Ultrasound Obstet Gynecol 2009; 34: 188–195

Published online 15 June 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.6394

Imaging in gynecological disease (5): clinical and ultrasound

characteristics in fibroma and fibrothecoma of the ovary
D. PALADINI*, A. TESTA†, C. VAN HOLSBEKE‡, R. MANCARI†, D. TIMMERMAN‡ and
L. VALENTIN§
Departments of Gynecology and Obstetrics, *University Hospital, University Federico II of Naples, Naples and †Università Cattolica del
Sacro Cuore, Rome, Italy, ‡University Hospital, Leuven University, Leuven, Belgium and §Malmö University Hospital, Lund University,
Malmö, Sweden

K E Y W O R D S: fibroma; fibrothecoma; ovarian neoplasms; ultrasonography

ABSTRACT
Objectives To describe the clinical and ultrasound
features of fibroma and fibrothecoma of the ovary.
Methods Sixty-eight women with a histological diagnosis
of fibroma or fibrothecoma of the ovary who had under-
gone a preoperative ultrasound examination between
1999 and 2007 were identified from the databases of
four ultrasound centers. The tumors were characterized
on the basis of ultrasound images, ultrasound reports and
research protocols (when applicable) using the terms and
definitions of the International Ovarian Tumor Analy-
sis (IOTA) group. In 51 patients, ultrasound information
had been collected prospectively; in the remaining 17 cases
it was retrieved retrospectively from ultrasound reports
and images. In 44 cases, electronic ultrasound images of
good quality were available. These were reviewed by two
observers, who described them using pattern recognition.
spaces and one was described as being mainly cystic. Half
of the women with fibroma/fibrothecoma had fluid in
the pouch of Douglas and 16% (11/68) had ascites; CA
125 titers ≥ 35 U/mL were found in 34% (17/50) of the
cases in which CA 125 results were available.
Conclusions Most fibromas and fibrothecomas are
round, oval or lobulated solid tumors that cast stripy shad-
ows and are associated with fluid in the pouch of Douglas,
and most manifest minimal to moderate vascularization.
A fibroma/fibrothecoma with atypical ultrasound appear-
ance may be mistaken for a malignancy, in particular if
associated with fluid in the pouch of Douglas or ascites,
high color content and raised CA 125 levels. Copyright 
2009 ISUOG. Published by John Wiley & Sons, Ltd.
INTRODUCTION

Results Of the 68 patients identified, 53 had fibroma and Aim

15 had fibrothecoma. The mean patient age was 54 (range,
17–80) years. Sixty-three percent (41/65) were post-
menopausal and 60% (39/65) had no symptoms. Most
(75%; 51/68) fibromas/fibrothecomas were solid tumors
and most (75%; 51/68) manifested minimal or moderate
blood flow on color Doppler examination. Using pat-
tern recognition, all solid fibromas/fibrothecomas were
described as round, oval or slightly lobulated tumors.
Most (66%; 29/44) were solid tumors, with regular or
slightly irregular internal echogenicity with stripy shad-
ows, and some contained cystic spaces. Others (23%,
10/44) were solid tumors with regular or slightly irregular
internal echogenicity without stripy shadows and with or
without cystic spaces. Two were solid tumors that were
so dense it was difficult to assess their internal echogenic-
ity, two were multilocular solid tumors with large cystic
To describe clinical and gray-scale and color Doppler
ultrasound findings of fibroma and fibrothecoma of the
ovary.
Background
Epidemiology
Fibromas and fibrothecomas of the ovary are benign
tumors arising from the stromal component of the
ovary. According to the World Health Organization
classification of ovarian neoplasms, they represent a
subgroup of the granulosa-theca cell tumors and belong to
the thecoma-fibroma group1,2 . The fibroma arises from
spindle cells which produce collagen, while thecomas

Correspondence to: Prof. D. Paladini, Via Petrarca 72 – 80123 – Naples, Italy (e-mail: paladini@unina.it)
Accepted: 17 December 2008

Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER
Ovarian fibroma and fibrothecoma
arise from stromal cells which resemble the perifollicular
thecal cells3 . One theory is that fibromas are ‘burnt out’
fibrothecomas1 .
Fibromas are the most commonly encountered subtype
of the sex cord-stromal tumors. They account for almost
two-thirds of neoplasms in this group and for 6% of all
ovarian primary tumors. The mean age at diagnosis is
48 years and 90% of patients are at least 30 years old
when they are diagnosed with fibroma/fibrothcoma1,4 .
Unlike other sex cord-stromal tumors, fibromas are rarely
associated with estrogen production. Ascites or classic
Meig’s syndrome with additional hydrothorax has been
found in 10% of all cases and in 40% of tumors larger
than 10 cm in maximum diameter4 . Ovarian fibromas
have also been described in association with Gorlin,
Maffucci and Sotos syndromes5 – 7 .
Clinical symptoms
Fibromas and fibrothecomas rarely cause symptoms4 .
These tumors are often an unexpected finding on
transvaginal ultrasound, computer tomography or mag-
netic resonance imaging performed for various reasons.
However, symptoms related to ascites and pleural effusion
may develop, especially in those cases with large tumors.
Macroscopic appearance
Fibromas are rarely bilateral (5% of cases). They are
often large, sometimes more than 10–15 cm in maximum
diameter, with only one third of them being smaller than
3 cm1,2,4 . Large tumors have a smooth or slightly irregular
serosal surface and are solid. Small lesions may appear as
polypoid nodules on the external surface of the ovary or
as non-capsulated nodules in the ovary. The cut surface of
a fibroma is white and slightly spiralled and may manifest
areas of cystic degeneration. If these areas are large, they
appear as cysts filled with protein-rich serous fluid and
with ragged walls. Dystrophic calcifications may occur,
especially if the fibromas are seen in association with
basal cell nevus syndrome (features of this syndrome
include basal cell carcinomas appearing early in life,
and bilateral multinodular calcified ovarian fibromas)5 .
The macroscopic appearance of fibrothecomas is virtually
indistinguishable from that of ovarian fibromas1,2 .
Microscopic appearance
Fibroma. Fibromas consist of cellular bundles and
intersecting strips of hyaline-appearing collagen and
fibrous tissue. The fibroblastic tumor cells have spindle-
shaped nuclei with no signs of atypia1,2,4 . The cellularity
varies inversely with the amounts of collagen production
and stromal edema, both of which may be quite intense.
Dystrophic calcifications, focal necrosis and hemorrhage
are common. Interestingly, the normal adjacent ovarian
tissue and the contralateral ovary may show signs of
stromal hyperplasia. If fibromas exhibit aggregates of
lipid-laden lutein-like cells they are defined as luteinized
Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd.
189
thecomas or fibromas1 . Mitoses are rare, but occasionally
fibromas may be hypercellular and/or show substantial
mitotic activity. Cellular fibromas contain one to three
mitoses per 10 high-power fields but display ordinary
nuclei and usually behave in a benign fashion, though
local recurrences after surgery have been reported.
Fibrothecoma. In comparison with fibromas, fibrotheco-
mas show significant cellularity, a relatively large amount
of collagen and, in up to 50% of cases, pronounced
edema. The collagenous component is usually fibrillary
in appearance but hyalinization is sometimes seen1,2 . The
typical thecal cells may present in small clusters, often
being observed only on close examination of several
sections, or as larger and isolated fields. The presence
of luteinized thecal cells would change the diagnosis to
luteinized thecoma.
Prognosis
The prognosis of fibroma and fibrothecoma is extremely
good1,2,4 . In cases associated with ascites or Meig’s
syndrome, the fluid collections regress following surgical
removal of the tumor. Cellular fibromas may recur locally
but this happens rarely.
METHODS
Sixty-eight women with a histological diagnosis of
fibroma (n = 53) or fibrothecoma (n = 15) of the ovary
who had undergone preoperative ultrasound examination
before surgical removal of the mass between 1999
and 2007 were identified from the databases of four
ultrasound centers participating in the International
Ovarian Tumor Analysis (IOTA) studies8 : Malmö
University Hospital, Lund University, Malmö, Sweden;
University Hospitals, Leuven, Belgium; Università del
Sacro Cuore, Rome, Italy; and University Hospital,
Università Federico II, Naples, Italy. All women had
undergone surgery within 6 months after the ultrasound
examination. Twenty-two of the women were included
in the IOTA study and were examined using the
IOTA study protocol8 ; the remaining women had been
examined within the framework of other scientific studies
using a standardized examination technique, standardized
color Doppler settings and following a strict research
protocol (n = 29) or had undergone an ordinary clinical
examination (n = 17). Ultrasound images, ultrasound
reports, research protocols (when applicable) and patient
records were retrieved. One author from each center
retrospectively characterized the tumors from his/her
own center on the basis of the ultrasound images,
ultrasound reports and research protocols using the terms
and definitions published by the IOTA group9 . Briefly,
ovarian lesions were classified as unilocular, unilocular-
solid, multilocular, multilocular-solid or solid tumor. In
cases with bilateral lesions, the largest was described. A
subjective semiquantitative assessment of the amount of
detectable color Doppler signals within each tumor was
Ultrasound Obstet Gynecol 2009; 34: 188–195.
190
made using a color score. A color score of 1 was given
when no color could be detected in the lesion, a score of
2 was given when only minimal color could be detected,
a score of 3 was given when a moderate amount of color
was present and a score of 4 was given when abundant
color Doppler signals were detected in the tumor9 .
In 44 of the cases, electronic images of good quality
were available. Two authors (L.V., A.T.) independently
reviewed these ultrasound images and described the
ultrasound morphology of the tumors using pattern
recognition10 . Their agreed description is reported.
In the patients who had been examined within the
framework of a scientific study, some clinical information
had been collected prospectively and missing clinical
information was retrieved retrospectively from patient
records. The following clinical information was collected:
presenting symptoms, personal history of breast cancer
or ovarian cancer, number of first-degree relatives with
ovarian or breast cancer, menopausal status, use of
hormone replacement therapy, and CA 125 levels, which
were measured using immunoradiometric assay kits from
various companies. A woman was considered to be
postmenopausal if she reported a period of at least
12 months of amenorrhea after the age of 40 years,
provided that pregnancy, medication or disease could
not explain the amenorrhea. Women aged 50 years or
older who had undergone hysterectomy, so that the time
of menopause could not be determined, were also defined
as being postmenopausal.
Statistical analysis was carried out using the SPSS
11.0 software (SPSS Inc., Chicago, IL, USA). Univariate
analysis was performed using Fisher’s exact test and the
chi-square test. Two-sided tests were used with 5% as the
level of significance.
RESULTS
The mean age of the 68 patients with benign fibroma/
fibrothecoma was 54 (SD, 14.3; range, 17–80 years).
Sixty-three percent (41/65) were postmenopausal and
20% (13/65) were nulliparous. Information on family
history of ovarian and breast cancer and presenting symp-
toms were unavailable in four, four and three women,
respectively. There was a personal history of ovarian
cancer in 1.5% (1/68) of patients and a family history
in 1.6% (1/64), and there was a personal history of
breast cancer in 8.8% (6/68) of patients and a family
history in 4.7% (3/64). Most (60%; 39/65) patients with
fibroma/fibrothecoma were asymptomatic. In those with
symptoms, the most common were pain (n = 16), bloat-
ing (n = 9) and urinary symptoms (n = 4), some women
having more than one symptom. In four women, the lesion
was twisted at surgery, the torsion being asymptomatic in
three, while the fourth patient presented with pain. Only
one (1.5%) of the 68 patients had Meig’s syndrome. Four
patients (6%) had bilateral lesions.
Ultrasound findings and the diagnosis suggested by the
original ultrasound examiner are presented in Table 1.
Gray-scale ultrasound and Doppler findings were similar
Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd.
Paladini et al.
for fibromas and fibrothecomas. Both tended to be large,
solid tumors, some of them with cystic anechogenic or
low-level echogenic locules. One third (35%; 24/68) had
a largest diameter ≥ 9.0 cm and one third (32%; 22/68)
manifested shadowing. Half of the patients had fluid
in the pouch of Douglas and 16% had ascites. Most
(75%) fibromas/fibrothecomas manifested a minimal or
moderate amount of color Doppler signals, but some
showed none and some showed abundant vascularization
(Figure 1).
The four twisted lesions were large tumors (largest
diameter ranging from 67 to 258 mm). Three were solid
while the largest twisted tumor was multicystic. Both
the internal echogenicity and the contours of the tumors
were regular. One tumor manifested shadows. A mini-
mal or moderate amount of color Doppler signals were
detectable in three of the four twisted lesions; this infor-
mation was missing in the fourth case. Two of the twisted
lesions were classified as being certainly malignant by
the original ultrasound examiner and in one of the cases
the examiner was uncertain about whether the mass was
benign or malignant. The specific diagnoses suggested by
the original examiner were metastatic carcinoma (n = 2),
tubo-ovarian abscess in the case in which the examiner
was uncertain regarding malignancy, and serous cystade-
noma in the case of the large multicystic tumor.
Results of CA 125 measurements were available for
50 women; 17 (34%) had values ≥ 35 U/mL and nine
(18%) had values > 80 U/mL (median, 19.5; range,
9–1409 U/mL). There was an association between the
largest tumor diameter, the presence of ascites and high
CA 125 titers (≥ 35 U/mL): ascites was present in 7%
(3/44) of the cases with a largest tumor diameter < 9 cm
and in 33% (8/24) of the cases with a largest tumor diam-
eter ≥ 9 cm (P < 0.05). CA 125 titers ≥ 35 U/mL were
found in 12% (4/32) of the lesions with a largest diameter
< 9 cm and in 72% (13/18) of the lesions with a largest
diameter ≥ 9 cm (P < 0.01). Ascites was present in 12%
(4/33) of the cases with CA 125 ≥ 35 U/mL and in 41%
(7/17) of the cases with CA 125 < 35 U/mL (P < 0.05).
The two independent observers who used pattern
recognition10 to describe the 44 masses for which
good electronic images were available agreed fairly well
in their descriptions of fibroma/fibrothecoma, identify-
ing five patterns (Table 2). Most (66%; 29/44) fibro-
mas/fibrothecomas were solid tumors with regular (n =
25) or slightly irregular (n = 4) internal echogenicity with
stripy shadows, and some of these contained cystic spaces
(Figure 2). Another 23% (10/44) were solid tumors with
regular or slightly irregular internal echogenicity with-
out stripy shadows and with or without cystic spaces
(Figure 3a and b). Two were solid tumors that were so
dense it was difficult to assess their internal echogenicity
(Figure 3c and d). All solid fibromas/fibrothecomas were
described as round, oval or slightly lobulated tumors. Two
fibromas/fibrothecomas were multilocular solid tumors
with large cystic components and the solid components
not casting any stripy shadows (Figure 4a and b) and one
Ultrasound Obstet Gynecol 2009; 34: 188–195.
Ovarian fibroma and fibrothecoma 191

Table 1 Sonographic characteristics in 68 cases of ovarian fibroma/fibrothecoma, described using terms and definitions of the International
Ovarian Tumor Analysis (IOTA) group9 , with diagnosis suggested by original ultrasound examiner

Fibroma Fibrothecoma
Characteristic (n = 53) (n = 15)

Largest diameter (mm) 78 (19–258) 64 (27–143)

Type of tumor
Unilocular 0 0
Unilocular-solid 4 (7) 0
Multilocular 2 (4) 0
Multilocular-solid 8 (15) 3 (20)
Solid 39 (74) 12 (80)
Number of locules
None 33 (65) 11 (73)
One 5 (10) 0
Two 0 2 (13)
Three 3 (6) 0
Four 4 (8) 1 (7)
Five or more 6 (12) 1 (7)
Unknown 2 0
Largest diameter of the solid component (mm) 70 (9–170) 53 (27–131)
Incomplete septum 2 (4) 0
Papillations
None 50 (94) 14 (93)
One 2 (4) 1 (7)
Two 1 (2) 0
Irregular papillations 3 (6) 1 (7)
Irregular wall 8 (15) 2 (13)
Shadowing 17 (32) 5 (33)
Echogenicity of cyst fluid
Anechoic 9 (17) 2 (13)
Low-level 4 (8) 2 (13)
‘Ground glass’ 1 (2) 0
Mixed 4 (8) 1 (7)
No cyst fluid 33 (62) 10 (67)
Unknown 2 0
Fluid in the pouch of Douglas 27 (51) 7 (47)
Ascites 10 (19) 1 (7)
Doppler results: color content
None 9 (17) 0
Minimal 23 (43) 6 (40)
Moderate 15 (28) 7 (47)
Abundant 6 (11) 1 (7)
Unknown 0 1 (7)
Benign/malignant diagnosis suggested by original ultrasound examiner
Benign or probably benign 32 (60) 12 (80)
Malignant or probably malignant 10 (19) 2 (13)
Uncertain 8 (15) 1 (7)
Unknown 3 0
Specific diagnosis suggested by original ultrasound examiner
Fibroma or fibrothecoma 25 (47) 12 (80)
Cystoadenoma 1 (2) 1 (7)
Teratoma 1 (2) 0
Serous cyst 1 (2) 0
Tubo-ovarian abscess 1 (2) 0
Meig’s syndrome 1 (2) 0
Primary ovarian cancer 1 (2) 2 (13)
Metastatic carcinoma 3 (6) 0
Borderline malignant tumor 1 (2) 0
Sarcoma 1 (2) 0
Not possible 2 (4) 0
Unknown 15 (28) 0

Data are given as median (range) or n (%).

Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2009; 34: 188–195.
192 Paladini et al.

Figure 1 Color score in ovarian fibroma. The panel of images shows that all four classes of color score (1–4), as defined in the IOTA
study8,9 , can be found in ovarian fibromas and fibrothecomas. The classes are as follows: 1: no flow; 2: minimal blood flow; 3: moderate
blood flow; 4: abundant blood flow.

Table 2 Results of pattern recognition (consensus of two independent observers) in 44 cases of ovarian fibroma/fibrothecoma for which
electronic ultrasound images of high quality were available for analysis

Fibroma Fibrothecoma
Tumor characteristics according to pattern recognition (n = 36) ( n = 8)

1. *Solid tumor with smooth contour, regular or irregular internal echogenicity, stripy shadows, with 23 (64) 6 (75)
or without cystic structures inside or in periphery of tumor, cyst fluid usually anechoic, cyst
borders usually regular
2. †Solid tumor, regular or irregular internal echogenicity, no stripy shadows, with or without cystic 10 (28) 0
structures inside or in periphery of tumor, cyst fluid usually anechoic, cyst borders usually regular
3. ‡Solid, very dense tumor with smooth contour, difficult to assess internal echogenicity, no stripy 1 (3) 1 (12)
shadows, no cystic structures
4. §Multilocular solid tumor, solid components with irregular internal echogenicity, no stripy 1 (3) 1 (12)
shadows, many cystic areas, echogenic cyst fluid in some locules
5. §Mainly cystic 1 (3) 0

Data are given as median n (%). *Of the 29 tumors with this ultrasound morphology, 72% (n = 21) were classified as benign by the original
ultrasound examiner, and 59% (n = 17) were assigned a correct specific diagnosis of fibroma/fibrothecoma. The only twisted lesion for
which pattern recognition was assessed belonged to this group. One of the four tumors in this category with irregular internal echogenicity
was classified as benign by the original ultrasound examiner and was assigned a correct specific diagnosis of fibroma/fibrothecoma. †Six of
the 10 tumors with this ultrasound morphology were classified as benign by the original ultrasound examiner and four were assigned a
correct specific diagnosis of fibroma/fibrothecoma. Two of the four tumors in this category with irregular internal echogenicity were
classified as benign by the original ultrasound examiner and both were assigned a correct specific diagnosis of fibroma/fibrothecoma. ‡Both
tumors with this ultrasound morphology were classified as benign by the original ultrasound examiner and both were assigned a correct
specific diagnosis of fibroma/fibrothecoma. §None of the tumors with these ultrasound morphologies was classified as benign by the original
ultrasound examiner and none was assigned a correct specific diagnosis of fibroma/fibrothecoma.

tumor was described as being mainly cystic (Figure 4c). DISCUSSION

Of the four twisted fibromas/fibrothecomas, only one was
assessed using pattern recognition and this was assigned
to the first category (solid tumor with regular internal
echogenicity and stripy shadows). The original ultra-
sound examiners were confident about a diagnosis of
benign lesion in most fibromas manifesting regular inter-
nal echogenicity (24/31, 77%); however, if the internal
echogenicity was irregular, only three of eight (38%)
fibromas were correctly classified as benign.
The clinical characteristics of our patients with benign
fibroma/fibrothecoma of the ovary were in good
agreement with data reported by others1,4 : 94% of the
patients in our series were more than 30 years old and
the tumor was bilateral in only 6% of the patients. In
agreement with previous published studies11 – 16 , we found
a positive association between the presence of ascites, the
largest tumor diameter and the level of CA 125. Meig’s
syndrome occurred in only one (1.5%) of our patients,

Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2009; 34: 188–195.
Ovarian fibroma and fibrothecoma 193

Figure 2 Ultrasound images of fibroma/fibrothecoma. Using pattern recognition (Table 2, Pattern 1), these tumors are described as round,
oval or lobulated solid tumors with regular (a–c) or irregular (d) internal echogenicity, with stripy shadows (arrows) and with no cystic
structures (a,b) or with cystic structures in the periphery or inside the tumor (c,d). The cyst fluid is anechoic and the cyst borders are regular.
These are the most common ultrasound features of fibroma/fibrothecoma, 66% (29/44) of those in our series belonging to this category.

confirming that it occurs rarely in patients with this type
of tumor14,15 . It has been hypothesized that the increased
amount of peritoneal fluid seen in many women with
benign fibromas/fibrothecomas, which is evident initially
only in the pouch of Douglas (50% of women in our
series), may be explained by transudation through the
tumor surface exceeding the resorptive capacity of the
peritoneum15 , or by irritation of the peritoneal surface
by the solid (and usually large) tumors. Irritation of
the peritoneal surface may also explain the increased
CA 125 levels associated with fibroma/fibrothecoma.
Indeed, on immunoperoxydase staining, CA 125 is
found to be localized within the peritoneum and not
in the tumor itself14,15 . The relatively high association
rate with increased abdominal fluid and not infrequent
elevation of CA 125 levels and the solid aspect of
most fibromas/fibrothecomas may help explain why
they can be mistaken for malignancies: in this series,
experienced ultrasound examiners classified 12 of the
68 fibromas/fibrothecomas as probably malignant or
malignant and were uncertain about the nature of the
mass in another nine cases. Hence, in at least 18% (12/68)
of the cases, laparoscopic removal of the mass could not
be recommended.
Most fibromas and fibrothecomas were completely solid
tumors with smooth contours, although some of them
contained (usually only a few) cystic spaces (Table 1).
According to pattern recognition, the presence of stripy
shadows was typical of benign fibromas/fibrothecomas,
with 29 of the 44 (66%) tumors evaluated using this
technique manifesting the feature. It is possible that these
stripy shadows can be explained by the cellular bundles
and intersecting strips of hyaline-appearing collagen and
fibrous tissue which are responsible for the ‘spiral pattern’
seen on the cut surface of typical fibromas/fibrothecomas
on macroscopic examination1,2,4 .
Variability in ultrasound morphology of fibro-
mas/fibrothecomas (Tables 1 and 2 and Figures 1–4)
might be explained by the varying degrees of cellular-
ity, collagen content and stromal edema that characterize
these lesions1,2,4 . Hemorrhage, edema and necrosis may
explain the varying echogenicity of the fluid in the cystic

Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2009; 34: 188–195.
194 Paladini et al.

Figure 3 Ultrasound images of fibroma/fibrothecoma. Using pattern recognition (Table 2, Patterns 2 and 3), these tumors are described as
round, oval or lobulated solid tumors, without stripy shadows and with regular or irregular internal echogenicity (a,b), or such density that
evaluation of internal echogenicity is very difficult (c,d). These patterns were seen in 27% (12/44) of the fibromas/fibrothecomas in our series.

Figure 4 Ultrasound images of fibroma/fibrothecoma. Using pattern recognition (Table 2, Patterns 4 and 5), these tumors are described as
multilocular solid tumors (a,b) or mainly cystic tumors (c). These ultrasound features are rare in fibromas/fibrothecoma, 7% (3/44) of those
in our series belonging to this category.

spaces. A few fibromas/fibrothecomas in our series were
atypical (Figure 4) in that they were mainly cystic or
contained a large number of cystic spaces and lacked
stripy shadows. Such atypical ultrasound morphology
(e.g. irregular internal echogenicity without stripy shad-
ows or mainly cystic lesion) has also been reported by
others16 – 18 and might explain why some of the benign
fibromas and fibrothecomas in our series were misdiag-
nosed as malignant, borderline or benign tumors other
than fibromas19 . The original ultrasound examiners sug-
gested a benign diagnosis in most fibromas manifesting
regular internal echogenicity (77%) but in only three

Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2009; 34: 188–195.
Ovarian fibroma and fibrothecoma
of eight fibromas with irregular internal echogenicity;
irregular contour or internal echogenicity is considered to
be a sign of malignancy20 .
Because of the limited number of cases in our series,
we cannot draw any conclusions as to whether cellular
fibromas (n = 3) or twisted fibromas (n = 4) manifest
ultrasound features that might help distinguish them from
other fibromas/fibrothecomas. We found that twisted
tumors misled the ultrasound examiners, metastatic
cancer (n = 2), cystadenoma and tubo-ovarian abscess
being the specific diagnoses suspected in the four such
cases.
In conclusion, we have described the clinical,
ultrasound and color Doppler features of ovarian
fibroma/fibrothecoma. We have shown that most are
round, oval or lobulated solid tumors that cast stripy
shadows and that many are associated with fluid in the
pouch of Douglas. Color Doppler findings are variable,
but most fibromas/fibrothecomas manifest minimal to
moderate vascularization. Some fibromas/fibrothecomas
are sonographically atypical, very few being mostly cystic.
A fibroma/fibrothecoma with atypical ultrasound appear-
ance may be mistaken for a malignancy, in particular if
associated with fluid in the pouch of Douglas or ascites,
high color content on Doppler examination and raised
CA 125 levels.
ACKNOWLEDGMENTS
This work was supported by the Swedish Medi-
cal Research Council (grants nos. K2001-72X-11605-
06A, K2002-72X-11605-07B, K2004-73X-11605-09A
and K2006-73X-11605-11-3) and by funds administered
by Malmö University Hospital.
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