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Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. Transabdominal sonographic examination, transverse and sagittal planes: A large complex pelvic mass (cursors) is seen. The lesion is composed of cystic parts and solid echogenic tissue, the latter finding suggestive of malignancy.

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. Unenhanced CT scanning of the pelvis, transverse plane: A sharply-defined left pelvic mass is detected, mainly composed of hyperdense elements, with a mean CT density of 70 HU, suggestive of acute hemorrhage. There are also cystic parts within the lesion, measuring within the water range (10-20 HU).

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. Contrast-enhanced CT scanning of the abdomen after i.v. administration of iodinated contrast material (portal phase) transverse plane: A large, heterogeneous pelvic lesion is seen, involving the left adnexa. No obvious lesion enhancement is detected on post-contrast CT images; therefore the lesion is interpreted as non-enhancing. Neither pelvic nor retroperitoneal lymphadenopathy is revealed. Based on MDCT findings, the diagnosis of a benign hemorrhagic left adnexal mass lesion is suggested. There is thinning of upper pole left renal parenchyma and a cystic renal lesion, with a small calcification peripherally, a finding considered as postinflammatory in origin.

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. Contrast-enhanced CT scanning of the abdomen after i.v. administration of iodinated contrast material (portal phase), coronal plane: Left pelvic mass is sharply-demarcated and in close relationship to the uterine body, without signs of invasion. The dimensions of the tumor are 15.8 X 8 X 15.4 cm. The lesion is composed mainly of hyperdense parts, with a CT density range from 45-85 HU, both on unenhanced and contrast-enhanced images, findings suggestive of acute hemorrhage. Other parts with a CT density within the water range (10-20 HU), also non-enhancing after contrast material administration are detected within the mass. On MDCT examination, no signs suspicious of malignancy are revealed.

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. MR imaging examination, T1-weighted images, transverse plane: A large, sharply delineated left adnexal mass lesion is demonstated. It is composed mainly of parts with signal intensity slightly higher and higher than that of normal myometrium, suggestive for the presence of hemorrhage of various ages (acute and subacute hemorrhage, respectively). Cystic parts with low signal intensity, similar to that of urine are also seen. The soft-tissue component within the mass is detected mainly isointense to normal myometrium (Figure 4).

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. MR imaging examination, T2-weighted images, transverse plane: A sharply delineated, heterogeneous left adnexal mass is depicted. Slightly hyperintense parts on T1-weighted images within the lesion are detected with very low signal intensity on T2-weighted images, suggestive of acute hemorrhage, and others hyperintense on both T1 and T2-weighted images (one of them with a hematocrit level) suggestive of subacute hemorrhage. Cystic parts are detected hyperintense, with signal intensity similar to that of urine. A soft-tissue component is also demonstrated, of signal intensity slightly higher than that of muscle and similar to that of normal myometrium (Figure 5).

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. MR imaging examination, T2-weighted images, sagittal plane: Lesion signal heterogeneity is seen. The mass is sharply-defined, close the uterine body. Cystic parts are detected, with high signal intensity and hemorrhagic parts, others extremely hypointense (acute hemorrhage), and others hyperintense (subacute hemorrhage). The soft tissue element is of intermediate signal intensity, similar to that of normal myometrium (Figure 5, 6).

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. MR imaging examination, T2-weighted images, coronal plane: Lesion signal heterogeneity and close relationship to the uterus is seen.

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. MR imaging examination, diffusion-weighted images, transverse plane: The soft-tissue element within left adnexal mass is detected hyperintense on diffusion-weighted sequences due to the restricted diffusion, caused by the malignant neoplastic tissue. Areas of subacute hemorrhage are detected of intermediate signal intensity and areas of acute hemorrhage cause dramatic signal drop, due to T2* effect. Cystic parts are hyperintense both on DW images and ADC maps, due to their watery content. Urinary bladder is hypointense, due to free diffusion.

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. Apparent diffusion coefficients maps (ADC), transverse plane: The soft-tissue component is detected hypointense, with a low ADC value: 1.05 x 10-3 mm2/sec. This finding is caused by restricted diffusion and is highly suggestive of malignancy. Subacute hemorrhagic components have intermediate signal intensity and ADC values of 1.37 x 10-3 mm2/sec. The presence of blood products or thick colloid fluid within endometriotic cysts is reported to cause restricted diffusion in these masses. Areas of acute haemorrhage have no measurable ADC values, because they cause a dramatic signal drop in the area, due to T2* effect. Cystic parts are detected with free diffusion, therefore hyperintense, with high ADC values (2.54 x 10-3 mm2/sec). Normal ADC values for urinary bladder: 3.24 x 10-3 mm2/sec; myometrium 1.79 x 10-3 mm2/sec; endometrium 1.43 x 10-3 mm2/sec.

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. Dynamic contrast-enhanced MR imaging after gadolinium administration (early: portal phase), T1-weighted images with fat suppression, sagittal plane: Soft-tissue component is strongly, early and heterogeneously enhancing, a finding strongly suggestive of malignancy.

Click 30-year old woman with left endometrioid adenocarcinoma developed in a pre-existing ovarian endometrioma. MR imaging examination, post-contrast fat-suppressed T1-weighted images after gadolinium administration, transverse plane: There is enhancement of the wall and septa of the multicystic lesion, which are detected smooth and thin (of thickness less than 3 mm). The presence of strong and inhomogeneous enhancement by the soft-tissue component is highly suggestive of malignancy.