Difficulties in the differential diagnosis of tumors in the female reproductive system

Introduction. Most pelvic tumors originate from reproductive organs. Even using the up-to-date imaging techniques, radiologists experience difficulties in determining the source of the lesion since a wide range of tumors look similar to each other on the distorted backdrop of pelvic anatomy, large invasive formations, and an active inflammatory reaction of the pelvic peritoneum.

Aim: to evaluate “pitfalls” in the preoperative noninvasive diagnosis of female pelvic tumors by applying the clinical diagnostic tools.

Materials and methods. Four rare clinical cases were analyzed; all of them posed difficulties in interpreting the diagnostic examination due to their atypical characteristics. There were 2 cases of ovarian cancer, initially identified by an experienced team of radiologists as benign pelvic pathology. Also, there were fibroids with degeneration, marked proliferative activity, and a massive inflammatory reaction of the peritoneum – that was diagnosed as a malignant ovarian tumor. Tumor biopsies were examined using morphological and immunohistochemical methods (with the р16, Ki-67, p53, CD 117, S 100, CD 34 markers). Immunohistochemical (IHC) studies were performed with formalin-fixed paraffin materials using the avidin-biotin-peroxidase method. Antibodies to estrogen receptor (ER), progesterone receptor (PR), cytokeratin 7 (CK7), cytokeratin 20 (CK20) and Wilms tumor protein 1 (WT1) were also used.

Results. A thorough analysis of the clinical picture and a joint multidisciplinary discussion (gynecologist, oncologist, radiologist, etc.) made it possible to avoid diagnostic errors.

Conclusion. These observations demonstrate the difficulties of differential diagnosis between ovarian metastases of uterine cancer and primary multiple ovarian and uterine cancer, as well between leiomyosarcoma and uterine myoma with high mitotic activity. Obviously, the change in diagnosis calls for a change in the treatment strategy.

1. Iyer V.R., Lee S. MRI, CT, and PET/CT for ovarian cancer detection and adnexal lesion characterization. AJR Am J Roentgenol. 2010;194(2):311–21. DOI: 10.2214/AJR.09.3522.

2. Timmerman D., Ameye L., Fischerova D. et al. Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery: prospective validation by IOTA group. BMJ. 2010;341:c6839. DOI: 10.1136/bmj.c6839.

3. Anthoulakis C., Nikoloudis N. Pelvic MRI as the “gold standard” in the subsequent evaluation of ultrasound-indeterminate adnexal lesions: a systematic review. Gynecol Oncol. 2014;132(3):661–8. DOI: 10.1016/j.ygyno.2013.10.022.

4. Karaosmanoglu D., Karcaaltincaba M., Karcaaltincaba D. et al. MDCT of the ovarian vein: normal anatomy and pathology. AJR Am J Roentgenol. 2009;192(1):295–9. DOI: 10.2214/AJR.08.1015.

5. Lee J.H., Jeong Y.K., Park J.K., Hwang J.C. “Ovarian vascular pedicle” sign revealing organ of origin of a pelvic mass lesion on helical CT. AJR Am J Roentgenol. 2003;181(1):131–7. DOI: 10.2214/ajr.181.1.1810131.

6. Arikawa S., Uchida M., Shinagawa M. et al. Significance of the “beak sign” in the differential diagnosis of uterine lipoleiomyoma from ovarian dermoid cyst. Kurume Med J. 2006;53(1–2):37–40.

7. Stern R.C., Dash R., Bentley R.C. et al. Malignancy in endometriosis: Frequency and comparison of ovarian and extraovarian types. Int J Gynecol Pathol. 2001;20(2):133–9. DOI: 10.1097/00004347-200104000-00004.

8. Jain D., Siraj F., Aggarwal N. Endometrioid adenofibroma arising in an endometriotic cyst. J Obstet Gynaecol. 2011;31(4):352–4. DOI: 10.3109/01443615.2011.562333.

9. Tanase Y., Kawaguchi R., Takahama J., Kobayashi H. Factors that differentiate between endometriosis-associated ovarian cancer and benign ovarian endometriosis with mural nodules. Magn Reson Med Sci. 2018;17(3):231–7. DOI: 10.2463/mrms.mp.2016-0149.

10. Rosai J. Rosai and Ackerman’s surgical pathology. 10th еd. London: Mosby, 2011. 2892 p.

11. Xu Y., Yang J., Zhang Z., Zhang G. MRI for discriminating metastatic ovarian tumors from primary epithelial ovarian cancers. J Magn Reson Imaging. 2013;38(4):794–801. DOI: 10.1002/jmri.24058.

12. Oranratanaphan S., Manchana T., Sirisabya N. Clinicopathologic variables and survival comparison of patients with synchronous endometrial and ovarian cancers versus primary endometrial cancer with ovarian metastasis. Asian Pac J Cancer Prev. 2008;9(3):403–7.