Mammography and

BIRADS
Tiffanie Uy, MD, MBA
Mammography
• Radiographic examination for detecting breast pathology, particularly
breast cancer
• Detects at an earlier, more treatable stage
• Low-cost, low-radiation dose procedure
• Screening mammography: identify breast CA in asymptomatic
patients
• Single best test for early detection of breast cancer to reduce mortality
• Mediolateral oblique and craniocaudal views
• Diagnostic mammography: assess palpable lesions or evaluate
suspicious findings from screening mammography
• Additional x-ray projections, magnification views, spot compression views,
ultrasound, magnetic resonance imaging (MRI), or mammoscintigraphy.
Screening Guidelines
• Annual screening starting age of 45
• Optional biennial screening at age 55
• Women at high risk for breast CA should seek advice about screening
• Personal history of breast/ovarian CA
• BRCA1/BRCA2 gene mutation carrier
• Family history of breast CA
• Atypical ductal hyperplasia or lobular neoplasia on previous biopsy
• History of chest irradiation between ages 10 and 30 years

• Earlier screening for high risk women (as early as 25-30 years old)
Physics
• Molybdenum: Most common anode used to generate x-rays
• Lower energy x-rays (<40 kV)  Greater contrast between soft tissues
• Tungsten: More efficient, better longevity, yield lower radiation doses
than molybdenum

• Compression
• Spread overlapping structures for differentiation
• Minimize motion blurring and geometric unsharpness
• Reduce radiation dose
• Make the breast thickness uniform
Screening Mammography
• Mediolateral Oblique (MLO)
view: shows greatest amount of
breast tissue
• X-ray tube and image receptor
paralleling the patient’s pectoralis
major muscle
• Compression applied from
superomedial direction
• Shows pectoralis major muscle to
posterior nipple line, nipple in
profile
Screening Mammography
• Craniocaudal (CC) view
• X-ray tube is perpendicular to the
floor
• Pectoralis muscle is seen centrally
on the film, nipple in profile
Screening Mammography
• Artifacts
• Motion artifact: Due to patient
movement
• Obscure details of normal structures
and microcalfications
Tomosynthesis
• Digital breast tomosynthesis (DBT) = 3D mammography
• X-ray tube pivots in an arc while the patient is stationary
• Detects masses, asymmetries, and architectural distortion
• Thin slices of fibroglandular tissues  Increase chance of detecting
cancer
• Ability to differentiate true masses from superimposing breast tissue
Breast Density
• The breast is composed of radiopaque
breast parenchyma and radiolucent
fatty elements
• Relative amount of tissue density to
fat  Classified into 4 by the BIRADS
lexicon
• BIRADS a: Almost entirely fatty
• BIRADS b: Scattered fibroglandular tissue
• BIRADS c: Heterogenously dense
• BIRADS d: Extremely dense
Breast Density
• Increased breast density leads to
decreased mammographic sensitivity
to malignancy
• Due to masking effect
• Breast density is an independent risk
factor for breast cancer
• High density = more glandular tissue =
more epithelial cells that may become
malignant
Diagnostic Mammography
• Done in women with
• Recent abnormal screening mammogram
• Current sign/symptom of malignancy
• Follow-up for a probably benign finding
• Personal history of breast CA

• Uses MLO and CC views, as well as supplemental views

Diagnostic Mammographic Views
Diagnostic Mammography
• Asymmetries: Mammographic findings that do not conform to a
radiosense mass and seen only in one projection
• Evaluated with true lateral and rolled CC views
• If seen only in MLO view  True lateral
• If seen only in CC view  Rolled CC
• Spot compression views can also aid
• Tomosynthesis
• Ultrasound is useful in differentiating cystic from solid masses
Evaluation of the Symptomatic Patient
• Palpable breast mass
• Initial imaging modality depends on age.
• Ultrasound is preferred in young and/or pregnant women due to
• Relative radiation risk from mammography
• Higher breast density  Decreased mammographic sensitivity
Evaluation of the Symptomatic Patient
• Breast pain
• Second most common breast symptom for which advice is sought for
• Cyclical pain: Intermittent breast pain during the luteal phase, right before
menses
• No imaging evaluation is necessary
• Noncyclical pain: More focal and unilateral
• No imaging evaluation is necessary
Evaluation of the Symptomatic Patient
• Nipple discharge
• Third most common breast complaint
• Pathologic discharge: serous or bloody, spontaneous, unilateral, from one
duct
• Initial evaluation is dependent on age
• If mammography is negative, ultrasound is performed
• Physiologic discharge: green, yellow, milky, only with expression, bilateral,
from multiple ducts
• No imaging necessary
 Evaluation of the Symptomatic Patient
• Breast inflammation (erythema and
swelling)
• Ultrasound is initial imaging of choice
• Mastitis and breast abscesses occur more
often in younger women
• Mastitis: Common complication of
breastfeeding women
• Caused by Staphylococcus aureus
• On ultrasound: Area of heterogeneously altered
echotexture from the edema within the parenchyma,
skin thickening, and increased vascularity.

• Abscess: Palpable mass with overlying erythema

• Irregular, indistinct, heterogeneously hypoechoic
collection, sometimes with multiple loculations
 Evaluation of the Symptomatic Patient
• Breast inflammation (erythema
and swelling)
• Inflammatory breast cancer:
Important mimicker of mastitis
• Older patient, antibiotics do not provide
complete resolution within 1-2 weeks
• Presents with breast inflammation and
tenderness rapidly; sometimes with peau
d’orange (dimpling of skin)
• Skin punch biopsy can be diagnostic to
confirm the diagnosis
• On mammography: diffuse breast
enlargement, diffuse increased density, skin
thickening, and enlarged axillary lymph nodes
 Evaluation of the Symptomatic Patient
• Axillary adenopathy
• Frequently visualized on the MLO view
• Normal: Lucent centers/notches due to hilar fat
• Benign: Fatty infiltration of nodes  Lucent enlargement and replacement
• Pathologic: Homogenously dense and enlarged
• Can also enlarge due to inflammation
• RA, SLE, scleroderma, psoriasis, lymphoma, leukemia: Bilateral adenopathy
• Ipsilateral infection, metastatic breast cancer or skin cancer: Unilateral adenopathy
• Ultrasound used to assess the nodes
• Benign/normal: Hyperechoic hilum with him hypoechoic cortical rim
• Metastatic: Focal hypoechoic cortical thickening or complete replacement of the lymph
node
 The Male Breast
• Gynecomastia: Most common Causes of Gynecomastia
indication for imaging a male
breast
• Benign proliferation of ductal and
stromal tissue
• Triangular or flame-shaped area of
subareolar glandular tissue that points
toward the nipple with fat interspersed
within the parenchymal elements

• Initial imaging depends on patient’s age

Post-Operative Surveillance
• Annual mammography with either 2D or DBT should be performed to
check for recurrence
• Any calcification that develops within the lumpectomy site should be
evaluated closely
Assessment and Recommendation
• Role of diagnostics is to assign a final BI-RADS assessment to help
guide management
• Breast Imaging-Reporting and Data System (BI-RADS): Risk assessment and
quality assurance tool developed by ACR in 2013
• Standardize mammography practice and reporting
• Improve communication through breast imaging reports
• Standardize recommendations and management
 BI-RADS
INCOMPLETE
BI-RADS 0 Needs further imaging evaluation, for mammography, previous images not available at
time of reading
NEGATIVE
BI-RADS 1
Symmetrical and no masses, architectural distortion, or suspicious calcifications
BENIGN
BI-RADS 2
0% probability of malignancy
PROBABLY BENIGN
BI-RADS 3
< 2% probability of malignancy; short interval follow-up suggested
SUSPICIOUS FOR MALIGNANCY
2-94% probability for malignancy
- BI-RADS 4A: Low suspicion for malignancy (2-9%)
BI-RADS 4 - BI-RADS 4B: Moderate suspicion for malignancy (10-49%)
- BI-RADS 4C: High suspicion for malignancy (50-94%)
Biopsy should be considered
HIGHLY SUGGESTIVE OF MALIGNANCY
BI-RADS 5 >95% probability of malignancy
Appropriate action should be taken

BI-RADS 6 KNOWN BIOPSY-PROVEN MALIGNANCY

Mammography Lexicon
• Breast composition/density: Amount of fibroglandular tissue in breast
relative to amount of fat
• Fibroglandular tissue attenuates x-rays more than fat
• Assessment should be based on the densest area
Mammography Lexicon
• Breast masses: 3D structure that occupies space in the breast
• Seen on two different projections and has outward convex margins
• Characterized by shape, margin, and density
 Breast Mass Descriptions
Oval Similar to an egg; one axis longer than the others
Round Like a sphere/ball
Shape
Irregular Neither round/oval; can have small projections extending from a dominant portion of the
mass – more likely to be assessed as BI-RADS 4 or BI-RADS 5
Circumscribed Well-defined, smooth interface; usually benign (except phyllodes tumors, IDCs)
Obscured More than 25% of margin is not well seen due to overlapping fibroglandular tissue
Margin Microlobulated Several small bumps along the surface; usually seen in benign clustered microcysts
Indistinct Vague interface; looks fuzzy
Spiculated Straight lines extending out from the mass due to desmoplastic reaction; BI-RADS 5
High density Whiter than the surrounding tissue; most worrisome of mass-density categories
Equal density Similar x-ray attenuation to the surrounding tissue
Density
Low density Less white than the surrounding tissue; usually seen with cysts; more benign feature
Fat containing Dark gray area as a fat lobule
Mammography Lexicon
• Calcifications
• Described according to morphology and distribution
• Pathologic microcalcifications usually associated with necrotic tumor debris
• Most commonly seen with ductal carcinoma in situ (DCIS)
• Calcifications that follow a ductal distribution  Higher chance of malignancy
Calcifications
Small and fuzzy; seen in DCIS low grade, LCIS, atypical lobular
Amorphous hyperplasia, atypical ductal hyperplasia, fibrocystic changes,
sclerosing adenosis
Larger, between 0.5-1mm; seen in DCIS high grade, degenerating
Morphology Coarse heterogenous
fibroadenoma/papilloma, fibrocystic changes, fat necrosis
Fine pleomorphic <0.5mm, variety of size and shapes; higher chance of malignancy
Fine linear/ Thin and linear; like branches of a tree; ”Y” or “V” shapes  location
fine linear branching within branches of a milk duct; highest chance of malignancy
Diffuse Scattered randomly throughout the breast; lowest risk for malignancy
Regional Large area more than one ductal system
Grouped Small area, usually 2cm
Distribution
Linear Arranged in a line, suggestive of being within a milk duct; seen in DCIS
Wedge-shaped with broad base closer to the chest wall and tapering
Segmental
toward the nipple; 62% chance of malignancy
Typically Benign Calcifications
Skin Lucent-centered and multiple; superficial on one of the projections
Vascular In walls of arteries; tram-track appearance; follow path of arterial supply
Coarse/Popcorn Large, 2-3mm in size, oval and circumscribed mass
Seen in the duct, smooth and cigar-shaped; diffuse, bilateral, seen in postmenopausal
Large rod-like
women; “secretory calcifications”
Smooth, round circles, identical in appearance
Round - Diffuse/regional round = benign
- Grouped round = BI-RADS 3
- Linear/segmental/new/increasing/near known cancer = Suspicious
Rim Round/oval with lucent center like an eggshell; wall of an oil cyst or fat necrosis
Dystrophic Lucent center but with more irregular shape due to prior trauma or radiation
Milk of calcium Calcium precipitated out of the fluid within the cyst; fuzzy puddles in CC view;
teacup/curvilinear meniscus on ML/LM view
Suture Deposited around suture material; known history of surgery
Mammography Lexicon
• Architectural Distortion (AD)
• Normal architecture: Undulating intermixed fat lobules and fibroglandular
tissue
• Fibrosing process makes lines that mark the tissue-fat interface straight 
Distorting normal architecture
• Adjacent parenchyma may look retracted
• Causes: Prior surgery, trauma, fibrosis, fibrocystic changes, radial scar, cancer
(IDC and ILC)
• AD is a classic appearance of ILC, which may present without a visible mass
Mammography Lexicon
• Asymmetries
• Resembles a clump of normal fibroglandular tissue interspersed with fat
• NOT a mass
• Groups
• Asymmetry: Seen only on one view, due to superimposition of structures
• Global asymmetry: Large, involving more than one quadrant; benign variant
• Focal asymmetry: Seen on two views, smaller than a quadrant
• Developing asymmetry: Most suspicious type of asymmetry, new or larger compared to
priors
Mammography Lexicon
• Associated Features
• Important signs of malignancy
• Skin retraction
• Nipple retraction
• Skin thickening
• Trabecular thickening
• Axillary adenopathy
 Ultrasound Lexicon
• Masses are described according to their shape, margin, orientation,
echo pattern, and posterior features
• Shape descriptors are the same as in mammography
• Margin descriptors: circumscribed or not circumscribed
Oval Similar to an egg; one axis longer than the others
Round Like a sphere/ball
Shape
Irregular Neither round/oval; can have small projections extending from a dominant portion of the
mass – more likely to be assessed as BI-RADS 4 or BI-RADS 5
Circumscribed Well-defined, smooth interface; usually benign (except phyllodes tumors, IDCs)
Angular Edges of mass form acute angles or tail-like extensions – extension of mass from milk duct
Margin Microlobulated Several small bumps along the surface; usually seen in benign clustered microcysts
Indistinct Vague interface; looks fuzzy
Spiculated Straight lines extending out from the mass due to desmoplastic reaction; BI-RADS 5
Ultrasound Lexicon
• Masses are described according to their shape, margin, orientation,
echo pattern, and posterior features
• Shape descriptors are the same as in mammography
• Margin descriptors: circumscribed or not circumscribed
• Echo pattern: Echogenicity of internal contents
• No sound waves detected: Anechoic
• More echogenic than fat: Hyperechoic
• Less echogenic than fat: Hypoechoic
• Same as fat: Isoechoic
 Ultrasound Lexicon
• Orientation: Relative to chest wall
• Parallel to chest wall: Usually benign
• Anti-parallel (taller than wide): Suspicious for breast cancer
• Posterior features: Appearance of tissue deep to a mass
• No posterior features
• Enhancement: Structures with high water content (e.g. cysts or necrotic tumors)
• Shadowing: Dense structures (e.g. invasive breast cancers, fibrosis, large
calcifications)
• Combined
• Associated features: AD, duct changes, skin changes, edema vascularity
• Elastography: Assess stiffness of tissue – malignant cells may have firm
elastography
Ovarian Masses
Tiffanie Uy, MD, MBA
Ovarian Masses

Benign Malignant
• Simple Cyst • Serous Ovarian
• Physiologic ovarian Cyst Cystadenocarcinoma
• Serous cystadenoma • Endometrioid Carcinoma
• Mucinous cystadenoma
• Ovarian Metastases
• Hemorrhagic Cyst
• Endometrioma
• Mature Cystic Teratoma
 Simple Cyst
• US: Thin wall, anechoic internal contents,
posterior acoustic enhancement, no
septations or solid components
• Ex. Follicular or corpus luteal cysts, serous
cystadenoma
• Seen in 4-17% of postmenopausal women
• Remain stable or resolve on follow-up
ultrasound
• Annual follow-up sonography done if > 1 cm
• In premenopausal women, yearly follow-up
done if cyst measures between 5 and 7 cm
 Physiologic Ovarian Cyst
• MRI: Hypointense on T1WI, hyperintense
on T2WI
• Uniform, thin, dark wall evident on T2WI
• CT: Well-defined, thin-walled,
homogenous internal density near water
• > 3cm size indicative of physiologic
ovarian follicle
Serous Cystadenoma
• US: Unilocular cystic/anechoic without papillary projections, no flow
on Doppler
• Most common ovarian serous tumor
• Most common ovarian epithelial neoplasm
• Peak incidence at the 4th-5th decades of life
• Usually asymptomatic, but may have mass effect
• Treatment: Surgical removal
Serous Cystadenoma
• CT: Unilocular (typically) or multilocular cystic mass with
homogeneous CT attenuation, with a thin regular wall or septum, and
usually no endocystic or exocystic vegetation 
• MRI: Hypointense on T1WI, hyperintense on T2WI, with gadolinium
wall enhancement
Mucinous Cystadenoma
• US: Multilocular cystic/anechoic with
thin septations, low level internal
echoes due to increased mucin content
• Larger than serous cystadenomas
• Peak incidence at the 3rd-5th decades of
life
• Usually asymptomatic, but may have
mass effect Multiloculated cystic lesions measuring approx. 10 cm x
7 cm on right side, and 7 cm x 6 cm on left side are seen.
• Treatment: Surgical removal Lesions are anechoic with no solid areas within, and
shows thin internal septations.
Mucinous Cystadenoma
• MRI: Large multilocular cysts with fluid of various viscosity  Variable
signal intensities on both T1 and T2  “Stained glass” appearance
 Hemorrhagic Cyst
• US: Fibrin strands and retracting clot: Highly specific features
• Usually resolves within 8 weeks
• When to do follow-up study in 6-12 weeks
• Sonographically typical hemorrhagic cyst > 5cm
• Suspected hemorrhagic cyst with atypical morphologic features
• Hemorrhagic cysts in perimenopausal or early post-menopausal women
• Most significant potential complication: Rupture with hemoperitoneum
• May be difficult to distinguish from a ruptured ectopic pregnancy  Must check
hCG level
• Usually managed expectantly in hemodynamically stable patients
 Hemorrhagic Cyst
• MRI: May be low signal on both T1WI and T2WI, high signal on T1WI
and low signal on T2WI, or low signal on T1WI and high signal on T2WI
• Absence of enhancement differentiates internal blood clot affixed to the cyst
from a solid nodule
• CT: Thin-walled cysts with internal density near water or higher in
attenuation depending on the physical state of the blood products
Endometrioma
• US: Cystic lesions with diffuse low-level internal echoes (“ground
glass”), multilocularity, and echogenic foci in the wall
• Endometrial tissue outside the uterus—most commonly located in
the ovaries
• Common in women of childbearing age and 10x increase in
prevalence with an affected first-degree relative
• Symptoms: Cyclic pain, infertility, or sometimes asymptomatic
• Suspect malignancy (clear cell carcinoma or endometrioid
adenocarcinoma) if with solid mural nodules or rapid size increase
Endometrioma
• Surgical removal is considered for
symptomatic endometriomas
• Asymptomatic lesions can be
followed annually with
ultrasound
Endometrioma
• MRI: Homogeneous high intensity on T1WI and characteristically
low signal on T2WI (“T2 shading”)
• CT: Complex cystic pelvic masses, frequently with relatively high
attenuation fluid components; prominent inflammation and fibrosis
Mature Cystic Teratomas
• US: Focal/diffuse hyperechoic component, areas of acoustic
shadowing (“tip of the iceberg” sign), echogenic lines and dots
(dermoid ”mesh” or “dot-dash” sign)
• Hyperechoic component = Rokitansky nodule  Mixed hair and sebaceous
material or calcification
• Dermoids are composed of at least 2 of the 3 germ cell layers
(ectoderm, mesoderm, endoderm)
• 20% of ovarian neoplasms; most common germ cell ovarian neoplasm
• Seen in premenopausal women
• Most are asymptomatic and are incidental findings
Mature Cystic Teratomas
• May present with symptoms related to large size  Compression
• Torsion or rupture of dermoid may cause significant pain
• Potential complications:
• Malignancy: 80% of which are squamous cell carcinoma
• Features to watch out for: Isoechoic branching structures, demonstration of central flow
within mass by Doppler
• Hyperthyroidism: If with large amount of thyroid tissue
• Chemical peritonitis: Following spontaneous/iatrogenic rupture
• Ovarian torsion
Mature Cystic Teratomas
• MRI: Hyperintense on T1WI, hypointense on T2WI
• CT: Demonstration of fat density within a cystic adnexal mass is
definitive
Fibroma
• US: Hypoechoic solid masses, with marked posterior acoustic
shadowing
• Most common solid ovarian mass
• Usually asymptomatic, but can cause pelvic pain
• Occurs in women aged 40-50
• Meigs syndrome: Ascites + pleural effusion + ovarian fibroma
• Resolves following surgical removal of tumor
• MRI: Well-defined ovarian mass, hypointense on both T1WI and T2WI
• CT: Solid mass with minimal enhancement
Adnexal Torsion
• US: Unilaterally enlarged ovary (> 4cm), with or without smooth-walled
adnexal mass – nidus for twisting, concentric wall thickening; fallopian tube
appears as amorphous mass; uterus deviated toward the torsed adnexa
• Follicular ring sign: Perifollicular hyperechoic rim, 1-2mm thickness surrounding the
peripheral antral follicles of the torsed ovary
• Signs of hemorrhagic infarction:
• Marked wall thickening of adnexal mass (> 10mm)
• Hemorrhage within the mass and within the twisted tube
• Hemoperitoneum
• Partial or complete rotation of adnexal structures with obstruction of
vascular flow
• Involves either the ovary, the fallopian tube, or both
Adnexal Torsion
• Occurs predominantly in reproductive aged women, but can occur at any
age
• Predisposing factors:
• Ipsilateral adnexal mass
• Pregnancy
• Ovulation induction
• PCOS
• Prior pelvic surgery
• Hypermobility of adnexal structures
• Sudden onset abdominal/pelvic pain, palpable adnexal mass, peritoneal
signs, nausea/vomiting, fever, flank pain
Adnexal Torsion
• Ultrasound primary modality of choice
• CT scan may be the first study done in an
ER setting if ovarian torsion is not initially
considered.
• Enlarged ovary with or without an associated
mass, ovarian stromal edema with peripheral
follicles, inflammatory stranding in the
periovarian fat, a twisted vascular pedicle, a
thickened fallopian tube, pelvic free fluid,
midline position of the ovary, and deviation
of the uterus to the side of the twist
Ovarian Malignancy
• US findings suggestive of malignancy (similar to MR/CT findings)
• Presence of solid component, with detectable flow by Doppler imaging,
within a cystic ovarian mass  Most important sonographic feature for
predicting ovarian malignancy
• Larger solid component within a cystic mass  Higher chance of malignancy
• Presence of solid nodules (papillary projections, excrescences, or vegetations)
• Focal wall thickening (> 3mm)
• Invasion of adjacent structures
• Adenopathy
Ovarian Cancer
• Epithelial type: Most common
• Peak age of onset: 55-59 years old
• Insidious onset and silent growth pattern
• Increased CA-125: Serologic marker for ovarian cancer
• Spreads via peritoneal seeding, direct extension, and lymphatics
• CT primarily for follow-up
• MRI provides most detailed imaging evaluation
• Initial treatment: TAHBSO, with omentectomy, and tumor debulking
Ovarian Cancer
• Risk factors
• Nulliparity
• Early menarche
• Late menopause
• Positive family history
• Infertility
Ovarian Serous Cystadenocarcinoma
• US: Mixed cystic/solid lesion (more heterogenous than serous
cystadenoma), papillary projections, thick septations, and/or solid
components, with vascularity of solid components
• Most common type of invasive epithelial ovarian cancer
• Seen in postmenopausal women in their 60s and 70s
• Diagnosed at advanced stages 70% of the time
• Malignant form of ovarian serous cystadenoma
• Symptoms: Pain, swelling, or pressure in the pelvis; abnormal uterine
bleeding; lump in pelvic area
Ovarian Serous Cystadenocarcinoma
• MRI: Hypointense cystic portions on T1, hyperintense cystic portions
on T2, restricted diffusion on DWI on solid components
US: complex solid-cystic mass in the left ovary, and
another, very large complex solid-cystic mass in the
right hemi-pelvis

CT of the same patient shows a complex solid-cystic mass with

thick, enhancing septations in the right ovary. These findings
are very suspicious for a malignant cystic neoplams. There is
also bilateral lymphadenopathy (arrows)
Endometrioid Carcinoma
• Imaging findings are usually non-specific and include a large, complex
cystic mass with solid components
• Second most common malignant ovarian neoplasm
• 10-25% of primary ovarian carcinomas
• 15% coexist with endometriosis
• Treatment: Surgical removal
• US: Enlarged ovaries with cystic components and interspersed solid
components
• CT: Large bilateral complex solid-cystic lesions, bulging into the abdomen
Ovarian Metastases
• Occur by peritoneal spread,
direct extension, or
hematogenous dissemination
• Most come from colon cancers
• Most metastases: Solid, bilateral,
enhance avidly
• Krukenberg tumor: Mucinous
tumors metastatic to the ovary
from a mucinous gastric
carcinoma
References
• Brant, W. E., & Helms, C. A. (2018). Fundamentals of diagnostic radiology 5th
ed. Baltimore: Williams & Wilkins.
• Bushberg, J. T., Seibert, J. A., Leidholdt, E. M., & Boone, J. M. (2012). The
essential physics of medical imaging.
• Callen, P. W. (2016). Ultrasonography in obstetrics and gynecology.
Philadelphia: Saunders Elsevier.
• Veldhuis, W., Smithuis, R., Oguz, A., & Hricak, H. (n.d.). Ovarian Cysts -
Common Lesions. Retrieved May 26, 2020, from
https://radiologyassistant.nl/abdomen/ovarian-cysts-common-
lesions#malignant-cystic-ovarian-neoplasms-mucinous-ovarian-
cystadenocarcinoma