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Large Left Adnexal Mass: Ovarian Fibroma

This case report presents a 36-year-old female with a large left adnexal mass causing abdominal enlargement and severe flank pain. Imaging studies, including contrast-enhanced CT and ultrasound, reveal a well-circumscribed solid mass with a whirled appearance of the mesenteric vessels, consistent with torsion. The mass is predominantly solid, heterogeneous, and hypoechoic on ultrasound. The differential diagnosis includes granulosa cell tumor, thecoma, fibroma, and cystadenocarcinoma. Surgical intervention confirms ovarian fibroma with hemorrhagic infarction.

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Large Left Adnexal Mass: Ovarian Fibroma

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

  2. 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.

  3. Radiological Presentations IMAGE #1 Contrast Enhanced CT Abdomen

  4. Radiological Presentations Contrast Enhanced CT Pelvis IMAGE #2

  5. Radiological Presentations IMAGE #3 Contrast Enhanced CT Pelvis

  6. Radiological Presentations IMAGE #4 Transverse Ultrasound Image Left Adnexa

  7. Radiological Presentations Longitudinal Ultrasound Left Adnexa with Doppler IMAGE #5

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

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

  10. 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 40-50 % 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, 2002. 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: 619-22, 2002. 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, 1996. Thurmond A, Jones M, and Deborah Cohen: Gynecologic, Obstetric, andBreast Radiology: 259-64, 1996.

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

  12. Ovarian fibroma with hemorrhagic infarction. Diagnosis

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