Original Research
Ovarian Fibromas and
Cystadenofibromas: MRI Features
of the Fibrous Component
1 Eric K. Outwater, MD Evan S. Siegelman, MD
Ovarian fibromas and cystadenofibromasare neoplasms
that share a similar distinctive tissue component of
dense fibrous tissue. We sought to describe the fea-
tures of these neoplasms and to determine if the fibrous
component shows distinctive characteristics. Fourteen
patients in whom MR images performed with multicoil
and fastapin-echo images and who subsequentlyunder-
went surgery for resection of ovarian fibromas or cys-
tadenofibromas were identified from two institutions.
Five patients had ovarian fibromas, and nine patients
had fourteen cystadenofibromas. 1.5-TMR studies used
T1-weighted spin echo and multiplanar "2-weighted
fast-spin-echo images, with fat saturation gadolinium-
enhanced fast multiplanar gradient-echo images in
seven patients. Studies were reviewed for findings of
low (- skeletal muscle) signal intensity solid compo-
nents on T2-weighted images, characteristics of gado-
linium enhancement, and associated endometrial
findings. Images were obtained ex vivo from three ad-
nexal surgical specimens with an 8-cm field of view and
correlated with histology. All five of the fibromas
showed predominantly very low signal intensity, similar
to skeletal muscle, on T2-weighted images. Two of five
fibromas were in patients with endometrial polyps and
increased amounts of fluid in the pelvis. Thirteen cys-
tadenofibromas were multicystic masses with bands of
very low signal intensity ranging from 2 to 20 nun In
the wall of the mass, and one was predominantly solid
fibrous tissue. Pathologiccorrelationwith specimen im-
ages showed that the low signal intensity material was
the subepithelial fibrous component of the cystadeno-
fibromas. Fibrous components of ovarian fibromas and
cystadenofibromas are demonstrable by MR as solid
components representing fibrous tissue of very low sig-
nal intensity on "2-weighted images.
Index terms: Fibromas * Cystadenofihromas * MRl * Ovarianneoplasms
JMRI 1997: 7 4 6 5 4 7 1
Abbreviations: FOV = field of view, FSE = fast spin echo, GRASS = @a-
dient-recalled acquisition in steady state.
From the Ucpartments of Radiology (E.K.O.), Pathology (A.T.),and Obstetrics
and Gynecology IC.D.1, Thomas Jefferson University Hospital, 132 South
Tenth Street. 1096 Main, Philadelphia. PA 19107-5244, and the Hospital of
the University of Pennsylvania (E.S.S.),Philadelphia, PA. Received September
17, 1996; levision requested December 3; revision received January 6, 1997
accepted January 17. Address reprint requests to E.K.O. E-mail: outwatel@
jeflin.tju.edu.
ISMRM, 1997
Alexander Talerman, MD, PhD Charles Dunton, MD
SEVERAL STUDIES HAVE established the usefulness of
MRI for characterizing adnexal masses (1-5). Despite the
superior accuracy of MRI for adnexal masses, few studies
have been conducted that describe the essential MRI fea-
tures of ovarian neoplasms, other than for mature tera-
tomas (dermoid cysts). Dermoid cysts are characterized
on MRI by specific chemical-shift methods, which can
identify lipid within the fluid or solid component of these
neoplasms (&9). Similarly, MRI has been used to evalu-
ate hemorrhagic masses, to diagnose ovarian endome-
triomas based on the distinctive, albeit not specific,
properties of concentrated hemoglobin breakdown prod-
ucts within these cysts (10,111.
Another tissue that has distinctive suggestive charac-
teristics on MRI is dense fibrous tissue. Specifically,
dense fibrous tissue has very low signal intensity on T2-
weighted images, similar to skeletal muscle. Fibrous tis-
sue can be found in a wide variety of ovarian neoplasms
to some degree. However, in ovarian fibromas and cys-
tadenofibromas, it forms a distinctive component rather
than a n admixture of tissue ( 12- 15). Identification of the
fibrous component to a ovarian neoplasm has clinical sig-
nificance because fibromas are benign neoplasms and
cystadenofibromas are rarely malignant. In this study, we
sought to determine whether the fibrous component of
these tumors is demonstrable on MRI.
PATIENTS AND METHODS
MRI records from two institutions from June 1991
through March 1996 were cross-referenced with pathol-
ogy records to identlfy women who had pelvic MRI
performed with multicoil and fast-spin-echo (FSE) se-
quences and who subsequently underwent resection of
an ovarian fibroma, thecoma, fibrosed thecoma, fibrothe-
coma, or cystadenofibroma. Patients who were enrolled
in the radiologic diagnostic oncology group study were
excluded. Fourteen women were identified: five patients
with ovarian fibromas and nine with ovarian cystadeno-
fibromas. The mean age of the patients was 59 years,
ranging from 17 to 82 years. Eight patients were post-
menopausal, four patients were premenopausal, and one
patient had primary amenorrhea. The interval between
the MRI and surgery was 4.5 t 2.6 weeks.
MRr
All pelvic MR examinations were performed at 1.5 T
(Signa, GE Medical Systems, Milwaukee, WI)using a
465
Figure 1. Images of a 79-year-old woman with an ovarian fibroma. (a) T2-weighted FSE image (TR/TEeff = 4,600/126) and 0) T1-
weighted spin-echo image (TR/TE = 366/ 16) show a mass (F)in the cul de sac surrounded by free pelvic fluid. The mass has predom-
inantly low signal intensity on the T2-weighted FSE image (a) with areas of signal intensity lower than that of muscle. T1-weighted fast
spoiled gradient-recalled acquisition in steady state (GRASS) image with frequency-selected fat saturation (TR/TE = 250/2.9) before
(c) and after (d) the administration of gadopentetate dimeglumine shows subtle enhancement of the mass (F)with areas that enhance
more than others.

phased-array multicoil. All patients had spin-echo T1-
weighted images (TR/TE = 366-750/1@17) and axial
T2-weighted FSE images (TR/TEeff = 4,300-5,000/ 100-
140; echo train length = 16). T2-weighted FSE images
also were obtained in the sagittal and coronal planes with
similar parameters. FSE sequences were performed with
a field of view (FOV) of 20-24 cm, acquisition matrix of
256 X 256, slice thickness of 4 6 mm, and interslice gap
of 0-1 mm. Gadolinium-enhanced T1-weighted fat satu-
ration sequences were performed before and after intra-
venous injection of gadopentetate dimeglumine (. 1
mmol/kg; Magnevist, Berlex Laboratories, Wayne, NJ) in
seven patients. Fat saturation images were performed
with fast multiplanar spoiled gradient-echo fat-saturated
sequence; parameters were TR/TE = 150-300/2.9-3.1,
192 matrix, slice thickness of 5 mm, interslice gap of 0-
1 mm, 1-2 NEX, and 20-cm FOV. Glucagon (1 m a was
injected intramuscularly before imaging to suppress
bowel motion (15).
Specimen Imaging
High resolution specimen imaging was performed on
three ovarian surgcal specimens in the fresh state before
fixation and histologic examination. Two were cystaden-
ofibromas (one of which had been imaged in vivo) and one
was a fibroma. A whole volume transmit/receive coil de-
signed for imaging the wrist (Medrad, Pittsburgh, PA) or
two 3-inch surface coils linked together as a multicoil
(phased-array coil) array was used at 1.5 T. Specimen
imaging was performed with FSE images using TR/TEeff
of 3,000/125, 256 X 256 matrix, 2 NEX, 3-mm inter-
leaved slices with no interslice gap, and 8-cm FOV for a
pixel size of .3 mm2. T1-weighted images also were per-
formed with TR/TE of 300-500/17-20, 256 X 256 ma-
trix,2 NEX, 3-mm interleaved slices, and 8-cm FOV.
Specimens were correlated to histologic sections stained
with hematoxylin and eosin.
Specimen sectioning was performed in a similar plane
to the MR images; however, no special apparatus was
used to ensure that the pathologic specimens and the MR
images were obtained in exactly the same plane.
Image Analysis
MR images were reviewed by two radiologists in confer-
ence for measurement of specific features. The thickness
of any low signal intensity component (mm), the size of
any cysts, and the overall size of the mass on T2-weighted
images was measured in three orthogonal planes. The
thickness of the endometrium and the largest dimension
of any papillary projections within the cysts also were re-
corded. Relative signal intensity of the solid components
and cystic contents was scored as described previously
(17). Signal intensity was rated on a scale of 1 to 5; 1
signified very low signal intensity, similar to muscle on
T2-weighted sequences, and a score of 5 signified very
high signal intensity, similar to simple fluid on T2-

466 JMRl MaylJune 1997

Figure 2. Histologic correlation in a small ovarian fibroma from a 70-year-old woman. (a) T2-weighted FSE image (TR/TEeff = 3,000/
125) shows an ovarian specimen performed with an 8-cm FOV and local coil shows an exophytic fibroma (F) arising from the ovary (0).
Coiled adjacent to the ovary is the fallopian tube (T). [a) Whole mount histologic section from the ovary shows the fibroma (F) arising
from the ovary (0).(c) Higher magnification image shows the fibroma [F)composed of spindle cells and fibrous tissue.

Figure 3. Bilateral cystadenofibromas in a 67-year-old woman. (a) T1-weighted spin-echo image (TR/TE = 400/16) and [b) T2-
weighted FSE image (TR/TEeff = 3,400/ 126) show bilateral ovarian masses. The right ovarian mass (black arrow) is predominantly
solid and very low signal intensity on the T2-weighted image [a). Multiple irregular fluid-filled cavities with higher signal intensity are
present within it. The left ovarian mass, in contrast, is predominantly cystic with irregular nodular areas that are very low signal
intensity on the T2-weighted images (open arrows). A very subtle papillary projection is seen (arrowhead). Pathologic examination
confirmed that the right ovarian mass was predominantly composed of solid fibrous tissue with serous cystic areas within it, and the
left ovarian mass was predominantly cystic with nodules of fibrosis.

Volume 7 Number 3 JMRl 467

Figure 4. Bilateral cystadenofibromas in a 79-year-old woman. Specimen images of a right ovarian cystadenofibroma with T1-weighted
(a) and T2-weighted FSE image (b) demonstrate the cystadenofibroma as a multicystic mass with fibrotic nodules (black arrows) and
irregular low signal intensity fibrous plaques (arrowheads). Note that the nodules and plaques are lower signal intensity on the T2-
weighted images than the ovarian stroma (0).The serous cystic portions of the tumor show high signal intensity on the T2-weighted
images [a). (c) T2-weighted FSE image [TR/TEeff = 4,000/126) of the patient before resection of the tumors shows bilateral cystic
ovaries (white arrows). Note the low signal intensity nodule of the right ovary @lark arrow). (a) Bisected specimen image of the right
ovarian cystadenofibroma demonstrates the fibrotic nodule (black arrow) and yellowish fibrous plaques throughout the tumor (black
arrowheads). Ovarian stroma is denoted by (0).(bar = 1 cm.)

weighted sequences. A score of 3 was intermediate, with
signal intensity similar to outer myometrium on T1- or
=-weighted sequences.
The largest pocket of fluid in the pelvis was measured
in three orthogonal dimensions [anterior to posterior,
transverse, and cephalocaudad) in a standardized fash-
ion, as described (17).For these measurements, the larg-
est linear measurement was taken so that the measure-
ment lies entirely within the boundaries of the fluid on
the image in any one dimension. The studies that were
performed with gadolinium enhancement also were re-
viewed for the presence of enhanced peritoneal solid com-
ponents or papillary projections.
RESULTS
Five patients had ovarian fibromas on histologic ex-
amination [four fibromas and one fibrothecoma, hereafter
referred to as “fibromas”).The predominant signal inten-
sity of the fibromas was scored as 1 (signal intensity sim-
ilar to skeletal muscle on T2-weighted images) for all five
fibromas (Fig. 1). Pathologic examination showed pre-
dominantly fibrous tissue corresponding to the low signal
intensity areas on T2-weighted images (Fig. 2). No cysts
were associated with the fibromas, although the fibromas
demonstrated patchy areas of higher signal intensity on
T2-weighted images. On T1-weighted images, the masses
were scored a s 2 or 3 , indicating signal intensity equal to
myometrium or slightly below myometrium, respectively
(Fig. l ) ,Two patients had gadolinium-enhanced studies.
The signal intensity after the administration of gadolin-
ium increased compared with nonenhanced images but
was less than that of myometrium for both fibromas.
Nine patients had cystadenofibromas. Five of these pa-
tients’ lesions were bilateral; therefore, the total number
of cystadenofibromas was fourteen. Cystadenofibromas
appeared a s multicystic masses with rims, plaques, or
nodules of low signal intensity, except for one mass,
which was predominantly solid (Fig. 3). The =-weighted
signal intensity of the low signal intensity component was
rated as 1 [= skeletal muscle) for 12 cystadenofibromas
and 2 (< myometrium) for two. The thickness of this com-
ponent ranged from 2 to 20 mm, with a n average of 7
mm. Gadolinium-enhanced images of 10 tumors in 5 pa-
tients showed enhancement of the low signal intensity
component. Pathologic correlation showed that the low
signal intensity plaques corresponded to the subepithe-
tial fibrous tissue (Fig. 4).
Two patients had tumors of low malignant potential aris-
ing within the cystadenofibroma [Fig. 5), and none were
malignant. Papillary projections were detected in five of the
cystadenofibromas (Fig. 3).These ranged in size from .2 to
4.3 cm. Papillary projections enhanced after injection of
gadopentetate dimeglumine. Both tumors of low malignant
potential had papillary projections (Fig. 5).
Signal intensity of cyst contents ranged from very low
(rating of 1) to intermediate (rating of 3) on T1-weighted

468 JMRl May/June1997

Figure 5. Bilateral cystadenofibromas in a 53-year-old woman. Pathologic examination showed focal borderline features to the right
ovarian tumor. (a),(b)T2-weighted FSE images (TR/TEeff = 4.3 16/ 120) show a large multicystic mass arising from the right ovary and
a much smaller multicystic mass in the left ovary (open arrow]. Irregular low signal intensity plaques are associated with portions of
the right ovarian mass [white arrows: bar = 1 cm). (c) T1-weighted fat-saturation fast multiplanar spoiled GRASS image (TR/TE =
250/2.9) shows irregular enhancement of portions of the right ovarian mass with internal projections in some of the cystic areas (black
arrow]. Specimen image shows yellowish areas representing fibrous plaques within the tumor (arrowheads).(d)Photomicrograph of the
right ovarian mass shows fibrosis (F)underlying the serous epithelium of the cystadenofibroma. (e) Note the papillary projection in one
of the cystic spaces (open arrow). (bar = 1 cm.)

images. One patient was scored as 5 [high signal inten- DISCUSSION

sity). Signal intensity of the cyst contents was rated as 5
(very high signal intensity) on T2-weighted images for all
cystadenofibromas.
Mean endometrial thickness for the patients with fibro-
mas was higher than that for cystadenofibromas (Table
1). Two of these patients had abnormally thickened en-
dometria with thicknesses or 1.6 cm and 3.8 cm: respec-
tively, and associated endometrial cysts (Fig. 6). Both of
these patients had large endometrial polyps that were ap-
parent on pathology. Analysis of the fluid in the pelvis
showed that there was more fluid in patients with fibro-
mas than with cystadenofibromas, although the differ-
ence was not significant (Table 1). Maximal dimensions
of the fluid were 4 cm and 4.5 cm, respectively, for two
patients with fibromas.
Ovarian fibromas are important from a n imaging
standpoint because they appear as solid masses and
therefore mimic malignant neoplasms ( 18).Fibromas of-
ten are associated with ascites and occasionally with
pleural effusions, which, in combination with a solid
ovarian mass, is womsome for malignancy. Furthermore,
fibromas often are associated with pelvic pain (19) and
elevated CA- 125 levels (ZO), therefore increasing the con-
cern for ovarian cancer. A varied appearance of these tu-
mors is seen on sonography (21-23). Specific imaging
features of the tumor would be helpful in distinguishing
these tumors from malignant neoplasms. In this study,
we have confirmed in a larger series the anecdotal reports
that fibromas have a characteristic MFU appearance con-
sisting of a solid mass of very low signal intensity tissue
on T2-weighted sequences (24-27).

Volume7 * Number3 JMRl 469

Figure 6. Left ovarian fibroma with associated endometrial polyp in a 53-year-old woman. (a) Axial "%weighted FSE image (TR/TEeff
= 5,000/ 126) shows the high signal intensity endometrial polyp (white arrows) with small cystic areas and a large predominantly low
signal intensity left ovarian mass (F). [b) Axial gadolinium dimeglumine-enhanced T1-weighted fat saturation image mR/TE = 150/
2.9) shows enhancement of the subendometrial myometrium and the central fibrous core of the polyp but little enhancement of the
cystic areas (white arrows). There is mild enhancement of the fibroma (F).The fibroma and endometrial polyp were proven at pathologic
examination.
Table 1
Summary of Tumor Characteristics and Associated Findings
Number
Tumor Type
.. Patients Tumors
Fibromasb 5 5
Cvstadenofibromas 9 14
OAverage of three orthogonal measurements.
bIncludes one fibrothecoma.
Ovarian fibromas are not an uncommon cause of a
solid ovarian mass. Low signal intensity on T2-weighted
sequences results from dense fibrous tissue in these tu-
mors. Thecomas, fibrosed thecomas, fibrothecomas, and
fibromas are stromal neoplasms and may be variants of
single entity. These tumors are composed of admixtures
of fibrous tissue and theca cells, and therefore have a
tendency toward endocrine activity (13,15,19,28),and
may be associated with endometrial hyperplasia and en-
dometrial polyps (13,14).This was observed in two of five
patients with fibromas in our series. The polyp tissue en-
hanced, whereas the cysts within the polyp did not. A
central fibrous core, which is characteristic of endome-
trial polyps, was observed in these two cases (29). It is
possible that the occurrence of the endometrial polyps in
these patients was circumstantial, because we did not
have direct clinical evidence that these tumors were hor-
monally active.
Like fibromas, cystadenofibromas mimic malignancy
by imaging criteria, but for different reasons; they are
multilocular cystic masses with a solid component
(12,23,30).This study also demonstrates that cystaden-
ofibromas have a typical appearance on MRI and that the
fibrous component can be appreciated on T2-weighted
sequences. This fibrous component causes an irregular
wall thickening to the multicystic neoplasm and exceeds
3 mm in thickness in some cases. The fibrous component
has signal intensity that is similar to that of the ovarian
fibromas. The MR appearance of the cystic components
of the cystadenofibromas was nonspecific and usually
consisted of numerous cystic loculations. This is in con-
470 JMRl May/June 1997
Associated Findings
Endometrial
Size- Thicknessa Pelvic Fluida
[mean cm (rangell
I
[mean cm [range)] [mean cm (range)]
-
5.3 (.8-12) 1.2 [.2-3.8) 2.0 (0-4.5)
3.7 12.1-9.0) .2 r. M I 1.4 10-3.01
trast to most benign serous cystadenomas, in that these
usually are unilocular or with one or two loculi
(23,31,32). Unlike fibromas, cystadenofibromas were not
associated with endometrial thickening in our series, al-
though they may be hormonally active in unusual cases
( 19,331.
Histologically, fibromas and cystadenofibromas are not
related. Fibromas are of stromal derivation and have no
epithelial component. In contrast, in cystadenofibromas,
the fibrous component is part of the neoplasm, which is
believed to be of epithelial and stromal origin similar to
cystadenomas and cystadenocarcinomas (12,30,3437),
Cystadenofibromas can be associated with a malignant
epithelial component, although rarely (12,30,36).In a re-
cent study of 845 epithelial tumors of the ovary, 118 ad-
enofibromas and cystadenofihromas were diagnosed.
Thirteen were atypical proliferative lesions and five (4%)
were carcinomas (38).In our series, both tumors of low
malignant potential were associated with numerous pap-
illary projections. Benign cystadenofibromas also had
projections, but to a markedly lesser degree.
Some limitations of this study should be noted. First,
the relatively small number of patients in this study may
not accurately reflect the full spectrum of these tumors.
Specifically, thecomas and fibrothecomas have been re-
ported to show different higher signal intensity on the T2-
weighted images than the fibromas shown here. Second,
because clinically indicated surgical exploration was a re-
quirement in this study, verification bias may have
overrepresented larger, more complex lesions. Lastly, we
did not assess the specificity of our findings in a blinded
reader study. The purpose of this study was to describe
these findings and determine the anatomic correlates in
the specimens: therefore, these findings may assist pro-
spective studies of the ability of MRI to characterize ad-
nexal disease. Recently, Ha et al. (39)described metastatic
tumors of the ovary that contained relatively lower signal
intensity areas on T2-weighted images of the mass. These
areas tended to correspond to areas of desmoplasia
within the tumor. Comparison of the imaging features of
these with the cystadenofibromas and fibromas here
shows that relatively hypointense areas in Krukenberg
tumors are not of as low signal intensity as that of skel-
etal muscle and of most of the fibromas and cystadeno-
fibromas shown in our series. In addition, the metastases
to the ovaries described by Ha et al. (39)have irregular
solid components and necrosis that would not be mis-
taken for a benign fibroma or a cystadenofibroma. Cer-
tain other ovarian neoplasms, notably Brenner tumors or
adnexal leiomyomas, also may have a prominent fibrous
or smooth muscle component, respectively (13,14).
The MR appearance of ovarian fibromas consists of a
low signal intensity mass on T2-weighted sequences, re-
flecting its fibrous content. Some of the MRI features of
cystadenofibromas seem characteristic. The actual spec-
ificity of the MRI diagnosis was not assessed and would
require a larger study of cystadenofibromas and other ad-
nexal masses.
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