Ultrasound Differentiation of Benign Versus Malignant Adnexal Masses

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Ultrasound differentiation of benign versus malignant adnexal masses

Author: Maitray D Patel, MD
Section Editors: Barbara Goff, MD, Deborah Levine, MD
Deputy Editor: Alana Chakrabarti, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2020. | This topic last updated: Feb 28, 2020.
INTRODUCTION
An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a common gynecologic problem. Pelvic ultrasound
is typically the first-line imaging study used to characterize an adnexal mass [1]. Adnexal masses may present as pelvic pain or pressure and
may be found on pelvic examination or be an incidental finding on pelvic imaging.
A principal concern regarding adnexal masses is whether a malignancy is present. Sonographic findings enable imagers to establish when
an adnexal mass is almost certainly benign compared with when an adnexal mass has a reasonable chance of being malignant.
Characterization of the mass into one of these two categories is of paramount importance, since clinical management of the mass will greatly
depend upon this categorization.
The sonographic findings that help to distinguish a benign from a malignant adnexal mass are reviewed here. The general diagnostic
approach and differential diagnosis of adnexal masses are discussed separately. (See "Approach to the patient with an adnexal mass" and
"Differential diagnosis of the adnexal mass".)
OVERVIEW OF SONOGRAPHIC APPROACH
The sonographic approach to the evaluation of adnexal masses is based upon the ability to evaluate the likelihood of malignancy and also to
recognize masses that are consistent with a normal physiologic structure or a benign neoplasm. To accomplish this, the sonologist must take
into consideration normal and abnormal anatomy and physiology, clinical information, and ultrasound techniques, and they must set
appropriate diagnostic thresholds to help guide further management.
Goals of sonographic evaluation — The goal of ultrasound evaluation of the adnexal mass is not, strictly speaking, to determine if the
mass is "definitely" benign versus "definitely" malignant. Instead, the goal is to determine whether the mass is almost certainly benign or
whether the mass has some reasonable chance of being malignant.
The asymmetry in these categories with respect to specificity is purposeful. The adnexal mass that is "almost certainly benign" should have
practically no risk for malignancy (very high specificity). Thus, it should be reasonable not to proceed with surgical intervention in these
cases. Some of these masses may require surgical intervention or imaging follow-up for reasons other than excluding malignancy. On the
other hand, some of the adnexal masses that ultrasound characterizes as having "a reasonable chance of being malignant" may in fact turn
out to be benign (higher sensitivity but lower specificity), but these masses require therapeutic or diagnostic intervention because the goal is
to detect nearly all malignant masses.
Anatomy and physiology of adnexal masses — Anatomically, most adnexal masses arise from the ovary or fallopian tube. However, other
gynecologic structures may give rise to an adnexal mass, including the mesovarium or mesosalpinx (eg, paratubal cysts). Uterine
leiomyomas may protrude toward the adnexa and be palpated or visualized as an adnexal mass. In addition, adnexal masses may arise from
other proximal structures, including the urinary tract (eg, bladder diverticulum), bowel (eg, appendiceal abscess, diverticular abscess, bowel
neoplasm), or pelvic connective tissue (eg, peritoneal cyst) or nerves (nerve sheath tumor). The types of adnexal masses are shown in the
table (table 1).
In terms of physiology and histology, adnexal masses may be physiologic (a normal component of ovulation) or pathologic. Normal ovulatory
physiology is the most common cause of an adnexal mass in premenopausal women. Thus, the sonographic identification of features in an
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adnexal mass that give an interpretation that the mass is one arising from normal physiology is one of the most important ways to identify a
mass as being benign. A brief review of normal menstrual cycle physiology is essential to understanding the sonographic approach.
Most physiologic masses are cystic. In general, the chance of a malignancy is low if there are no solid areas in the mass on sonographic
evaluation (table 2). This becomes one of the most important principles that underlie the sonographic approach to the adnexal mass.
During the menstrual cycle, normal physiology results in establishment of typically one (but occasionally more than one) dominant follicle in
either or both ovaries, which is usually around 20 to 25 mm in diameter at ovulation. Prior to ovulation, the dominant follicle is round, has a
smooth wall, and is internally anechoic on ultrasound imaging; if the follicle wall seals quickly after ovulation, the resultant corpus luteum cyst
can also exhibit the same sonographic features and may be larger than the dominant follicle from which it arose. Cysts that exhibit these
imaging characteristics are termed "simple cysts" (image 1).
In premenopausal women, upon release of an oocyte, the dominant follicle usually loses most or all of its internal fluid, collapsing into a
sonographically "solid" appearing structure, with thickened crenulated walls: the corpus luteum. Sometimes follicles, dominant follicles,
and/or the corpus luteum will develop internal hemorrhage which causes cyst enlargement; when this occurs, it happens most commonly at
the time of ovulation, resulting in a hemorrhagic corpus luteum cyst (image 2). Hemorrhagic corpus luteum cysts are typically 3 to 5 cm in
diameter but can be larger. Evidence now shows that sporadic ovulation can occur in postmenopausal women [2], but when this occurs, it
almost always happens within the first few years following the final menstrual period; thus the existence of a non-neoplastic hemorrhagic cyst
in a postmenopausal woman is possible in the first five years following the final menstrual period but very uncommon. When there are
sonographic features characteristic of hemorrhage into a cyst without solid areas (as detailed below), there is a strong presumption that the
cyst is physiologic.
It was previously believed that physiologic ovarian cysts were almost exclusively a premenopausal phenomenon, but there is now substantial
evidence to indicate that simple ovarian cysts are also routinely found in postmenopausal women [3], in many cases believed to be arrested
physiologic follicles from an anovulatory cycle. They are usually smaller and less frequently encountered with increasing time interval from
the final menstrual period. All of these ovarian "simple cysts" (follicles, dominant follicles, corpus luteum, and arrested physiologic cysts) can
be grouped together as physiologic non-neoplastic cysts.
Sonographic techniques — Most adnexal masses can be characterized using pelvic gray-scale sonography alone or with addition of color
Doppler evaluation.
The basic principle of ultrasound imaging is that ultrasound waves are delivered into the body from the crystal surface of a hand-held
transducer, which then also records the waves that are reflected back to the crystal ("echoes") from internal structures and interfaces.
Gray-scale — Gray-scale ultrasound imaging refers to the technique in which the reflected ultrasound wave is displayed on the image as
a pixel of a particular shade of gray based on the signal intensity, with the depth of the pixel on the image based on the time it took for the
reflected wave to return to the crystal. This results in a two-dimensional display of anatomy.
Doppler — Doppler evaluation refers to the change in frequency that results from sound waves that reflect off of moving particles, such as
blood flow. In ultrasound imaging, those Doppler changes can be displayed using color maps (known as color Doppler) or as a waveform
showing the change in frequency as a function of time (known as spectral Doppler).
Using color Doppler evaluation during pelvic ultrasound is a routine maneuver that is usually considered part of a standard evaluation and not
an additional test. In particular, for adnexal masses that do not have a typical benign appearance, using color or power Doppler to look for the
presence or absence of flow in solid-appearing areas or septations can be useful (image 3 and image 4) [4]. Within a cyst, Doppler
evaluation helps to distinguish clot (avascular, related to non-neoplastic physiologic etiology) from a mural nodule (vascularized and a feature
suspicious for malignancy).
Combined gray-scale and Doppler evaluation — Meta-analyses of observational studies concluded that combined evaluation of
ovarian masses with gray-scale morphology and color Doppler assessment performed better than morphologic assessment, pulsed Doppler
assessment, or color Doppler assessment alone [5,6].
Combined evaluation can be performed with the use of a scoring system, in which numerical values are assigned to different features and a
total score calculated for the mass or a probability of malignancy can be calculated. In daily practice, however, many experienced sonologists
will use the features that individual studies have identified as most valuable [7-10] to arrive at a subjective impression of the likelihood of

malignancy. Using gray-scale and color Doppler features is a subjective approach that has been shown to be highly reliable and usually
superior to other methods [11-13]. (See 'Malignancy' below.)
Auxiliary techniques
Three-dimensional techniques — Adding three-dimensional color Doppler angiography has not shown any improvement in the ability
to discriminate benign from malignant lesions [4]. Some investigators feel three-dimensional gray-scale imaging can be helpful to make a
specific diagnosis of hydrosalpinx [14].
Spectral Doppler — Ultrasound with spectral Doppler evaluation for adnexal masses was initially proposed as a means of decreasing
the false-positive rate of sonography for ovarian carcinoma [15]. The neovascularization that accompanies malignant tumors is associated
with poor muscular support in the arterial walls, leading to less vascular resistance that potentially can be detected by pulsed Doppler.
However, spectral Doppler does not appear to be useful in diagnosing ovarian malignancy, as many studies have found too broad an overlap
in resistive index and pulsatility index between benign and malignant masses. Other spectral Doppler features, such as velocity criteria or the
presence or absence of a diastolic notch in the pulsed Doppler waveform, have been investigated and are generally not found to be reliable
for differentiating benign and malignant masses [7,16,17], although some believe them to be useful [18].
Pertinent clinical information — Clinical characteristics can help in formulating a differential diagnosis and the sonographic evaluation of
adnexal pathology must account for the clinical context.
Clinical examples include:
● Tubo-ovarian abscesses, for example, may have a gray-scale sonographic appearance that would be worrisome for malignancy (picture
1 and image 5), but the presence of fever, leukocytosis, and pelvic tenderness helps to suggest the correct diagnosis. (See
"Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)
● Bilateral multiseptated cystic adnexal masses in a woman with gestational trophoblastic disease, multiple pregnancies, ovarian
hyperstimulation, or a pregnancy complicated by hydrops are likely to represent theca lutein cysts rather than malignancy. (See
"Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation syndrome".)
● Women with ovarian cancer often have one or more nonspecific symptoms, such as lower abdominal discomfort or pressure, bloating,
constipation, irregular menstrual cycles, urinary frequency, or dyspareunia (table 3). More advanced disease may be associated with
abdominal distention, nausea, anorexia, or early satiety due to the presence of ascites and omental or bowel metastases. Unfortunately,
these clinical findings are rarely useful in helping to distinguish benign and malignant disease when the sonographic findings are
indeterminate. (See "Early detection of epithelial ovarian cancer: Role of symptom recognition" and "Epithelial carcinoma of the ovary,
fallopian tube, and peritoneum: Clinical features and diagnosis", section on 'Clinical presentation'.)
The woman's age, family history, and menopausal status should be considered for predicting risk, since malignancy is more common in older
and menopausal women and those with certain heritable conditions (table 2). (See "Epithelial carcinoma of the ovary, fallopian tube, and
peritoneum: Incidence and risk factors", section on 'Probable risk factors'.)
Diagnostic performance of ultrasound — Pelvic ultrasound is highly effective at guiding the further management of adnexal masses: that
is, in determining which masses are "almost certainly benign" and which have a "reasonable chance of malignancy."
Multiple studies have evaluated the diagnostic performance of ultrasound in determining whether an adnexal mass is benign or malignant
[19]. Many of these studies have important limitations. First, it should be noted that the presence or absence of demonstrable color Doppler
flow is an evaluated feature of some of these studies, but the use of color Doppler is considered an inherent aspect of the "sonographic
evaluation." It is misleading to think that Doppler evaluation is an ancillary or follow-up test after gray-scale ultrasound. Second, it should be
recognized that a dichotomous approach (benign versus malignant) does not reflect the goal of the ultrasound examination as describe
above ("almost certainly benign" or "reasonable chance of malignancy"). In making this determination, the expertise of the sonologist
influences the likelihood of arriving at a correct diagnosis [20]. This last point was illustrated in a multicenter study reporting that 90 percent of
extrauterine masses could be correctly classified by the expert sonologist as "definitely benign" or "definitely malignant" with 100 percent
accuracy, but 10 percent were unclassifiable by their ultrasound findings [21]. These unclassifiable masses, which were neither "definitely
malignant" nor "definitely benign" as analyzed by the sonologist, were usually borderline tumors, struma ovarii, papillary cystadenofibromas,
or myomas; these are among the adnexal masses that have higher chance of being misclassified as benign or malignant if one takes a
dichotomous approach.

The largest diagnostic accuracy study regarding sonographic differentiation of benign and malignant adnexal masses was the International
Ovarian Tumor Analysis (IOTA) study, an international multicenter prospective study the evaluated the use of a set of sonographic features
(the "Simple Rules") in almost 5000 women with adnexal masses [22,23]. The IOTA data show that the performance of ultrasound depends
upon which level of "risk of malignancy" one is willing to accept for patients who are deemed NOT to have a malignancy based on any
algorithm using sonographic features. For example, if one pursues a strategy in which an adnexal mass that is deemed not to be malignant
based on certain sonographic findings has only 1 percent risk of being malignant (high sensitivity/low specificity), then ultrasound shows 99.7
percent sensitivity, 33.7 percent specificity, positive predictive value (PPV) 44.8 percent, and negative predictive value (NPV) 98.9 percent.
Alternatively, if one pursues a strategy in which an adnexal mass deemed not to be malignant based on certain sonographic findings has 30
percent risk of malignancy, ultrasound sensitivity was 89.0 percent, specificity 84.7, PPV 75.4 percent, and NPV 93.9 percent. In a meta-
analysis comparing the ability of 19 methods to discriminate between benign and malignant adnexal masses before surgery, the Simple
Rules had a sensitivity of 93 percent and a specificity of 81 percent when inconclusive tumors were all considered malignant [19]. The Simple
Rules are described in detail below. (See 'Malignancy' below.)
The American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) is a United States risk stratification and
management system created to assist those who interpret pelvic ultrasound examinations by providing a framework for rendering consistent
interpretations that avoid ambiguity in assessment of malignancy risk [24]. Using O-RADS, an adnexal finding is placed into one of six
malignancy-risk categories based on relevant sonographic features, described using specified terms. The O-RADS system is new in 2020
and has not yet been widely adopted. The step-by-step method provided below is the approach we use when characterizing an adnexal
mass found on ultrasound.
STEPS IN CHARACTERIZING A MASS
The sonographic approach to adnexal mass characterization can be summarized as a four-step approach:
Step one: Is it a simple cyst? — The first observation that helps to characterize a mass is to determine whether it appears to be a simple
cyst. Simple cysts are characterized by:
● Round or oval shape
● Anechoic fluid filling the cyst cavity
● Thin walls
● No impairment of sound transmission through the mass (in other words, no loss of signal from tissues behind the cyst)
● No internal flow with color Doppler imaging
In premenopausal women, simple adnexal cysts (image 1) that are <3 cm in diameter typically represent normal follicles or may be a
corpus luteal cyst (these may appear simple or complex) and may be considered a normal finding. Even when up to 5 cm in diameter, these
simple cysts are so commonly due to normal menstrual physiology that the Society of Radiologists in Ultrasound (SRU) does not recommend
follow-up when asymptomatic [25,26]. (See "Differential diagnosis of the adnexal mass", section on 'Functional or corpus luteal cysts'.)
In 2010 and 2019, the SRU published a consensus approach to the management of asymptomatic adnexal findings identified on ultrasound
based on sonographic features including size [25,26]. In 2017, a retrospective study of 570 adnexal cysts in 500 women validated the clinical
performance of the guidelines in patients who had clinically inconsequential symptoms [27]. Understandably, the SRU approach does not
apply to adnexal findings with clinically consequential symptoms, as the clinical context may be more important than the sonographic findings
[26]. The guidelines also do not apply to cysts that are not well characterized by ultrasound. In these patients, magnetic resonance imaging
may be helpful.
In premenopausal women, the 2019 SRU consensus advises [26]:
● Simple cysts up to 3 cm are considered normal.
● Simple cysts ≥3 but ≤5 cm in size should be described but do not require follow-up imaging.
● Simple cysts do not need follow-up imaging unless they are >5 to 7 cm, using the higher threshold for exceptionally well-visualized cysts.
When sonographic evaluation is pursued, it is done in 2 to 12 months, depending on whether there is any uncertainty about

characterization of the cyst (for which a shorter 2 to 6 month interval would be appropriate) or whether the purpose of the follow-up is to
assess growth (for which a longer 6 to 12 month interval would be appropriate).
In postmenopausal women, because malignancy in a simple cyst is rare, the 2019 SRU consensus is [26]:
● Cysts greater than 1 cm in size should be documented.
● Practices may choose any threshold from 3 to 5 cm as a justifiable cutoff for not following a simple cyst in a postmenopausal woman.
The 5 cm cutoff is advised only for "exceptionally well visualized cysts." At the time of unpublished 2018 survey data from the SRU, most
practices were using a 3 cm threshold for imaging follow-up.
● Initial repeat imaging is advised in 3 to 12 months, depending on the features of the cyst and the clinical concern of the patient and
clinician. As for premenopausal patients, if the main purpose of follow-up is to assess growth, then follow-up is best done at 6 to 12
months with interval follow-up in 3 to 6 months reserved for those instances in which increased confidence in cyst characterization is
desired.
● Once a simple cyst has been observed for two years, one should be able to distinguish between a cyst that is measurably growing
(favoring a benign neoplasm) as compared with a cyst that is resolving, waxing/waning, or stable (favoring a non-neoplastic cyst).
Further imaging follow-up after two years should be pursued on a case-by-case basis using clinical parameters.
There is accumulating evidence that simple cysts are not associated with an increased risk of malignancy in pre- or postmenopausal women
[28-30]. The risk of malignancy in a simple cyst in a postmenopausal woman is discussed in detail separately. (See "Differential diagnosis of
the adnexal mass", section on 'Simple ovarian cysts'.)
The SRU 2019 revision reflects the available data that simple cysts are not precursors to malignancy. These revised recommendations will
decrease the duration of follow-up with serial ultrasound for simple cysts.
Some clinicians have asked why ultrasound follow-up is needed at all for simple cysts if there is no risk of malignancy regardless of size. The
two potential reasons for follow-up of some simple cysts are (1) to ensure that the cyst was not initially mischaracterized; and (2) to
understand the growth rate of a relatively large simple cyst in the event it proves to be a neoplasm (eg, benign cystadenoma). Our
perspective is that, given how common simple cysts are in both pre- and postmenopausal women, it is not reasonable to routinely reevaluate
every simple cyst to assure that it was not initially mischaracterized. Follow-up ultrasound to increase confidence in proper characterization of
simple cysts and to understand the rate of growth is best reserved for cysts that are larger than usually detected for the patient's menstrual
status. This forms the basis for the size thresholds in the SRU guidelines.
As noted above, simple cysts in premenopausal women are typically physiologic. Other masses that may appear as simple cysts include the
following:
● A cystadenoma is a benign neoplasm that usually arises from the ovary but sometimes from the fallopian tube. A cystadenoma should
be considered as a possible etiology if there is a relatively large simple cyst (>5 cm in diameter in premenopausal women or >3 cm in
diameter in postmenopausal women). Paraovarian cystadenomas are uncommon but typically have a small nodule within a cystic
extraovarian mass (thus making them cystadenofibromas) [31]. (See "Differential diagnosis of the adnexal mass", section on 'Serous or
mucinous cystadenoma'.)
● Simple adnexal cysts are usually ovarian in etiology but may also be paraovarian or paratubal cysts. These are common and generally
appear as simple cysts adjacent to the ovary (image 6). If a simple adnexal cyst is clearly paraovarian in location (with a normal separate
ovary), then it typically does not require clinical or imaging follow-up if asymptomatic. (See "Differential diagnosis of the adnexal mass",
section on 'Paraovarian/paratubal cysts and tubal and broad ligament neoplasms'.)
Step two: Is there a physiologic process that can account for potentially confusing findings? — If the mass is not a simple cyst, the
next question to consider is whether a physiologic process, such as corpus luteal involution, hemorrhage into a cyst, or adjoining simple
cysts, could account for the sonographic features that make the cyst "not simple" [32].
Potentially confusing features that may be present in a cyst caused by physiologic processes include:
● Corpus luteum – The corpus luteum has a characteristic appearance to experienced sonographers, with thickened walls, circumferential
color Doppler flow, and a small central lucency containing echoes that can be confusing to less experienced imagers. These physiologic
structures do not need imaging follow-up once recognized.

● Two simple cysts – Two simple cysts next to each other can simulate a septated single cyst.
● Hemorrhagic cyst – Hemorrhage into a cyst, which usually indicates a physiologic cyst, can simulate septations and mural nodules. A
fine network of thin linear to curvilinear echoes, sometimes called a fishnet or reticular pattern, is strongly suggestive of a hemorrhagic
cyst (image 2) [33]. These linear echoes are usually very thin and do not extend completely uninterrupted across the cyst, unlike true
septa.
For patients with the characteristic appearance of a hemorrhagic cyst who are asymptomatic or have symptoms that resolve as
expected, follow-up imaging is not needed [34]. If follow-up imaging is performed, while most hemorrhagic cysts will have resolved or
become smaller within six to eight weeks after diagnosis, not all of them resolve by eight weeks. Therefore, when one is fairly confident
of the initial diagnosis of hemorrhagic cyst, it is most cost effective to follow-up with ultrasound in three to six months to allow more time
for the cyst to change, with recommendations for earlier follow-up in six to eight weeks reserved for instances when there is less
confidence in the initial diagnosis of a hemorrhagic cyst. Likewise, if it is deemed possible that a septation in a cyst actually reflects the
interface of two adjacent physiologic simple cysts, then follow-up in six months would be reasonable to reassess, allowing for the
physiologic cysts to resolve.
Step three: Are there characteristics of specific entities? — If the adnexal mass does not have recognizable features of physiologic
processes of hemorrhage, involution of a corpus luteum or other physiologic cyst, or adjoining cysts, the next task for the sonologist is to
critically evaluate the mass for any features that are characteristic of specific entities. These include the following entities that can (but do not
always) have characteristic features.
Endometrioma — An endometrioma is a benign cause of an ovarian mass arising from the growth of ectopic endometrial tissue. It is a
finding in some women with endometriosis. The management of an endometrioma is discussed elsewhere. (See "Endometriosis:
Management of ovarian endometriomas".)
Sonographic characteristics of an endometrioma include:
● Homogeneous low- to medium-level echoes in a cystic mass (whether unilocular or multilocular), in the absence of a solid component, is
suggestive of an endometrioma (image 7) [35-37].
● This is especially true if there are also small echogenic foci on the inner wall of the cyst [35].
● There may be varying degrees of echogenicity in the different locules.
Not all endometriomas have the typical appearance described here [35]. The appearance of hemorrhagic cysts and endometriomas may
overlap. An ultrasound report in which the sonologist gives the likely diagnosis of an endometrioma is best reserved for cases in which all the
typical features are identified and at least one sonographic follow-up study has been performed [35].
In addition, up to 25 percent of endometriomas will have a solid-appearing nodular component due to clot (or to focal endometrial tissue in
endometriomas) that may be difficult to distinguish from the true solid tissue of a neoplasm [38,39]. Unfortunately, color Doppler is not as
useful as hoped in these cases, although it is true that clot generally does not exhibit detectable blood flow (image 2), while a solid mass is
more likely to have identifiable blood flow. Additionally, focal endometrial tissue in endometriomas may have detectable flow by color Doppler
imaging, and thus these lesions are also problematic since the vascularized nodule simulates malignancy.
It is important that an ultrasound report of a likely diagnosis of endometrioma is reserved for those masses that do not have features that can
be mimicked by malignancy and that the presumption that a mass in a postmenopausal woman is an endometrioma based on sonographic
features be subject to skepticism and close follow-up observation. This was illustrated based on data from the International Ovarian Tumor
Analysis (IOTA) studies, a set of prospective multinational studies [40]. One report included 3511 women with an adnexal mass who
underwent surgery; 713 (20 percent) had endometriomas. Features of histologically proven endometriomas included one or more of the
following: unilocular cyst (51 percent), cyst fluid with ground glass echogenicity (73 percent), solid parts (17 percent), and papillary
projections (10 percent). Several of these features were also found in malignant masses. Histopathology among masses with ground glass
echogenicity included postmenopausal women (15.6 percent endometriomas and 44 percent malignant) and premenopausal women (83.3
percent endometriomas and 3.8 percent malignant). Solid parts were visualized in 17 percent of endometriomas and 93 percent of malignant
tumors. On the basis of subjective impression, 5 of 26 postmenopausal patients presumed to have an endometrioma had a malignant tumor.
Mature teratoma — Mature cystic teratomas (dermoid cysts) are benign germ cell tumors. These neoplasms may have features that can
be mistaken for malignancy, especially by ultrasound imagers with less experience [41]. The management of dermoid cysts is discussed

elsewhere. (See "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and diagnosis", section on 'Mature teratoma
(dermoid)'.)
Sonographic characteristics of a mature teratoma include (image 8 and image 9):
● The presence of a markedly hyperechoic nodule within the mass [37,42-48]. This appearance, particularly if the hyperechoic nodule has
distal acoustic shadowing, is generally a strong indicator of a teratoma.
● Teratomas may also be uniformly hyperechoic or have bright linear to punctate echoes (the latter sometimes referred to as the dermoid
mesh [42]); these latter two appearances may occasionally be difficult to distinguish from bowel in the absence of peristalsis.
● Teratomas occasionally contain a fluid-fluid level. If the echogenic fluid is nondependent, this is predictive of a teratoma, although this
occurs in the minority of teratomas that have a fluid-fluid level [49].
● Calcification also can be present and may vary in size. Calcification alone is not a sufficient criterion to diagnose a dermoid and should
be evaluated in the context of the overall appearance of the ovary [50].
● Floating globules is an uncommon appearance of teratomas but seems to be predictive [51].
The diagnostic performance of ultrasound for teratomas was evaluated in a study that found that 75 percent of teratomas exhibit more than
one of these features [43]. In that study, there was no false-positive diagnosis of teratoma when more than one feature of teratomas was
demonstrated on ultrasound. Any mass with features of a teratoma must be evaluated with color Doppler imaging, since the identification of
flow within the suspected teratoma makes the diagnosis quite unlikely and raises the possibility of struma ovarii, malignant teratoma,
exophytic lipoleiomyoma, or other cause for the mass [52].
Pedunculated leiomyoma — Pedunculated uterine leiomyomas (fibroids) usually appear as heterogeneous, hypoechoic, solid masses
(image 10). They are more likely to be confused with an ovarian mass if the ipsilateral ovary is not seen and/or if there is cystic change within
the fibroid. Visualization of the ipsilateral ovary or additional studies with MRI can help with the diagnosis. The pedicle can be difficult to
identify; Doppler may be useful to detect a bridging vascular pedicle [53]. The management of leiomyomas is discussed elsewhere. (See
"Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Imaging and endoscopy'.)
Hydrosalpinx — A hydrosalpinx is a postinflammatory process in which fluid fills the fallopian tube. (See "Differential diagnosis of the
adnexal mass", section on 'Hydrosalpinx'.)
On ultrasound, a hydrosalpinx usually appears tubular in shape and may have septations or nodules in its wall (image 11A-B) [54]. The
nodules are due to thickened endosalpingeal folds and may raise concern for ovarian malignancy if one does not recognize the extraovarian
location of the mass. The septation typically appears to be incomplete and is really not a true septation but is just due to the wall of the tube
folded in on itself. These incomplete or partial septations are suggestive of a hydrosalpinx [54] but can be seen with other lesions [55]. The
waist sign, indentations along opposite walls, was found to be a useful feature for identifying a hydrosalpinx [55].
When asymptomatic, a confidently diagnosed hydrosalpinx does not need clinical management.
Peritoneal inclusion cyst — Peritoneal inclusion cysts (also called multicystic inclusion cysts) are uncommon mesothelial lesions that
appear as septated, cystic masses that surround the ovary, usually in women with pelvic adhesions [56,57]. Adhesions may be visualized on
ultrasound as bands of tissue with surrounding fluid.
Peritoneal inclusion cysts differ from neoplasms in that the fluid within the peritoneal inclusion cyst has angular margins with surrounding
structures, insinuating between structures instead of causing mass effect upon them. The imager should look carefully for a distorted ovary
recognizable as containing follicles (either within or at the edge of the mass) when considering the diagnosis of peritoneal inclusion cyst for a
septated cystic adnexal mass. If a mass can be confidently characterized as a peritoneal inclusion cyst, the mass does not need clinical
management; sometimes, one or two follow-up imaging studies will be performed to achieve more confidence in the diagnosis. However,
making the diagnosis of a peritoneal inclusion cyst on ultrasound can be difficult and often requires more than average experience and
expertise; if characteristic features are not demonstrated or recognized, the mass justifies further evaluation under the presumption that it is
an ovarian neoplasm.
Malignancy — Sonographic characteristics that have been typically associated with an ovarian or fallopian tubal malignancy are [58]:

● Solid component that is not hyperechoic and is often nodular or papillary – A solid component is the most significant gray-scale feature
of malignancy (image 12) [7].
● Septations, if present, that are irregularly thick (>2 to 3 mm) – A thick wall can be seen with malignancy, but many benign masses, such
as hemorrhagic cysts or endometriomas, can also have a thick wall. Wall thickness alone does not seem to be a reliable feature for
distinguishing benign from malignant ovarian masses.
● Color or power Doppler demonstration of flow in the solid component.
● Presence of ascites (any intraperitoneal fluid in postmenopausal women and more than a small amount of intraperitoneal fluid in
premenopausal women is usually abnormal).
● Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect by ultrasound).
Historically, size of the mass was considered useful, with larger masses more likely to be malignant. While many ovarian malignancies are
larger masses, as a general statement, this relationship has not been confirmed, as several studies have found no significant difference in
size between malignant and benign masses [7,8]. This is because the overall size of a mass includes the cystic component, and the risk of
malignancy is a function of the size of the solid component, not the cystic component. The data show that size of any suspected solid
component of an adnexal mass is a risk factor for malignancy [59]. Therefore, a 10 cm simple cyst is not more worrisome than a 2 cm cyst
with solid vegetative nodule because the solid component of the 2 cm cyst is larger than the nonexistent solid portion of a simple cyst.
Similarly, a 10 cm mass with multiple features of a benign teratoma is not more worrisome than a 2 cm mass with multiple features of a
cystadenocarcinoma because a dermoid cyst has no vascularized solid component.
One approach to determining the likelihood of malignancy in an adnexal mass on ultrasound is described by the IOTA study group and has
been termed the "Simple Rules." This is based on a set of five ultrasound features indicative of a benign tumor (B-features) and five
ultrasound features indicative of a malignant tumor (M-features) [23]. The B-features are: (1) unilocular cyst, any size; (2) solid components
either not present or less than 7 mm in diameter; (3) presence of acoustic shadowing; (4) smooth multilocular cyst less than 10 cm in
diameter; and (5) no blood flow. The M-features are: (1) irregular solid tumor; (2) ascites; (3) at least four papillary structures; (4) irregular
solid-multilocular tumor, largest diameter over 10 cm; and (5) very strong color flow. When using the Simple Rules, tumors are classified as
benign if only B-features are observed and as malignant if only M-features are observed. If no features are observed or if conflicting features
are present, the Simple Rules are deemed unable to classify the tumor as benign or malignant (inconclusive results). These inconclusive
masses are then analyzed using subjective assessment by an experienced sonologist or more simply all classified as malignant in order to
increase the sensitivity for identifying ovarian cancer (this is the "reasonable chance of malignancy" approach).
Step four: Follow-up ultrasound or additional testing? — In some cases, sonographic features are indeterminate or ultrasound images
are suboptimal. Follow-up with other imaging modalities or combinations of tests may be useful. (See "Approach to the patient with an
adnexal mass", section on 'Imaging studies'.)
Serial ultrasound — One strategy is to repeat a pelvic ultrasound after an interval of time. It is important to consider the appropriateness
and role of repeat ultrasound imaging when physiologic processes remain in the differential diagnosis [52]. For example, when a cyst has
complex features that are worrisome for a neoplasm but may still potentially be due to hemorrhage, short interval follow-up sonographic
evaluation can be invaluable. In this situation, the imager might be unable to conclude that the cyst is "almost certainly benign." The
impression may also be consistent with the possibility that hemorrhage in a physiologic cyst could account for the features that simulate
neoplasm. In such cases, there is a concern of subjecting the patient to surgical evaluation that may prove unnecessary. A follow-up
sonogram in even a few weeks would help to assess for evolution of findings if due to hemorrhage and would not adversely affect the
patient's clinical outcome if the findings prove secondary to tumor. (See "Management of an adnexal mass", section on 'Surveillance'.)
If a follow-up sonogram is indicated, performing it approximately the second week of the menstrual cycle in the follicular phase
(approximately cycle days 7 to 12) should help minimize the detection of a hemorrhagic corpus luteal cyst in another cycle. Practically,
however, it is not always easy or necessary to schedule the follow-up sonogram at such a specific time, particularly if a patient's menstrual
cycle is irregular.
Even if a cyst does not completely resolve on follow-up, a decrease in the size or a dramatic change in the appearance of the internal
contents over a short interval is compatible with physiologic activity.

Magnetic resonance imaging — When further characterization of an adnexal mass is indicated because ultrasound has failed to lead to
a confident diagnosis, MRI evaluation can be helpful [26,32]. MRI can demonstrate findings that lead to a confident diagnosis of a particular
entity.
One indication for follow-up imaging with MRI is further evaluation when it appears that an adnexal mass may be an exophytic leiomyoma.
This is a particularly good use of MRI because an exophytic myoma generally does not need operative intervention, whereas a solid adnexal
mass that is not an exophytic myoma almost always needs surgical removal. This highlights the underlying principle that further
characterization of an adnexal mass with MRI is most useful when the results change the gynecologic approach to management of the mass.
As another example, if the imager thinks that an adnexal mass is probably a benign cystic teratoma based on sonographic appearance but
does not have enough confidence in concluding that malignancy is practically excluded (let us say 1 percent chance or less), MRI would be
of tremendous additional value but only if it was used to change who or where the surgical treatment was performed.
If the surgeon removing the tumor has oncologic training and is able to effectively stage ovarian cancer if the mass does prove to be
malignant, then preoperative MRI distinction between a benign cystic teratoma and an ovarian malignancy may not be really needed; on the
other hand, if the gynecologist planning to remove the mass is comfortable with removing a benign cystic teratoma but not experienced in
surgical staging of ovarian malignancy, then preoperative distinction between those two possibilities becomes of tremendous value. If the
MRI provides evidence that the mass is malignant, the patient will benefit from having her surgical evaluation performed by a gynecologic
oncologist [60]. Ultimately, the need for further MRI characterization of an adnexal mass evaluated sonographically depends on the
experience and diagnostic confidence of the imager as well as the experience and surgical approach of the gynecologic surgeon.
Other additional tests
CA 125 — Combined testing with serum CA 125 and sonographic features of an adnexal mass appears have a higher specificity for
ovarian malignancy than CA 125 alone.
This is discussed in detail separately. (See "Approach to the patient with an adnexal mass".)
Multimodal tests — Multiple risk scoring systems have been proposed to differentiate between benign and malignant adnexal
masses, including the Risk of Malignancy Index. These systems include sonographic features and other factors, such as menopausal status
and serum CA 125. Such models can be cumbersome to use, however; as stated above, the sonographic component is often best utilized by
the subjective approach rather than a scoring system.
This is discussed in detail separately. (See "Serum biomarkers for evaluation of an adnexal mass for epithelial carcinoma of the ovary,
fallopian tube, or peritoneum", section on 'Biomarker panels and multimodal tests'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See
"Society guideline links: Ovarian and fallopian tubal disease".)
SUMMARY AND RECOMMENDATIONS
● An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a common gynecologic finding. Pelvic
ultrasound is typically the first-line imaging study used to characterize an adnexal mass. (See 'Introduction' above.)
● The goal of ultrasound evaluation of the adnexal mass is not to determine if the mass is definitely benign or malignant. The goal is to
determine whether the mass is almost certainly benign or whether the mass has some reasonable chance of being malignant. (See
'Overview of sonographic approach' above.)
● Adnexal masses may be physiologic, usually a normal component of ovulation, or pathologic. Most physiologic masses are cystic. In
general, the chance of a malignancy is low if there are no solid areas in the mass on sonographic evaluation (table 2). (See 'Overview of
sonographic approach' above.)
● Most adnexal masses can be characterized using gray-scale sonography with addition of color Doppler evaluation. Surgery for histologic
evaluation or therapy may be indicated; in occasional cases, magnetic resonance imaging may provide additional useful information.
(See 'Sonographic techniques' above.)
● The first step in assessing an adnexal mass with gray-scale sonography is to determine if the mass is a simple cyst. If the mass meets
criteria for a simple cyst, malignancy is practically excluded. The mass might still be a benign neoplasm (usually a cystadenoma),
however, so surgical intervention may eventually be needed, based on growth rate and clinical symptoms. (See 'Step one: Is it a simple
cyst?' above.)
● The second step in sonographic evaluation of a mass that is not a simple cyst is to assess for potential features of normal physiology.
When these physiologic features are suspected but not confidently identified, sonographic follow-up may be an important strategy to
understand the evolution of the mass. (See 'Step two: Is there a physiologic process that can account for potentially confusing findings?'
above.)
● The third step in sonographic assessment is to determine if there are features that are predictive for specific entities. Endometriomas,
dermoids, hydrosalpinges, peritoneal inclusion cysts, and pedunculated fibroids are all entities that can exhibit characteristic features.
(See 'Step three: Are there characteristics of specific entities?' above.)
● Adnexal masses that are suspicious for malignancy are those with the following characteristics (see 'Malignancy' above):
• Solid component that is not hyperechoic and is often nodular or papillary

• Septations, if present, that are irregularly thick (>2 to 3 mm)
• Color or power Doppler demonstration of flow in the solid component
• Presence of ascites
• Peritoneal masses, enlarged nodes, or matted bowel (may be difficult to detect by ultrasound)
● In some cases, sonographic features are indeterminate or ultrasound images are suboptimal. Follow-up with other imaging modalities or
combinations of tests may be useful as a fourth step. This may include repeat ultrasound, magnetic resonance imaging, or serum CA
125.
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge Douglas L Brown, MD, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 3208 Version 30.0

GRAPHICS
Differential diagnosis of an adnexal mass
Gynecologic: Extraovarian
Gynecologic: Ovarian Gynecologic: Tubal Nongynecologic
and extratubal
Benign
Functional (physiologic) cyst Ectopic pregnancy Paraovarian cyst Constipation

Corpus luteal cyst Hydrosalpinx Paratubal cyst Appendiceal abscess
Luteoma of pregnancy Uterine leiomyoma (pedunculated or Diverticular abscess
Theca lutein cyst cervical) Pelvic abscess
Polycystic ovaries Tubo-ovarian abscess Bladder diverticulum
Endometrioma Ureteral diverticulum
Cystadenoma Pelvic kidney
Benign ovarian germ cell tumor Peritoneal cyst
(eg, mature teratoma) Nerve sheath tumor
Benign sex cord-stromal tumor
Malignant or borderline
Epithelial carcinoma Epithelial carcinoma Metastatic endometrial carcinoma Appendiceal neoplasm

Epithelial borderline neoplasm Serous tubal intraepithelial neoplasia Bowel neoplasm
Malignant ovarian germ cell tumor Metastasis (eg, breast, colon,
Malignant sex cord-stromal tumor lymphoma)
Retroperitoneal sarcoma
Modified from: Rauh-Hain JA, Melamed A, Buskwofie A, Schorge JO. Adnexal mass in the postmenopausal patient. Clin Obstet Gynecol 2015; 58:53.
Graphic 107713 Version 4.0

Sonographic appearance of adnexal masses
Sonographic appearance and specific etiologies Malignant?
Simple cysts
Non-neoplastic physiologic cyst (dominant follicle, arrested follicle, corpus luteum) No
Paraovarian or paratubal cyst No
Cystadenoma (ovarian or tubal) No
Anechoic cysts with thin septations (complete or incomplete)
Two adjacent non-neoplastic physiologic cysts No
Paratubal cyst No
Hydrosalpinx No
Peritoneal inclusion cyst No
Theca lutein cysts No
Cysts with internal echoes, no solid areas
Non-neoplastic physiologic cyst with hemorrhage No
Endometrioma No
Abscess (gynecologic or gastrointestinal) No
Benign ovarian neoplasm (cystadenoma, cystic teratoma) No
Borderline ovarian tumor Yes
Gastrointestinal (duplication cyst, mucocele) Usually not (mucoceles

may be malignant)
Cysts with solid-appearing areas (including irregularly thick septations and walls or septal/mural nodules)
Corpus luteum No
Mature cystic teratoma No
Cystadenoma (ovarian or tubal) No
Cystadenocarcinoma (ovarian or tubal, including borderline tumors) Yes
Ectopic pregnancy No
Mostly or completely solid mass
Adnexal torsion No
Leiomyoma (pedunculated or broad ligament) No (but rarely may be

a sarcoma)
Epithelial ovarian or tubal carcinoma Yes
Ovarian sex cord-stromal tumors (eg, fibroma, Sertoli-Leydig) May be benign or

malignant
Ovarian germ cell tumors (eg, teratocarcinoma, struma ovarii) May be benign or
malignant
Metastasis to ovary Yes
Nongynecologic primary tumor (gastrointestinal, neurogenic) Some

Normal follicle
Transvaginal ultrasound image of the left ovary. A normal-appearing left ovary

containing a simple anechoic clear cyst, which is consistent with a follicle. A
small amount of ovarian tissue is identified surrounding the follicle, as indicated
by the arrow.
Reproduced with permission from: Thomas D Shipp, MD. Copyright ©Thomas D

Shipp, MD.

Hemorrhagic ovarian cyst
Transvaginal ultrasound image in a 38-year-old female shows a complex ovarian cyst

(cursors) that contains a reticular pattern of internal echoes. This appearance is classic
for a hemorrhagic ovarian cyst.
Courtesy of Dr. Douglas Brown.

Endometrioma with color Doppler
Transvaginal ultrasound with color Doppler image of the left adnexa showing a
benign endometrioma of the left ovary viewed with color Doppler imaging. No
flow within the cyst can be demonstrated; however, blood flow is demonstrated
within the wall of the cyst in the ovarian tissue itself (long arrow). Also identified
within the left ovary is a small follicle (short arrow).
Reproduced with permission from: Thomas D Shipp, MD. Copyright © Thomas D

Shipp, MD.

Ovarian cancer color Doppler
Transvaginal ultrasound image of an ovarian cancer of the left ovary. The

ovarian mass is 4.7 cm and primarily solid, as indicated by the long arrow. Color
Doppler imaging demonstrates blood flow within the solid portion of the ovarian
mass (short arrow). Almost no normal ovary is visible in the image.

Shipp, MD.

Tubo-ovarian abscess
Gross intraoperative photograph of a left tubo-ovarian abscess in a patient with

pelvic inflammatory disease.
Courtesy of Mitchel Hoffman, MD.

Tubo-ovarian abscess
Transvaginal ultrasound image of the left adnexa showing a tubo-ovarian

abscess. A complex solid and cystic mass is identified in the left adnexa. The
tubo-ovarian abscess is seen as a complex cyst (large arrow) and fluid-filled
tube (short arrow).

Shipp, MD.

Frequency of symptom categories in women with ovarian cancer
Type of symptom Percent
Abdominal 77
Gastrointestinal 70
Pain 58
Constitutional 50
Urinary 34
Pelvic 26
Data from: Goff BA, Mandel L, Muntz HG. Melancon CH. Ovarian carcinoma diagnosis. Cancer 2000; 89:2068.

Paraovarian cyst
Transvaginal ultrasound image of the left adnexa showing a paraovarian cyst. An

anechoic structure is noted in the left adnexa separate from the left ovary. The
cyst has a thin wall, as indicated by the arrow, with no identifiable ovarian tissue
surrounding the cyst.

Shipp, MD.

Endometrioma
Transvaginal ultrasound image of the right adnexa showing an endometrioma of

the right ovary. The homogeneous echo pattern of the cyst contents (ie,
"ground-glass" appearance) is characteristic of an endometrioma (short arrow).

Shipp, MD.

Benign mature ovarian teratoma (dermoid cyst) on ultrasound
Transvaginal ultrasound image of a benign teratoma that features heterogeneous contents, smooth outer surface. The arrow points to lines that are hair. There are
hyperechoic portions and homogeneous echoes (mucin).
Courtesy of Lauri Hochberg, MD.

Benign mature ovarian teratoma (dermoid cyst) on ultrasound
Transvaginal ultrasound of a mature teratoma in the ovary containing heterogeneous contents, which often shadow. It is round and well circumscribed. This image
contains the "ovarian crescent" sign, which is a rim of normal-appearing ovary with follicles. These features suggest a benign cyst.
Courtesy of Lauri Hochberg, MD.

Pedunculated fibroid
Transvaginal ultrasound image of the right adnexa showing a pedunculated

fibroid. A solid-appearing mass is noted in the right adnexa (long arrow). No
cystic areas are identified. The mass is slightly heterogeneous and has no
appreciable posterior enhancement but has some areas of shadowing (short
arrow). The mass is separate from the right ovary. The arrowhead demonstrates
a thick stalk that connects the fibroid to the uterus.

Shipp, MD.

Hydrosalpinx
Transvaginal ultrasound image of the adnexa showing a hydrosalpinx. There is a

tubular fluid collection with low-level echoes. An incomplete septation is
identified by the arrow.

Shipp, MD.

Hydrosalpinx
Transvaginal ultrasound image of the adnexa showing a

hydrosalpinx with three-dimensional rendering. A cystic structure
with a septation (arrow) is identified in the adnexa. The rendered image (on right side of
illustration) demonstrates a tubular fluid collection with incomplete septations indicating a
serpiginously dilated fallopian tube.
Reproduced with permission from: Thomas D Shipp, MD. Copyright © Thomas D Shipp, MD.

Sonographic appearance of ovarian cystadenocarcinoma
(A) Gray-scale.
(B) Color Doppler.
Reproduced with permission from Maitray Patel, MD.

Contributor Disclosures
Maitray D Patel, MD Nothing to disclose Barbara Goff, MD Employment (Spouse): Lilly [General oncology] - No relevant conflict on topics. Deborah
Levine, MD Nothing to disclose Alana Chakrabarti, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review
process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Ultrasound Differentiation of Benign Versus Malignant Adnexal Masses - UpToDate

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OVERVIEW OF SONOGRAPHIC APPROACH

https://sibib2.ucm.cl:2141/contents/ultrasound-differentiation-of-benign-versus-malignant-adnexal-masses/print?search=patologia anexial&source=se… 1/31

https://sibib2.ucm.cl:2141/contents/ultrasound-differentiation-of-benign-versus-malignant-adnexal-masses/print?search=patologia anexial&source=se… 2/31

Clinical examples include:

https://sibib2.ucm.cl:2141/contents/ultrasound-differentiation-of-benign-versus-malignant-adnexal-masses/print?search=patologia anexial&source=se… 3/31

STEPS IN CHARACTERIZING A MASS

● Round or oval shape

● Anechoic fluid filling the cyst cavity

● No internal flow with color Doppler imaging

In premenopausal women, the 2019 SRU consensus advises [26]:

● Simple cysts up to 3 cm are considered normal.

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● Cysts greater than 1 cm in size should be documented.

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Sonographic characteristics of an endometrioma include:

● There may be varying degrees of echogenicity in the different locules.

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Sonographic characteristics of a mature teratoma include (image 8 and image 9):

● Floating globules is an uncommon appearance of teratomas but seems to be predictive [51].

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● Color or power Doppler demonstration of flow in the solid component.

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Other additional tests

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

(See 'Sonographic techniques' above.)

• Solid component that is not hyperechoic and is often nodular or papillary

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2. Seungdamrong A, Weiss G. Ovulation in a postmenopausal woman. Fertil Steril 2007; 88:1438.e1.

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Topic 3208 Version 30.0

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Differential diagnosis of an adnexal mass

Functional (physiologic) cyst Ectopic pregnancy Paraovarian cyst Constipation

Epithelial carcinoma Epithelial carcinoma Metastatic endometrial carcinoma Appendiceal neoplasm

Graphic 107713 Version 4.0

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Sonographic appearance of adnexal masses

Sonographic appearance and specific etiologies Malignant?

Non-neoplastic physiologic cyst (dominant follicle, arrested follicle, corpus luteum) No

Paraovarian or paratubal cyst No

Cystadenoma (ovarian or tubal) No

Anechoic cysts with thin septations (complete or incomplete)

Two adjacent non-neoplastic physiologic cysts No

Peritoneal inclusion cyst No

Theca lutein cysts No

Cysts with internal echoes, no solid areas

Non-neoplastic physiologic cyst with hemorrhage No

Abscess (gynecologic or gastrointestinal) No

Benign ovarian neoplasm (cystadenoma, cystic teratoma) No

Borderline ovarian tumor Yes

Gastrointestinal (duplication cyst, mucocele) Usually not (mucoceles

Mature cystic teratoma No

Cystadenoma (ovarian or tubal) No

Cystadenocarcinoma (ovarian or tubal, including borderline tumors) Yes

Mostly or completely solid mass

Leiomyoma (pedunculated or broad ligament) No (but rarely may be

Epithelial ovarian or tubal carcinoma Yes