The document discusses the approach to evaluating ovarian masses through imaging. It describes how ovarian masses can be categorized and that epithelial tumors are the most common type of malignant ovarian tumor. The evaluation involves considering patient factors like age and mass characteristics on ultrasound like size, wall thickness, and presence of septations or solid areas. Scoring systems can help characterize masses as benign or malignant, though some remain indeterminate. MRI may help in these cases by identifying tissue types and infiltrative features suggestive of malignancy. The goal is to determine if the mass is ovarian in origin and the degree of suspicion for malignancy to guide clinical management.

1. APPROACH TO
OVARIAN MASSES
Diagnostic radiology resident

3. • Ovarian tumors can be
categorized as epithelial, germ
cell, sex cord–stromal, or
metastatic.
• Epithelial tumors are the most
common histopathologic type of
malignant ovarian tumor (85% of
cases).
• Epithelial tumors are rare before
puberty
Jeong, Y.Y., Outwater, E.K. and Kang, H.K., 2000. Imaging evaluation of ovarian masses. Radiographics, 20(5), pp.1445-1470

4. • Patient age
• Menopausal status
• Personal or family history of breast or ovarian cancer
• And serum CA-125
Brown, D.L., Dudiak, K.M. and Laing, F.C., 2010. Adnexal masses: US characterization and reporting. Radiology, 254(2), pp.342-354

5. • There does not seem to be any direct correlation between
tumor size and serum CA-125 level
• CA-125 is not a tumor-specific antigen; it is also
elevated in approximately 1% of healthy control subjects,
in patients with liver cirrhosis, endometriosis, first-
trimester pregnancy, pelvic inflammatory disease,
pancreatitis, and in 40% of patients with advanced
intraabdominal nonovarian malignancy
Jeong, Y.Y., Outwater, E.K. and Kang, H.K., 2000. Imaging evaluation of ovarian masses. Radiographics, 20(5), pp.1445-1470

6. • New tumor marker.
• Have higher sensitivity (89%) and specifcity (92%) than
CA-125 for distinguishing ovarian cancer from benign
ovarian disease in premenopausal women
Mohaghegh, P. and Rockall, A.G., 2012. Imaging strategy for early ovarian cancer: characterization of adnexal masses with conventional and advanced imaging
techniques. Radiographics, 32(6), pp.1751-1773

7. APPROACH TO
OVARIAN MASS
IMAGING
FINDING
Investigation
Clinical
data

8. • DETERMINATION OF A DEGREE OF SUSPICION FOR
MALIGNANCY IN AN ADNEXAL MASS IS THE MOST
CRITICAL STEP AFTER IDENTIFICATION OF THE MASS.
• The degree of suspicion for malignancy in a given mass is
based largely ON IMAGING APPEARANCE, but other factors
such as serum CA-125 level must also be considered.
Jeong, Y.Y., Outwater, E.K. and Kang, H.K., 2000. Imaging evaluation of ovarian masses. Radiographics, 20(5), pp.1445-1470

9. BENIGN or
MALIGNANT
Clinical data
Laboratory
findings
Radiological
finding

10. • US evaluation and ultrasound Scoring System
• Doppler US Evaluation
• MR Imaging Evaluation
• CT Evaluation
• PET scan

11. • Imaging plays a crucial role in the initial detection of
adnexal lesions and is used:
• Confirm the presence of a mass
• Identify the organ of origin
• Characterize the features of the mass and the
likelihood of malignancy or benignity.
Mohaghegh, P. and Rockall, A.G., 2012. Imaging strategy for early ovarian cancer: characterization of adnexal masses with conventional and advanced imaging
techniques. Radiographics, 32(6), pp.1751-1773

12. • US remains the study of choice in the
initial evaluation of suspect adnexal
masses because it is relatively
inexpensive, noninvasive, and widely
available.
• Transabdominal US, endovaginal US,
or both should be performed for the
evaluation of adnexal masses .
Jeong, Y.Y., Outwater, E.K. and Kang, H.K., 2000. Imaging evaluation of ovarian masses. Radiographics, 20(5), pp.1445-1470

13. • Endovaginal US is essential for imaging adnexal
masses whose nature is not apparent at
transabdominal US.
• US, whether transabdominal or endovaginal, relies on
MORPHOLOGIC ASSESSMENT of the tumor to
distinguish between benign and malignant disease.
Jeong, Y.Y., Outwater, E.K. and Kang, H.K., 2000. Imaging evaluation of ovarian masses. Radiographics, 20(5), pp.1445-1470

14. • Helps identify vascularized tissue and can assist in
differentiating solid tumor tissue from nonvascularized
structures.

15. • Is the mass ovarian in origin?
• Is it solid or cystic?
• If cystic is it benign, malignant or intermediate?
(morphological assessment)
• If benign, what most likely it is?
• Dose it required follow up? Or go for the next modality?
• Do patient have risk factor for malignancy?

16. • The “phantom (invisible) organ sign,
• The “beak sign,
• The “embedded organ sign.
• Synchronous mobility of the mass and
ovaries.
• Bridging vessels sign
Nishino, M., Hayakawa, K., Minami, M., Yamamoto, A., Ueda, H. and Takasu, K., 2003. Primary retroperitoneal neoplasms: CT and MR imaging findings with anatomic and pathologic diagnostic
clues. Radiographics, 23(1), pp.45-57
Forstner, R., Thomassin-Naggara, I., Cunha, T.M., Kinkel, K., Masselli, G., Kubik-Huch, R., Spencer, J.A. and Rockall, A., 2017. ESUR recommendations
for MR imaging of the sonographically indeterminate adnexal mass: an update. European radiology, 27(6), pp.2248-2257

20. • Many morphologic scoring systems have been proposed
and are based on :
• SIZE AND WALL THICKNESS,
• INNER WALL STRUCTURE,
• SEPTAL CHARACTERISTICS,
• ECHOGENICITY OF THE LESION.

21. Lerner JP, Timor-Tritsch IE, Federman A, Abramovich G. Transvaginal ultrasonographic characterization
of ovarian masses with an improved, weighted scoring system. Am J Obstet Gynecol 1994; 170:81-85
Sensitivity 96.8 %
Specificity 77 %

22. RMI
Mohaghegh, P. and Rockall, A.G., 2012. Imaging strategy for early ovarian cancer: characterization of adnexal masses with conventional and advanced imaging
techniques. Radiographics, 32(6), pp.1751-1773
Sensitivity, 85%;
specifcity, 97%

23. Mohaghegh, P. and Rockall, A.G.,
2012. Imaging strategy for early
ovarian cancer: characterization of
adnexal masses with conventional
and advanced imaging
techniques. Radiographics, 32(6),
pp.1751-1773

24. IOTA =international Ovarian tumor analysis

25. ADNEX estimates the probability that an adnexal
tumor is benign, borderline, stage I cancer, stage II-IV
cancer, or secondary metastatic cancer (i.e.
metastasis of non-adnexal cancer to the ovary).
Abramowicz, J.S. and Timmerman, D., 2017. Ovarian mass-differentiating benign from malignant. The value of the International Ovarian Tumor Analysis (IOTA)
ultrasound rules. American Journal of Obstetrics and Gynecology
*22 % of lesions remained indeterminate on
ultrasound
* Forstner, R., Thomassin-Naggara, I., Cunha, T.M., Kinkel, K., Masselli, G., Kubik-Huch, R., Spencer, J.A. and Rockall, A., 2017.
ESUR recommendations for MR imaging of the sonographically indeterminate adnexal mass: an update. European radiology, 27(6),
pp.2248-2257

28. The parameters of ultrasonographic evaluation of adnexal
mass are:
• Size
• Septum thickness
• Cyst wall thickness
• Presence of papillary or solid excrescences
• Presence of central vascularity on color Doppler
Don’t forget:
Ascites
Lymph node
Peritoneal masses

29. • Larger masses (>4 cm)* are often considered more
suspicious for malignancy;
• However, malignancy is more reliably predicted on the
basis of morphologic features than size.
Brown, D.L., Dudiak, K.M. and Laing, F.C., 2010. Adnexal masses: US characterization and reporting. Radiology, 254(2), pp.342-354
* Forstner, R., Meissnitzer, M. and Cunha, T.M., 2016. Update on imaging of ovarian cancer. Current radiology reports, 4(6), p.31.

30. • Strong evidence of a neoplasm.
• More likely to indicate malignancy if they are greater than
2–3 mm in thickness or have detectable flow on Doppler
US scans.
Brown, D.L., Dudiak, K.M. and Laing, F.C., 2010. Adnexal masses: US characterization and reporting. Radiology, 254(2), pp.342-354

31. Malignant ovarian mass
Cross septaion
Benign ovarian mass
Uncross septaion

33. Adnexal mass
Incomplete septaion

34. • A thickened cyst wall has been described as a feature of
malignancy, but its usefulness is limited since this feature
can be seen in many benign lesions
• Small solid areas that protrude 3 mm or more from the
cyst wall be considered as papillary projections.
Brown, D.L., Dudiak, K.M. and Laing, F.C., 2010. Adnexal masses: US characterization and reporting. Radiology, 254(2), pp.342-354

35. • Most important predictor of malignancy
• Solid or nearly completely solid masses include
metastases, lymphoma, neoplasms of the sex cord-
stromal group, and other rare malignancies such as
malignant teratomas or dysgerminomas
Brown, D.L., Dudiak, K.M. and Laing, F.C., 2010. Adnexal masses: US characterization and reporting. Radiology, 254(2), pp.342-354

36. Hyperechoic papillary projection

37. Intralesional mass like projection with concave borders and absent flow

39. Cyst with internal homogenous echoes and Hyperechoic nodule

40. Left adnexal solid mass
It show bridging vessels with uterus
with doppler

41. • Pattern recognition on ultrasound often allows a
fairly confident diagnosis of common cystic ovarian
masses.
• The mass fit to which category??
• Simple cyst
• Hemorrhagic cyst,
• Endometrioma
• Mature cystic teratoma

45. Tumor % Age Features of malignancy Period
Endometriomas
1% 45 years
>9 cm
Rapid cyst growth or development of a
significant solid component with flow at
Doppler US
4.5 years
Dermoids
2% 50 years
>10 cm
Isoechoic (echogenicity similar to the wall of
the cyst) branching structures, solid areas
with flow at Doppler US (central flow), or
invasion into adjacent organs
15-20 years
Levine, Deborah, et al. "Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference
Statement." Radiology 256.3 (2010)

46. • CT is a very attractive method for evaluating the extent of
disease in women with ovarian malignancy
• The few reports on CT used for the primary diagnosis of
ovarian lesions show sensitivities and specificities of
up to 89% and 83%
• The nature of a solitary adnexal mass may remain
unclear at CT.
Lutz, A.M., Willmann, J.K., Drescher, C.W., Ray, P., Cochran, F.V., Urban, N. and Gambhir, S.S., 2011. Early diagnosis of ovarian carcinoma: is a solution in
sight?. Radiology, 259(2), pp.329-345
Mohaghegh, P. and Rockall, A.G., 2012. Imaging strategy for early ovarian cancer: characterization of adnexal masses with conventional and advanced imaging
techniques. Radiographics, 32(6), pp.1751-1773

47. • Among women with ovarian disorders, CT has been used
primarily in patients with ovarian malignancies, either to
assess disease extent prior to surgery or as a substitute
for second-look laparotomy.
• Although CT may play a useful role in diagnosing adnexal
masses, it is more often of limited value in this setting.
Jeong, Y.Y., Outwater, E.K. and Kang, H.K., 2000. Imaging evaluation of ovarian masses. Radiographics, 20(5), pp.1445-1470
Forstner, R., Thomassin-Naggara, I., Cunha, T.M., Kinkel, K., Masselli, G., Kubik-Huch, R., Spencer, J.A. and Rockall, A., 2017. ESUR recommendations for MR imaging of the sonographically indeterminate
adnexal mass: an update. European radiology, 27(6), pp.2248-2257

48. • In the assessment of sonographically indeterminate
lesions, it is currently not recommended, due to its
adherent limitations, including physiological uptake in
normal ovaries, uptake in common benign lesions, and its
potential lack of uptake in cystic or in necrotic tumours
Forstner, R., Thomassin-Naggara, I., Cunha, T.M., Kinkel, K., Masselli, G., Kubik-Huch, R., Spencer, J.A. and Rockall, A., 2017. ESUR recommendations for MR imaging of the sonographically indeterminate
adnexal mass: an update. European radiology, 27(6), pp.2248-2257

49. • Most useful modality for evaluating adnexal lesions
that are indeterminate at gray-scale US
• It determining the origins of pelvic masses.
• High sensitivity (97% and 100%, respectively) for
depicting malignant adnexal masses.
• Much higher specifcity (84%) and accuracy (89%) for
depicting malignant characteristics than Doppler US.
Mohaghegh, P. and Rockall, A.G., 2012. Imaging strategy for early ovarian cancer: characterization of adnexal masses with conventional and advanced imaging
techniques. Radiographics, 32(6), pp.1751-1773

50. The complementary use of MRI is most beneficial in the following
clinical scenarios:
• A complex adnexal mass with
equivocal malignant features.
• A large pelvic mass of indeterminate origin.
• A mass adjacent to the uterus with equivocal origin.
• A solid adnexal mass.

51. Forstner, R., Thomassin-Naggara, I., Cunha, T.M., Kinkel, K., Masselli, G., Kubik-Huch, R., Spencer, J.A. and Rockall, A., 2017. ESUR recommendations for MR imaging of the sonographically indeterminate
adnexal mass: an update. European radiology, 27(6), pp.2248-2257

53. • T1 ‘bright’ masses
• T2 (dark, intermediate) solid masses
• Complex cystic or cystic-solid masses

54. Forstner, R., Thomassin-Naggara, I., Cunha, T.M.,
Kinkel, K., Masselli, G., Kubik-Huch, R., Spencer,
J.A. and Rockall, A., 2017. ESUR
recommendations for MR imaging of the
sonographically indeterminate adnexal mass: an
update. European radiology, 27(6), pp.2248-2257

55. Forstner, R., Thomassin-Naggara, I., Cunha, T.M.,
Kinkel, K., Masselli, G., Kubik-Huch, R., Spencer,
J.A. and Rockall, A., 2017. ESUR
recommendations for MR imaging of the
sonographically indeterminate adnexal mass: an
update. European radiology, 27(6), pp.2248-2257

56. Forstner, R., Thomassin-Naggara, I., Cunha, T.M.,
Kinkel, K., Masselli, G., Kubik-Huch, R., Spencer,
J.A. and Rockall, A., 2017. ESUR
recommendations for MR imaging of the
sonographically indeterminate adnexal mass: an
update. European radiology, 27(6), pp.2248-2257

57. Simple
cyst
Hemorrhagic Endometriom

58. Dermoid

63. Hopefully, further research
will confirm the usefulness of
this approach.

65. Pelvicmassispresent
Isitarisefrom
ovary
Is it solid or cystic
It is solid
It is cystic
High risk
Intermediate/
Malignant
ULTRASOUND / DOPPLER OTHER MRI/CT
ANOTHER APPROACH
Follow up if
indicated
Benign