DIFFERENTIAL DIAGNOSIS OF BORDERLINE OVARIAN TUMOURS, OVARIAN ENDOMETRIOMAS, AND WELL-DIFFERENTIATED OVARIAN CARCINOMA: AN IMAGING-PATHOLOGY NARRATIVE REVIEW

Olga Yakubet, Kateryna Isayeva
In: Acta Medica Leopoliensia · 2025 · vol. 31(3-4) , pp. 42–51 · doi:10.25040/aml2025.3-4.042 · W7138268790
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This review outlines an imaging-pathology framework, incorporating clinical context and MRI findings with O-RADS, to differentiate borderline ovarian tumours, endometriomas, and well-differentiated ovarian carcinoma by identifying key discriminators and common pitfalls.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-14 · read from full text ⓘ

This narrative review examined how to differentiate borderline ovarian tumours, ovarian endometriomas, and well-differentiated ovarian carcinoma when they share overlapping clinical and imaging presentations, using a PubMed/MEDLINE search (with reference chaining) focused on comparative imaging literature from 2019–2025 plus earlier defining studies. It reports that diagnostic performance improves by integrating clinical risk context (including endometriosis history), first-line ultrasound morphology and vascularity, and MRI “problem-solving” with diffusion-weighted imaging and post-contrast assessment, with O-RADS MRI emphasizing enhancing solid tissue and diffusion restriction patterns. The review highlights that typical endometriomas are characterized by T1 hyperintensity and T2 shading without enhancing solid tissue, while malignant transformation is suggested by new enhancing mural nodules and diffusion-restricted solid components; it also notes overlap and that histology remains definitive. This paper is centrally about endometriosis — it focuses on imaging-pathology differentiation of endometriosis-associated ovarian cancer arising within endometriomas and describes key malignant transformation signs in endometriosis.

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Abstract

Borderline ovarian tumours (BOTs), ovarian endometriomas, and well-differentiated ovarian carcinoma may present with overlapping clinical and imaging features, yet their prognostic implications and surgical planning differ markedly. Diagnostic errors commonly arise when haemorrhagic or fibrous benign lesions mimic solid tumour, or when early malignant transformation within endometriosis manifests as subtle mural change. Aim of this work was to provide a pragmatic, stepwise, imaging-pathology differential diagnosis framework for distinguishing BOTs, endometriomas, and well-differentiated ovarian carcinoma, emphasising reproducible discriminators and common pitfalls. Material and Methods. A narrative review was conducted in PubMed/MEDLINE and supplemented by reference-chaining. Search terms included "borderline ovarian tumour", "serous borderline tumour", "mucinous borderline tumour", "endometrioma", "endometriosis-associated ovarian cancer", "low-grade serous carcinoma", "endometrioid ovarian carcinoma", "ultrasound", "MRI", "diffusion-weighted imaging", "dynamic contrast enhancement", and "O-RADS". Priority was given to consensus systems and comparative imaging literature from 2019-2025, supplemented by seminal earlier studies defining enduring diagnostic signs. Results and Discussion. A practical differential diagnosis requires integration of 1) clinical risk context (age, menopausal status, endometriosis history), 2) first-line ultrasound morphology and vascularity, and 3) MRI problem-solving with diffusion and post-contrast assessment. O-RADS MRI provides a reproducible framework centred on enhancing solid tissue, diffusion restriction and enhancement characteristics. Typical endometriomas show T1 hyperintensity and T2 shading without enhancing solid tissue; malignant transformation is suggested by new enhancing mural nodules and diffusion-restricted solid components. BOTs often demonstrate papillary projections; well-differentiated carcinoma more often shows more convincing solid tissue and restricted diffusion, although overlap persists and histology remains definitive. Conclusions. Standardised reporting (O-RADS) combined with MRI confirmation of true enhancement and multidisciplinary imaging-pathology correlation reduces misclassification. Key pitfalls include clot-related "pseudo-nodules", decidualised endometrioma and fibrous benign tumours such as cystadenofibroma.
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Abstract

Borderline ovarian tumours (BOTs), ovarian endometriomas, and well-differentiated ovarian carcinoma may present with overlapping clinical and imaging features, yet their prognostic implications and surgical planning differ markedly. Diagnostic errors commonly arise when haemorrhagic or fibrous benign lesions mimic solid tumour, or when early malignant transformation within endometriosis manifests as subtle mural change. Aim of this work was to provide a pragmatic, stepwise, imaging-pathology differential diagnosis framework for distinguishing BOTs, endometriomas, and well-differentiated ovarian carcinoma, emphasising reproducible discriminators and common pitfalls.

Material

and Methods. A narrative review was conducted in PubMed/MEDLINE and supplemented by reference-chaining. Search terms included "borderline ovarian tumour", "serous borderline tumour", "mucinous borderline tumour", "endometrioma", "endometriosis-associated ovarian cancer", "low-grade serous carcinoma", "endometrioid ovarian carcinoma", "ultrasound", "MRI", "diffusion-weighted imaging", "dynamic contrast enhancement", and "O-RADS". Priority was given to consensus systems and comparative imaging literature from 2019-2025, supplemented by seminal earlier studies defining enduring diagnostic signs.

Results

and Discussion. A practical differential diagnosis requires integration of 1) clinical risk context (age, menopausal status, endometriosis history), 2) first-line ultrasound morphology and vascularity, and 3) MRI problem-solving with diffusion and post-contrast assessment. O-RADS MRI provides a reproducible framework centred on enhancing solid tissue, diffusion restriction and enhancement characteristics. Typical endometriomas show T1 hyperintensity and T2 shading without enhancing solid tissue; malignant transformation is suggested by new enhancing mural nodules and diffusion-restricted solid components. BOTs often demonstrate papillary projections; well-differentiated carcinoma more often shows more convincing solid tissue and restricted diffusion, although overlap persists and histology remains definitive. Conclusions. Standardised reporting (O-RADS) combined with MRI confirmation of true enhancement and multidisciplinary imaging-pathology correlation reduces misclassification. Key pitfalls include clot-related "pseudo-nodules", decidualised endometrioma and fibrous benign tumours such as cystadenofibroma.

References

Sadowski EA, Thomassin-Naggara I, Rockall A, et al. O-RADS MRI Risk Stratification System: Guide for Assessing Adnexal Lesions from the ACR O-RADS Committee. Radiology. 2022;303(1):35-47. Radzynski L, Boyer L, Kossai M, et al. MRI evaluation of endometriosis-associated neoplasms (pictorial review). Insights into Imaging. 2023;14:144. McDermott S, et al. MR imaging features of malignancies arising in endometriomas; importance of mural nodule enhancement and subtraction imaging. Radiographics. 2012. Kawaguchi M, Kato H, Hatano Y, et al. MR imaging findings of low-grade serous carcinoma of the ovary: comparison with serous borderline tumour. Jpn J Radiol. 2020;38(8):782-789. Avesani G, et al. Pearls and pitfalls for correct diagnosis of ovarian masses on MRI (including fibrous benign mimics such as cystadenofibroma). 2021. Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR O-RADS Committee. Radiology. 2020;294(1):168-185. WHO Classification of Tumours Editorial Board. Female Genital Tumours. WHO Classification of Tumours, 5th ed. 2020. Zwimpfer TA, et al. Low-grade serous ovarian cancer: a distinct entity (clinical-molecular review). 2023. This work is licensed under a Creative Commons Attribution 4.0 International License.

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