Diagnostic Ultrasound - Abdomen and Pelvis

Sex Cord-Stromal Tumor
TERMINOLOGY
Definitions
• Group of ovarian tumors arising from either embryonic sex
cords or mesenchyme
○ Fibroma, thecoma, fibrothecoma
○ Granulosa cell tumor: Occurs in both adult and juvenile
forms
○ Sertoli-Leydig tumor (androblastoma)
○ Sclerosing stromal tumor, steroid cell tumors,
gynandroblastoma, and sex cord tumor with annular
tubules
IMAGING
General Features
• Sex cord-stromal tumors are generally solid or have
significant solid components
• Hormonally active tumors may be small and difficult to find
Ultrasonographic Findings
• Ultrasound findings of sex cord-stromal tumors are diverse
and nonspecific
○ Range from small, solid tumors to large, multicystic
masses
• Granulosa cell tumors
○ More often contain cysts, with a sponge-like, Swiss
cheese appearance
○ Cysts may be complex and contain hemorrhagic fluid
– May rupture and cause hemoperitoneum
○ Adult and juvenile forms have similar appearance
○ Cysts will be thick-walled
○ Calcifications are rare
○ May be bilateral in 5%
• Sertoli-Leydig tumors
○ Significant overlap with granulosa cell tumors
○ Not as frequently cystic as granulosa cell tumors
– 70% purely solid
– 95% have solid component
○ Less likely to have hemorrhage
• Fibrothecomas
○ Hypoechoic with dense posterior acoustic attenuation
– Similar to uterine leiomyoma
○ 1% associated with Meigs syndrome
• Steroid cell tumors
○ Typically small, without cysts
MR Findings
• T1WI
○ May see high signal from hemorrhage in granulosa cell
tumor
○ High lipid content may cause steroid tumors to be high
signal
• T2WI
○ Most intermediate signal with cystic area being high
signal
– Granulosa cell tumors may have network of smaller
cysts creating sponge-like appearance
– Fibrothecomas tend to be mild to markedly
hypointense (compared to myometrium)
• T1WI C+
○ Most enhance avidly except fibrothecomas
Imaging Recommendations
• Protocol advice
○ Evaluate uterus carefully
– Hormonal stimulation may cause uterine enlargement
and endometrial thickening (hyperplasia, polyps, or
carcinoma) and can be tip-off to correct pathology
DIFFERENTIAL DIAGNOSIS
Ovarian Carcinoma
• Most epithelial tumors have dominant cystic component
• Confusion may occur if there is large, solid component
Germ Cell Tumors
• Much more heterogeneous with calcifications, fluid-fluid
levels, dirty posterior shadow
Ovarian Torsion
• Edematous, enlarged ovary with peripheral cysts
• Patient is acutely symptomatic
Hormonally Functioning Ovarian Masses
• Patients may present with symptoms related to hormone
production rather than mass
• May present with either hyperandrogenism or
hyperestrogenism (some may do both)
• Hyperandrogenism (virilization with hirsutism, male
pattern baldness, loss of female body contour,
clitoromegaly)
○ Sertoli-Leydig tumor
○ Sclerosing stromal tumor
○ Gonadoblastoma
○ Brenner tumor
○ Polycystic ovarian disease
○ Stromal hyperplasia
○ Stromal hyperthecosis
○ Hyperreactio luteinalis
○ Nonovarian causes
– Pituitary (Cushing disease)
– Adrenal (Cushing syndrome)
• Hyperestrogenism (pseudoprecocious puberty,
postmenopausal bleeding)
○ Granulosa cell tumor
○ Thecoma
○ Serous tumors
○ Mucinous tumors
○ Endometrioid tumors
○ Autonomously functioning follicular cyst most common
in isosexual pseudoprecocious puberty
PATHOLOGY
General Features
• Etiology
○ Derive from 2 embryologically distinct groups of cells
– Stromal cells: Fibroblasts, theca cells, and Leydig cells
– Sex cords: Granulosa cells and Sertoli cells
○ Most tumors have more than 1 cell type
• Associated abnormalities
○ Adult granulosa cell tumor
Diagnoses: Female Pelvis
851