Adnexal Masses: Benign Ovarian Lesions and Characterization

Benign Ovarian Masses
  • Alexander SchlattauEmail author
  • Teresa Margarida Cunha
  • Rosemarie Forstner
Part of the Medical Radiology book series (MEDRAD)


Incidental adnexal masses are commonly identified in radiologists’ daily practice. Most of them are benign ovarian lesions of no concern. However, sometimes defining the origin of a pelvic mass may be challenging, especially on ultrasound alone. Moreover, ultrasound not always allows the distinction between a benign and a malignant adnexal tumor.

Most of sonographically indeterminate adnexal masses turn out to be common benign entities that can be readily diagnosed by magnetic resonance imaging. The clinical impact of predicting the likelihood of malignancy is crucial for proper patient management.

The first part of this chapter will cover the technical magnetic resonance imaging aspects of ovarian lesions characterization as well as the imaging features that allow the radiologist to correctly define the anatomic origin of a pelvic mass. Next, the authors will go through different benign ovarian entities and through the different histologic types of benign ovarian tumors. Finally the functional ovarian tumors and the ovarian tumors in children, adolescents, young females, and pregnant women will be covered.


  1. Acien P, Acien N, Ruiz-Macia E, Martin-Estefania C (2014) Ovarian teratoma-associated anti-NDMDAR encephalitis: a systematic review of reported cases. Orphanet J Rare Dis 9:157. doi:10.1186/s13023-014-0157-xCrossRefPubMedPubMedCentralGoogle Scholar
  2. Buy JN, Ghossain MA, Moss AA et al (1989) Cystic teratoma of the ovary: CT detection. Radiology 171:697–670. doi:10.1148/radiology.171.3.2717741.CrossRefPubMedGoogle Scholar
  3. Caspi B, Appelman Z, Rabinerson D et al (1997) The growth pattern of ovarian dermoid cysts: a prospective study in premenopausal and postmenopausal women. Fertil Steril 68:501–505CrossRefGoogle Scholar
  4. Cass DL, Hawkins E, Brandt ML et al (2001) Surgery for ovarian masses in infants, children, and adolescents: 102 consecutive patients treated in a 15-year period. J Pediatr Surg 36:693–699. doi:10.1053/jpsu.2001.22939CrossRefPubMedGoogle Scholar
  5. Chiang G, Levine D (2004) Imaging of adnexal masses in pregnancy. J Ultrasound Med 23:805–819CrossRefGoogle Scholar
  6. Christensen JT, Boldsen JL, Westergaard JG (2002) Functional ovarian cysts in premenopausal and gynecologically healthy women. Contraception 66:153–157CrossRefGoogle Scholar
  7. Cho SM, Byun JY, Rha SE et al (2004) CT and MRI findings of cystadenofibromas of the ovary. Eur Radiol 14:798–804. doi:10.1007/s00330-003-2060-zCrossRefPubMedGoogle Scholar
  8. Chung BM, Park SB, Lee JB, Park HJ, Kim YS, Oh YJ (2015) Magnetic resonance imaging features of ovarian fibroma, fibrothecoma, and thecoma. Abdom Imaging 40:1263–1272. doi:10.1007/s00261-014-0257-zCrossRefPubMedGoogle Scholar
  9. Clement PB (2002) Non-neoplastic lesions of the ovary. In: Kurman RJ (ed) Blaustein’s pathology of the female genital tract. Springer Verlag, New York, pp 675–728Google Scholar
  10. Corwin MT, Gerscovich EO, Lamba R, Wilson M, McGahan JP (2014) Differentiation of ovarian endometriomas from hemorrhagic cysts at MR imaging: utility of the T2 dark spot sign. Radiology 271:126–132. doi:10.1148/radiol.13131394CrossRefPubMedGoogle Scholar
  11. Dias JL, Veloso Gomes F, Lucas R, Cunha TM (2015) The shading sign: is it exclusive of endometriomas? Abdom Imaging 40:2566–2572. doi:10.1007/s00261-015-0465-1CrossRefPubMedGoogle Scholar
  12. Duijkers IJ, Klipping C (2010) Polycystic ovaries, as defined by the 2003 Rotterdam consensus criteria, are found to be very common in young healthy women. Gynecol Endocrinol 26:152–160. doi:10.1080/​09513590903247824
  13. Forstner R, Thomassin-Naggara I, Cunha TM et al (2016) ESUR recommendations for MR imaging of the sonographically indeterminate adnexal mass: an update. Eur Radiol Oct 21 [Epub ahead of print] Erratum in: Eur Radiol. 2016 Dec 5. doi:10.1007/s00330-016-4600-3CrossRefGoogle Scholar
  14. Foshager MC, Hood LL, Walsh JW (1996) Masses simulating gynaecologic diseases at CT and MRI. RadioGraphics 16:1085–1099. doi:10.1148/radiographics.16.5.8888392CrossRefPubMedGoogle Scholar
  15. Franks S (2006) Controversy in clinical endocrinology: diagnosis of polycystic ovarian syndrome: in defense of the Rotterdam criteria. J Clin Endocrinol Metab 91:786–789. doi:10.1210/jc.2005-2501CrossRefPubMedGoogle Scholar
  16. Frisch LS, Copeland KC, Boepple PA (1992) Recurrent ovarian cysts in childhood: diagnosis of McCune-Albright syndrome by bone scan. Pediatrics 90:​102–104PubMedGoogle Scholar
  17. Garcia-Villanueva M, Badia Figuerola N, Ruiz del Arbol L, Hernandez Ortiz MJ (1990) Zollinger Ellison syndrome due to a borderline mucinous cystadenoma of the ovary. Obstet Gynecol 75:549–552PubMedGoogle Scholar
  18. Ghattamaneni S, Bhuskute N, Weston MJ, Spencer JA (2009) Discriminative MR imaging features of Fallopian tube masses. Clin Radiol 64:815–831. doi:10.1016/j.crad.2009.03.007CrossRefGoogle Scholar
  19. Hassen K, Ghossain MA, Rousset P et al (2011) Characterization of papillary projections in benign versus borderline and malignant ovarian masses on conventional and color Doppler ultrasound. AJR Am J Roentgenol 196:1444–1449. doi:10.2214/AJR.10.5014CrossRefPubMedGoogle Scholar
  20. Hermans RH, Fisher DC, van der Putte HW et al (2003) Adnexal masses in pregnancy. Onkologie 26:167–172. doi:69838PubMedGoogle Scholar
  21. Heifetz SA, Cushing B, Giller R et al (1998) Immature teratomas in children: pathologic considerations: a report from the combined Pediatric Oncology Group/Children's Cancer Group. Am J Surg Pathol 22:1115–1124CrossRefGoogle Scholar
  22. Hochberg L, Hoffman MS (2017) Differential diagnosis of adnexal mass. www uptodate 2017Google Scholar
  23. Honoré LH, O’Hara KE (1980) Serous papillary neoplasms arising in paramesonephric paraovarian cysts: a report of 8 cases. Acta Obstet Gynecol Scand 59:525–528CrossRefGoogle Scholar
  24. Horta M, Cunha TM (2015) Sex cord-stromal tumors of the ovary: a comprehensive review and update for radiologists. Diagn Interv Radiol 21:277–286. doi:10.5152/dir.2015.34414CrossRefPubMedPubMedCentralGoogle Scholar
  25. Hricak H, Chen M, Coakley FV et al (2000) Complex adnexal masses: detection and characterization with MRI—multivariate analysis. Radiology 214:39–46. doi:10.1148/radiology.214.1.r00ja3939CrossRefPubMedGoogle Scholar
  26. Johnstone EB, Rosen MP, Neri R et al (2010) The polycystic ovary post-Rotterdam: a common, age-dependent finding in ovulatory women without metabolic significance. J Clin Endocrinol Metab 95:4965–4972. doi:10.1210/jc.2010-0202CrossRefPubMedPubMedCentralGoogle Scholar
  27. Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST (2002) CT and MRI of ovarian tumors with emphasis on the differential diagnosis. RadioGraphics 22:1305–1325. doi:10.1148/rg.226025033CrossRefPubMedGoogle Scholar
  28. Jung DC, Kim SH, Kim SH (2006) MR imaging findings of ovarian cystadenofibroma and cystadenocarcinofibroma: clues for the differential diagnosis. Korean J Radiol 7:199–204. doi:10.3348/kjr.2006.7.3.199CrossRefPubMedPubMedCentralGoogle Scholar
  29. Kaijser J, Vandecaveye V, Deroose CM et al (2014) Imaging techniques for the pre-surgical diagnosis of adnexal tumours. Best Pract Res Clin Obstet Gynaecol 28:683–695. doi:10.1016/j.bpobgyn.2014.03.013CrossRefPubMedGoogle Scholar
  30. Kier R (1992) Nonovarian gynaecologic cysts: MR imaging findings. AJR Am J Roentgenol 158:1265–1269. doi:10.2214/ajr.158.6.1590120CrossRefPubMedGoogle Scholar
  31. Kim JS, Lee HJ, Woo SK, Lee TS (1997) Peritoneal inclusion cysts and their relationship to the ovaries: evaluation with sonography. Radiology 204:481–484. doi:10.1148/radiology.204.2.9240539CrossRefPubMedGoogle Scholar
  32. Kim JC, Kim SS, Park JY (2000) Bridging vascular sign in the MR diagnosis of exophytic uterine leiomyoma. J Comput Assist Tomogr 24:57–60CrossRefGoogle Scholar
  33. Koonings PP, Campbell K, Mishell DR Jr, Grimes DA (1989) Relative frequency of primary ovarian neoplasm: a 10-year review. Obstet Gynecol 74:921–926PubMedGoogle Scholar
  34. Kurman RJ, Ellenson LH, Ronnett B (2011) Blaustein’s pathology of the female genital tract, 6th edn. Springer, New YorkCrossRefGoogle Scholar
  35. Kurman RJ, Carcangiu ML, Herrington CS, Young RH (2014) Classification of tumors of the ovary. In: WHO classification of tumours, vol. 6, 4th edn. IARC, Lyon, pp 44–56Google Scholar
  36. Lakhani K, Seifalian AM, Atiomo WU, Hardiman P (2002) Polycystic ovaries. Br J Radiol 75:9–16. doi:10.1259/bjr.75.889.750009CrossRefPubMedGoogle Scholar
  37. Laufer MR (2017) Ovarian cysts and neoplasm in infants, children, and adolescents.
  38. Lee JH, Jeong YK, Park JK, Hwang JC (2003) “Ovarian vascular pedicle” sign revealing organ of origin of a pelvic mass lesion on helical CT. AJR Am J Roentgenol 181:131–137CrossRefGoogle Scholar
  39. Lee TT, Rausch ME (2012) Polycystic ovarian syndrome: role of imaging in diagnosis. RadioGraphics 32:1643–1657CrossRefGoogle Scholar
  40. Lengyel E (2010) Ovarian cancer development and metastasis. Am J Pathol 177:1053–1064. doi:10.2353/ajpath.2010.100105CrossRefPubMedPubMedCentralGoogle Scholar
  41. Levine CD, Patel UJ, Ghanekar D, Wachsberg RH, Simmons MZ, Stein M (1997) Benign extraovarian mimics of ovarian cancer: distinction with imaging studies. Clin Imaging 21:350–358CrossRefGoogle Scholar
  42. Levine D, Brown DL, Andreotti RF et al (2010) Management of asymptomatic ovarian and other adnexal cysts imaged at US: society of radiologists in ultrasound consensus conference statement. Radiology 256:943–954. doi:10.1148/radiol.10100213CrossRefPubMedGoogle Scholar
  43. Lujan ME, Jarrett BY, Brooks ED et al (2013) Updated ultrasound criteria for polycystic ovary syndrome: reliable thresholds for elevated follicle population and ovarian volume. Hum Reprod 28:1361–1368. doi:10.1093/humrep/det062CrossRefPubMedPubMedCentralGoogle Scholar
  44. Matsubayashi R, Matsuo Y, Doi J, Kudo S, Matsuguchi K, Sugimori H (1999) Sclerosing stromal tumor of the ovary: radiologic findings. Eur Radiol 9:1335–1338. doi:10.1007/s003300050844CrossRefPubMedGoogle Scholar
  45. Matsuki M, Kaji Y, Matsuo M, Kobashi Y (2000) Struma ovarii: MRI findings. Br J Radiol 73:87–90. doi:10.1259/bjr.73.865.10721328CrossRefPubMedGoogle Scholar
  46. Moon WJ, Koh BH, Kim SK et al (2000) Brenner tumor of the ovary: CT and MR findings. J Comput Assist Tomogr 24:72–76CrossRefGoogle Scholar
  47. Moyle PL, Kataoka MY, Nakai A, Takahata A, Reinhold C, Sala E (2010) Nonovarian cystic lesions of the pelvis. RadioGraphics 30:921–938. doi:10.1148/rg.304095706CrossRefPubMedGoogle Scholar
  48. Norris HJ, Jensen RD (1972) Relative frequency of ovarian neoplasm in children and adolescents. Cancer 30:713–719CrossRefGoogle Scholar
  49. Okada S, Ohaki Y, Inoue K et al (2005) Calcifications in mucinous and serous cystic ovarian tumors. J Nippon Med Sch 72:29–33CrossRefGoogle Scholar
  50. Outwater EK, Mitchell DG (1996) Normal ovaries and functional cysts: MR appearance. Radiology 198:397–402. doi:10.1148/radiology.198.2.8596839CrossRefPubMedGoogle Scholar
  51. Palmeiro MM, Cunha TM, Loureiro AL, Esteves G (2016) A rare benign ovarian tumour. BMJ Case Rep (2016) Mar 1;2016. pii: bcr2015214101. doi: 10.1136/bcr-2015-214101Google Scholar
  52. Patel MD, Ascher SM, Paspulati RM et al (2013) Managing incidental findings on abdominal and pelvic CT and MRI, part 1: white paper of the ACR Incidental Findings Committee II on adnexal findings. J Am Coll Radiol 10:675–681. doi:10.1016/j.jacr.2013.05.023CrossRefPubMedGoogle Scholar
  53. Rha SE, Byun JY, Jung SE et al (2004) Atypical CT and MRI manifestations of mature ovarian cystic teratomas. AJR Am J Roentgenol 183:743–750. doi:10.2214/ajr.183.3.1830743CrossRefPubMedGoogle Scholar
  54. Sala EJ, Atri M (2003) MRI of benign adnexal disease. Top Magn Reson Imaging 14:305–327CrossRefGoogle Scholar
  55. Saksouk FA, Johnson SC (2004) Recognition of the ovarian origin of pelvic masses with CT. RadioGraphics 24(Suppl 1):S133–S146. doi:10.1148/rg.24si045507CrossRefPubMedGoogle Scholar
  56. Seidman JD, Russell P, Kurman RJ (2002) Surface epithelial tumors of the ovary. In: Kurman RJ (ed) Blaustein’s pathology of the female genital tract. Springer Verlag, New York, pp 791–904Google Scholar
  57. Sherard GB 3rd, Hodson CA, Williams HJ, Semer DA, Hadi HA, Tait DL (2003) Adnexal masses and pregnancy: a 12-year experience. Am J Obstet Gynecol 189:358–362. discussion 362–363CrossRefGoogle Scholar
  58. Spencer JA, Gore RM (2011) The adnexal incidentaloma: a practical approach to management. Cancer Imaging 11:48–51. doi:10.1102/1470-7330.2011.0008CrossRefPubMedPubMedCentralGoogle Scholar
  59. Tanaka YO, Tsunoda H, Kitagawa Y, Ueno T, Yoshikawa H, Saida Y (2004) Functioning ovarian tumors: direct and indirect findings at MR imaging. RadioGraphics 24(Suppl 1):S147–S166. doi:10.1148/​rg.24si045501CrossRefGoogle Scholar
  60. Tannus JF, Hertzberg BS, Haystead CM, Paulson EK (2009) Unilateral luteoma of pregnancy mimicking a malignant ovarian mass on magnetic resonance and ultrasound. J Magn Reson Imaging 29:713–717. doi:10.1002/jmri.21530CrossRefPubMedGoogle Scholar
  61. Telischak NA, Yeh BM, Joe BN, Westphalen AC, Poder L, Coakley FV (2008) MRI of adnexal masses in pregnancy. AJR Am J Roentgenol 191:364–370. doi:10.2214/AJR.07.3509CrossRefPubMedPubMedCentralGoogle Scholar
  62. Timmerman D, Moerman P, Vergote I (1995) Meigs syndrome with elevated CA-125 levels: two case reports and review of the literature. Gynecol Oncol 59:405–408. doi:10.1006/gyno.1995.9952CrossRefPubMedGoogle Scholar
  63. Timmerman D, Van Calster B, Testa A et al (2016) Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group. Am J Obstet Gynecol 214:424–437. doi:10.1016/j.ajog.2016.01.007CrossRefPubMedGoogle Scholar
  64. Thomassin-Naggara I, Daraï E, Cuenod CA et al (2009) Contribution of diffusion-weighted MR imaging for predicting benignity of complex adnexal masses. Eur Radiol 19:1544–1552. doi:10.1007/s00330-009-1299-4CrossRefPubMedGoogle Scholar
  65. Thomassin-Naggara I, Toussaint I, Perrot N et al (2011) Characterization of complex adnexal masses: value of adding perfusion- and diffusion-weighted MR imaging to conventional MR imaging. Radiology 258:793–803. doi:10.1148/radiol.10100751CrossRefPubMedGoogle Scholar
  66. van Winter JT, Simmons PS, Podratz KC (1994) Surgically treated adnexal masses in infancy, childhood, and adolescence. Am J Obstet Gynecol 170:1780–1786. discussion 1786–1789CrossRefGoogle Scholar
  67. Young RH, Scully RE (2002) Sex cord stromal, steroid cell, and other ovarian tumors. In: Kurman RJ (ed) Blaustein’s pathology of the female genital tract. Springer Verlag, New York, pp 903–966Google Scholar
  68. Yamashita Y, Hatanaka Y, Torashima M, Takahashi M, Miyazaki K, Okamura H (1994) Mature cystic teratomas of the ovary without fat in the cystic cavity: MR features in 12 cases. AJR Am J Roentgenol 163:613–616. doi:10.2214/ajr.163.3.8079854CrossRefPubMedGoogle Scholar
  69. Yoshitake T, Asayama Y, Yoshimitsu K et al (2005) Bilateral ovarian leiomyomas: CT and MRI features. Abdom Imaging 30:117–119. doi:10.1007/s00261-004-0202-7CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Alexander Schlattau
    • 1
    Email author
  • Teresa Margarida Cunha
    • 2
  • Rosemarie Forstner
    • 1
  1. 1.Salzburger LandesklinikenParacelsus Medical UniversitySalzburgAustria
  2. 2.Serviço de RadiologiaInstituto Português de Oncologia de Lisboa Francisco GentilLisboaPortugal

Personalised recommendations