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Diagnostic and Interventional Imaging
Volume 97, n° 11
pages 1187-1188 (novembre 2016)
Doi : 10.1016/j.diii.2016.05.009
Ruptured benign serous ovarian cystadenoma mimicking ovarian malignancy with peritoneal carcinomatosis
 

S. Boussouar a, L.S. Fournier a, M.-A. Le-Frere-Belda b, E. Kao c, A.-S. Bats d, F. Chamming's a,
a Radiology Department, Hôpital Européen Georges Pompidou, AP–HP, 20, rue Leblanc, 75015 Paris, France 
b Pathology Department, Hôpital Européen Georges Pompidou, AP–HP, Paris, France 
c McGill University Health Center, Radiology department, Montréal, QC, Canada 
d Gynecology Department, Hôpital Européen Georges Pompidou, AP–HP, Paris, France 

Corresponding author.

Keywords : Benign serous cystadenoma, Ovarian tumor, Papillary projections, Peritoneal carcinomatosis, MR imaging


Dear editor ,

When an adnexal mass is detected, the presence of extracystic papillary projections associated with peritoneal implants is highly suggestive of ovarian malignancy. We report a rare case of a ruptured benign serous ovarian cystadenoma resulting in ascites and externalization of papillary projections mimicking ovarian malignancy with peritoneal carcinomatosis.

A 63-year-old woman presented with a recent increase in abdominal volume. Carcinoembryonic antigen serum level (CA) 125 was 128U/mL (normal<35U/mL). Transabdominal and transvaginal ultrasound showed a large ovarian mass with multiple anechoic cysts along with peritoneal implants and ascites. Pelvic magnetic resonance imaging (MRI) (Signa 1.5T, GE Medical Systems, Milwaukee, WI, USA) revealed the presence of a 12-cm heterogeneous left ovarian mass with cystic portions and diffuse ascites. On fat-suppressed T1-weighted MR images obtained after intravenous administration of a gadolinium chelate (gadoterate meglumine, Dotarem®; Guerbet, Aulnay sous Bois, France) at a dose of 0.2mL per kilogram of body weight, extracystic papillary projections and peritoneal implants displayed enhancement (Figure 1). These findings were considered as strongly suspicious for a malignant epithelial tumor with peritoneal carcinomatosis even though 18fluorodeoxyglucose positron emission tomography-computed tomography showed no signs of increased metabolism. Intraoperative findings through laparoscopy revealed a ruptured left ovarian mass, with multiloculated cysts and extracystic papillary projections (Figure 2). Considering the suspicious features on MRI, the lesion was entirely removed and treatment was completed by hysterectomy, bilateral salpingo-oophorectomy and omentectomy. However, no signs of malignancy were found at histopathological examination, which yielded the diagnosis of ruptured benign ovarian serous cystadenoma with externalized papillary projections (Figure 3).



Figure 1


Figure 1. 

Ruptured benign serous ovarian cystadenoma mimicking peritoneal carcinomatosis; a: T2-weighted fast spin echo MR image (TR/TE, 6840ms/123.8ms) in the transverse plane shows a complex left ovarian cystic mass with a pattern of extracystic papillary projections (*); b: T2-weighted fast spin echo MR image (TR/TE, 6840ms/123.8ms) in the sagittal plane shows diffuse ascites with peritoneal thickening (arrow); c: fat-suppressed T1-weighted MR image (TR/TE, 320ms/12.7ms; flip angle 70°) after intravenous administration of a gadolinium chelate (gadoterate meglumine, Dotarem®; Guerbet, Aulnay, France), shows peritoneal (arrow) and papillary projections (*) enhancement.

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Figure 2


Figure 2. 

Celioscopic view shows ruptured cyst wall with papillary projections (*) and no evidence of peritoneal carcinomatosis.

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Figure 3


Figure 3. 

Histopathological analysis of resected specimen shows a large papillary projection (*) of the ruptured cyst, with normal epithelium (arrow) and no malignant cells (hematoxylin-eosin-safranin staining; original magnification, ×4).

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This case illustrates a rare complication of a benign epithelial ovarian tumor mimicking malignancy on imaging. When an ovarian mass is suspected, transabdominal and transvaginal ultrasound is routinely performed. In case of a large or complex pelvic mass, MRI is recommended in pretreatment work-up in order to confirm the ovarian origin and to assess suspicion for malignancy. On MRI, the presence of extracystic papillary projections and peritoneal involvement (ascites, peritoneal thickening or nodules), as described in our patient, are associated with higher risk of malignancy [1]. However, ascites was actually related to leakage of intracystic fluid. In addition, the lesions that were considered as extracystic projections and peritoneal implants were actually intracystic, papillary projections externalized in the peritoneal cavity after rupture of a benign ovarian serous cystadenoma. As they deposited over the peritoneum, papillary projections were interpreted as peritoneal thickening, although there was no actual peritoneal invasion in our case, which differs from other benign diseases mimicking peritoneal carcinomatosis, as tuberculosis or peritoneal leiomyomatosis [2]. Serous cystadenoma is the most frequent ovarian epithelial tumor [3]. Lesion size is usually<10cm, the presentation is often plain or paucilocular. In 50% of cases, it contains papillary projections, usually<5mm) [4]. As reported by Outwater et al., vegetations are present in 13% of benign, 67% of borderline and 38% of serous invasive ovarian carcinomas [5]. Extracystic papillary projections are strongly suggestive of serous borderline cystadenoma. Rupture, which is a classical complication of ovarian tumors, as is torsion, hemorrhage, infection or compression, has to our knowledge only been previously reported for borderline or malignant tumors [6]. The possibility that extracystic vegetations, peritoneal implants and ascites could have been related to the rupture of a benign epithelial tumor has, therefore, not been suggested. Addition of functional sequences such as diffusion weighted (DW) MRI and dynamic contrast-enhanced (DCE) MRI, which are now routinely used for the characterization of ovarian masses [7], could have been helpful in our case. If present, it is possible that the presence of a hyposignal on DWI and persistent enhancement on DCE MRI would have helped to consider the diagnosis of benign ovarian tumor. Our observation shows that it is important to keep in mind that benign ovarian lesions may demonstrate morphological imaging features of ovarian malignancy, and that complementary functional sequences may be helpful to avoid misinterpretation.

Disclosure of interest

The authors declare that they have no competing interest.

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