Images in GYN Ultrasound

Imaging the suspected ovarian malignancy: 14 cases

Last of 4 parts on cystic adnexal pathology

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The presented cases demonstrate transvaginal ultrasonography, as well as intraoperative imaging, of cystadenoma, low malignant potential tumors, and ovarian neoplasia in symptomatic and asymptomatic patients


Pelvic ultrasonography remains the preferred imaging method to evaluate most adnexal cysts given its ability to characterize such cysts with high resolution and accuracy. Most cystic adnexal masses have characteristic findings that can guide counseling and management decisions. For instance, mature cystic teratomas have hyperechoic lines/dots and acoustic shadowing; hydrosalpinx are tubular or s shaped and show a “waist sign.”

In parts 1 through 3 of this 4-part series on adnexal pathology, we presented images detailing common benign adnexal cysts, including:

In this conclusion to the series, we detail imaging for ovarian neoplasias (including cystadenoma and cystadenocarcinoma).


A woman’s lifetime risk of undergoing surgery for suspected ovarian malignancy is 5% to 10% in the United States, and only about 13% to 21% of those undergoing surgery will actually be diagnosed with ovarian cancer.1 Therefore, the goal of diagnostic evaluation is to exclude malignancy.

Diagnostic evaluation includes:

  • imaging
  • lab work
  • history
  • physical findings.

The preferred imaging modality for a pelvic mass in asymptomatic premenopausal and postmenopausal women is transvaginal ultrasonography according to the American College of Obstetricians and Gynecologists (ACOG) practice bulletin, which was reaffirmed in 2013.1 “No alternative imaging modality has demonstrated sufficient superiority to transvaginal ultrasonography to justify its routine use.”1

Transvaginal ultrasonography with color Doppler interrogation has demonstrated a sensitivity of 0.86% and a specificity of 0.91% for discriminating between malignant and benign ovarian masses.

Sonographic features that are worrisome for malignancy include:

  • Multiple thin septations (if indeterminate, the mass may possibly be benign)
  • Thick (> 3 mm), irregular septations
  • Focal areas of wall thickening (> 3 mm)
  • Mural nodules or papillary projections
    • Levine and colleagues note that a cyst with a mural nodule with internal blood flow on color Doppler has the highest likelihood of being malignant2
  • Moderate or large amount of ascitic fluid in pelvis (in conjunction with ovarian mass showing the above characteristics)

Various morphology indices have been developed that combine these criteria with ovarian mass volume to determine the preoperative predictive value for malignancy.

In the images that follow, we present 14 cases that demonstrate cystadenoma, low malignant potential tumors, and ovarian neoplasia.

CASE 1. Right ovarian mucinous cystadenoma in 68-year-old woman with uterine prolapse and history of ovarian cyst

CASE 2. Borderline serous cystadenoma in 56-year-old woman with right lower quadrant pain, nausea, and loss of appetite

CASE 3. Mucinous cystadenoma in 38-year-old woman undergoing sonography for spontaneous abortion

CASE 4. Mucinous cystadenoma in 54-year-old woman undergoing follow-up ultrasound for persistent ovarian cyst

CASE 5. Mucinous borderline tumor in 68-year-old patient with anal cancer and ovarian mass
CASE 6. Ovarian tumor of borderline malignant potential in asymptomatic 25-year-old woman

CASE 7. Mature cystic teratoma in 31-year-old woman with progressively heavier bleeding and pelvic pain

CASE 8. Ovarian fibroma in 72-year-old woman with postmenopausal bleeding
CASE 9. Ovarian fibrothecoma in asymptomatic 26-year-old patient
CASE 10. 15-cm solid and cystic pelvic mass in 41-year-old patient with abdominal pain and early satiety

CASE 11. Sex-cord stromal tumor in 61-year-old woman with postmenopausal bleeding

CASE 12. Juvenile granulosa cell tumor in 19-year-old patient with secondary amenorrhea

CASE 13. High-grade papillary serous carcinoma in 62-year-old woman with pelvic pain

CASE 14. Mucinous borderline tumor in 55-year-old woman with pelvic discomfort

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