Ultrasound Case of the Week: Ovarian Cyst with Mural Nodule
In this post we discuss a challenging case of a 50 year old female patient who presented with pelvic pain and irregular menstrual bleeding. She underwent a transvaginal ultrasound examination, which revealed a 4 cm cystic mass in the right adnexa with a 0.9 cm mural nodule. The cystic mass had thin walls and no septa, and the mural nodule was non-calcified and non-vascular. The left ovary was normal, and there was no ascites or lymphadenopathy.
Ultrasound images of the ovarian cyst:
#Differential Diagnoses:
The differential diagnoses for an ovarian cyst with a mural nodule include:
- Ovarian mucinous cystic tumor with mural nodules: This is a rare type of ovarian tumor that consists of a cystic component lined by mucinous epithelium and solid nodules composed of anaplastic or sarcomatoid cells. The mural nodules are usually non-calcified and non-vascular, and may show papillary projections. This tumor has a high risk of malignant transformation and recurrence.
- Ovarian mucinous cystadenocarcinoma: This is a malignant epithelial ovarian tumor that is filled with mucin and may have thick septa, papillary projections, or mural nodules. The mural nodules are usually vascular and may show calcifications. This tumor has a poor prognosis and may spread to other organs.
- Ovarian endometrioid carcinoma: This is a malignant epithelial ovarian tumor that is associated with endometriosis and may have a cystic or solid appearance. The cystic component may have hemorrhagic fluid and mural nodules that are vascular and may show calcifications. The mural nodules may also have squamous differentiation or clear cell features. This tumor has a moderate prognosis and may invade the uterus or the fallopian tubes.
- Ovarian mature cystic teratoma: This is a benign germ cell ovarian tumor that contains elements from all three germ layers, such as skin, hair, teeth, bone, cartilage, or fat. The cystic component may have sebaceous fluid and mural nodules that are calcified and non-vascular. The mural nodules may also have immature components or somatic malignancies. This tumor has a low risk of malignancy and recurrence.
- Hydrosalpinx: This is a dilated fallopian tube filled with serous fluid due to inflammation, infection, or obstruction. It may mimic an ovarian cystic mass on ultrasound, especially if the longitudinal folds are not seen. The mural nodules may represent incomplete septa or debris within the tube. This condition is usually benign but may cause infertility or pelvic pain.
#Diagnostic Approach
To narrow down the differential diagnoses, we need to consider the following factors:
- Patient's age: The patient is 50 years old, which is postmenopausal for most women. This increases the likelihood of malignant tumors over benign ones.
- Patient's symptoms: The patient had pelvic pain and irregular menstrual bleeding, which are suggestive of hormonal imbalance or endometrial pathology. This may favor endometrioid carcinoma over other tumors.
- Cyst size: The cyst is 4 cm in diameter, which is relatively small for most ovarian tumors. However, this does not exclude malignancy, as some tumors can be small but aggressive.
- Cyst morphology: The cyst has thin walls and no septa, which are favorable features for benignity. However, the presence of a mural nodule raises suspicion for malignancy.
- Mural nodule characteristics: The mural nodule is non-calcified and non-vascular, which are features that can be seen in both benign and malignant tumors. However, the absence of calcifications and vascularity makes mucinous cystadenocarcinoma less likely. The size of the nodule is also important, as larger nodules (>1 cm) are more likely to be malignant than smaller ones (<1 cm).
- Other findings: The absence of ascites or lymphadenopathy is reassuring for benignity. However, these findings can be absent in early stages of malignancy.
Based on these factors, we can rank the differential diagnoses as follows:
- Ovarian endometrioid carcinoma: This is the most likely diagnosis, as it fits the patient's age, symptoms, cyst morphology, and mural nodule characteristics. It also has a moderate prognosis and may require surgery and chemotherapy.
- Ovarian mucinous cystic tumor with mural nodules: This is the second most likely diagnosis, as it also fits the patient's age, cyst morphology, and mural nodule characteristics. However, it is a rare tumor and has a high risk of malignancy and recurrence. It may also require surgery and chemotherapy.
- Ovarian mature cystic teratoma: This is the third most likely diagnosis, as it is a benign tumor that can have a cystic component and mural nodules. However, it is more common in younger women and the mural nodules are usually calcified and non-vascular. It may also have other components such as hair or teeth that can be seen on ultrasound. It usually requires surgery but has a low risk of recurrence.
- Hydrosalpinx: This is the fourth most likely diagnosis, as it can mimic an ovarian cyst on ultrasound. However, it is more common in women with a history of pelvic inflammatory disease or tubal ligation. It also has longitudinal folds that can be seen on ultrasound. It may cause infertility or pelvic pain but does not require surgery unless symptomatic.
- Ovarian mucinous cystadenocarcinoma: This is the least likely diagnosis, as it is a malignant tumor that usually has thick septa, papillary projections, or mural nodules that are vascular and calcified. It also has a poor prognosis and may spread to other organs. It requires surgery and chemotherapy.
#Prognosis and Management
The prognosis and management of the patient depend on the final diagnosis, which can be confirmed by MRI or biopsy. However, based on the ultrasound findings, we can assume that the patient has a malignant ovarian tumor that requires surgical removal and possibly chemotherapy. The prognosis will depend on the stage of the tumor, which can be determined by imaging or pathology. The survival rates for ovarian cancer vary depending on the type and stage of the tumor, but generally range from 10% to 90%.
The management of the patient will also depend on her fertility status and preferences. If she wishes to preserve her fertility, she may opt for conservative surgery that spares the uterus and the contralateral ovary. However, this may increase the risk of recurrence or metastasis. If she does not wish to preserve her fertility, she may opt for radical surgery that removes the uterus, both ovaries, both fallopian tubes, and any other affected organs or tissues. She may also need adjuvant chemotherapy to reduce the risk of recurrence or metastasis.
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: Ovarian Mucinous Cystic Tumor with Mural Nodules. https://www.ncbi.nlm.nih.gov/medgen/269341.
: Ovarian mucinous borderline tumor with anaplastic carcinomatous nodules .... https://ovarianresearch.biomedcentral.com/articles/10.1186/s13048-022-01010-3.
: Ovarian cystic neoplasms | Radiology Reference Article - Radiopaedia.org. https://radiopaedia.org/articles/ovarian-cystic-neoplasms-1.
: Hydrosalpinx | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/hydrosalpinx.
: The Radiology Assistant : Roadmap to evaluate ovarian cysts. https://radiologyassistant.nl/abdomen/unsorted/roadmap-to-evaluate-ovarian-cysts.
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