Sonographic differentiation of benign versus malignant adnexal masses
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
Sonography is a clinically important imaging modality for assessing whether an adnexal mass is likely benign or possibly malignant. This is important for assessing the need for surgery and for planning preoperative evaluation/preparation, the type of surgical procedure, and the surgical expertise required.
Optimal gray-scale sonographic criteria, the usefulness of Doppler sonography, and the value of combined gray-scale and Doppler sonography for assessing the probability of benign versus malignant ovarian disease will be reviewed here. A general overview of evaluation of the adnexal mass and the general principles of gynecologic ultrasonography are discussed separately. (See "Approach to the patient with an adnexal mass" and "Differential diagnosis of the adnexal mass" and "Ultrasound examination in obstetrics and gynecology".)
APPROACH TO CHARACTERIZATION OF AN ADNEXAL MASS
Ultrasound versus other diagnostic methods — Morphologic assessment by pelvic ultrasound is the first line study for evaluation of malignancy in an adnexal mass . Ultrasound is relatively less expensive than other imaging modalities, its diagnostic performance is comparable or better, and it does not involve exposure to ionizing radiation. Use of other imaging studies is reasonable in the minority of patients in whom adequate characterization of the mass is not possible with ultrasound. Magnetic resonance imaging (MRI) is generally the next best imaging modality after ultrasound to characterize an adnexal mass .
The diagnostic performance of pelvic ultrasound compared with other methods of evaluation of an adnexal mass was best illustrated in a meta-analysis of 204 studies by the United States Agency for Healthcare Research and Quality . The sensitivity and specificity for the diagnosis of ovarian cancer for the diagnostic tools evaluated were:
●Bimanual pelvic examination: 45 and 90 percent
- Liu J, Xu Y, Wang J. Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis of ovarian carcinoma. Eur J Radiol 2007; 62:328.
- http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ClinicallySuspectedAdnexalMass.pdf (Accessed on June 12, 2012).
- Myers ER, Bastian LA, Havrilesky LJ, et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025). AHRQ Publication No. 06-E004, Agency for Healthcare Research and Quality, Rockville, MD February 2006.
- Yazbek J, Raju SK, Ben-Nagi J, et al. Effect of quality of gynaecological ultrasonography on management of patients with suspected ovarian cancer: a randomised controlled trial. Lancet Oncol 2008; 9:124.
- Valentin L, Ameye L, Jurkovic D, et al. Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis? Ultrasound Obstet Gynecol 2006; 27:438.
- Kim SH, Sim JS, Seong CK. Interface vessels on color/power Doppler US and MRI: a clue to differentiate subserosal uterine myomas from extrauterine tumors. J Comput Assist Tomogr 2001; 25:36.
- Timor-Tritsch IE, Lerner JP, Monteagudo A, et al. Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol 1998; 12:56.
- Patel MD, Acord DL, Young SW. Likelihood ratio of sonographic findings in discriminating hydrosalpinx from other adnexal masses. AJR Am J Roentgenol 2006; 186:1033.
- Kim JS, Lee HJ, Woo SK, Lee TS. Peritoneal inclusion cysts and their relationship to the ovaries: evaluation with sonography. Radiology 1997; 204:481.
- Hoffer FA, Kozakewich H, Colodny A, Goldstein DP. Peritoneal inclusion cysts: ovarian fluid in peritoneal adhesions. Radiology 1988; 169:189.
- Korbin CD, Brown DL, Welch WR. Paraovarian cystadenomas and cystadenofibromas: sonographic characteristics in 14 cases. Radiology 1998; 208:459.
- Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 2010; 256:943.
- Ekerhovd E, Wienerroith H, Staudach A, Granberg S. Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis. Am J Obstet Gynecol 2001; 184:48.
- Patel MD, Feldstein VA, Chen DC, et al. Endometriomas: diagnostic performance of US. Radiology 1999; 210:739.
- Mais V, Guerriero S, Ajossa S, et al. The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma. Fertil Steril 1993; 60:776.
- Jermy K, Luise C, Bourne T. The characterization of common ovarian cysts in premenopausal women. Ultrasound Obstet Gynecol 2001; 17:140.
- Filly RA. Ovarian masses: what to look for, what to do. In: Ultrasonography in obstetrics and gynecology, Callen PW (Ed), W.B. Saunders Company, Philadelphia 1994. p.625.
- Okai T, Kobayashi K, Ryo E, et al. Transvaginal sonographic appearance of hemorrhagic functional ovarian cysts and their spontaneous regression. Int J Gynaecol Obstet 1994; 44:47.
- Jain KA. Sonographic spectrum of hemorrhagic ovarian cysts. J Ultrasound Med 2002; 21:879.
- Swire MN, Castro-Aragon I, Levine D. Various sonographic appearances of the hemorrhagic corpus luteum cyst. Ultrasound Q 2004; 20:45.
- Alcázar JL, Castillo G, Jurado M, García GL. Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women? Hum Reprod 2005; 20:3231.
- Malde HM, Kedar RP, Chadha D, Nayak S. Dermoid mesh: a sonographic sign of ovarian teratoma. AJR Am J Roentgenol 1992; 159:1349.
- Patel MD, Feldstein VA, Lipson SD, et al. Cystic teratomas of the ovary: diagnostic value of sonography. AJR Am J Roentgenol 1998; 171:1061.
- Cohen L, Sabbagha R. Echo patterns of benign cystic teratomas by transvaginal ultrasound. Ultrasound Obstet Gynecol 1993; 3:120.
- Caspi B, Appelman Z, Rabinerson D, et al. Pathognomonic echo patterns of benign cystic teratomas of the ovary: classification, incidence and accuracy rate of sonographic diagnosis. Ultrasound Obstet Gynecol 1996; 7:275.
- Mais V, Guerriero S, Ajossa S, et al. Transvaginal ultrasonography in the diagnosis of cystic teratoma. Obstet Gynecol 1995; 85:48.
- Quinn SF, Erickson S, Black WC. Cystic ovarian teratomas: the sonographic appearance of the dermoid plug. Radiology 1985; 155:477.
- Sheth S, Fishman EK, Buck JL, et al. The variable sonographic appearances of ovarian teratomas: correlation with CT. AJR Am J Roentgenol 1988; 151:331.
- Kim HC, Kim SH, Lee HJ, et al. Fluid-fluid levels in ovarian teratomas. Abdom Imaging 2002; 27:100.
- Brown DL, Laing FC, Welch WR. Large calcifications in ovaries otherwise normal on ultrasound. Ultrasound Obstet Gynecol 2007; 29:438.
- Tongsong T, Wanapirak C, Khunamornpong S, Sukpan K. Numerous intracystic floating balls as a sonographic feature of benign cystic teratoma: report of 5 cases. J Ultrasound Med 2006; 25:1587.
- Brown DL, Doubilet PM, Miller FH, et al. Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features. Radiology 1998; 208:103.
- Tailor A, Jurkovic D, Bourne TH, et al. Sonographic prediction of malignancy in adnexal masses using multivariate logistic regression analysis. Ultrasound Obstet Gynecol 1997; 10:41.
- Bourne T, Campbell S, Steer C, et al. Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer. BMJ 1989; 299:1367.
- Buy JN, Ghossain MA, Hugol D, et al. Characterization of adnexal masses: combination of color Doppler and conventional sonography compared with spectral Doppler analysis alone and conventional sonography alone. AJR Am J Roentgenol 1996; 166:385.
- Sladkevicius P, Valentin L, Marsál K. Transvaginal Doppler examination for the differential diagnosis of solid pelvic tumors. J Ultrasound Med 1995; 14:377.
- Alcázar JL, Ruiz-Perez ML, Errasti T. Transvaginal color Doppler sonography in adnexal masses: which parameter performs best? Ultrasound Obstet Gynecol 1996; 8:114.
- Kinkel K, Lu Y, Mehdizade A, et al. Indeterminate ovarian mass at US: incremental value of second imaging test for characterization--meta-analysis and Bayesian analysis. Radiology 2005; 236:85.
- Kinkel K, Hricak H, Lu Y, et al. US characterization of ovarian masses: a meta-analysis. Radiology 2000; 217:803.
- Timor-Tritsch LE, Lerner JP, Monteagudo A, Santos R. Transvaginal ultrasonographic characterization of ovarian masses by means of color flow-directed Doppler measurements and a morphologic scoring system. Am J Obstet Gynecol 1993; 168:909.
- Timmerman D, Schwärzler P, Collins WP, et al. Subjective assessment of adnexal masses with the use of ultrasonography: an analysis of interobserver variability and experience. Ultrasound Obstet Gynecol 1999; 13:11.
- Valentin L. Pattern recognition of pelvic masses by gray-scale ultrasound imaging: the contribution of Doppler ultrasound. Ultrasound Obstet Gynecol 1999; 14:338.
- Van Calster B, Timmerman D, Bourne T, et al. Discrimination between benign and malignant adnexal masses by specialist ultrasound examination versus serum CA-125. J Natl Cancer Inst 2007; 99:1706.
- Valentin L. Use of morphology to characterize and manage common adnexal masses. Best Pract Res Clin Obstet Gynaecol 2004; 18:71.
- Geomini P, Kruitwagen R, Bremer GL, et al. The accuracy of risk scores in predicting ovarian malignancy: a systematic review. Obstet Gynecol 2009; 113:384.
- Kaijser J, Bourne T, Valentin L, et al. Improving strategies for diagnosing ovarian cancer: a summary of the International Ovarian Tumor Analysis (IOTA) studies. Ultrasound Obstet Gynecol 2013; 41:9.
- APPROACH TO CHARACTERIZATION OF AN ADNEXAL MASS
- Ultrasound versus other diagnostic methods
- Diagnostic performance of ultrasound
- PERTINENT CLINICAL INFORMATION
- GRAY-SCALE EVALUATION
- Ovarian versus extraovarian
- - Differential diagnosis
- Characteristics of the mass
- - Characteristics suggestive of a benign mass
- - Characteristics suggestive of a malignant mass
- ADDITIONAL TECHNIQUES
- Spectral Doppler
- Combined gray-scale and Doppler evaluation
- Other techniques
- ULTRASOUND COMBINED WITH OTHER APPROACHES
- Prediction models
- SUMMARY AND RECOMMENDATIONS