1.
LETTER TO THE EDITOR
Sonographic Pictures of Suspicious Adnexal Masses
Ahmed Samy El Agwany1
Received: 18 March 2018 / Revised: 3 April 2018 / Accepted: 9 April 2018 / Published online: 29 May 2018
Ó Association of Gynecologic Oncologists of India 2018
Abstract
Pelvic ultrasound is important in the routine gynecologic evaluation of adnexal masses, the majority of which are func-
tional or benign. However, due to the possible complications as adnexal torsion, infection and the utmost importance of
early diagnosis and treatment of ovarian cancer, ultrasound evaluation of suspicious adnexal masses is essential in clinical
practice. This report will show the suspicious ultrasound appearance of adnexal masses with the aim of aiding clinicians to
reach the correct diagnosis.
Keywords Adnexal mass Á Doppler Á Ovarian cancer Á Ultrasound
Dear editor,
We are aiming here to show different ultrasound pic-
tures of adenxal masses and their correlation with malig-
nancy. Pelvic ultrasonography is commonly performed for
women of reproductive and menopausal age for assessing
the adnexa. Although it is highly sensitive in detecting
adnexal masses, its specificity in detecting malignancy is
lower. Adnexal masses (such as endometrioma, mature
cystic teratoma, paraovarian cysts, tubo-ovarian abscess
and peritoneal inclusion cysts) are also important to
be diagnosed correctly before rushing to the diagnosis of
malignancy and some ovarain masses as fibroma may
simulate subserous fibroids that needs to be evaluated
adequately [1]. Clinical assessment for adnexal masses is
important in guiding management weather conservative
follow-up with timed repeat scans or surgical interven-
tion will be required. The first clinical parameter to be
considered is the patients’ age where the likelihood of
malignancy in extremes of age is high, and most functional
cysts in reproductive age, tend to resolve over time. Other
factors to be considered are symtopms as pelvic pain (as
in adnexal torsion, endometriosis, pelvic inflammatory
disease, or hemorrhagic corpus luteum cyst); abdominal
distention, gastrointestinal complaints and weight loss
(in advanced ovarian malignancy). Personal or family
history of breast and/or ovarian cancer as well as carrier
state for the BRCA 1 or 2 genes will likely direct clinical
management towards a less conservative approach [2].
Although malignant masses are rare, their timely diagnosis
is of the utmost importance for survival. Ultrasound fea-
tures suggestive of epithelial malignancy include thick
septations (2–3 mm in width), solid components, multi-
locualrity, bilaterality, ascites, metastatic deposits and cyst
wall thickening (Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13). The diameter of the mass is less predictive of malig-
nancy than other features. Malignancies have been
described in small cysts of 3–4 cm in diameter. The
addition of Doppler provide additional information in
suspicious cases, and increases the sensitivity, specificity of
ultrasound in diagnosing ovarian malignancy [3]. This
modality is used to detect abnormal blood vessels which
arise from the neovascularization induced by the malignant
lesion. These blood vessels are characterized by low
resistance to flow (RI 0.4 but not specific) [4]. The best
approach to suspect malignancy now appears to be a
combined assessment of gray scale morphologic features
and color Doppler imaging. Three-dimensional ultrasound
visualizes the adnexa in three planes (coronal, sagittal, and
frontal) and allows for reconstruction and further analysis
of the volumes acquired, while three-dimensional power
& Ahmed Samy El Agwany
Ahmedsamyagwany@gmail.com;
ahmed.elagwany@alexmed.edu.eg
1
Gyneoncology specialized center, Shatby maternity
university hospital, Alexandria, Egypt
123
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https://doi.org/10.1007/s40944-018-0197-6(0123456789().,-volV)(0123456789().,-volV)

2.
Doppler allows for assessment of the vascularity of the
mass in all three planes. Findings associated with malig-
nancy are vascular flow in the center of the mass (‘‘central
flow’’), blood flow within septations and excrescences, and
a complex appearance of the vascular architecture. Current
studies have not shown a definite advantage of the three-
dimensional power Doppler over two-dimensional power
Doppler in diagnosing ovarian malignancy [5]. With the
aim of increasing the accuracy of ultrasound in the detec-
tion of ovarian malignancy, risk clinical factors (such as
menopausal status and serum CA-125 level) are used in
RMI with ultrasound criteria as Multilocular cyst, Solid
areas, Bilateral lesions, Ascites and Intraabdominal
metastases. The combination direct the clinician towards
conservative follow-up versus surgical intervention espe-
cially in score more than 200–250. Magnetic resonance
imaging (MRI) may be used as an adjunct imaging
Fig. 1 Ultrasound showing ascites and echogenic intraabdominal
mass (Omental cake, intrabdominal metastasisn) (two suspicious
criteria in RMI)
Fig. 2 Ultrasound showing complex adnexal mass mainly solid vascular with mural nodules and papillae. Also, thick ill defined endometrium is
seen in menopausal patient that presented with postmenopausal bleeding suspicous of granulosa cell tumor
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3.
Fig. 4 Ultrasound showing multiple large nabothian follicles in the
cervix that can be misdiagnosed by in experienced sonographers as
ovarian follicles
Fig. 3 Ultrasound showing multilocular complex adnexal mass mainly cystic with swirling turbid contents with septal nodules (two suspicous
criteria in RMI)
Fig. 7 Complex multilocular adnexal mass mainly cystic with turbid
contents and vascular septae (tubo-ovarain abcess) (one suspicous
criteria of RMI so multiple criteria is highly suspicous with low role
of Doppler ultraosund)
Fig. 6 Ultrasound showing complex adnexal mass mainly cystic with
avascualr echogenic mass (tubercle) and spots (hair) of ovarain der-
moid cyst with thick wall (chronic torsion with ovarai infarcion)
Fig. 5 Ultrasound showing complex adnexal mass mainly cystic with
avascular floating echogenic contents and distal shadowing charac-
teristic of ovarian dermoid cyst
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4.
modality when the initial ultrasound characterization of an
adnexal mass as benign or malignant is inconclusive. The
cost of MRI studies and their limited availability should be
taken into account. Furthermore, in most clinical scenarios,
an ultrasound exam performed by an experienced sonog-
rapher may provide sufficient information upon which to
counsel patients whether or not surgical investigation is
necessary [6–8].
Fig. 8 Fixed adnexal multilocular cyst to the back of the uterus (ovarian not peritoneal cysts as delinated with vascularity and peipheral follicles
are seen with small perionteal cysts seen related)
Fig. 9 Multilocular adnexal cyst with peritoneal inclusion pockets or
cysts seen as small structures traversed by adhesions at the periphery
of ovary as irregular ill-defined structures
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5.
Fig. 10 Mulilocular Adnexal cystic mass with vascular septae, ascites and echogenic intestine and omentum (intrabdominal metastasis and
surface deposits)
Fig. 11 Complex multilocular adnexal mass mainly cystic with
daughter cysts and septae with septal nodules and papillae
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cFig. 13 Right complex mulolocular adnexal mass mainly cystic with
vascular solid areas, papillae, thick septae and ascites. Left side with
large ovary of multiple small cysts in postmenopausal female. Also
uterus is showing fiborids (3 criteria of RMI)
Fig. 12 Bilateral adnexal masses with ascites, one side is mainly cys-
tic with daughter cysts and solid vascular component surrounded by
ascites, other side is mainly solid above the uterus, irregular with
ascites surrounding and echogenic omentum and intestine character-
istic of surface deposits (5 suspicous criteria of RMI)
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Conclusion
Grayscale ultrasound combined with Doppler measurements
allows the experienced sonographer to reliably diagnose
functional, benign, and malignant adnexal masses. The
information obtained from the pelvic ultrasound, combined
with patient’s history and gynecologic exam, will guide
treatment, for conservative follow-up versus surgery. RMI is
highly important. Other adnexal masses may simulate
ovarain neoplasms and ovarian neoplasms may simulate
uterine masses so assessment is highly needed with keeping
in mind all diagnosis.
Authors’ contributions El Agwany had done the diagnoses, ultra-
sound and surgery along with writing the article.
Compliance with Ethics Standards
Conflict of interest The author declares that he has no conflict of
interest.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from the patient
included in the study.
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