Baseline knowledge of sufferers
A complete of 10 sufferers with AGCT-NEL have been enrolled on this examine, with baseline knowledge proven in Desk 1. The age of the ten sufferers ranged from 28 to 81 years, with a median age of 54 ± 16 years. Amongst them, 6 sufferers have been postmenopausal. One affected person had an elevated CA-125 stage of 76.4 U/ml (regular worth < 35 U/ml), whereas the tumor markers for the remaining sufferers have been regular. Among the many 10 sufferers, 3 offered with irregular vaginal bleeding, 1 with decrease stomach ache, and the others had no important signs. Pathological outcomes indicated that among the many 10 sufferers, 3 had easy endometrial hyperplasia, 1 had advanced endometrial hyperplasia, 1 had a uterine leiomyoma, and a couple of had adenomyosis. Within the follow-up after surgical procedure, 8 sufferers had no recurrence, 1 affected person was misplaced to follow-up, and 1 affected person skilled a recurrence 2 years post-operation.
MRI options of AGCT-NEL
Main tumors
Among the many 10 sufferers, 9 had main tumors, and a couple of had metastatic tumors. The fundamental traits of all tumors are offered in Desk 2. A complete of 9 main tumors have been recognized in 9 sufferers, with 6 positioned in the appropriate adnexa and three within the left adnexa. The utmost diameter of the tumors ranged from 2.9 cm to 21.4 cm (common 8.1 cm), with the FIGO staging primarily being IA or IC [6].
Unilocular cystic tumor (affected person 9, Fig. 1)
The tumor was spherical with clear borders; the cystic portion exhibited low sign on T1WI and really excessive sign on T2WI. On DWI, it confirmed barely increased sign depth, with an ADC worth of two.940 × 10⁻³ mm²/s. A hemorrhagic fluid stage was seen throughout the tumor, and there was important enhancement of the cyst wall after distinction administration, with no enhancement throughout the cyst.
Affected person 9, offered with decrease stomach ache for five days, clinically and pathologically confirmed as AGCT-NEL, FIGO stage IIIA. (A) T1WI axial view: A unilocular cystic mass is noticed in the appropriate adnexa, well-defined, showing hypointense on T1WI (purple arrow), with homogeneous sign and the presence of a hemorrhagic fluid stage, which seems barely hyperintense (yellow arrow). (B) T2WI axial view: The mass reveals very excessive sign depth (purple arrow), and a hemorrhagic fluid stage is seen (yellow arrow). (C) DWI sequence: The mass exhibits barely elevated sign depth (purple arrow). (D) Axial view post-contrast scan: The wall of the mass exhibits marked enhancement (purple arrow), whereas the contents of the cyst don’t exhibit enhancement (yellow arrow)
Stable tumors (sufferers 1, 3, 7)
Three strong tumors have been discovered, presenting as oval or spherical shapes with clear margins. All tumors exhibited homogeneous indicators, showing as isointense or barely hypointense on T1WI and barely hyperintense on T2WI. DWI confirmed excessive sign depth, and ADC values ranged from 0.520 to 0.913 (×10⁻³ mm²/s), with important enhancement noticed after distinction enhancement. Two of the tumors exhibited excessive sign on T1WI, indicating hemorrhage, and each displayed patchy excessive indicators on T2WI. The MRI findings for Affected person 7 are proven in Fig. 2. The sign depth ratios of the tumors in comparison with the myometrium throughout T1WI, T2WI, and arterial part enhancement have been 1.019 to 1.340, 1.186 to 1.500, and 0.800, respectively (Desk 2).
Affected person 7, offered with a left ovarian mass for six months, clinically and pathologically confirmed as AGCT-NEL, FIGO stage IC. (A) Axial T1WI with fats suppression (T1WI-FS): A strong mass is noticed within the left adnexa, well-defined, showing barely hypointense on T1WI (purple arrow) with a homogeneous sign. (B) Axial T2WI with fats suppression (T2WI-FS): The mass exhibits barely hyperintense sign (purple arrow), with punctate hyperintense foci famous (yellow arrow). (C) DWI: The mass demonstrates considerably excessive sign depth (purple arrow). (D) ADCmap: The mass reveals considerably low sign depth (purple arrow), indicating restricted diffusion. (E) Axial view post-contrast scan: The mass exhibits reasonable enhancement (purple arrow), and the sign stays homogeneous. (F) Coronal view post-contrast scan: The mass shows uniform enhancement (purple arrow), with enhancement depth decrease than that of the myometrium (yellow arrow)
Cystic-solid tumors (sufferers 2, 4, 5, 6, 8)
On this group, there have been 5 cystic-solid tumors: three have been oval-shaped and two exhibited irregular shapes. The lesions had clear boundaries, with varying-sized cystic areas demonstrating low sign depth on T1WI and really excessive sign depth on T2WI. The distribution was domestically clustered, presenting honeycomb and Swiss cheese indicators. The strong parts confirmed isointense to barely hypointense sign on T1WI and barely hyperintense sign on T2WI, with ADC values starting from 0.630 to 0.783 (×10⁻³ mm²/s). Among the many 5 tumors, three exhibited patchy or irregular excessive sign depth on T1WI, indicative of hemorrhage. After distinction enhancement, there was important enhancement of the cyst wall and the strong portion, whereas no enhancement was noticed throughout the cyst. The MRI findings for Affected person 2 are illustrated in Fig. 3. Within the strong parts, the sign depth ratios in comparison with the myometrium throughout T1WI, T2WI, and arterial part enhancement have been 0.980 to 1.171, 1.131 to 1.312, and 0.720 to 0.920, respectively (Desk 2).
Affected person 2, offered with a pelvic mass for 7 days throughout a well being examination, clinically and pathologically confirmed as AGCT-NEL, FIGO stage IA. (A) Axial T1WI: A cystic-solid mass within the left adnexa is noticed (purple arrow), predominantly strong, with a intact capsule. The mass seems primarily isointense on T1WI, with scattered patchy hyperintensities famous (yellow arrow). (B) Axial T2WI-FS: The mass exhibits predominantly barely hyperintense indicators, whereas within the areas of excessive sign noticed on T1WI, T2WI demonstrates very low sign depth (purple arrow), indicative of hemorrhage. (C) DWI: The mass presents considerably excessive sign depth, with patchy low indicators noticed (purple arrow), equivalent to the hemorrhage. (D) Submit-contrast scan: The mass reveals marked enhancement, with a visual tumor vessel (purple arrow). (E) Pathology: tumor cells are predominantly spherical, oval, or polygonal, with some exhibiting lobulation; cells are organized in clusters or strands, with seen nuclear grooves, intermixed with fibrous tissue parts and ranging numbers of Name-Exner our bodies (black arrow). (F) Below 40× magnification: A number of capillaries are seen (black arrow)
Metastatic tumors
Among the many two sufferers with metastases, there have been a complete of 11 plenty. In a single case, there was a main tumor in the appropriate adnexa with a number of pelvic metastases, totaling 10 metastatic plenty which displayed each implantative and distant metastasis, involving the mesoappendix, mesentery, sigmoid colon, and peri-uterine tissue, with the most important diameter roughly 3.0 cm. This case was categorised as FIGO stage IIIC (Affected person 9). The opposite case concerned a single mass which represented a solitary distant metastasis within the rectal space after surgical procedure (no main lesion was current), with a diameter of about 2.5 cm, categorised as FIGO stage IIIA (Affected person 10).
Unilocular cystic tumors (3 tumors from affected person 9, Fig. 4)
The metastatic lesions have been spherical in form with clear borders, exhibiting low sign on T1WI, excessive sign on T2WI, and barely increased sign on DWI, with a median ADC worth of two.920 (×10⁻³ mm²/s). One of many tumors exhibited hemorrhage, demonstrating a hemorrhagic fluid stage. After enhancement, there was important enhancement of the cyst wall, whereas no enhancement was noticed throughout the cyst.
Affected person 9, offered with decrease stomach ache for five days, clinically and pathologically confirmed as AGCT-NEL, FIGO stage IIIA. (A) Axial T2WI-FS: A number of cystic plenty are noticed within the pelvic cavity, that are both unilocular or multilocular cystic plenty (purple arrow). The multilocular cystic plenty exhibit septations, demonstrating honeycomb and Swiss cheese indicators, with hemorrhagic fluid ranges seen in a number of plenty (yellow arrow). (B) Coronal T2WI: Punctate very low sign depth is noticed throughout the multilocular cystic mass (purple arrow), indicating hemorrhage. Pathology confirms endometrial thickening (yellow arrow). (C) Axial T1WI-FS: Cystic lesions (purple arrow) present scattered hyperintensities (yellow arrow), indicating hemorrhage. (D) Submit-contrast scan: The cyst wall of the mass (purple arrow) and the septations (yellow arrow) exhibit marked enhancement
Multilocular cystic tumors (8 tumors, 7 in affected person 9 and 1 in affected person 10)
The plenty are oval-shaped with inconsistently thickened septations, and when there are a number of septations, honeycomb and Swiss cheese indicators are observable (Fig. 4). The tumors exhibit low sign on T1WI, excessive sign on T2WI, with heterogeneous indicators, and barely increased sign on DWI, with a median ADC worth of two.780 (×10⁻³ mm²/s). 5 of the tumors confirmed hemorrhage, with a visual hemorrhagic fluid ranges. After enhancement, important enhancement of the cyst partitions and septa was noticed, whereas there was no enhancement throughout the cysts. Affected person 10 had fewer septations, and the MRI findings are proven in Fig. 5.
Affected person 10, underwent resection of a main left adnexal lesion 5 years prior and was discovered to have a rectal fossa mass (purple arrow), clinically and pathologically confirmed as AGCT-NEL, FIGO stage IIIA. (A) Axial T2WI-FS: A multilocular cystic mass within the rectal fossa shows excessive sign depth on T2WI, with seen septations and comparatively clear boundaries. (B) Axial T1WI: The mass seems isointense, with comparatively clear margins. (C) DWI: The mass exhibits considerably uneven excessive sign depth
Pathological outcomes
All 10 sufferers underwent surgical therapy, and the intraoperative findings relating to the placement, dimension, and morphology of the plenty have been typically in line with the MRI observations. The gross examination of the specimens revealed that the plenty within the 10 sufferers had various levels of softness, with gelatinous areas current throughout the cystic foci. Below microscopy, the tumor cells appeared predominantly spherical, oval, or polygonal, with some exhibiting lobulation. The cells have been organized in clusters or strands, with seen nuclear grooves and interspersed fibrous tissue parts, together with capillary lumina of various sizes. All 10 sufferers exhibited various numbers of Name-Exner our bodies, which confirmed eosinophilic proteinaceous materials and discernible condensed nuclei. Eight sufferers underwent immunohistochemical evaluation: all 8 have been constructive for Vimentin, all 8 have been constructive for α-inhibin, 7 have been constructive for CR, and 5 have been constructive for CD99.
Statistical evaluation outcomes
The Kappa values for the evaluation of tumor location, quantity, dimension, morphology, edge traits, sign depth, and enhancement traits by two radiologists have been all ≥ 0.75, indicating good settlement.
