JBRBTR, 2005, 88: 245-246.

LEFT OVARIAN BRENNER TUMOR

S. Heye, D. Bielen, D. Vanbeckevoort1
Ovarian Brenner tumors are uncommon neoplasms of the ovary, representing approximately 2% of all ovarian neoplasms. Nowadays there is general agreement that Brenner tumors are derived from the surface epithelium of the
ovary or the pelvic mesothelium through transitional cell metaplasia. Association with other surface-derived neoplasms, either in the ipsilateral or contralateral ovary, is reported in 30% of the cases.
We report a case of benign ovarian Brenner tumor and discuss the typical features on magnetic resonance imaging
(MRI) and computed tomography (CT) scan as well as the differential diagnosis.
Key-word: Ovary, neoplasms.

Case report
A 66-year-old Caucasian woman
was referred for an MRI examination, because of a palpable mass at
the left side on endovaginal examination. The patient had no complaints.
Her medical history showed a
hysterectomy 23 years previously.
On MR imaging a mass (4.5 x
5.5 cm) was seen left intrapelvic,
most likely in the left ovary. The
mass showed a homogeneous isointensity on T1-weighted images
(Fig. 1A) and a uniformly hypointense signal intensity on T2-weighted
images (Fig. 1B).
CT-scan demonstrated a solid
mass with diffuse calcifications in
the left ovary (Fig. 2).
The right ovary was normal on
both MR-imaging and CT-scan and
no lymphadenopathies were found
in the pelvic cavity.
At laparotomy, an enlarged, hard
left ovary and a normal right ovary
were resected.
Macroscopically, the tumor was
solid, white in colour and showed
some calcifications. Microscopically,
the tumor showed abundant dense
fibrous stroma with extensive amorphous calcifications. Within this
stroma, several nests of solidly
aggregated epithelial tumour cells
were seen. No cellular atypia was
noted. Some of these cells presented a clear cell cytoplasm. Small foci
of endometriosis were also seen in
the left ovary, at the edge of the first
tumor. Microscopically a small
nodus with the same characteristics
as the large one in the left ovary was
found in the right ovary.
Histopathologically, these were
typical findings in a benign ovarian
Brenner tumor.

B
Fig. 1. A. Axial T1-weighted image showing an isointense
mass in the left ovary (arrows). B. Sagittal T2-weighted image
demonstrating that the mass is uniformly hypointense (arrows).

Discussion
From: 1. Department of Radiology, University Hospitals Gasthuisberg, Leuven,
Belgium.
Address for correspondence: Dr S. Heye, M.D., Department of Radiology, University
Hospitals Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium.

Brenner tumors account for 1.52.5% of all ovarian neoplasms and

are usually diagnosed as incidental

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JBRBTR, 2005, 88 (5)

Fig. 2. Contrast-enhanced CT-scan showing a solid mass with

diffuse calcifications in the left ovary (arrow).

pathologic findings (1, 2). They arise

from ovarian surface epithelium or
pelvic mesothelium (coelomic
epithelium) through a transitional
metaplastic process (2, 3). In 30% of
the cases an association with another epithelial ovarian neoplasm,
including mucinous cystadenomas,
serous cystadenomas, dermoid
cysts, fibromas and simple cysts
can be found (3, 4). Bilaterality is
seen in 5-7% of the cases (2). Mostly
asymptomatic symptoms like lower
abdominal pain, vaginal bleeding
and palpable mass have been
reported (2). The vast majority of the
Brenner tumors are benign, with a
few reports of borderline or malignant counterparts.
The median age of the patient at
diagnosis is 45-50. The size of
Brenner tumors varies from microscopic to huge, but most measure
less than 5 cm in diameter (2).
Macroscopically, they usually
appear as grey-white solid and firm
tumors (2). Microscopically, they are
made of abundant dense fibrous
stroma with epithelial nests of transitional cells resembling those lining
the urinary bladder. Extensive calcification may occur in the stroma as
sign of a degenerative change (2).
The ultrasonographic appearance
of Brenner tumors is nonspecific.
They appear as solid hypoechoic
masses, often with calcification (1).
CT findings can show a solid
tumor or a mixed solid-cystic tumor,
usually with calcifications in the
solid parts of the tumor. These calcifications are frequently extensive
and amorphous in appearance, but
peripheral round calcification or

cloudlike hazy granular calcification

compatible with psammomatous
calcification has been reported (2).
Moon et al. demonstrated a mild
to moderate contrast enhancement
of the solid components of the
Brenner tumor, but this enhancement pattern is not specific for
Brenner tumor and is also seen in
other ovarian neoplasms.
On MR imaging the benign
Brenner tumor typically displays
homogeneous isointensity to the
uterine muscle on T1-weighted
images and markedly low signal
intensity on T2-weighted images.
Patchy mild enhancement on T1weighted images after intravenous
administration of gadolinium is also
seen.
Differentiating the benign Brenner
tumor from a fibroma and a fibrothecoma can be difficult with MRI, but
they have similar clinical implications because they are rarely malignant. Moreover, fibromas, when they
are large, can show internal edema
and cystic changes and fibromas and
fibrothecomas are associated with
endometrial polyps and hyperplasia
and not with ipsilateral (or contralateral) ovarian neoplasms (1, 4).
Other differential diagnoses
include solid ovarian masses, such
as benign teratoma, metastatic
tumors of the ovary (Krukenberg
tumours) and primary lymphoma. It
also includes subserosal pedunculated or intraligamentous uterine
leiomyomas and malignant Brenner
tumors (2, 3).
The benign teratoma usually contains fat density and characteristic
calcification consistent with teeth (2).

The Krukenberg tumor may contain hypointense components on T2weighted images, but these do not
show as low a signal as skeletal
muscle or most fibromas.
Krukenberg tumors are usually
bilateral, with additional findings of
primary malignancy (2, 3).
Primary lymphomas of the ovary
usually show a non-specific solid
mass, but no calcification (2).
Uterine leiomyomas display a
low or isointense signal compared
with the myometrium on T1-weighted images and a low signal intensity on T2-weighted images, but they
may be partially or completely
hyperintense depending on the
degree of cellularity, hyalinization
and hemorrhage. When finding dystrophic-type calcifications, they usually have a mottled appearance with
a curvilinear rim or they appeared
whorled and streaked (2, 3, 4).
Malignant Brenner tumors are
extremely rare and consist of solid
and cystic areas with necrosis and
proliferating components. The solid
components show marked patchy
enhancement after IV administration of gadolinium (3). These findings could help to differentiate
benign from malignant Brenner
tumor, although Moon et al postulated that no MRI finding discriminates a benign from a malignant
Brenner tumor.
Conclusion
In summary, benign Brenner
tumors show typical imaging features on MRI and CT-scan. It must be
kept in mind however that in 30% of
the cases an association with another epithelial ovarian neoplasm can
be found, which may produce confusing MRI signs.
References
1.

Outwater E.K., Siegelman E.S.,

Kim B., Chiowanich P., Blasbalg R.,
Kilger A.: Ovarian Brenner tumors:
MR imaging characteristics. Magn
Reson Imaging, 1998, 16: 1147-1153.
2. Moon W.J., Koh B.H., Kim S.K., et al.:
Brenner tumor of the ovary: CT and
MR findings. J Comput Assist
Tomogr, 2000, 24: 72-76.
3. Ohara N., Teramoto K.: Magnetic
resonance imaging of a benign
Brenner tumor with an ipsilateral
simple cyst. Arch Gynecol Obstet,
2001, 265: 96-99.
4. Siegelman E.S., Outwater E.K.:
Tissue characterization in the female
pelvis by means of MR imaging.
Radiology, 1999, 212: 5-18.