Ovarian Fibrothecoma: Imaging Findings and Management Considerations

Introduction:

Ovarian fibrothecoma are a rare type of benign tumor that occurs in the ovary, accounting for one percent of all ovarian tumors. They originate from the stromal cells, a connective tissue that surrounds the ovarian follicles and encapsulates them. These tumors consist of fibrous tissue and theca cells, specialized cells that produce hormones such as estrogen and progesterone. While these are considered benign tumors, they can cause complications due to hormonal activity. Diagnosis can be made with the help of CT (computed tomography), MRI (magnetic resonance imaging), or ultrasounds. Management usually involves surgical removal of the tumor.

What Are the Clinical Features of Ovarian Fibrothecoma?

Ovarian fibrothecoma mainly occurs in adult and postmenopausal women (66 percent). The clinical features depend on the size of the tumor and its impact on hormonal activity. Some of the clinical features of ovarian fibrothecoma are:

• Abdominal Pain: This is the most common feature, which can range from mild to stabbing pain.

• Abdominal Swelling: Large tumors can cause distension of the abdomen.

• Menstrual Irregularities: Due to its effect on hormonal activity, irregularities in menstruation can occur, ranging from heavy menstrual flow to amenorrhea (absence of menstrual flow).

• Hormonal Effects: The production of excess hormones can cause mood changes, breast tenderness, and changes in libido.

• Urinary Symptoms: These occur in large tumors due to their impact on surrounding structures, such as the urinary bladder, leading to feelings of urgency or frequent urination.

• Gastrointestinal Symptoms: These depend on the size and location of the tumor, which can lead to symptoms such as constipation or diarrhea due to the impact on the intestines.

• Endometrial Hyperplasia: This is characterized by excessive growth of cells in the inner lining (endometrium) of the uterus.

• Pelvic Discomfort: A general discomfort or pressure around the pelvic area can occur.

• Painful Intercourse: Some affected individuals may experience this symptom.

• Infertility: This is not a common symptom, but some large tumors can interfere with regular ovulation, affecting fertility.

What Are the Imaging Findings of Ovarian Fibrothecoma?

Imaging findings play the most crucial role in the diagnosis of ovarian fibrothecoma. Various imaging modalities, such as CT, ultrasound, and MRI, can provide insights into its appearance, location, and size. The imaging findings include:

1. Ultrasound (Us) Imaging Findings Include: These can be seen as homogeneous hypoechoic masses with a consistent texture and a darker appearance in ultrasound due to the tumor reflecting fewer ultrasound waves.

• Solid Mass: Ovarian fibrothecomas usually present as solid masses inside the ovary, varying in size from large to small nodules.

• Well-Defined Borders: These tumors have clear borders separate from the surrounding tissues.

• Whorled Appearance: This is one of the characteristic features of the tumor. A spiral or whorled pattern is seen in an ultrasound. This pattern consists of alternating bands of dark and bright areas within the tumor. It occurs due to the combination of theca and fibrous tissues.

• Mixed Echogenicity: These tumors give an appearance of mixed echogenicity, where there are areas of both dark and bright echoes.

• Color Doppler Imaging: Doppler imaging assesses the blood flow within the tumor. These tumors typically contain very little blood flow. Therefore, this imaging can help differentiate them from other vascular tumors.

2. Computed Tomography (CT) Imaging Findings Include:

• Solid Density: These tumors appear as solid masses inside the ovary with well-defined borders.

• Heterogeneous Attenuation: The density in these tumors varies due to the presence of mixed cells, including fibrous and theca cells.

• Contrast Enhancement: Contrast agents are used to show the flow of blood. These types of tumors show minimal enhancement due to low blood flow. Some may exhibit no contrast flow.

• Calcifications can sometimes be present, resulting in a heterogeneous pattern.

3. Magnetic Resonance Imaging (MRI) Imaging Findings Include:

• T1-Weighted and T2-Weighted Images: Different MRI sequences are used to provide distinct information about the body. On T1-weighted MRI images, these tumors appear as low-intensity signal masses. On T2-weighted MRI images, they appear as heterogeneous masses. This high intensity is due to both cell types in the tumor, which are fibrous and theca cells.

• Whorled Appearance: This finding is similar to the ultrasound observation, involving alternating dark and bright bands that create a spiral or whorled pattern appearance.

• Anatomical Information: Apart from the tumor findings, these images also provide information about the relationship of the tumor with adjacent structures. This information can be helpful during surgical removal. Large masses, more than 2.36 inches in size, were encapsulated. Some exhibited degenerative changes, uneven signals, and peripheral cysts on MRI.

What Are the Management Considerations of Ovarian Fibrothecoma?

The management of ovarian fibrothecoma depends on factors such as the size of the tumor, age, severity of symptoms, hormonal effects, and overall health of the patients. Different management options include:

• Observation and Monitoring: Small asymptomatic tumors that do not cause complications can be managed with regular monitoring and follow-ups. Regular imaging studies, such as ultrasounds, can track changes and tumor growth.

• Surgical Removal: Surgical removal is indicated for large tumors that cause severe symptoms, discomfort, and complications. The surgical removal of this tumor can be done using a laparoscopic approach, which is minimally invasive, or open surgery, depending on the size and location of the tumor. Complete removal of the tumor reduces the chances of recurrence.

• Hormone Therapy: In some cases where these tumors cause excessive hormone production and related symptoms, hormone therapy can be considered. This therapy, using oral contraceptives or GnRH agonists, can help regulate hormone production and alleviate the symptoms caused by it.

Regardless of the chosen management approach, follow-up care is necessary to monitor recurrence or any associated complications resulting from this tumor. Follow-up care can be conducted through physical assessments, imaging studies, and hormone level assessments.

Conclusion:

Ovarian fibrothecoma requires careful imaging assessment along with appropriate management. Ultrasonography, CT, and MRI play essential roles in the diagnosis. With accurate diagnosis and proper management, positive outcomes can be achieved. The prognosis is generally favorable due to its benign nature. However, long-term regular follow-up is crucial for monitoring potential complications or recurrences arising from these tumors.