Wo m e n ’s I m a g i n g • O r i g i n a l R e s e a r c h

Hassen et al.
Ultrasound of Ovarian Masses

Women’s Imaging
Original Research

Characterization of Papillary
Projections in Benign Versus
Borderline and Malignant Ovarian
Masses on Conventional and Color
W O M E N ’S
IMAGING Doppler Ultrasound
Kamel Hassen1 OBJECTIVE. The purpose of our study was to evaluate on endovaginal ultrasound the
Michel A. Ghossain2 morphologic and color Doppler characteristics of papillary projections in benign compared
Pascal Rousset 1 with borderline and malignant epithelial stromal ovarian tumors.
Catherine Sciot 1 MATERIALS AND METHODS. A total of 283 women (mean age, 52 years; age range,
Danielle Hugol 3 20–85 years) with 343 operated adnexal masses comprising 167 epithelial stromal tumors of
the ovary with 76 tumors containing papillary projections at pathology were retrospectively
Rafic Baddoura4
studied on ultrasound. We systematically evaluated the topography of the papillary
American Journal of Roentgenology 2011.196:1444-1449.

Dominique Vadrot 1 projections, the morphologic features of the largest papillary projection, and the presence or
Jean-Noël Buy 1 absence of color Doppler findings. All these findings were correlated with macroscopic and
Hassen K, Ghossain MA, Rousset P, et al. microscopic features.
RESULTS. Ultrasound detected papillary projections in 78% of tumors. Papillary
projections were disseminated in 33% of malignant, 20% of borderline, and 0% of benign
tumors (p = 0.0049). The mean size of the papillary projections was 9.6, 15.7, and 35.3 mm
in benign, borderline, and malignant tumors, respectively (p = 0.0007). An acute angle
was present in 68% of benign tumors and an obtuse angle in 40% of borderline and 89%
of malignant tumors (p = 0.0001). The surface was regular in 77% of benign tumors and
irregular in 50% of borderline and 88% of malignant tumors (p = 0.0000). Calcifications
were present only in benign tumors (18%). For papillary projections ≥ 10 mm, color flow was
present in all malignant, in 86% of borderline, and absent in all benign tumors.
CONCLUSION. Association of morphologic and vascular ultrasound findings can
Keywords: color Doppler imaging, ovarian neoplasm, highly suggest the diagnosis of benign or malignant papillary projection.
ovary, papillary projection

DOI:10.2214/AJR.10.5014
Received May 18, 2010; accepted after revision
November 29, 2010.
1
Department of Radiology, Hôtel Dieu de Paris,
Assistance Publique des Hôpitaux de Paris, Université
Paris Descartes, 1 Pl du Parvis Notre Dame, 75004, Paris,
France. Address correspondence to P. Rousset
(roussetpascal@gmail.com).
2
Department of Radiology, Hôtel Dieu de France CHU,
Université Saint-Joseph, Beirut, Lebanon.
3
Department of Pathology, Hôtel Dieu de Paris,
Assistance Publique des Hôpitaux de Paris, Université
Paris Descartes, Paris, France.
4
Faculty of Medicine, Hôtel Dieu de France CHU,
Université Saint-Joseph, Beirut, Lebanon.
AJR 2011; 196:1444–1449
0361–803X/11/1966–1444
© American Roentgen Ray Society
A
t pathology, papillary projections
in an ovarian mass are considered
diagnostic of epithelial stromal
tumor, commonly referred to as
epithelial tumors, which can be benign, bor-
derline, or malignant [1–4]. This statement
applies to pathology because on ultrasound a
clot or any other amorphous material can sim-
ulate a true papillary projection. Papillary
projection is defined at pathology as folding of
the proliferating neoplasmic epithelium
growing over a central fibrovascular stromal
core as opposed to more nondescript solid tis-
sue [1]. Papillary projections are mainly locat-
ed against the inner wall of the cyst (endocys-
tic papillary projections) or more rarely on the
septa or the outer wall of the mass (exocystic
papillary projections). Although a definite di-
agnosis of benignity versus malignancy or
borderline malignancy can only be made at
microscopy, macroscopic findings of these
papillary projections can highly suggest the
diagnosis [3, 4]. Papillary projections in be-
nign cystic tumors have already been reported
by different imaging techniques but, to our
knowledge, no attempt was made to differen-
tiate them from their borderline or malignant
counterparts on the basis of morphologic find-
ings [5, 6]. Thus, the primary purpose of this
article was to retrospectively evaluate on ul-
trasound a detailed analysis of the morpholog-
ic findings of papillary projections in these tu-
mors correlated with macroscopic and micro-
scopic findings. We also reevaluated the color
Doppler findings previously described [5, 7, 8]
in the differentiation of benign versus border-
line and malignant tumors.
Materials and Methods
From January 2003 to January 2009, with the ap-
proval of our institutional review board that waived
the need to obtain patient consent, 345 consecutive
women (mean age, 50 years; age range, 18–85 years)
with a suspicion of an adnexal mass on a previous

1444 AJR:196, June 2011

 Ultrasound of Ovarian Masses

ultrasound or at pelvic examination were retrospec- TABLE 1:  Histology of Tumors

tively studied with endovaginal ultrasound and col-
Tumors With Papillary
or Doppler imaging.
Tumor Type No. of Patients No. of Tumors Projections at Pathology
All ultrasound studies were made by two radiolo-
gists with more than 15 and 20 years’ experience Epithelial stromal tumors 132 167 76
in gynecologic ultrasound on an ATL HDI 5000 Germ cell tumors 38 46 0
(Philps Healthcare) sonography scanner with a 5–2- Sex and stroma cell tumors 17 17 0
MHz transabdominal probe and an 8–4-MHz trans-
Endometriomas 40 56 0
vaginal probe. On color Doppler imaging, color flow
was evaluated with a pulse repetition frequency be- Functional hemorrhagic cysts 41 41 0
tween 1000 and 1500. The presence or absence of Pelvic inflammatory disease 10 11 0
Doppler flow, arterial or venous, was identified by Paraovarian cysts and hydrosalpinx 5 5 0
spectral Doppler imaging to rule out artifact.
Total 283 343 76
All gross and histologic examinations were
done by one pathologist who specialized in gyne-
cology or his assistant using the same standard- ing in a cystic portion but usually of a larger size • Its size: the largest transverse diameter (i.e., par-
ized protocol as the search for papillary projec- with a more or less round shape, homogeneous, allel to the wall or the septum) was measured.
tions and their description. or with degenerative changes (particularly necro- • The angles with the wall of the cyst: a large base of
Two hundred eighty-three women (mean age, sis). However, in some cases a clear landmark be- implantation forming an obtuse angle with the wall
52 years; age range, 20–85 years) with 343 adnex- tween papillary projection and solid tissue can be of the cyst or a short base of implantation forming
al masses underwent surgery (Table 1). Among difficult to define. In these cases, identification of an acute angle with the wall of the cyst. If the pap-
American Journal of Roentgenology 2011.196:1444-1449.

these patients, 132 had 167 ovarian epithelial stro- the echoic portion as solid tissue was retained. illary projection had an acute angle on one side and
mal tumors at pathology; 76 of 167 of these ovar- • Presence or absence of classical findings of ma- an obtuse angle on the other side, it was recorded
ian tumors had papillary projections. Papillary lignancy other than papillary projections, i.e., as having an obtuse angle. When this angle could
projections were present in 26 of 75 (35%) benign an irregular thickened septa or irregular thick- not be definitely assessed, the character of the base
tumors, 11 of 15 (73%) borderline tumors, and 39 ened wall, presence or absence of an irregu- of implantation was classified as indeterminate.
of 77 (51%) malignant tumors (Table 2). Papillary lar homogeneous or heterogeneous echogenic • The surface of the papillary projection: regular
projections were not present in nonepithelial stro- structure suggesting solid tissue [5, 9]. or irregular or indeterminate.
mal tumors at pathology (Table 1). When one or several papillary projections were • The presence or absence of calcification identified
The ultrasound examinations of the 283 women present, we systematically evaluated the following: as a hyperechoic focus with acoustic shadowing.
were reviewed by two radiologists who were blind- • The topography of the papillary projections: local-
ed to the pathologic results. They systematical- ized (< 50% of the inner surface of the cyst) or dis- Color Doppler Ultrasound
ly and retrospectively evaluated together the mass seminated (≥ 50% of the inner surface of the cyst). The presence or absence of color flow in the pap-
on contiguous sagittal and transverse still images • The morphologic features of the largest papil- illary projections (either arterial or venous as iden-
spaced 3–5 mm. Interobserver variation was re- lary projection (when multiple in a tumor, the tified by spectral Doppler ultrasound to eliminate
solved by consensus. In all 283 patients, presence largest papillary projection was considered as artifact) was reported. Spectral Doppler ultrasound
or absence of papillary projections and presence the most representative of the tumor). findings, such as resistivity index, pulsatility index,
or absence of flow in these papillary projections
were evaluated. In a second evaluation, a more de- TABLE 2:  Histology of Epithelial Stromal Tumors and Papillary Projections
tailed study as specified in the following sections
was made of tumors in which papillary projections No. of Adnexal Tumors with Papillary
were present at pathology. Histology No. of Patients Masses Projections at Pathology
Serous 33 42 25
Conventional Ultrasound Mucinous 27 27 0
For each tumor in which one or several papillary
Brenner 6 6 1
projections were detected on ultrasound and con-
firmed at pathology, we evaluated the following: Borderline serous 9 10 10
• The characteristics of the mass, whether unilat- Borderline mucinous carcinoma 5 5 1
eral or bilateral, unilocular or multilocular, and Serous carcinoma 19 32 24
its size.
Mucinous carcinoma 9 10 3
• Presence or absence of an echogenic structure
against the wall of the cyst suggesting a papillary Endometrioid carcinoma 10 13 5
projection. A papillary projection was defined on Clear cell carcinoma 4 4 3
ultrasound as a focal echoic structure against the Undifferentiated carcinoma 5 9 1
inner or outer wall or septum or protruding inside
Composite carcinomaa 5 9 3
a cystic portion or outside a mass. On the other
hand, solid tissue was defined as an echoic struc- Total 132 167 76
ture not protruding in a cystic portion or protrud- aComposite carcinoma: association of different histologic type of carcinoma in the same tumor.

AJR:196, June 2011 1445

 Hassen et al.

and maximum systolic velocity, were not analyzed
in this study because these findings have been ex-
tensively studied in the literature and are of lim-
ited value [5].
Statistical Analysis
For statistical analysis, borderline and carcinoma
findings were placed in one group to have enough
values to compute the different tests. For size, we
compared papillary projections < 10 mm versus pap-
illary projections ≥ 10 mm. For angles, we compared
acute angles versus obtuse and indeterminate angles.
For surface, we compared regular surface versus ir-
regular and indeterminate surface. For location,
we compared nondisseminated versus disseminat-
ed papillary projections. The following tests were
performed: chi-square test with a p value of < 0.05
considered statistically significant; sensitivity, spec-
ificity, positive predictive value (PPV), negative
predictive value (NPV), and accuracy with evalua-
tion of the 95% CI; and multivariate analysis.
American Journal of Roentgenology 2011.196:1444-1449.
jections in 59 tumors (22 benign, 10 border-
line, and 27 malignant). The size of these tu-
mors ranged from 2.5 to 24.0 cm (mean, 8.3
cm): 2.5 to 24.0 cm (mean, 8.4 cm) in benign
tumors; 4.0 to 9.0 cm (mean, 6.2 cm) in bor-
derline tumors, and 4.0 to 15.0 cm (mean, 8.3
cm) in malignant tumors.
Benign tumors were bilateral in four patients
and unilateral in 14 patients. Borderline tumors
were bilateral in one patient and unilateral in
eight patients. Malignant tumors were bilateral
in six patients and unilateral in 15 patients.
Among the 27 carcinomas with papillary
projections, associated irregular solid tissue
was observed in seven (26%) of 27 tumors;
irregular thickened wall was present in two
(7%) of 27 tumors; and septa were thickened
and irregular in two tumors, one of which
had solid tissue. Finally, classic findings of
malignancy other than papillary projections
were present in 10 (37%) of 27 tumors, three
es and thin and regular in one case. The wall
was regular in all cases. Solid tissue was pres-
ent in none of the cases. Finally, classic find-
ings of malignancy other than papillary projec-
tions were present in two tumors.
Among the 22 benign tumors with papillary
projections, 15 serous tumors were bilocular
or trilocular, with thin and regular septa
and wall in all cases. Associated solid tissue
was present in none of these cases. Classic
findings of malignancy other than papillary
projections were present in none of 22 tumors.
Detection of Papillary Projections
Among 343 masses of all kinds, ultrasound
detected endocystic papillary projections in 59
of 76 (78%) epithelial tumors with papillary
projections. Among the 267 ovarian tumors
without papillary projection at pathology, ul-
trasound falsely diagnosed papillary projec-
tions in 11/267 (4%) adnexal masses. Finally,

Results
Characteristics of the Mass
Among the 76 tumors with papillary pro-
jections, ultrasound detected papillary pro-
of which had papillary projections < 10 mm.
Among the 10 borderline tumors with pap-
illary projections, the tumors were unilocular
in seven, multilocular in two, and bilocular in
one. Septa were thick and irregular in two cas-
ultrasound detected papillary projections with
a sensitivity of 78%, a specificity of 96%, a
PPV of 84%, an NPV of 94%, and an accuracy
of 92%). The morphologic findings of detected
papillary projections are shown in Table 3.

TABLE 3:  Morphologic Findings of Papillary Projections in Benign, Borderline, and Malignant Tumors
No. of Lesions Performance Value
Tumor Characteristic Benign (n = 22) Borderline (n = 10) Malignant (n = 27) Odds Ratio (95% CI) p
Size (mm) 7.46 (1.89–29.43) 0.0007
≤5 7 2 2
6–9 6 1 1
10–14 4 0 1
15–19 4 4 0
≥ 20 mm 1 3 23
Angle 11.07 (2.51–48.84) 0.0001
Acute 15 5 1
Obtuse 3 4 24
Indeterminate 4 1 2
Surface 12.33 (2.68–56.60) 0.0000
Regular 17 5 3
Irregular 1 4 21
Indeterminate 4 1 3
Dissemination ND 0.0049
Not disseminated 22 8 18
Disseminated 0 2 9
Calcificationa
Present 4 0 0
Absent 18 10 27
Note—ND = odds ratio could not be estimated because no benign lesion had disseminated papillary projections but the p value was significant.
aThe number of calcifications was too small to compute the chi-square test.

1446 AJR:196, June 2011

 Ultrasound of Ovarian Masses

A B C
Fig. 1—40-year-old woman with malignant papillary projections in serous cystadenocarcinoma.
A, Endovaginal ultrasound image shows 7-cm cystic ovarian mass containing endocystic papillary projections, largest one > 2 cm, with broad base of implantation
forming obtuse angle with inner wall and irregular surface. Cystic content is uniformly low echoic.
B, Color Doppler ultrasound image shows large vessels at base of papillary projection.
C, Photograph of surgical specimen shows multiple papillary projections, some of which are confluent. Scale is cm.

Among the 76 tumors with papillary pro-
jections at pathology, papillary projections
were not detected on ultrasound in 17 (22%)
of 76 tumors: four benign, 12 malignant,
American Journal of Roentgenology 2011.196:1444-1449.
and one functional cyst, accumulation of mu-
cin in one mucinous cystadenoma, a small por-
tion of normal parenchyma protruding in a se-
rous cyst, a small echogenic portion in a der-
moid cyst, and a tubal fold in a hydrosalpinx
of 100%, NPV of 76%, and an accuracy of
88%. Color flow was absent in all papillary
projections < 10 mm whether benign, bor-
derline, or malignant (Figs. 1–3).
For the assessment of tumors containing

and one borderline. In the four benign tu-

mors, the size of papillary projections was
≤ 2 mm. These four tumors were unilocular
cysts with a thin wall and without solid tis-
sue, so that these tumors were preoperative-
ly considered benign tumors. In the one bor-
derline and 12 malignant tumors, endocystic
papillary projections could not be visualized
in 12 tumors in which the size of papillary
projections was ≤ 2 mm and in one tumor
in which the size was 5 mm; moreover, in
these 13 tumors, exocystic papillary projec-
tions with size ≤ 5 mm were invisible in six
tumors. It must be noted that in all these 13
cases, malignant irregular solid tissue was
present, and therefore these cases were con-
sidered malignant preoperatively.
Among the 267 ovarian tumors with­out
papillary projection at pathology, papillary
projections on ultrasound were falsely iden-
tified in 11 (4%) of 267 cases. These cases
were related to a clot in six endometriomas
falsely considered as an ovarian cyst. Color
flow was absent in all these 11 echoic struc-
tures falsely considered as papillary projection.
Morphologic Findings of Papillary Projections
Morphologic findings and topography of the
largest papillary projection assessed in 59 tu-
mors (22 benign, 10 borderline, 27 malignant)
(Figs. 1–3) showed that dissemination, size,
wide angle, and irregular surface were indica-
tive of malignancy (p values in Table 3). Cal-
cification was indicative of benign lesions, but
we did not have sufficient data to compute the
chi-square test.
Color Doppler Findings in Papillary Projections
Color Doppler findings were present in 30
of 37 borderline and malignant tumors and
absent in all 22 benign tumors, with sensi-
tivity of 81% (95% CI, 64.8–92.0%), speci-
ficity of 100% (95% CI, 84.6–100%), PPV
papillary projections ≥ 10 mm, color Doppler
findings were absent in nine of nine (100%)
benign tumors. Conversely, color Doppler
findings were present in 24 of 24 malignant
tumors and in six of seven borderline tu-
mors, with sensitivity of 97% (95% CI, 83.3–
99.9%), specificity of 100% (95% CI, 66.4–
100%), PPV of 100%, NPV of 90%, and an
accuracy of 97%.
Multivariate Analysis
Three variables were dropped from the
multivariate analysis because they were ful-
ly predictive of the outcome of interest—that
is, malignancy (presence of color Doppler
flow in the papillary projection and dissemi-
nation of papillary projections ≥ 50% of the
surface) or benignity (presence of calcifica-
tions in the papillary projection). Therefore,
we performed a logistic regression test with
malignancy as the binary dependent variable,

Fig. 2—20-year-old woman with serous

cystadenoma.
A and B, Endovaginal color Doppler ultrasound image
(A) and photograph of surgical specimen (B) show
4-cm ovarian cyst with small group of four papillary
projections, measuring less than 5 mm at base of
implantation. Papillary projections form acute angle
with inner wall of cyst. No color flow is detected in
papillary projections. Scale is cm.
A B

AJR:196, June 2011 1447


A B
Fig. 3—58-year-old woman with serous cystadenoma.
A, Endovaginal ultrasound image discloses right cystic ovarian mass of 6 cm containing 2.5-cm endocystic papillary projection with broad base of implantation and
obtuse angle.
B, Color Doppler ultrasound image shows no vessel is detected in this papillary projection, which measured greater than 1 cm.
C, Photograph of surgical specimen shows that papillary projection seen on ultrasound corresponds to group of gathered small endocystic benign papillary projections.
Scale is cm.
and three independent binary variables signif-
icantly associated with malignancy in univar-
iate analysis were included in the model: size
American Journal of Roentgenology 2011.196:1444-1449.
of the papillary projection (using a threshold
of 10 mm or more), angle within the cyst (ob-
tuse or indeterminate versus acute), and as-
pect of the surface of the papillary projection
(irregular or indeterminate versus regular).
Using a backward approach, only size ≥ 10
mm and irregular or indeterminate surface
remained significant predictors of malignan-
cy, with odds ratios (95% CI) as 8.35 (1.85–
37.61) and 13.46 (3.15–57.52), respectively.
Because color Doppler flow was negative
in all 19 subjects with size of papillary projec-
tions < 10 mm, we looked more specifically at
this subgroup. None had a dissemination ≥ 50%
of the surface. The presence of one of the two
remaining characteristics, i.e., irregular sur-
face and an obtuse angle, was more common
in the presence of malignancy, with odds ratios
of 4.15 (0.42–40.79) and 1.21 (0.12–11.99), re-
spectively, although not statistically significant.
Discussion
As has already been reported, papillary
projections can be missed on ultrasound
[10] and MRI [2], mainly because of their
small size (< 5 mm). Papillary projections
can also be missed because of their exocys-
tic location, as in six (8%) of the 76 cases in
our study; however, in these cases, these exo-
cystic papillary projections were associated
with endocystic papillary projections.
On the contrary, echogenic structures
against the inner wall of the cyst can be false-
ly considered as papillary projections [11]. In
our study, the main source of false-positive
findings was amorphous material, essentially
clots; however, vascularized structures, es-
1448 AJR:196, June 2011
Hassen et al.
pecially tubal fold in a hydrosalpinx, can also
be confused with an endocystic papillary pro-
jection. No color flow was detected in these
false-positive cases, but this is not sufficient
to exclude papillary projections because color
flow may be absent in benign, borderline, and
even small malignant papillary projections.
On the other hand, although not present in this
series, tubal folds in a hydrosalpinx or protru-
sion of normal ovarian parenchyma may show
exceptional color flow.
Although all patients with a cyst containing
papillary projections will likely undergo sur-
gical removal of the cyst [2], preoperative as-
sessment of a tumor or a papillary projection
as benign, borderline, or malignant is funda-
mental, particularly in young women. This
will help the surgeon to decide the type of
surgery (cystectomy, ovariectomy, or adnex-
ectomy) and the surgical approach (laparos-
copy or laparotomy through Pfannenstiel
or midline incision).
Although several scoring systems and
models for masses containing papillary pro-
jections have been suggested to character-
ize papillary projections [12, 13], this study
shows that on conventional ultrasound, topog-
raphy, size, and morphologic findings corre-
lated with macroscopic findings, and presence
or absence of color flow can be used to char-
acterize papillary projections.
Benign epithelial tumors have fewer papil-
lary projections than borderline or malignant
masses [1, 3, 4, 14]. In our study, dissemi-
nated papillary projections (covering ≥ 50%
of the surface of the tumor) were present in
0% of benign, 25% of borderline, and 50%
of malignant tumors.
At pathology, benign epithelial tumors show
smaller papillary projections than borderline
C
or malignant masses [1, 3, 4]. However, there
is an overlap of sizes, and our data outline the
problem of choosing a threshold. If a thresh-
old < 10 mm was chosen for benignity, there
would be 13 (59%) of 22 benign, three (30%)
of 10 borderline, and three (11%) of 27 car-
cinomas. However, in these three cases of
malignant tumors, the small papillary pro-
jections were associated with solid irregular
tissue, and these tumors would be correct-
ly classified as malignant on the basis of the
solid irregular tissue. The problem would be
with the three borderline tumors. If a thresh-
old ≤ 5 mm was chosen, there would be still
a problem with two borderline tumors. If a
threshold > 20 mm was chosen for malignan-
cy, papillary projections would be found in
23 (85%) of 27 malignant tumors, in three
(30%) of 10 borderline tumors, and in only
one (5%) of 22 benign tumors.
The angle of the papillary projection with
the wall could not be assessed as acute or ob-
tuse in seven (12%) of 59 tumors. In the other
cases, an acute angle was more common in be-
nign tumors and an obtuse angle in malignant
tumors, whereas no significant difference was
found in borderline tumors (Table 3).
As reported by Krigman et al. [1], the lin-
ing of the surface of benign papillary pro-
jections is usually smooth, whereas papillary
projections of malignant tumors have high-
ly irregular angular margins. These findings
could not be clearly defined in eight (14%)
of 59 tumors in our series. As for the angle
in the other cases, there was a difference for
benign and malignant tumors but not for bor-
derline (Table 3).
Although calcifications have been reported
in carcinoma at pathology [1], calcifications of
a sufficient size to be detected on ultrasound

were only encountered in four of 22 benign tu-
mors and never in borderline and malignant tu-
mors in our series. Although the sensitivity of
this finding was low (18%), its specificity was
high (100%) for prediction of a benign lesion.
Although papillary projections in benign
tumors have a loose stromal fibromatous
core, malignant tumors have intricate papil-
lary projections with a central fibrovascular
core [1]. Because of the presence or absence
of angiogenesis, size and number of vessels
are substantially more common in malignant
than in borderline or benign tumors [5]. The
size of a structure is also an important factor
that can influence the detection of Doppler
flow [15]. This study and a previous study [5]
show the absence of color flow in all papil-
lary projections < 10 mm and in all benign
papillary projections, even in those ≥ 10 mm.
Conversely, color flow was present in all ma-
lignant and borderline papillary projections
American Journal of Roentgenology 2011.196:1444-1449.
≥ 10 mm except in one borderline tumor in
this study.
Association of morphologic findings and
color Doppler findings seems to be the best
method to characterize the type of papillary
projections. When size of the papillary
projection is ≥ 10 mm, the PPV for malignancy
is 77.5%. If, in addition, color Doppler flow is
detected or dissemination ≥ 50% is present,
then the PPV is 100%. If size of the papillary
projection is ≥ 10 mm but neither Doppler
flow nor dissemination ≥ 50% is present, an
irregular surface significantly increases the
likelihood of malignancy.
When the size of the papillary projection
is < 10 mm, the corresponding NPV is
68.4% regardless of the other determinants
of malignancy defined in our method, i.e.,
an irregular thickened septa or wall and an
irregular solid component. Excluding subjects
with such determinants of malignancy, the
NPV is 86.7%. It is worth noting that among
subjects with papillary projections < 10 mm,
dissemination ≥ 50% was always absent. In
this group, an irregular surface or obtuse-
indeterminate angle favored malignancy,
although the association was not statistically
significant because of the small sample size.
Our study has limitations. The study is ret-
rospective and purely descriptive. The use of
AJR:196, June 2011 1449
Ultrasound of Ovarian Masses
still images may limit the descriptive accu-
racy of some findings, such as angle and dis-
semination, but this is tempered by the use
of contiguous images obtained by an experi-
enced radiologist aware of the importance of
these features. A large prospective study com-
bining the different morphologic and vascu-
lar findings defined as suggestive of benign
versus malignant tumor is needed to provide
more elaborate statistical results in the char-
acterization of papillary projections.
Only surgically proven masses were in-
cluded in this series. Thus, all functional
hemorrhagic cysts that disappeared on fol-
low-up were excluded, limiting the false-
positive diagnosis of papillary projections
because of clots that can occur in practice.
Exocystic papillary projections are pres-
ent in as many as 70% of cases [3, 4] in bor-
derline serous tumors. However, these pap-
illary projections, which were present in six
borderline serous tumors of our series, were
overlooked on ultrasound.
In conclusion, this study shows that a cer-
tain number of morphologic and Doppler
findings can highly suggest the diagnosis of
benign versus malignant papillary projec-
tion, although an overlap exists, especially
with borderline tumors. Large size, acute an-
gle, irregular surface, and disseminated pat-
tern are suggestive of malignancy whereas
calcification is suggestive of benignity. Ab-
sence of color flow in a papillary projection ≥
10 mm is suggestive of benignity. These find-
ings will help the surgeon decide the type of
surgery and the surgical approach.
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