International Cancer Imaging Society Course Oct 17. Incidental adnexal masses, Gabriele Masselli

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Gabriele Masselli and Gianfranco Gualdi, Radiology Department, Umberto I Hospital, Sapienza University Rome, Rome, Italy

Incidentally discovered adnexal lesions are common, most are benign, but a minority can represent ovarian cancer, difficult to detect before it has spread. The frequency raised with increased use of cross-sectional imaging.

The point prevalence for significant cysts has been reported to be almost 8% in premenopausal women [1]. Surprisingly, the prevalence in postmenopausal women is as high as 14% to 18%, with a yearly incidence of 8%. From 30% to 54% of postmenopausal ovarian cysts persist for years [2].

The correct differentiation between malignant and benign lesions prevents unnecessary interventions and avoids delays in treatment of ovarian carcinoma.

US is the study of choice for primary evaluation of adnexal masses but it is less accurate for complex or indeterminate lesions, even when combined with color Doppler imaging.

The differential diagnosis for any particular mass or finding will vary based on the specific imaging features present, and ultrasound can be used to try to detect features that would enable a confident diagnosis or management strategy [3,4].

The most worrisome findings at US are the presence of solid areas that are not hyperechoic, especially when there is blood flow to them, thick septations, more than 2 or 3 mm wide, especially if there is blood flow within them, excrescences on the inner or outer aspect of a cystic area, ascites and other pelvic or omental masses.

Further evaluation with MRI may be critical for diagnosis, especially when it is not clear on US. MRI has been shown to be more specific and accurate than US and Doppler assessment.

MRI can determine, using frequency-selective fat saturation, whether a mass contains fat, which can be useful in the diagnosis of a teratoma. MRI can distinguish benign ovarian cysts from ovarian neoplasms because of the presence of papillary projections and nodular septa in neoplasms.

CT, and to a larger extent MRI, can show imaging features of adnexal masses that are characteristic or highly suggestive for particular diagnostic entities, such as paraovarian cyst, hydrosalpinx, peritoneal inclusion cyst, cystic teratoma, endometrioma, exophytic leiomyoma, ovarian fibroma, and ovarian carcinoma

MRI provides additional information on the composition of soft-tissue tumours. Usually, MRI is ordered with contrast, unless there are contraindications to it. The radiologist will evaluate morphologic features, signal intensity, and enhancement of solid areas. Techniques such as dynamic contrast-enhanced MRI (following the distribution of contrast material over time), in- and out-of-phase T1 imaging (looking for fat, such as in dermoids), and the diffusion-weighted imaging improve characterization.

Contrast-enhanced MRI contributes to a greater change in the probability of ovarian cancer than did CT, Doppler ultrasonography, or MRI without contrast. This may result in a reduction in unnecessary surgeries and in an increase in proper referrals in cases of suspected malignancy [5].

References

1. Borgfeldt C, Andolf E: Transvaginal sonographic ovarian findings in a random sample of women 25–40 years old. Ultrasound Obstet Gynecol 1999; 13:345–350.

2. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR: Risk of malignancy in unilocular ovarian cystic tumours less than 10 centimeters in diameter. Obstet Gynecol 2003; 102:594–599.

3. Greenlee RT, Kessel B, Williams CR, et al: Prevalence, incidence, and natural history of simple ovarian cysts among women 55+ years old in a large cancer screening trial. Am J Obstet Gynecol 2010; 202:373.e1–373.e9.

4. Sharma A, Gentry-Maharaj A, Burnell M, et al: UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Assessing the malignant potential of ovarian inclusion cysts in postmenopausal women within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a prospective cohort study. BJOG 2012; 119:207–219.

5. 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; 256:943–954.

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