Research articleLongitudinal changes in magnetic resonance imaging of malignant and borderline tumors associated with ovarian endometriotic cyst comparing with endometriotic cysts without arising malignancy
Introduction
Endometriosis is a common gynecological disorder affecting up to 10% of women of reproductive age [1]. In addition to dysmenorrhea and infertility, women with endometriosis confront a higher risk of malignancy [2,3]. An increasing amount of evidence suggests that pre-existing endometriosis increases the risk of developing tumors. The risk of ovarian cancer with a standard incidence ratio is 2.48–8.95 [3,4]. Endometrioid carcinoma, clear cell carcinoma, and seromucinous borderline tumor (SMBT) are associated with endometriotic cysts [5,6]. Advanced age and a large size of the endometriotic cyst are independent predictors of the development of ovarian cancer [7]. Although slightly elevated serum cancer antigen 125 (CA125) level and benign-appearing ovarian cysts are usually present several years before the diagnosis of ovarian cancer, especially in patients with non-serous type ovarian cancer, CA125 level is often elevated in patients with endometriosis without malignancy [4,8,9].
Ultrasonography (US) remains the primary modality of choice for evaluation of ovarian endometriotic cyst, whereas magnetic resonance imaging (MRI) is used as a problem-solving tool for more detailed evaluation. When surgical treatment for endometriosis is under consideration, including pain, infertility and clinical suspicion of malignancy, MRI is commonly used [10]. In MRI studies comparing benign endometriotic cysts with endometriotic cysts associated with malignant ovarian tumors, enhanced solid portion and large cyst size are signs suggesting malignancy [[11], [12], [13]]. Disappearance of shading within the tumor on T2-weighted images (WI) also suggests malignant transformation [11,13,14]. Obtaining these MR findings would be useful to diagnose malignancy associated with endometriotic cysts. Nevertheless, other than case reports, no report in the relevant literature has described a study confirming the longitudinal changes of the MR findings and the development of previously described findings in a follow up study with the same patients comparing the longitudinal change of endometriotic cysts [15]. The comparison conducted for the present study facilitates detection of early signs of malignancy in the follow-up of endometriotic cysts (Fig. 1).
Therefore, we aimed at evaluating MR findings for detecting malignant transformation of ovarian endometriotic cysts. To do so, we compared longitudinal changes in MRI of patients with endometriotic cysts and of patients with ovarian malignant/borderline tumors associated with ovarian endometriotic cysts.
Section snippets
Study population and patient information
Our institutional review board approved this study. Because of the retrospective study design, informed consent was not necessary. Regarding the tumor group, the radiology database of our institution from 1988 to 2016 was searched to identify patients who had been diagnosed as ovarian malignant or borderline tumors associated with endometriotic cysts on MRI and who underwent surgical resection at our institution. Inclusion criteria were 1) patients with pathologically confirmed ovarian cancer
Results
In the tumor group, 10 women were included in these analyses. Details related to clinical and histopathologic findings of these 10 patients are presented in Table 1, Table 2. Mean age at the time of diagnosis of neoplasm was 43.5 yr (33–51 yr). The mean follow-up period before the neoplasm appearance was 2.8 yr (0.5–6 yr). Of the 10 patients, 5 underwent treatment for ovarian endometriotic cyst before the neoplasm diagnosis. Treatment included GnRH analogue (n = 3) and low-dose oral
Discussion
This report is the first of a study comparing longitudinal changes on MR findings observed with a series of patients from pre-existing ovarian endometriotic cyst to the development of malignant or borderline tumors and patients with endometriotic cysts. Some risk factors and imaging findings supporting malignant transformation from ovarian endometriotic cysts to malignant tumors have been reported, such as age of more than 40 years, large cyst size (≥9 cm), increase of tumor size, lack of
Conflict of interest
The authors declare that they have no conflict of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author declaration
We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.
We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to
Author contributions
Conception and design of the study: Naoko Nishio, Aki Kido, Masako Kataoka, Ryo Kuwahara, Kyoko.
Nakao, Yasuhisa Kurata, Kaori Togashi.
Analysis and interpretation of data: Naoko Nishio, Aki Kido, Masako Kataoka.
Collection and assembly of data: Naoko Nishio, Masako Kataoka, Ryo Kuwahara, Kyoko Nakao, Yasuhisa.
Kurata, Noriomi Matsumura, Masaki Mandai.
Drafting of the article: Naoko Nishio, Aki Kido.
Final approval of the article: Aki Kido, Kaori Togashi.
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