Ovarian germ cell tumor differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

Ovarian germ cell tumor must be differentiated from other diseases that cause ovarian mass, such as Stein-Leventhal syndrome, ovarian teratoma, tubal pregnancy, ovarian epithelial tumors, ovarian sex-cord stromal tumors, and tubo-ovarian abscess.

Differentiating Ovarian Germ Cell Tumor From Other Diseases

Ovarian germ cell tumor must be differentiated from other diseases that cause ovarian mass, such as Stein-Leventhal syndrome, ovarian teratoma, tubal pregnancy, ovarian epithelial tumors, ovarian sex-cord stromal tumors, and tubo-ovarian abscess.[1][2]

  • Stein-Leventhal syndrome[1][2][3]
  • Tubal pregnancy
  • Ovarian epithelial tumors
  • Ovarian sex-cord stromal tumors
  • Tubo-ovarian abscess

Dysgerminoma and other ovarian germ cell tumors capable of producing B-hCG must be differentiated from other diseases that cause abdominal/pelvic mass and elevated levels of B-hCG.[3]

Differentiating ovarian germ cell tumors from other diseases on the basis of age of onset, vaginal discharge, and constitutional symptoms

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Age of onset Symptoms Physical examination
Lab Findings Imaging Immunohistopathology
pelvic/abdominal pain or pressure vaginal bleeding/discharge GI dysturbance Fever Tenderness CT scan/US MRI
Gynecologic
Ovarian Embryonal carcinoma[4][5][6][7][8]
  • Individuals of any age, especially young adults
 +/– +/– _ _ _
Gonadoblastoma
[9][10][11][12][13][14]
  • Individuals of any age,but more common prior to 15 years of age
 +/– +/– _ _ _
  • NA
Follicular cysts
[15] 		+/– – – – +/–
  • In US we may see a >3 cm simple cyst with no internal echo and with posterior acoustic enhancement
  • simple cyst with no internal echo or septa
  • NA
Theca lutein cysts
[16][17][18] 		+/– – – – +/–
Serous cystadenoma/carcinoma
[19][20][21][22]
  • >55 y/o
 +/– – – – +/–
  • In US we may see simple or multiloculated cyst
  • In serous cystadenocarcinoma we may see papillary projection inside the cyst
  • In serous cystadenocarcinoma we may see ascites
  • In Serous cystadenoma we may see a simple cyst with beak sign, hypointense on T1 and hyperintense on T2
  • In serous cystadenocarcinoma we may see some Solid malignant components inside the cyst with intermediate signal on T1 and T2
Mucinous cystadenoma/carcinoma
[23][24][25]
  • >55 y/o
 +/– – – – +/–
  • Stained glass appearance due to variable signal intensity on T1 and T2
  • The more mucin we have, there is more intensity on T1
  • and less intensity on T2
Endometrioma
[26][27][28] 		+ + +/– – +
  • hyperintensity on T1-weighted images and a hypointensity on T2-weighted images
  • Powder burn hemorrhages
Teratoma
[29][30][31][32]
  • 10-30 y/o
 +/– – – – +/–
  • We may see evidence of fat components
Dysgerminoma
[33][34]
  • in the second to third decade of life
 + +/– – – +/–
  • We may see ovarian mass with septation which are hyperintense on T1 and hypo or isointense on T2 imaging
  • Sheets fried egg appearance cells
Yolk sac tumor
[35][36][37] 		+ – – – +
  • High levels of AFP
  • In US we may see a combination of echogenic and hypoechoic components
  • Yellow appearance
  • Schiller-Duval bodies (glomeruli like structures)
Fibroma
[38][39][40]
  • >50 y/o
  • Pulling sensation in the groin
 – – – +/–
  • In CT scan we may see a unilateral mass with poor contrast enhancement
  • Low signal intensity on T1 and T2
Thecoma
[41][42][43]
  • >50 y/o
 +/– – – –
Granulosa cell tumor
[44][45][46][47]
  • 50-60 y/o
 + +/– – –
Sertoli-leydig cell tumor
[48][49]
  • 15 to 35 y/o
 +/– – – – –
  • In US we may see unilateral Well-defined hypoechoic lesion
  • Low T2 signal intensity
  • areas of high signal intensity
Brenner tumor
[50][51]
  • >55 y/o
 +/– – – – – –
  • Hypointense on T2 because of fibrous content
  • Most of the times it's an accidental finding
Krukenberg tumor
[52][53]
  • >55 y/o
 +/– – +/–

Based on underlying malignancy

– –
Tubal tubo-ovarian abscess
[54][55][56][57] 		+ + – + +
  • hypointense in T1 and heterogeneous in T2
Ectopic pregnancy
[58] 		+ + +/– – +
  • NA
  • NA
Hydrosalpinx
[59][60][61]
  • NA
 + – – – +/– –
  • NA
Salpingitis
[62] 		+ + – + +
  • In US we may see , edematous and thickened endosalpingeal folds
  • NA
  • NA
Fallopian tube carcinoma
[63]
  • >60 y/o
 + + + – +/–
  • Low signal on T1
  • In case of hemorrhage inside the tumor we may see high signal intensity on T1
  • Low or of intermediate signal on T2
  • Based on the tumor type we may have different biopsy finding
Uterine Leiomyoma
[64][65] 		+ + – – +/–
  • Low to intermediate signal intensity on T1 and T2
  • In case of necrosis inside the mass, there might be some high signal lesions on T2
Choriocarcinoma
[66][67][68][69] 		+ + +/– – +
  • We may see an infiltrative uterine mass and thickening of uterine wall
Leiomyosarcoma
[70][71][72][73][74]
  • >55 y/o
 + + – – +/–
  • Increased uterine size
  • Irregular central zones of low signal intensity (tumor necrosis)
Pregnancy
[75] 		+/− +/− +/− – –
  • NA
Non-gynecologic
GIT Appendiceal abscess
[76]
  • NA
 + – + +/– +
  • NA
Appendiceal neoplasm
[77][78][79][80][81] 		+ – + – +/–
  • Soft tissue mass in the appendix
  • We may see invasion to other structures
  • Gray/yellowi color
  • Cystic structures with angiolymphatic invasion
Diverticular abscess
[82]
  • >50 y/o
 + – + +/– +
  • Ill-defined lesion with air and fluid inside
  • Adjacent bowel loop wall thickening
  • Smudged mesenteric fat
  • We may see a lesion with air and fluid inside
  • NA
Colorectal cancer
[83][84][85][86]
  • >50 y/o
 + – + – +/–
  • We may see tumor mass and the extension of tumor to other structures
Renal

Bladder

Pelvic kidney
[87][88]
  • NA
 −/+

In case of sever hydronephrosis or renal stone we may have pelvic pain

– − − − −
  • We may see normal kidney structure
  • NA
  • It may cause tract infection (UTI), obstruction, and renal calculi.
  • It may be associated with RCC
Bladder cancer
[89][90][91]
  • ≥65 y/o
 + – – – –
  • isointense compared to muscle in T1
  • slightly hyperintense compared to muscle in T2
Others Retroperitoneal sarcoma
[92][93][94][95]
  • 40-50 y/o
 + – + − −

ABBREVIATIONS

BTA=Bladder tumor associated antigen, NMP= Nuclear matrix proteins, CEA= Carcinoembryonic antigen, US= Ultrasound, HCG= Human chorionic gonadotropin, LDH= Lactate dehydrogenase, AFP= Alpha fitoprotein, CA125= Cancer antigen 125, H&E= Hematoxylin and eosin, MRI= Magnetic resonance imaging, GI= Gastrointestinal tract, PID= Pelvic inflammatory disease, CA19-9= Carbohydrate antigen 19-9, 5HIAA= 5-hydroxyindoleacetic acid, MEN syndrome= Multiple endocrine neoplasia syndrome, HNPCC= Hereditary nonpolyposis colorectal cancer, UTI= Urinary tract infection, RCC= Renal cell carcinoma

References

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  2. ↑ 2.0 2.1 Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. Radiographics. 2002;22(6):1305-25.http://www.ncbi.nlm.nih.gov/pubmed/12432104
  3. ↑ 3.0 3.1 Rozenholc A, Abdulcadir J, Pelte MF, Petignat P (June 2012). "A pelvic mass on ultrasonography and high human chorionic gonadotropin level: not always an ectopic pregnancy". BMJ Case Rep. 2012. doi:10.1136/bcr.01.2012.5577. PMID 22669919.
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