A new sonographic marker of borderline ovarian tumors: the microcystic pattern of papillary projections and solid components

Ilan E Timor-Tritsch, Christine E Foley, Caroline Brandon, Esther Yoon, Jeannine Ciaffarrano, Ana Monteagudo, Kushbakhat Mittal, Leslie Boyd
Ultrasound in Obstetrics & Gynecology 2019 April 4

OBJECTIVE: Accurate diagnosis of borderline ovarian tumors (BOTs) is important to ensure timely and appropriate management, especially in women desiring to preserve fertility. Transvaginal ultrasound (TVUS) is considered the best modality to diagnose adnexal tumors. Sonographic features of BOTs described in the literature include septa, solid components, mural nodules (papillae) and blood vessels within these structures. However, there is no single signature that differentiates BOTs from other adnexal masses. We have identified a microcystic pattern on ultrasound of BOTs. The objective of our study was to evaluate the utility of a new sonographic pattern to describe a novel, yet typical, microcystic pattern of papillary projections, solid components and/or septa as a new ultrasound marker of BOTs and present their histologic confirmation.

MATERIAL AND METHODS: In this retrospective study, we identified women with a histologic diagnosis of BOT following surgical resection who underwent pre-operative transvaginal ultrasound (TVUS) examination. All images were reviewed for presence or absence of thin-walled, fluid-filled cluster(s) of 1-3-mm cystic formations associated with solid components, papillary projections, and/or septa. Case-matched histopathologic slides of each BOT were examined for the presence of the above-described microcystic features identified on TVUS. To confirm that the microcystic TVUS pattern is unique to BOTs, we randomly selected 20 cases of epithelial cancer and 20 cases of benign cystadenomas from our ultrasound and surgical database. These were also reviewed by the same pathologists. To confirm the novelty of our findings, we searched PubMed for literature published in the English language between 2010 and 2018 to learn if the above described microcystic tissue pattern was previously described.

RESULTS: Sixty-seven cases with pre-operative ultrasound that had surgically confirmed BOT on pathologic examination were included in the final analysis. Median age at surgery was 39.8 years. Average size of the BOTs was 60.7mm. Of the 67 BOTs, 47 (70.14%) were serous, 15 (22.38%) were mucinous, and 5 (7.46%) were seromucinous. Sixty (89.7%) of 67 BOTs demonstrated the microcystic pattern in the papillary projections, solid components and/or septa. On ultrasound imaging, 46 of the 47 (97.9%) serous type BOTs had a microcystic pattern compared to 11 of the 15 (73.3%) mucinous and 3 of the 5 (60.0%) seromucinous BOTs. On microscopic evaluation, 60 (89.7%) of 67 samples had characteristic 1-3-mm fluid-filled cysts like those seen on transvaginal ultrasound. Only 7 cases revealed discrepancies between the sonographic and histologic identification of a microcystic pattern. The cystadenomas (we submitted 4 of the 20 pairs we studied for comparison for this article) were mostly unilocular and/or multilocular and largely avascular. None of the 20 cystadenomas or 20 epithelial ovarian malignancies case-matched to histology displayed microcystic characteristics on ultrasound. On review of 23 published articles in the English medical literature containing 163 sonographic pictures of BOT, no description of the microcystic tissue pattern was found.

CONCLUSION: In conclusion, we report a novel sonographic marker of BOTs termed "microcystic pattern" of their papillary projections, solid components and/or septa. This was seen in the majority of both the serous and the mucinous BOT cases. Importantly, based on comparison of sonographic images and histopathology of both benign entities and malignancies, the microcystic appearance appears to be unique to BOTs. No such or similar description was previously provided. We feel utilization of this new marker will help to correctly identify BOTs, discriminating them from ovarian cancers and benign ovarian pathologies, and ensure their appropriate clinical and surgical management. This article is protected by copyright. All rights reserved.

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