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Gynecologic Oncology 94 (2004) 229–231

Case Report

Color Doppler ultrasound in ovarian fibrosarcoma

Hakan Kaya,a,* Mekin Sezik,a Okan Ozkaya,a Raziye Desdicioglu,a and Nilgun Kapucuoglub

aDepartment of Obstetrics and Gynecology, Suleyman Demirel University, School of Medicine, Isparta, TurkeybDepartment of Pathology, Suleyman Demirel University, School of Medicine, Isparta, Turkey

Received in revised form 9 January 2004

Available online 18 May 2004

Abstract

Background. Primary ovarian fibrosarcoma is a very rare tumor. Its Doppler waveform characteristics have not been described before.

Case. A 35-year-old woman presented with a 5-cm solid ovarian mass. Intratumoral artery resistance index (RI) and pulsatility index (PI)

were very low (0.19 and 0.21, respectively). Peak systolic velocity calculated by using transvaginal Doppler ultrasound was higher than

expected (24.8 cm/s). Postoperatively, the histopathologic diagnosis was primary ovarian fibrosarcoma, stage Ia.

Conclusions. Low vascular resistance can be encountered in ovarian fibrosarcomas. In young patients presenting with a solid

adnexal mass, intratumoral Doppler waveform investigations might offer some help for earlier prediction of rare malignant tumors like

fibrosarcomas.

D 2004 Elsevier Inc. All rights reserved.

Keywords: Fibrosarcomas; Doppler waveform; Ultrasound

Introduction

Primary ovarian sarcomas represent a heterogeneous

group comprising <3% of all ovarian tumors [1]. Fibrosar-

coma, on the other hand, is an unusual type of ovarian

sarcomas and is an exceedingly rare tumor [2]. Doppler

waveform analysis of ovarian tumor blood flow by trans-

vaginal ultrasonography may help to differentiate malignant

from benign tumors of the ovary. Currently in the English

literature, there is no report of an ovarian fibrosarcoma with

its intratumoral artery Doppler waveform analysis available.

In our report, we describe a young patient presenting with

very low intratumoral resistance (RI) and pulsatility (PI)

index who was later diagnosed as ovarian fibrosarcoma.

Case

A 35-year-old white female was initially evaluated for

lower quadrant abdominal pain. Her family history is insig-

nificant. Physical and pelvic examination revealed a left

0090-8258/$ - see front matter D 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.ygyno.2004.04.010

* Corresponding author. Suleyman Demirel Universitesi Tip Fakultesi,

Kadin Hastaliklari ve Dogum Anabilim Dali, 32000 Isparta, Turkey. Fax:

+90-246-237-1762.

E-mail address: drhakankaya2002@yahoo.com (H. Kaya).

adnexal mass with firm and regular surface. Abdominopelvic

computerized tomography demonstrated a 50� 55� 50 mm

in diameter, solid and regular mass in the left ovarian region.

Ascites was not present, and the pelvic lymph nodes were

negative. Transvaginal ultrasound examination performed on

cycle day 8 showed an echo-complex mass on left adnexa.

The intratumoral artery RI and PI measured by transvaginal

Doppler investigations were 0.19 and 0.21, respectively.

Peak systolic velocity was measured as 24.8 cm/s (Fig. 1).

Tumor markers including CA 125, CA 19-9, and CEAwere

within normal limits. The patient underwent laparoscopic left

oophorectomy. Frozen section result reported an ovarian

fibrosarcoma. Accordingly, laparotomy with total abdominal

hysterectomy, right salpingo-oopherectomy, left salpingec-

tomy, total omentectomy, and bilateral pelvic lymph node

dissection was carried out.

The final pathology report described a 55 mm in diam-

eter, yellow-brownish, solid, firm mass confined to its

capsule. Microscopically parallel intersecting spindle cell

bundles, which were well demarcated from the ovarian

parenchyma, were observed (Fig. 2). The spindle cells

demonstrated moderate pleomorphism (Fig. 3) and in-

creased mitotic activity (five to seven mitoses per 10

high-power fields). Necrosis was not observed. To demon-

strate the mesenchymal origin of the tumor, immunostaining

Fig. 1. Transvaginal color Doppler imaging of the solid ovarian tumor showing low-resistance and high-velocity flow (RI = 0.19, PI = 0.21) in an intratumoral

vessel.

H. Kaya et al. / Gynecologic Oncology 94 (2004) 229–231230

with vimentin was performed. Diffuse cytoplasmic staining

was detected with vimentin in spindle cells. Nuclear staining

for estrogen and progesterone receptors was negative. Pro-

liferative index by using Ki-67 staining (Fig. 4) was 10.7%,

supporting the diagnosis of fibrosarcoma. Omentum and

pelvic lymph nodes were negative for metastasis.

The disease was labeled as stage Ia fibrosarcoma of the

ovary. In view of the patient’s stage, she was not treated

with adjuvant chemotherapy. Six months postoperatively,

the patient is alive with no recurrences.

Discussion

Primary ovarian fibrosarcoma is an exceedingly rare

tumor arising from the basic gonadal stroma [1]. Differ-

Fig. 2. Fibrosarcoma with streaming, parallel long bundles of spindle cells

(�100, H&E stain).

entiation from cellular fibroma may be difficult clinically

and histologically [2]. Ki-67 and PCNA immunostaining

assess the proliferative activity and can be used to

differentiate ovarian fibrosarcomas from cellular fibromas.

A proliferative index (number of cells in S + G2 + M

phase) above a ratio of 6.5–7.5 was found to correspond

to malignant fibrosarcomas [3]. In our case, increased

mitotic activity (>5 mitoses per 10 high-power fields) and

proliferative index (10.7%) supported the diagnosis of

fibrosarcoma.

Although ovarian fibrosarcomas usually occur in older

women, an 8-year-old girl with stage II disease was

reported [4]. Our patient’s age was 35. In the literature,

we were able to identify only two patients (aged 17 and

Fig. 3. Fibrosarcoma displaying mitotic figures and moderate pleomor-

phism (�400, H&E stain).

Fig. 4. Positive immunohistochemical staining with Ki-67 (�400). The

proliferative index is 10.7%.

H. Kaya et al. / Gynecologic Oncology 94 (2004) 229–231 231

35 years) with a diagnosis of ovarian fibrosarcoma <40

years of age [1,5]. Fibrosarcomas are often large tumors.

The size of tumor might be helpful to differentiate

fibrosarcoma from cellular fibroma [2]. However, smaller

fibrosarcomas have been described [1]. One tumor, which

was found on routine pelvic examination, was reported to

measure only 3 cm in greatest dimension [1]. Our

patient’s younger age and relatively small tumor size

were also unusual for an ovarian fibrosarcoma.

The intratumoral artery RI represents the blood flow

impedance distal to the sampling point. Malignant tumors

of the ovary have significantly lower vascular resistance

than benign tumors [6]. This holds true for both PI as

well as RI measurements. PI < 1 was reported to have

67% sensitivity and 97% specificity for predicting malig-

nant ovarian tumors [7]. Peak systolic velocity values in

malignant tumors are usually high, being between 20 and

60 cm/s [8]. This low-impedance, high-velocity flow is

secondary to tumoral neovascularization with increased

capillary permeability and altered basement membrane

structure [9,10]. Increased permeability is the result of

the formation of a network of capillaries whose walls are

devoid of smooth muscle cells and elastic fibers. RI

values have also been reported to show a strong positive

correlation with the fraction of arterioles that determine

the vascular resistance [6]. Fibrosarcomas are hypercellu-

lar and highly vascular tumors with evidence of intra-

tumoral hemorrhage [11]. To our knowledge, color

Doppler investigations of an ovarian fibrosarcoma have

not been reported before. In their series, Tekay and

Jouppila [8] reported a sarcomatic granulosa cell tumor

with an RI of 0.5 and PI of 0.7. In a study with 45

patients who have complex adnexal lesions, Kupesic and

Kurjak [12] misdiagnosed an ovarian fibroma as a

malignant tumor using contrast-enhanced power Doppler

sonography. Another case report described a postmeno-

pausal woman with luteinized ovarian thecoma and be-

nign ascites presenting with transvaginal color Doppler

sonography tumor vasculature, suggesting malignancy

[13]. Hence, distinguishing a cellular fibroma from fibro-

sarcoma by using Doppler investigations may not always

be possible. Since primary ovarian fibrosarcoma is very

rare, information regarding its sonomorphological charac-

teristics is lacking.

As a result, intraovarian RI, PI, and peak systolic flow

values determined by color Doppler studies might be

useful to detect rare ovarian malignancies like fibrosarco-

mas at an earlier stage, especially in younger patients

presenting with a solid adnexal mass. However, the

present single case would not allow us to draw further

conclusions.

References

[1] Shakfeh SM, Woodruff JD. Primary ovarian sarcomas: report of 46

cases and review of the literature. Obstet Gynecol Surv 1987;

42:331–49.

[2] Huang YC, Hsu KF, Chou CY, Dai YC, Tzeng CC. Ovarian fibro-

sarcoma with long-term survival: a case report. Int J Gynecol Cancer

2001;11:331–3.

[3] Tsuji T, Kawauchi S, Utsunomiya T, Nagata Y, Tsuneyoshi M. Fibro-

sarcoma versus cellular fibroma of the ovary: a comparative study of

their proliferative activity and chromosome aberrations using MIB-1

immunostaining, DNA flow cytometry, and fluorescence in situ hy-

bridization. Am J Surg Pathol 1997;21:52–9.

[4] Kraemer BB, Silva EG, Sneige N. Fibrosarcoma of ovary. A new

component in the nevoid basal-cell carcinoma syndrome. Am J Surg

Pathol 1984;8:231–6.

[5] Kiyozuka Y, Nishimura H, Iwanaga S, Yakushiji M, Ito K, Nakano

S, et al. Establishment and characterization of human ovarian fibro-

sarcoma cell line and its sensitivity to anticancer agents. [Abstract]

Nippon Sanka Fujinka Gakkai Zasshi 1992;44:461–8.

[6] Kidron D, Bernheim J, Aviram R, Cohen I, Fishman A, Beyth Y, et al.

Resistance to blood flow in ovarian tumors: correlation between re-

sistance index and histological pattern of vascularization. Ultrasound

Obstet Gynecol 1999;13:425–30.

[7] Buckshee K, Temsu I, Bhatla N, Deka D. Pelvic examination,

transvaginal ultrasound and transvaginal color Doppler sonography

as predictors of ovarian cancer. Int J Gynaecol Obstet 1998;

61:51–7.

[8] Tekay A, Jouppila P. Controversies in assessment of ovarian tumors

with transvaginal color Doppler ultrasound. Acta Obstet Gynecol

Scand 1996;75:316–29.

[9] Kurjak A, Kupesic S, Simunic V. Ultrasonic assessment of the peri-

and postmenopausal ovary. Maturitas 2002;41:245–54.

[10] Kurjak A, Jukic S, Kupesic S, Dabic D. A combined Doppler and

morphopathological study of ovarian tumors. Eur J Obstet Gynecol

Reprod Biol 1997;71:147–50.

[11] Celyk C, Gungor S, Gorkemly H, Bala A, Capar M, Colakodlu M, et

al. Ovarian fibrosarcomas. Acta Obstet Gynecol Scand 2002;

81:375–6.

[12] Kupesic S, Kurjak A. Contrast-enhanced, three-dimensional power

Doppler sonography for differentiation of adnexal masses. Obstet

Gynecol 2000;96:452–8.

[13] Williams LL, Fleischer AC, Jones HW. Transvaginal color Doppler

sonography and CA-125 elevation in a patient with ovarian thecoma

and ascites. Gynecol Oncol 1992;46:115–8.