between 70 and 75% of all ovarian tumors are of epithelial origin , with borderline ovarian tumors ( bots ) accounting for 10% of these neoplasms .
bots are defined as atypical proliferative tumors or tumors of low malignant potential with microinvasion into the stroma .
there are seven types of bots : serous , mucinous , endometrioid , clear cell , brenner , undifferentiated and mixed tumors .
the incidence of bots among cysts without obvious signs of malignancy is low  about 0.6% .
although the diagnosis of bot is based on histopathological examination , the preoperative evaluation of clinical , radiological and laboratory picture of the patient is of great importance .
accurate radiological findings related to the character of the lesion may play a crucial role in planning surgical treatment .
this is also important due to the fact that the disease usually affects young women who wish to maintain their reproductive potential by undergoing a possibly less radical surgery .
the aim of this article was to present a case of a patient with ovarian tumor in order to show the underestimated role of imaging techniques in the diagnostic process .
a 27-year - old woman with pelvic pain and abdominal discomfort presented to the department of gynecology , gynecologic oncology and gynecologic endocrinology in the medical university of gdask .
no changes were observed in the morphology of the external genitalia . the body of the uterus was movable but shifted posteriorly by a mass adherent to the right ovary .
the ca 125 was over 600 u / ml . transvaginal ultrasonography ( tvu ) of the lower pelvis showed an encapsulated , well - delineated structure mostly formed by a liquid content , measuring 12.2  3.3  5.2 cm , with a solid fraction present in its internal wall in the form of intraluminal exophytic papillary projections ( fig .
2 ) . ultrasound examination of mostly hypoechogenic multilocular cystic tumor with well - delineated smooth borders and a diameter of 12 cm , with small solid echogenic papillary projections ( multi - locular solid type , however only one loculus is seen ) ultrasound examination : a. the same hypoechoic cystic tumor ; b. there is a satellite tumor with a diameter of 3 cm of the same echostructure on the right cystoscopy revealed no lesions in the urinary bladder .
computed tomography ( ct ) confirmed the presence of cystic lesion with a solid fraction in the right ovary ( fig .
3 ) . a. a contrast - enhanced ct scan showing no enhancement of the cystic portion of the tumor and mild wall enhancement with clearly visible large amount of exophytic papillary projections
. b. non - contrast - enhanced ct scan showing a cystic tumor with smooth margins and a diameter of 11 cm ( 30 h.u . ) lying anteriorly to and above the bladder , slightly on the right laparotomy was selected as the surgical procedure due to the tumor size and the criteria for low risk malignancy .
a cystic , multilocular tumor with a diameter of 11 cm that was adherent the omentum , peritoneum , urinary bladder and vesicouterine pouch was found .
the wall of the cyst was up to 1.5 cm thick , the internal surface was covered with wide intraluminal papillae up to 1.5 cm in height .
mucinous cystadenoma with limited malignancy of right ovary was diagnosed and staged ia / pt1an0mx according to the international federation of gynecology and obstetrics ( figo ) and the american joint committee on cancer / union for international cancer control ( ajcc / uicc ) staging system .
ovarian cancer is the second most common gynecologic malignancy and the leading cause of death among women with gynecological cancers .
imaging modalities play an important role in the diagnosis , staging and treatment in this subgroup of neoplasms , however , it is difficult to suggest a simple algorithm .
ultrasound seems to be the first choice from the technical and economical point of view .
there are no specific radiological features selectively describing bots detectable by ultrasound or other , more advanced modalities .
us examination plays an important role in detecting and describing adnexal masses , with the tvu being of greater importance .
it is not sufficient to evaluate tumor masses as precisely as recommended by the iota ( international ovarian tumor analysis ) .
the questions that often arise are as follows : a ) which algorithms to follow ( images are only supportive ) b ) which course of action to take  operate or observe ?
detailed evaluation provides different approaches : like iota s terms or simple  tools  proposed by mcdonald et al . who based their research on 3 types of adnexal masses plus / minus tumor marker elevation ( solid vs. cystic vs. complex + ca 125 ) .
they found the combination of solid / complex mass with ca 125 elevation to be responsible for the identification of 77.3% of eoc cases .
however , unilocular solid cysts which most commonly contained papillary projections predominated among all groups .
ct is not a routine procedure for the evaluation of adnexal masses . in our case ,
ct was performed for preoperative confirmation of bot , however , it probably could have been avoided .
bent et al . described 4 categories of bot appearances on mri scans : 1 ) unilocular cysts ; 2 ) minimally septated cysts with papillary projections ; 3 ) markedly septated lesions with plaque - like excrescences and 4 ) predominantly solid lesions with exophytic papillary projections .
this research also described the most important clinical and imaging characteristics that could indicate a suspicion of bot : in young woman with normal or mildly elevated ca 125 levels , showing predominantly cystic lesion at tvu examination with regular thin wall and the presence of normal ipsilateral ovarian stroma .
although the mri findings did not differ from those derived from ultrasound studies , it allowed for a more objective and comprehensive evaluation of organs and disorders .
radiological assessment plays an important role in establishing the final diagnosis and treatment planning in patients with bot .
the role of a gynecologist is to make the final decision regarding further observation or surgery .
the role of radiologist is to provide clinicians with assistance during the diagnostic progress , using available imaging modalities with ultrasound as the first choice .
 borderline ovarian tumors represent about 10% of all epithelial ovarian cancers , but in contrast to epithelial ovarian cancers , they constitute a group of tumors with a much better prognosis . 
 an assessment of clinical presentation , physical examination , radiological and biochemical findings is necessary to tailor management strategies for patients with ovarian tumors . 
 the article , which is based on a case report , describes different approaches for preoperative diagnosis as well as discusses approaches that might bring some insights on tumor histology . 
 furthermore , it raises a question about which imaging techniques should be proposed for a reliable diagnosis of borderline ovarian tumors to ensure safe surgery planning . 
Background
Case report
Discussion
Conclusions