 30 of 48
Fig. 7: Pathologically, the thickened walls show many glands lined by intestinal-type
epithelia that exhibit nuclear stratification and goblet cells are noted.
Page 31 of 48
Fig. 8: Mucinous cystic tumor with a mural nodule (arrows). This part exhibits slight to
very low SI and homogenous enhancement. This part is an adenofibroma (It is not a
typical "black sponge", but a report showed that typical findings are found in only 43%
of the tumors (Jung et al. 2006)).
Page 32 of 48
Fig. 9: An MMBT exhibits polypoid papilla in the endometriotic cyst. The papilla
exhibits very high SI with delicate branching core on T2WI (cotton ball-like) and weak
enhancement on dynamic contrast study.
Page 33 of 48
Fig. 10: This MMBT exhibits a large papilla in the endometriotic cyst. The papilla exhibits
very high SI on T2WI with low SI core, and weak enhancement on dynamic contrast
study. Histologically, branching edematous papillae lined by endocervical type mucinous
cells are revealed.
Page 34 of 48
Fig. 11: An MEBT exhibits polypoid papilla in the endometriotic cyst. This papilla exhibits
very high SI in the periphery with low SI core on T2WI. These features resemble those
of MMBT. Weak enhancement of this papilla in the periphery is observed on dynamic
contrast-enhanced study.
Page 35 of 48
Fig. 12: This MEBT exhibits polypoid papilla in the endometriotic cyst, and these imaging
features are similar to MEBT-1; however, the surface of the lesion exhibits high SI on
T1WI. Histologically, this portion reflects clots on the surface of the lesion (There is no
contrast-enhanced image).
Page 36 of 48
Fig. 13: The papilla exhibits high intensity on T2WI with a low intensity core.
Histologically, a severely edematous branching papillae with fibrous core is noted. The
high intensity on T2WI may reflect the edematous stroma.
Page 37 of 48
Fig. 14: Histologically, they exhibit finely branching complex papillae with detached cell
clusters reminiscent of SBT, but they generally contain a mixture of endocervical-like cells
(mucinous, serous and endometrioid) and indifferent eosinophilic epithelium.
Page 38 of 48
Fig. 15: A large solid mass in the endometriotic cyst is observed. The mass primarily
exhibits intermediate homogenous SI on both T1 and T2WI, but the central portion
exhibits high SI on both T1 and T2WI.
Page 39 of 48
Fig. 16: The mass exhibits gradual enhancement on dynamic study. On early image,
reticular linear enhancement is seen. The central portion exhibits no enhancement.
Page 40 of 48
Fig. 17: Histologically, atypical or malignant endometrioid type glands set in a dense
fibrous stroma with absence of stromal invasion. The central portion contains hematoma.
Page 41 of 48
Fig. 18: A solid and cystic mass is shown. The solid portion exhibits calcification on CT.
On T2WI, the upper part of the solid portion exhibits intermediate SI (arrows) and the
lower part exhibits very low SI. Typical benign Brenner tumors exhibit very low SI on
T2WI.
Page 42 of 48
Fig. 19: The solid portion exhibits gradual enhancement on dynamic study.
Page 43 of 48
Fig. 20: Case 1. A large multilocular mass. This case is a postmenopausal woman, but
a large uterus is noted (arrow).Case 2. Mainly, the mass exhibits low SI on both T1 and
T2WI with cystic parts. High SI, which reflects the hemorrhage, is observed on T1WI.
Page 44 of 48
Fig. 21: A large multilocular mass exhibits a solid portion. The solid portion exhibits
relatively high SI on T1WI, low SI on T2WI and homogeneous enhancement on FS-GdT1WI.A fatty component is noted (arrow).
Page 45 of 48
Fig. 22: The solid portion of this case exhibits low SI on T2WI and high SI on T2WI:
We speculate that the stromal fibrosis, hemorrhage and neuroendocrine granules may
affect the SI.
Page 46 of 48
Conclusion
Conclusion
n It is important to know the characteristics of ovarian borderline
tumors to distinguish them from highly malignant tumors.
n In particular, in cases of tumors associated with endometriosis,
careful interpretation is recommended.
Personal Information
Roka Namoto Matsubayashi, MD, ph D.
Department of Radiology and Co-Director of Breast Care Center
National Hospital Organization Kyushu Medical Center
1-8-1 Jigyohama Chuo-ku Fukuoka 810-8563, Japan
Tel: +81-92-852-0700
Fax: +81-92-847-8802
E-mail: rokan@qmed.hosp.go.jp or
rokan@kyumed.jp
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