Gynecol Obstet Invest 1991;32:51-54
© 1991 S. Karger AG. Basel 0378-7346/91/0321-0051 $2.75/0
Ovarian Fibrothecoma: Sonographic and Histologic Findings Massimo Conte, Lorenzo Guariglia, Pierluigi Benedetti Panici, Giovanni Scambia, Carla Rabitti, Arnaldo Capelli, Salvatore Mancuso Department of Obstetrics and Gynecology and Department of Histopathology, Catholic University of Sacred Heart, Rome, Italy
Key Words. Ultrasonics • Ovary • Ovarian neoplasms
Introduction Fibrothecomas are mesenchymal tumors deriving from the ovarian stroma and consisting of theca-like ele ments and fibrous tissue [1], These tumors are usually benign and occur mostly in menopausal women. The reported incidence is between 0.4 and 8.0% of all ovar ian tumors, and this wide variability can be attributed to the difficulty in differentiating fibrothecomas from ovar ian fibromas or hyperplastic stromal nodules [1-4]. Macroscopically, fibrothecomas are very similar to fibromas from which they are distinguished by their col or, which varies from yellow to brown, and by focal or diffuse areas of stromal edema interspersed between cys tic spaces. Microscopically, fibrothecomas are composed of in termingling bundles or anastomosing trabeculae of ovoid theca-like cells, with round and pale nuclei, containing lipid droplets and fibroblastic fusiform elements. Granu losa cells, separated by collagen bundles, have also been observed. Depending on the prevalence of cells or fi
brous tissue, these tumors are pathologically classified as pure thecomas, fibrothecomas, and predominantly fi brous fibrothecomas [4], Clinically, most patients complain of menstrual dys function or atypical postmenopausal bleeding, second ary to hormonal production by thecal cells which can induce hyperplastic and/or neoplastic endometrial le sions. The presence of ascites, abdominal distension and pain has also been reported [5, 6], Even though the definitive diagnosis of fibrothecoma is histologic, some authors have recently described the presence of characteristic sonographic patterns whose detection may help clinicians in diagnosing these tumors preoperatively. In particular, the sonographic finding of an adnexal solid mass casting dense acoustic shadowing, in the absence of any calcification, has been reported to be highly suggestive of ovarian fibrothecomas [7-9], In this study, we compared the sonographic and the histologic findings of 11 fibrothecomas, making an at tempt to find a correlation between the ultrasound appear ance and the different histologic types of the tumor.
Downloaded by: Leiden University Medisch Centrum 132.229.13.63 - 10/27/2018 8:07:55 PM
Abstract. The sonographic and histologic findings observed in 11 cases of ovarian fibrothecoma were compared, and an attempt was made to find a correlation between each histologic type of the tumor (pure thecoma, predomi nantly fibrous fibrothecoma, mixed fibrothecoma) and its sonographic appearance. The presence of a homogeneous echogenic pattern, with marked posterior acoustic shadowing, in the absence of any calcification, was highly sugges tive of a predominantly fibrous ovarian fibrothecoma; the presence of a diffusely hypoechoic ovarian mass, with no posterior echo enhancement, was strikingly correlated with pure thecomas; mixed fibrothecomas were characterized by the presence of an echogenic pattern with no posterior acoustic shadowing. Sonographic findings, even though nonspecific, can provide the clinician with useful information which permits to detect these rare neoplasms preoperatively.
52
Conte/Guariglia/Benedetti Panici/Scambia/Rabitti/Capelli/Mancuso
Material and Methods From February 1986 to June 1990, at the Department of Obstet rics and Gynecology of the Catholic University in Rome, 426 patients with adnexal masses, aged between 20 and 70 years (me dian age 51 years), were examined sonographically and underwent surgery followed by a histologic examination of the specimen. Ultrasound examinations were performed by a General Electric RT 3600 system, equipped with 3.5 MHz electronic linear and sec tor probes, and transvaginal 5.0- and 7.5-MHz probes. Surgical specimens were fixed in 10% formalin for 36 h, in cluded in paraffin, cut into 5-pm slices and then stained with hematoxilin and eosin. Histologically, those tumors classified as fibrothecomas were divided into three groups (F I, F2 and F3), depending on the prevalence of cells or fibrous tissue. Tumors classified as FI had a higher number of thecal cells, whereas the fibrous component pre dominated in those classified as F3 (fig. 1-3).
Results Eleven of the 426 patients examined (2.5%) had ovar ian fibrothecomas. In 6 cases (54.6%) the tumor was diagnosed during or after the menopause; in 5 cases (45.4%) the patients were of childbearing age. The me dian age of the patients at the moment of diagnosis was 40 years. Pathologically, 2 tumors were classified as pure thecomas (FI), 5 as fibrothecomas (F2), and 4 as pre dominantly fibrous fibrothecomas (F3). The results of the ultrasound examination are shown in table 1. Tumor volumes ranged between 50 and 1,989 cm3 (median volume 213 cm3). Ascites was observed in 3 cases (27.3%). The echostructure of the tumor was solid (echogenic) in 7 cases (63.6%), fluid-filled (hypoechoic) in 2 (18.2%) and mixed (complex) in 2 (18.2%). The presence of a dense acoustic shadow was observed in 2 cases (18.2%). The comparison between the sonographic pattern (echogenic, hypoechoic and complex) and the histologic tumor type (FI, F2 and F3) is shown in table 2.
2
Discussion
Fig. 1. Microscopic appearance of an ovarian fibrothecoma with prevalence of the thecal elements (FI type). HE. X 40. Fig. 2. Microscopic appearance of an ovarian fibrothecoma with mixed theco-cellular and fibrous components (F2 type). HE. X 40. Fig. 3. Microscopic appearance of an ovarian fibrothecoma with prevalence of the fibrous component (F3 type). HE. X 40.
To the best of our knowledge, this is the first study in which an attempt to correlate sonographic with histo logic findings of fibrothecomas was made in such a large patient sample. In our series, the incidence of ovarian fibrothecomas was in keeping with the data previously reported by other authors [1-4]. The tumors were mainly detected during or after menopause, thus confirming their preva lence in older women [1].
Downloaded by: Leiden University Medisch Centrum 132.229.13.63 - 10/27/2018 8:07:55 PM
3
53
Ovarian Fibrothecoma
Fig. 4. Sonographic appearance of an ovarian thecoma with hypoechoic pattern and no posterior echoenhancement (FI type), a Trans abdominal scan, b Transvaginal scan showing a positive filling pattern.
Table 1. Sonographic findings observed in 11 cases of ovarian fibrothecoma Patient
Age years
V.G. T.B. M.A. M.G. P.M. A.M. SI. D.M. C.L. D.N. D.G.
51 40 54 47 57 70 59 36 20 38 31
Volume cm3 213 448 96 126 1,989 127 95 230 735 406 50
Echostructure
Cone shadow
Ascites
hypoechoic complex echogenic echogenic echogenic echogenic echogenic complex echogenic hypoechoic echogenic
absent absent absent absent present present absent absent absent absent absent
absent present absent absent present absent absent present absent absent absent
Table 2. Histologic-sonographic correlation in 11 cases of ovar ian fibrothecoma Echostructure
Hypoechoic Echogenic Complex Total
Histotype FI
F2
F3
2
5 1 6
2 1 3
2
Downloaded by: Leiden University Medisch Centrum 132.229.13.63 - 10/27/2018 8:07:55 PM
The comparison of the sonographic features with the histologic tumor types showed a correlation between the hypoechoic structure and the FI type, and between the echogenic structure and the F2-F3 types. Moreover, the presence of a dense acoustic shadowing was observed exclusively in F3 tumors. This Finding could possibly be explained by the different amount of absorption of sound energy by the mass, minimal in the presence of a predominantly cellular component and elevated in fi brous tumors. The differential diagnosis between pure thecomas (histologic type FI) and ovarian cysts can, thus, present some difficulty. Diagnosis of ovarian thecomas will de pend on physical examination, coupled with a transvag inal scan showing the presence of an adnexal hypoechoic mass, with positive filling pattern and no posterior acoustic enhancement (fig. 4). With respect to the finding of a posterior dense acous tic shadow in the absence of any calcification, we agree with other authors who feel that its diagnostic impor tance needs to be further evaluated [10]. In our experi ence, in fact, the ‘cone shadow’ was observed in only 2 of 4 F3 tumors (fig. 5). In conclusion, our data confirm the value of ultra sound in the preoperative diagnosis of ovarian fibrothecomas. In particular, the presence of a homogeneous echogenic pattern, with marked posterior acoustic ab sorption, is highly suggestive of a predominantly fibrous
54
Conte/Guariglia/Benedetti Panici/Scambia/Rabitti/Capelli/Mancuso
References
ovarian fibrothecoma; an echogenic pattern, with no posterior acoustic shadowing appears to be correlated to the presence of a mixed fibrothecoma; finally, the find ing of a diffusely hypoechoic mass, with no posterior echo enhancement, is characteristic of pure ovarian the comas. We, thus, feel that sonographic findings, even though nonspecific, can provide the clinician with useful information to detect these rare ovarian neoplasms preoperatively.
Received: December 4, 1990 Accepted: February 6, 1991 Massimo Conte, MD Department of Obstetrics and Gynecology Catholic University of Sacred Heart Largo A. Gemelli, 8 1-00168 Rome (Italy)
Downloaded by: Leiden University Medisch Centrum 132.229.13.63 - 10/27/2018 8:07:55 PM
Fig. 5. Sonographic appearance of an ovarian fibrothecoma, with echogenic pattern and dense posterior acoustic shadowing (F3 type).
1 Novak, E.R.: Gynecologic and obstetric pathology (Saunders Philadelphia 1979). 2 Anikwue, C.; Yussof Dawood, M.; Kramer, E.: Granulosa and theca-cell tumors. Obstet. Gynec. 51: 214-220 (1978). 3 Bjorkholm, E.; Petterson, R: Granulosa-cell and theca-cell tu mors. Acta obstet, gynec. scand. 59: 361-365 (1980). 4 Stage, A.H.; Grafton, W.D.: Thecomas and granulosa-theca cell tumors of the ovary. An analysis of 51 tumors. Obstet. Gynec. 50: 21-27 (1977). 5 Aiman, J.; Edman, C.D.; Worley, R.J.; Vellios, F.; Mac Donald, P.C.: Androgen and estrogen formation in women with ovarian hyperthecosis. Obstet. Gynec. 51: 1-9 (1978). 6 Krön, B.: Fibro-thécome de l’ovaire avec épanchement pleural et ascite. Sem. Hôp. Paris 49: 1318-1319 (1973). 7 Diakoumakis, E.; Vieux, U.; Seife, B.: Sonographie demonstra tion of thecoma: report of two cases. Am. J. Obstet. Gynec. 150: 787-788 (1984). 8 Yaghoobian, J.; Pinck, R.L: Ultrasound findings in thecoma of the ovary. J. clin. Ultrasound 11: 91-93 (1983). 9 Stephenson, W.M.; Laing, F.C.: Sonography of ovarian fibro mas. Am. J. Roentg. 144: 1239-1240 (1985). 10 Merizzi, R.; Grazioli, G.: Cistoadenoma ovarico gigantc e tecofibroma ovarico bilaterale. Radiol. Med. 72: 766-768 (1986).
© 1991 S. Karger AG. Basel 0378-7346/91/0321-0051 $2.75/0
Ovarian Fibrothecoma: Sonographic and Histologic Findings Massimo Conte, Lorenzo Guariglia, Pierluigi Benedetti Panici, Giovanni Scambia, Carla Rabitti, Arnaldo Capelli, Salvatore Mancuso Department of Obstetrics and Gynecology and Department of Histopathology, Catholic University of Sacred Heart, Rome, Italy
Key Words. Ultrasonics • Ovary • Ovarian neoplasms
Introduction Fibrothecomas are mesenchymal tumors deriving from the ovarian stroma and consisting of theca-like ele ments and fibrous tissue [1], These tumors are usually benign and occur mostly in menopausal women. The reported incidence is between 0.4 and 8.0% of all ovar ian tumors, and this wide variability can be attributed to the difficulty in differentiating fibrothecomas from ovar ian fibromas or hyperplastic stromal nodules [1-4]. Macroscopically, fibrothecomas are very similar to fibromas from which they are distinguished by their col or, which varies from yellow to brown, and by focal or diffuse areas of stromal edema interspersed between cys tic spaces. Microscopically, fibrothecomas are composed of in termingling bundles or anastomosing trabeculae of ovoid theca-like cells, with round and pale nuclei, containing lipid droplets and fibroblastic fusiform elements. Granu losa cells, separated by collagen bundles, have also been observed. Depending on the prevalence of cells or fi
brous tissue, these tumors are pathologically classified as pure thecomas, fibrothecomas, and predominantly fi brous fibrothecomas [4], Clinically, most patients complain of menstrual dys function or atypical postmenopausal bleeding, second ary to hormonal production by thecal cells which can induce hyperplastic and/or neoplastic endometrial le sions. The presence of ascites, abdominal distension and pain has also been reported [5, 6], Even though the definitive diagnosis of fibrothecoma is histologic, some authors have recently described the presence of characteristic sonographic patterns whose detection may help clinicians in diagnosing these tumors preoperatively. In particular, the sonographic finding of an adnexal solid mass casting dense acoustic shadowing, in the absence of any calcification, has been reported to be highly suggestive of ovarian fibrothecomas [7-9], In this study, we compared the sonographic and the histologic findings of 11 fibrothecomas, making an at tempt to find a correlation between the ultrasound appear ance and the different histologic types of the tumor.
Downloaded by: Leiden University Medisch Centrum 132.229.13.63 - 10/27/2018 8:07:55 PM
Abstract. The sonographic and histologic findings observed in 11 cases of ovarian fibrothecoma were compared, and an attempt was made to find a correlation between each histologic type of the tumor (pure thecoma, predomi nantly fibrous fibrothecoma, mixed fibrothecoma) and its sonographic appearance. The presence of a homogeneous echogenic pattern, with marked posterior acoustic shadowing, in the absence of any calcification, was highly sugges tive of a predominantly fibrous ovarian fibrothecoma; the presence of a diffusely hypoechoic ovarian mass, with no posterior echo enhancement, was strikingly correlated with pure thecomas; mixed fibrothecomas were characterized by the presence of an echogenic pattern with no posterior acoustic shadowing. Sonographic findings, even though nonspecific, can provide the clinician with useful information which permits to detect these rare neoplasms preoperatively.
52
Conte/Guariglia/Benedetti Panici/Scambia/Rabitti/Capelli/Mancuso
Material and Methods From February 1986 to June 1990, at the Department of Obstet rics and Gynecology of the Catholic University in Rome, 426 patients with adnexal masses, aged between 20 and 70 years (me dian age 51 years), were examined sonographically and underwent surgery followed by a histologic examination of the specimen. Ultrasound examinations were performed by a General Electric RT 3600 system, equipped with 3.5 MHz electronic linear and sec tor probes, and transvaginal 5.0- and 7.5-MHz probes. Surgical specimens were fixed in 10% formalin for 36 h, in cluded in paraffin, cut into 5-pm slices and then stained with hematoxilin and eosin. Histologically, those tumors classified as fibrothecomas were divided into three groups (F I, F2 and F3), depending on the prevalence of cells or fibrous tissue. Tumors classified as FI had a higher number of thecal cells, whereas the fibrous component pre dominated in those classified as F3 (fig. 1-3).
Results Eleven of the 426 patients examined (2.5%) had ovar ian fibrothecomas. In 6 cases (54.6%) the tumor was diagnosed during or after the menopause; in 5 cases (45.4%) the patients were of childbearing age. The me dian age of the patients at the moment of diagnosis was 40 years. Pathologically, 2 tumors were classified as pure thecomas (FI), 5 as fibrothecomas (F2), and 4 as pre dominantly fibrous fibrothecomas (F3). The results of the ultrasound examination are shown in table 1. Tumor volumes ranged between 50 and 1,989 cm3 (median volume 213 cm3). Ascites was observed in 3 cases (27.3%). The echostructure of the tumor was solid (echogenic) in 7 cases (63.6%), fluid-filled (hypoechoic) in 2 (18.2%) and mixed (complex) in 2 (18.2%). The presence of a dense acoustic shadow was observed in 2 cases (18.2%). The comparison between the sonographic pattern (echogenic, hypoechoic and complex) and the histologic tumor type (FI, F2 and F3) is shown in table 2.
2
Discussion
Fig. 1. Microscopic appearance of an ovarian fibrothecoma with prevalence of the thecal elements (FI type). HE. X 40. Fig. 2. Microscopic appearance of an ovarian fibrothecoma with mixed theco-cellular and fibrous components (F2 type). HE. X 40. Fig. 3. Microscopic appearance of an ovarian fibrothecoma with prevalence of the fibrous component (F3 type). HE. X 40.
To the best of our knowledge, this is the first study in which an attempt to correlate sonographic with histo logic findings of fibrothecomas was made in such a large patient sample. In our series, the incidence of ovarian fibrothecomas was in keeping with the data previously reported by other authors [1-4]. The tumors were mainly detected during or after menopause, thus confirming their preva lence in older women [1].
Downloaded by: Leiden University Medisch Centrum 132.229.13.63 - 10/27/2018 8:07:55 PM
3
53
Ovarian Fibrothecoma
Fig. 4. Sonographic appearance of an ovarian thecoma with hypoechoic pattern and no posterior echoenhancement (FI type), a Trans abdominal scan, b Transvaginal scan showing a positive filling pattern.
Table 1. Sonographic findings observed in 11 cases of ovarian fibrothecoma Patient
Age years
V.G. T.B. M.A. M.G. P.M. A.M. SI. D.M. C.L. D.N. D.G.
51 40 54 47 57 70 59 36 20 38 31
Volume cm3 213 448 96 126 1,989 127 95 230 735 406 50
Echostructure
Cone shadow
Ascites
hypoechoic complex echogenic echogenic echogenic echogenic echogenic complex echogenic hypoechoic echogenic
absent absent absent absent present present absent absent absent absent absent
absent present absent absent present absent absent present absent absent absent
Table 2. Histologic-sonographic correlation in 11 cases of ovar ian fibrothecoma Echostructure
Hypoechoic Echogenic Complex Total
Histotype FI
F2
F3
2
5 1 6
2 1 3
2
Downloaded by: Leiden University Medisch Centrum 132.229.13.63 - 10/27/2018 8:07:55 PM
The comparison of the sonographic features with the histologic tumor types showed a correlation between the hypoechoic structure and the FI type, and between the echogenic structure and the F2-F3 types. Moreover, the presence of a dense acoustic shadowing was observed exclusively in F3 tumors. This Finding could possibly be explained by the different amount of absorption of sound energy by the mass, minimal in the presence of a predominantly cellular component and elevated in fi brous tumors. The differential diagnosis between pure thecomas (histologic type FI) and ovarian cysts can, thus, present some difficulty. Diagnosis of ovarian thecomas will de pend on physical examination, coupled with a transvag inal scan showing the presence of an adnexal hypoechoic mass, with positive filling pattern and no posterior acoustic enhancement (fig. 4). With respect to the finding of a posterior dense acous tic shadow in the absence of any calcification, we agree with other authors who feel that its diagnostic impor tance needs to be further evaluated [10]. In our experi ence, in fact, the ‘cone shadow’ was observed in only 2 of 4 F3 tumors (fig. 5). In conclusion, our data confirm the value of ultra sound in the preoperative diagnosis of ovarian fibrothecomas. In particular, the presence of a homogeneous echogenic pattern, with marked posterior acoustic ab sorption, is highly suggestive of a predominantly fibrous
54
Conte/Guariglia/Benedetti Panici/Scambia/Rabitti/Capelli/Mancuso
References
ovarian fibrothecoma; an echogenic pattern, with no posterior acoustic shadowing appears to be correlated to the presence of a mixed fibrothecoma; finally, the find ing of a diffusely hypoechoic mass, with no posterior echo enhancement, is characteristic of pure ovarian the comas. We, thus, feel that sonographic findings, even though nonspecific, can provide the clinician with useful information to detect these rare ovarian neoplasms preoperatively.
Received: December 4, 1990 Accepted: February 6, 1991 Massimo Conte, MD Department of Obstetrics and Gynecology Catholic University of Sacred Heart Largo A. Gemelli, 8 1-00168 Rome (Italy)
Downloaded by: Leiden University Medisch Centrum 132.229.13.63 - 10/27/2018 8:07:55 PM
Fig. 5. Sonographic appearance of an ovarian fibrothecoma, with echogenic pattern and dense posterior acoustic shadowing (F3 type).
1 Novak, E.R.: Gynecologic and obstetric pathology (Saunders Philadelphia 1979). 2 Anikwue, C.; Yussof Dawood, M.; Kramer, E.: Granulosa and theca-cell tumors. Obstet. Gynec. 51: 214-220 (1978). 3 Bjorkholm, E.; Petterson, R: Granulosa-cell and theca-cell tu mors. Acta obstet, gynec. scand. 59: 361-365 (1980). 4 Stage, A.H.; Grafton, W.D.: Thecomas and granulosa-theca cell tumors of the ovary. An analysis of 51 tumors. Obstet. Gynec. 50: 21-27 (1977). 5 Aiman, J.; Edman, C.D.; Worley, R.J.; Vellios, F.; Mac Donald, P.C.: Androgen and estrogen formation in women with ovarian hyperthecosis. Obstet. Gynec. 51: 1-9 (1978). 6 Krön, B.: Fibro-thécome de l’ovaire avec épanchement pleural et ascite. Sem. Hôp. Paris 49: 1318-1319 (1973). 7 Diakoumakis, E.; Vieux, U.; Seife, B.: Sonographie demonstra tion of thecoma: report of two cases. Am. J. Obstet. Gynec. 150: 787-788 (1984). 8 Yaghoobian, J.; Pinck, R.L: Ultrasound findings in thecoma of the ovary. J. clin. Ultrasound 11: 91-93 (1983). 9 Stephenson, W.M.; Laing, F.C.: Sonography of ovarian fibro mas. Am. J. Roentg. 144: 1239-1240 (1985). 10 Merizzi, R.; Grazioli, G.: Cistoadenoma ovarico gigantc e tecofibroma ovarico bilaterale. Radiol. Med. 72: 766-768 (1986).
