Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management

Abstract

Historically, cancer treatment has emphasized measures for the "cure" regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.

Keywords: Cancer; Fertility preservation; Gynecologic cancer; Magnetic resonance imaging; Oncofertility.

Figure 1

31-year-old woman with cervical cancer and ovarian hyperstimulation. A. A drawing shows the spoke-wheel appearance of hyperstimulated ovaries with multiple peripheral cysts centered on ovarian stroma. B. Axial T1WI shows symmetrically enlarged bilateral ovaries with low SI cysts; some cysts contain high SI blood products (white arrow). C. Axial oblique T2WI shows symmetrically enlarged bilateral ovaries with high SI cysts peripherally and edematous stroma centrally (black arrow); some cysts contain low SI foci due to blood products (white arrow). Note the small volume ascites (white arrowhead) and primary cervical tumor (black arrowhead). D. Axial oblique contrast-enhanced image shows symmetrically enlarged ovaries. Ovaries contain peripheral cysts (black arrow) with wall enhancement and enhancing central stroma. Note the absence of enhancing nodular septa or nodules. Primary cervical tumor is also seen (black arrowhead).

Figure 1

31-year-old woman with cervical cancer and ovarian hyperstimulation. A. A drawing shows the spoke-wheel appearance of hyperstimulated ovaries with multiple peripheral cysts centered on ovarian stroma. B. Axial T1WI shows symmetrically enlarged bilateral ovaries with low SI cysts; some cysts contain high SI blood products (white arrow). C. Axial oblique T2WI shows symmetrically enlarged bilateral ovaries with high SI cysts peripherally and edematous stroma centrally (black arrow); some cysts contain low SI foci due to blood products (white arrow). Note the small volume ascites (white arrowhead) and primary cervical tumor (black arrowhead). D. Axial oblique contrast-enhanced image shows symmetrically enlarged ovaries. Ovaries contain peripheral cysts (black arrow) with wall enhancement and enhancing central stroma. Note the absence of enhancing nodular septa or nodules. Primary cervical tumor is also seen (black arrowhead).

Figure 1

31-year-old woman with cervical cancer and ovarian hyperstimulation. A. A drawing shows the spoke-wheel appearance of hyperstimulated ovaries with multiple peripheral cysts centered on ovarian stroma. B. Axial T1WI shows symmetrically enlarged bilateral ovaries with low SI cysts; some cysts contain high SI blood products (white arrow). C. Axial oblique T2WI shows symmetrically enlarged bilateral ovaries with high SI cysts peripherally and edematous stroma centrally (black arrow); some cysts contain low SI foci due to blood products (white arrow). Note the small volume ascites (white arrowhead) and primary cervical tumor (black arrowhead). D. Axial oblique contrast-enhanced image shows symmetrically enlarged ovaries. Ovaries contain peripheral cysts (black arrow) with wall enhancement and enhancing central stroma. Note the absence of enhancing nodular septa or nodules. Primary cervical tumor is also seen (black arrowhead).

Figure 1

31-year-old woman with cervical cancer and ovarian hyperstimulation. A. A drawing shows the spoke-wheel appearance of hyperstimulated ovaries with multiple peripheral cysts centered on ovarian stroma. B. Axial T1WI shows symmetrically enlarged bilateral ovaries with low SI cysts; some cysts contain high SI blood products (white arrow). C. Axial oblique T2WI shows symmetrically enlarged bilateral ovaries with high SI cysts peripherally and edematous stroma centrally (black arrow); some cysts contain low SI foci due to blood products (white arrow). Note the small volume ascites (white arrowhead) and primary cervical tumor (black arrowhead). D. Axial oblique contrast-enhanced image shows symmetrically enlarged ovaries. Ovaries contain peripheral cysts (black arrow) with wall enhancement and enhancing central stroma. Note the absence of enhancing nodular septa or nodules. Primary cervical tumor is also seen (black arrowhead).

Figure 2

A. Drawing depicts common transposition locations for the ovaries. B. 48-year-old woman with cervical cancer who underwent ovarian transposition and definitive chemoradiation. Axial T2WI demonstrates transposed left ovary that re-migrated down into the pelvis (white arrow). It contains a dominant follicle, and is surrounded by a peritoneal inclusion cyst (black arrow). Transposed right ovary is not illustrated on this image. C and D. 32-year-old woman with cervical cancer and ovarian transposition prior to definitive chemoradiation. C. Coronal T2WI shows transposed ovaries in lower paracolic gutters (white arrows). D. Composite axial FDG-PET/CT image in the same patient demonstrates physiologically increased FDG uptake in the transposed right ovary (white arrow) and no increased FDG uptake in the transposed left ovary (white arrowhead).

Figure 2

A. Drawing depicts common transposition locations for the ovaries. B. 48-year-old woman with cervical cancer who underwent ovarian transposition and definitive chemoradiation. Axial T2WI demonstrates transposed left ovary that re-migrated down into the pelvis (white arrow). It contains a dominant follicle, and is surrounded by a peritoneal inclusion cyst (black arrow). Transposed right ovary is not illustrated on this image. C and D. 32-year-old woman with cervical cancer and ovarian transposition prior to definitive chemoradiation. C. Coronal T2WI shows transposed ovaries in lower paracolic gutters (white arrows). D. Composite axial FDG-PET/CT image in the same patient demonstrates physiologically increased FDG uptake in the transposed right ovary (white arrow) and no increased FDG uptake in the transposed left ovary (white arrowhead).

Figure 2

A. Drawing depicts common transposition locations for the ovaries. B. 48-year-old woman with cervical cancer who underwent ovarian transposition and definitive chemoradiation. Axial T2WI demonstrates transposed left ovary that re-migrated down into the pelvis (white arrow). It contains a dominant follicle, and is surrounded by a peritoneal inclusion cyst (black arrow). Transposed right ovary is not illustrated on this image. C and D. 32-year-old woman with cervical cancer and ovarian transposition prior to definitive chemoradiation. C. Coronal T2WI shows transposed ovaries in lower paracolic gutters (white arrows). D. Composite axial FDG-PET/CT image in the same patient demonstrates physiologically increased FDG uptake in the transposed right ovary (white arrow) and no increased FDG uptake in the transposed left ovary (white arrowhead).

Figure 2

A. Drawing depicts common transposition locations for the ovaries. B. 48-year-old woman with cervical cancer who underwent ovarian transposition and definitive chemoradiation. Axial T2WI demonstrates transposed left ovary that re-migrated down into the pelvis (white arrow). It contains a dominant follicle, and is surrounded by a peritoneal inclusion cyst (black arrow). Transposed right ovary is not illustrated on this image. C and D. 32-year-old woman with cervical cancer and ovarian transposition prior to definitive chemoradiation. C. Coronal T2WI shows transposed ovaries in lower paracolic gutters (white arrows). D. Composite axial FDG-PET/CT image in the same patient demonstrates physiologically increased FDG uptake in the transposed right ovary (white arrow) and no increased FDG uptake in the transposed left ovary (white arrowhead).

Figure 3

A. Drawing portrays cone biopsy/resection (en bloc resection of ectocervix and endocervcial canal) and vaginal/abdominal radical trachelectomy (resection of cervix, adjacent parametria and a cuff of the upper vagina). B. The remaining uterus is anastomosed to the vagina with a resultant isthmic vaginal anastomosis.

Figure 3

A. Drawing portrays cone biopsy/resection (en bloc resection of ectocervix and endocervcial canal) and vaginal/abdominal radical trachelectomy (resection of cervix, adjacent parametria and a cuff of the upper vagina). B. The remaining uterus is anastomosed to the vagina with a resultant isthmic vaginal anastomosis.

Figure 4

Drawings illustrate the location of the internal os seen as the waist of the uterine contour where low SI cervical stroma changes to intermediate SI myometrium (A) and as the entrance of uterine vessels (B).

Figure 4

Drawings illustrate the location of the internal os seen as the waist of the uterine contour where low SI cervical stroma changes to intermediate SI myometrium (A) and as the entrance of uterine vessels (B).

Figure 5

31-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates endophytic intermediate-SI tumor (white arrow). The tumor borders are obscured by post-cone resection changes making it challenging to accurately determine tumor size and endocervical extent. B and C. The tumor margins (white arrow) are more clearly defined on DWI and contrast-enhanced images, respectively, facilitating assessment of tumor size (2 cm in maximum dimension) and extent (1 cm caudal to internal os). D and E. Axial oblique and coronal oblique T2WI illustrate the location of internal os marked by the entrance of the uterine vessels (white arrows). F. Sagittal T2WI in the same patient after radical trachelectomy shows the normal appearing uterine remnant and isthmic vaginal anastomosis (white arrow).

Figure 5

31-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates endophytic intermediate-SI tumor (white arrow). The tumor borders are obscured by post-cone resection changes making it challenging to accurately determine tumor size and endocervical extent. B and C. The tumor margins (white arrow) are more clearly defined on DWI and contrast-enhanced images, respectively, facilitating assessment of tumor size (2 cm in maximum dimension) and extent (1 cm caudal to internal os). D and E. Axial oblique and coronal oblique T2WI illustrate the location of internal os marked by the entrance of the uterine vessels (white arrows). F. Sagittal T2WI in the same patient after radical trachelectomy shows the normal appearing uterine remnant and isthmic vaginal anastomosis (white arrow).

Figure 5

31-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates endophytic intermediate-SI tumor (white arrow). The tumor borders are obscured by post-cone resection changes making it challenging to accurately determine tumor size and endocervical extent. B and C. The tumor margins (white arrow) are more clearly defined on DWI and contrast-enhanced images, respectively, facilitating assessment of tumor size (2 cm in maximum dimension) and extent (1 cm caudal to internal os). D and E. Axial oblique and coronal oblique T2WI illustrate the location of internal os marked by the entrance of the uterine vessels (white arrows). F. Sagittal T2WI in the same patient after radical trachelectomy shows the normal appearing uterine remnant and isthmic vaginal anastomosis (white arrow).

Figure 5

31-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates endophytic intermediate-SI tumor (white arrow). The tumor borders are obscured by post-cone resection changes making it challenging to accurately determine tumor size and endocervical extent. B and C. The tumor margins (white arrow) are more clearly defined on DWI and contrast-enhanced images, respectively, facilitating assessment of tumor size (2 cm in maximum dimension) and extent (1 cm caudal to internal os). D and E. Axial oblique and coronal oblique T2WI illustrate the location of internal os marked by the entrance of the uterine vessels (white arrows). F. Sagittal T2WI in the same patient after radical trachelectomy shows the normal appearing uterine remnant and isthmic vaginal anastomosis (white arrow).

Figure 5

31-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates endophytic intermediate-SI tumor (white arrow). The tumor borders are obscured by post-cone resection changes making it challenging to accurately determine tumor size and endocervical extent. B and C. The tumor margins (white arrow) are more clearly defined on DWI and contrast-enhanced images, respectively, facilitating assessment of tumor size (2 cm in maximum dimension) and extent (1 cm caudal to internal os). D and E. Axial oblique and coronal oblique T2WI illustrate the location of internal os marked by the entrance of the uterine vessels (white arrows). F. Sagittal T2WI in the same patient after radical trachelectomy shows the normal appearing uterine remnant and isthmic vaginal anastomosis (white arrow).

Figure 5

31-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates endophytic intermediate-SI tumor (white arrow). The tumor borders are obscured by post-cone resection changes making it challenging to accurately determine tumor size and endocervical extent. B and C. The tumor margins (white arrow) are more clearly defined on DWI and contrast-enhanced images, respectively, facilitating assessment of tumor size (2 cm in maximum dimension) and extent (1 cm caudal to internal os). D and E. Axial oblique and coronal oblique T2WI illustrate the location of internal os marked by the entrance of the uterine vessels (white arrows). F. Sagittal T2WI in the same patient after radical trachelectomy shows the normal appearing uterine remnant and isthmic vaginal anastomosis (white arrow).

Figure 6

37-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates 2.7 cm endophytic intermediate-SI tumor (white arrow). B and C. Axial oblique T2WI and fused (T2WI + DWI) images, respectively, show tumor extension to the internal os and left parametrial invasion (black arrows). The internal os is demarcated as the entrance of the uterine vessels (white arrows).

Figure 6

37-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates 2.7 cm endophytic intermediate-SI tumor (white arrow). B and C. Axial oblique T2WI and fused (T2WI + DWI) images, respectively, show tumor extension to the internal os and left parametrial invasion (black arrows). The internal os is demarcated as the entrance of the uterine vessels (white arrows).

Figure 6

37-year-old woman with Stage IB1 cervical cancer. A. Sagittal T2WI demonstrates 2.7 cm endophytic intermediate-SI tumor (white arrow). B and C. Axial oblique T2WI and fused (T2WI + DWI) images, respectively, show tumor extension to the internal os and left parametrial invasion (black arrows). The internal os is demarcated as the entrance of the uterine vessels (white arrows).

Figure 7

40-year-old woman with new onset menorrhagia and D&C demonstrating FIGO grade 1 endometrioid adenocarcinoma. A and B. Sagittal and axial oblique T2WI demonstrate intermediate-SI tumor in the endometrial cavity and preserved smooth interface between the tumor and low-SI junctional zone (white arrows). C and D. Sagittal and axial oblique fused (T2WI + DWI) images confirm smooth interface between the tumor and junctional zone (white arrows). E and F. Sagittal early (E) and delayed DCE-MRI (F) images show intact band of junctional zone enhancement (black arrows) and smooth tumor-to-myometrium interface (black arrow), respectively.

Figure 7

40-year-old woman with new onset menorrhagia and D&C demonstrating FIGO grade 1 endometrioid adenocarcinoma. A and B. Sagittal and axial oblique T2WI demonstrate intermediate-SI tumor in the endometrial cavity and preserved smooth interface between the tumor and low-SI junctional zone (white arrows). C and D. Sagittal and axial oblique fused (T2WI + DWI) images confirm smooth interface between the tumor and junctional zone (white arrows). E and F. Sagittal early (E) and delayed DCE-MRI (F) images show intact band of junctional zone enhancement (black arrows) and smooth tumor-to-myometrium interface (black arrow), respectively.

Figure 7

40-year-old woman with new onset menorrhagia and D&C demonstrating FIGO grade 1 endometrioid adenocarcinoma. A and B. Sagittal and axial oblique T2WI demonstrate intermediate-SI tumor in the endometrial cavity and preserved smooth interface between the tumor and low-SI junctional zone (white arrows). C and D. Sagittal and axial oblique fused (T2WI + DWI) images confirm smooth interface between the tumor and junctional zone (white arrows). E and F. Sagittal early (E) and delayed DCE-MRI (F) images show intact band of junctional zone enhancement (black arrows) and smooth tumor-to-myometrium interface (black arrow), respectively.

Figure 7

40-year-old woman with new onset menorrhagia and D&C demonstrating FIGO grade 1 endometrioid adenocarcinoma. A and B. Sagittal and axial oblique T2WI demonstrate intermediate-SI tumor in the endometrial cavity and preserved smooth interface between the tumor and low-SI junctional zone (white arrows). C and D. Sagittal and axial oblique fused (T2WI + DWI) images confirm smooth interface between the tumor and junctional zone (white arrows). E and F. Sagittal early (E) and delayed DCE-MRI (F) images show intact band of junctional zone enhancement (black arrows) and smooth tumor-to-myometrium interface (black arrow), respectively.

Figure 7

40-year-old woman with new onset menorrhagia and D&C demonstrating FIGO grade 1 endometrioid adenocarcinoma. A and B. Sagittal and axial oblique T2WI demonstrate intermediate-SI tumor in the endometrial cavity and preserved smooth interface between the tumor and low-SI junctional zone (white arrows). C and D. Sagittal and axial oblique fused (T2WI + DWI) images confirm smooth interface between the tumor and junctional zone (white arrows). E and F. Sagittal early (E) and delayed DCE-MRI (F) images show intact band of junctional zone enhancement (black arrows) and smooth tumor-to-myometrium interface (black arrow), respectively.

Figure 7

40-year-old woman with new onset menorrhagia and D&C demonstrating FIGO grade 1 endometrioid adenocarcinoma. A and B. Sagittal and axial oblique T2WI demonstrate intermediate-SI tumor in the endometrial cavity and preserved smooth interface between the tumor and low-SI junctional zone (white arrows). C and D. Sagittal and axial oblique fused (T2WI + DWI) images confirm smooth interface between the tumor and junctional zone (white arrows). E and F. Sagittal early (E) and delayed DCE-MRI (F) images show intact band of junctional zone enhancement (black arrows) and smooth tumor-to-myometrium interface (black arrow), respectively.

Figure 8

23-year-old woman with dysgerminoma who presented with low back pain and elevated serum LDH and β-HCG. A and B. Axial and sagittal T2WI show solid intermediate-SI adnexal mass with low-SI fibrovascular septa (white arrows). C and D. Axial DWI and ADC map demonstrate diffusion restriction. E. Axial contrast-enhanced image shows solid enhancing adnexal mass with avidly enhancing fibrovascular septa (black arrows).

Figure 8

23-year-old woman with dysgerminoma who presented with low back pain and elevated serum LDH and β-HCG. A and B. Axial and sagittal T2WI show solid intermediate-SI adnexal mass with low-SI fibrovascular septa (white arrows). C and D. Axial DWI and ADC map demonstrate diffusion restriction. E. Axial contrast-enhanced image shows solid enhancing adnexal mass with avidly enhancing fibrovascular septa (black arrows).

Figure 8

23-year-old woman with dysgerminoma who presented with low back pain and elevated serum LDH and β-HCG. A and B. Axial and sagittal T2WI show solid intermediate-SI adnexal mass with low-SI fibrovascular septa (white arrows). C and D. Axial DWI and ADC map demonstrate diffusion restriction. E. Axial contrast-enhanced image shows solid enhancing adnexal mass with avidly enhancing fibrovascular septa (black arrows).

Figure 8

23-year-old woman with dysgerminoma who presented with low back pain and elevated serum LDH and β-HCG. A and B. Axial and sagittal T2WI show solid intermediate-SI adnexal mass with low-SI fibrovascular septa (white arrows). C and D. Axial DWI and ADC map demonstrate diffusion restriction. E. Axial contrast-enhanced image shows solid enhancing adnexal mass with avidly enhancing fibrovascular septa (black arrows).

Figure 8

23-year-old woman with dysgerminoma who presented with low back pain and elevated serum LDH and β-HCG. A and B. Axial and sagittal T2WI show solid intermediate-SI adnexal mass with low-SI fibrovascular septa (white arrows). C and D. Axial DWI and ADC map demonstrate diffusion restriction. E. Axial contrast-enhanced image shows solid enhancing adnexal mass with avidly enhancing fibrovascular septa (black arrows).

Figure 9

13-year-old teenager with immature cystic teratoma who presented with lower abdominal pain and no elevation in serum tumor markers. A and B. T1WI and FST1WI demonstrate left adnexal mass with small high-SI focus (white arrow) on T1WI (A) which becomes low-SI on FST1WI (white arrow) (B). C, D, and E. Axial T2WI, fused (T2WI + DWI), and contrast-enhanced images show complex predominantly cystic left adnexal mass with multiple cystic components and thickened and/or nodular septations with restricted diffusion and enhancement F. The same patient presented several years prior with right adnexal mass. Sagittal contrast-enhanced CT image obtained at that time shows a large cystic-solid right adnexal mass with several small foci of fat (white arrow) and small scattered calcifications (black arrow).

Figure 9

13-year-old teenager with immature cystic teratoma who presented with lower abdominal pain and no elevation in serum tumor markers. A and B. T1WI and FST1WI demonstrate left adnexal mass with small high-SI focus (white arrow) on T1WI (A) which becomes low-SI on FST1WI (white arrow) (B). C, D, and E. Axial T2WI, fused (T2WI + DWI), and contrast-enhanced images show complex predominantly cystic left adnexal mass with multiple cystic components and thickened and/or nodular septations with restricted diffusion and enhancement F. The same patient presented several years prior with right adnexal mass. Sagittal contrast-enhanced CT image obtained at that time shows a large cystic-solid right adnexal mass with several small foci of fat (white arrow) and small scattered calcifications (black arrow).

Figure 9

13-year-old teenager with immature cystic teratoma who presented with lower abdominal pain and no elevation in serum tumor markers. A and B. T1WI and FST1WI demonstrate left adnexal mass with small high-SI focus (white arrow) on T1WI (A) which becomes low-SI on FST1WI (white arrow) (B). C, D, and E. Axial T2WI, fused (T2WI + DWI), and contrast-enhanced images show complex predominantly cystic left adnexal mass with multiple cystic components and thickened and/or nodular septations with restricted diffusion and enhancement F. The same patient presented several years prior with right adnexal mass. Sagittal contrast-enhanced CT image obtained at that time shows a large cystic-solid right adnexal mass with several small foci of fat (white arrow) and small scattered calcifications (black arrow).

Figure 9

13-year-old teenager with immature cystic teratoma who presented with lower abdominal pain and no elevation in serum tumor markers. A and B. T1WI and FST1WI demonstrate left adnexal mass with small high-SI focus (white arrow) on T1WI (A) which becomes low-SI on FST1WI (white arrow) (B). C, D, and E. Axial T2WI, fused (T2WI + DWI), and contrast-enhanced images show complex predominantly cystic left adnexal mass with multiple cystic components and thickened and/or nodular septations with restricted diffusion and enhancement F. The same patient presented several years prior with right adnexal mass. Sagittal contrast-enhanced CT image obtained at that time shows a large cystic-solid right adnexal mass with several small foci of fat (white arrow) and small scattered calcifications (black arrow).

Figure 9

13-year-old teenager with immature cystic teratoma who presented with lower abdominal pain and no elevation in serum tumor markers. A and B. T1WI and FST1WI demonstrate left adnexal mass with small high-SI focus (white arrow) on T1WI (A) which becomes low-SI on FST1WI (white arrow) (B). C, D, and E. Axial T2WI, fused (T2WI + DWI), and contrast-enhanced images show complex predominantly cystic left adnexal mass with multiple cystic components and thickened and/or nodular septations with restricted diffusion and enhancement F. The same patient presented several years prior with right adnexal mass. Sagittal contrast-enhanced CT image obtained at that time shows a large cystic-solid right adnexal mass with several small foci of fat (white arrow) and small scattered calcifications (black arrow).

Figure 9

13-year-old teenager with immature cystic teratoma who presented with lower abdominal pain and no elevation in serum tumor markers. A and B. T1WI and FST1WI demonstrate left adnexal mass with small high-SI focus (white arrow) on T1WI (A) which becomes low-SI on FST1WI (white arrow) (B). C, D, and E. Axial T2WI, fused (T2WI + DWI), and contrast-enhanced images show complex predominantly cystic left adnexal mass with multiple cystic components and thickened and/or nodular septations with restricted diffusion and enhancement F. The same patient presented several years prior with right adnexal mass. Sagittal contrast-enhanced CT image obtained at that time shows a large cystic-solid right adnexal mass with several small foci of fat (white arrow) and small scattered calcifications (black arrow).

Figure 10

25-year-old woman with Sertoli-Leydig tumor who presented with pelvic discomfort and elevated serum testosterone. A. Axial T2WI shows intermediate-SI predominantly solid mass with few small cystic areas. B and C. Axial fused (T2WI + DWI) and ADC images demonstrate diffusion restriction within the solid portion of the mass. D. Axial contrast-enhanced image shows enhancement within the solid portion of the mass.

Figure 10

25-year-old woman with Sertoli-Leydig tumor who presented with pelvic discomfort and elevated serum testosterone. A. Axial T2WI shows intermediate-SI predominantly solid mass with few small cystic areas. B and C. Axial fused (T2WI + DWI) and ADC images demonstrate diffusion restriction within the solid portion of the mass. D. Axial contrast-enhanced image shows enhancement within the solid portion of the mass.

Figure 10

25-year-old woman with Sertoli-Leydig tumor who presented with pelvic discomfort and elevated serum testosterone. A. Axial T2WI shows intermediate-SI predominantly solid mass with few small cystic areas. B and C. Axial fused (T2WI + DWI) and ADC images demonstrate diffusion restriction within the solid portion of the mass. D. Axial contrast-enhanced image shows enhancement within the solid portion of the mass.

Figure 10

25-year-old woman with Sertoli-Leydig tumor who presented with pelvic discomfort and elevated serum testosterone. A. Axial T2WI shows intermediate-SI predominantly solid mass with few small cystic areas. B and C. Axial fused (T2WI + DWI) and ADC images demonstrate diffusion restriction within the solid portion of the mass. D. Axial contrast-enhanced image shows enhancement within the solid portion of the mass.

Figure 11

20-year-old woman with bilateral serous borderline ovarian tumors who presented with lower abdominal pain and elevated serum CA-125 level. A. Axial T2WI of the right adnexa shows cystic and solid right adnexal mass with large branching papillary projections (black arrow) extending into the pouch of Douglas. B. Axial T2WI of the left adnexa shows small cystic lesion with small intermediate-SI papillary projections (black arrow). C and D. Axial fused (T2WI + DWI) images demonstrate restricted diffusion within papillary projections (white arrows). E and F. Axial contrast-enhanced images show enhancement within these papillary projections (white arrows).

Figure 11

20-year-old woman with bilateral serous borderline ovarian tumors who presented with lower abdominal pain and elevated serum CA-125 level. A. Axial T2WI of the right adnexa shows cystic and solid right adnexal mass with large branching papillary projections (black arrow) extending into the pouch of Douglas. B. Axial T2WI of the left adnexa shows small cystic lesion with small intermediate-SI papillary projections (black arrow). C and D. Axial fused (T2WI + DWI) images demonstrate restricted diffusion within papillary projections (white arrows). E and F. Axial contrast-enhanced images show enhancement within these papillary projections (white arrows).

Figure 11

20-year-old woman with bilateral serous borderline ovarian tumors who presented with lower abdominal pain and elevated serum CA-125 level. A. Axial T2WI of the right adnexa shows cystic and solid right adnexal mass with large branching papillary projections (black arrow) extending into the pouch of Douglas. B. Axial T2WI of the left adnexa shows small cystic lesion with small intermediate-SI papillary projections (black arrow). C and D. Axial fused (T2WI + DWI) images demonstrate restricted diffusion within papillary projections (white arrows). E and F. Axial contrast-enhanced images show enhancement within these papillary projections (white arrows).

Figure 11

20-year-old woman with bilateral serous borderline ovarian tumors who presented with lower abdominal pain and elevated serum CA-125 level. A. Axial T2WI of the right adnexa shows cystic and solid right adnexal mass with large branching papillary projections (black arrow) extending into the pouch of Douglas. B. Axial T2WI of the left adnexa shows small cystic lesion with small intermediate-SI papillary projections (black arrow). C and D. Axial fused (T2WI + DWI) images demonstrate restricted diffusion within papillary projections (white arrows). E and F. Axial contrast-enhanced images show enhancement within these papillary projections (white arrows).

Figure 11

20-year-old woman with bilateral serous borderline ovarian tumors who presented with lower abdominal pain and elevated serum CA-125 level. A. Axial T2WI of the right adnexa shows cystic and solid right adnexal mass with large branching papillary projections (black arrow) extending into the pouch of Douglas. B. Axial T2WI of the left adnexa shows small cystic lesion with small intermediate-SI papillary projections (black arrow). C and D. Axial fused (T2WI + DWI) images demonstrate restricted diffusion within papillary projections (white arrows). E and F. Axial contrast-enhanced images show enhancement within these papillary projections (white arrows).

Figure 11

20-year-old woman with bilateral serous borderline ovarian tumors who presented with lower abdominal pain and elevated serum CA-125 level. A. Axial T2WI of the right adnexa shows cystic and solid right adnexal mass with large branching papillary projections (black arrow) extending into the pouch of Douglas. B. Axial T2WI of the left adnexa shows small cystic lesion with small intermediate-SI papillary projections (black arrow). C and D. Axial fused (T2WI + DWI) images demonstrate restricted diffusion within papillary projections (white arrows). E and F. Axial contrast-enhanced images show enhancement within these papillary projections (white arrows).

Figure 12

A diagram illustrates an algorithmic approach to the characterization of sonographically indeterminate adnexal masses using multi-parametric MRI. This approach is based on the recently updated ESUR guidelines (27).