Diagnostic Work Up of Ovarian Cysts

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Diagnostic Work up of Ovarian Cysts
Wouter Veldhuis, Robin Smithuis, Oguz Akin and Hedvig Hricak
Department of Radiology of the University Medical Center of Utrecht, of the Rijnland hospital in
Leiderdorp, the Netherlands and the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, USA
Publicationdate May 15, 2011
Ovarian cancer is the second most common of
all gynecologic malignancies. It is the leading
cause of death in this category of diseases, frequently presenting as a complex cystic mass.
The finding of an adnexal cyst causes considerable anxiety in women due to the fear of malignancy. However, the vast majority of adnexal
cysts - even in postmenopausal women - are
benign.
In this article we will focus on specific features
of ovarian cysts that are helpful in making a differential diagnosis. We will present a roadmap
for the diagnostic work-up and management of
ovarian cystic masses, based on ultrasound and
MRI findings.
In Ovarian Cystic Masses II the imaging features of normal ovaries and the most common
ovarian cystic masses will be presented, as well
as several less common cystic lesions.
Diagnostic work-up
Step 1
If a cystic pelvic mass is present, the first
step is to find out if it is ovarian or
non-ovarian in origin.
Step 2
The next step is to determine if the lesion
can be categorized as one of the common,
benign ovarian masses (simple cyst,
hemorrhagic cyst, endometrioma or
mature cystic teratoma), or is
indeterminate.
Step 3
To aid in selecting the proper work-up, the
final step is to determine whether a
patient falls into a low-risk category (i.e.
premenopausal women without additional
risk factors) or a high-risk category (i.e.
post-menopausal or premenopausal with
additional risk factors).
Based on these steps we can determine further
management: ignore, follow-up with US, further
evaluation with MRI or excision.
Role of imaging
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Role of Ultrasound
For characterization of ovarian masses, ultrasound is often the first-line method of choice,
especially for distinguishing cystic from complex
cystic-solid and solid lesions.
Role of CT
CT is useful for the N- and M-staging of proven
malignant lesions.
Role of MRI
For complex lesions, primary evaluation with ultrasound is often followed by further evaluation
with MRI.
Even with MRI it is often not possible to make
an accurate diagnosis of neoplastic subtype.
By using MRI as an adjunct to sonography a delay in the treatment of potentially malignant
ovarian lesions is prevented.
This is not only beneficial to the small number
of women who do have ovarian cancer, but also
a proven cost-effective approach to the management of sonographically indeterminate adnexal lesions.
Ovarian or non-ovarian
If a cystic adnexal mass is present and you suspect an ovarian origin, the first thing to do is try
to identify the ovaries.
If the gonadal vessels lead to the lesion with no
separately identifiable normal ovaries, then
most likely you are dealing with an ovarian lesion.
If both ovaries are separately identifiable from
the lesion, you are dealing with a non-ovarian
cystic lesion, or a lesion that mimics a cystic
mass.
The next step would be to check if there is unior bilateral disease and to look for any solid
components that may indicate malignancy.
Also look for secondary findings like ascites, enlarged lymph nodes and peritoneal deposits.
The table shows a differential diagnosis for possible cystic ovarian masses.
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A helpful tool to identify the ovaries is to follow

the ovarian veins caudally.
Scroll through the CT-images and follow the
right ovarian vein from where it joins the inferior vena cava, and the left ovarian vein where
it joins the left renal vein, until you identify the
ovaries.
Scroll through the images
Ultrasound pattern recognition

Pattern recognition on ultrasound often allows a
fairly confident diagnosis of common cystic
ovarian masses.
This means that in many cases the diagnostic
work-up is based on determining the probability
that we are dealing with a lesion which falls into
the category of a simple cyst, hemorrhagic cyst,
endometrioma or a mature cystic teratoma
(commonly referred to as a dermoid cyst).
Most other cystic lesions are indeterminate and
therefore possibly malignant. These therefore
require further evaluation, either with MRI or
surgical excision.
Simple cyst
US findings that allow a confident diagnosis of a
simple ovarian cyst are:
Anechoic lesion with posterior acoustic
enhancement
Unilocular
Thin, smooth walls
No solid or well-vascularized components
The US-image shows two simple cysts in the

right ovary with ovarian stroma in between.
The surrounding vessels are normal and there
are no vascularized septations.
These were simple follicular cysts in a premenopausal woman.
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Differential diagnosis
Most simple cysts are functional cysts, usually
follicular cysts.
They are commonly seen in premenopausal
women, but functional cysts also still do occur in
postmenopausal women.
Some simple cysts may turn out to be paraovarian or paratubal cysts.
A hydrosalpinx may also mimic an ovarian cyst.
Cystadenomas can also present as simple cysts,
but they usually present as a large cyst in a
postmenopausal woman.
In a large cancer screening study from 1987 to
2002 including 15,106 women of 50 years or
older, 2763 women (18%) were diagnosed with
a unilocular ovarian cyst.
None of these isolated unilocular cysts turned
out to be ovarian cancer (4).
In women of reproductive age, cysts up to 3 cm
are a normal physiologic finding.
These simple physiologic cysts do not need to
be described in the imaging report and do not
require follow-up (1).
Cysts up to 7 cm in both pre- and postmenopausal woman are almost certainly benign.
Cysts larger than 7 cm may be difficult to assess
completely with US and therefore further imaging with MR or surgical evaluation should be
considered.
Normal ovaries
Functional cysts
Hemorrhagic ovarian cyst - HOC

When a Graafian follicle or follicular cyst bleeds,
a complex hemorrhagic ovarian cyst (HOC) is
formed.
US findings that allow a confident diagnosis of a
hemorrhagic ovarian cyst are:
Hemorrhagic cyst
Low risk patient

Cystic mass The cyst may contain a solidappearing area with good throughtransmission, without internal flow at color
Doppler, and typically with concave
margins, consistent with a blood clot
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In premenopausal women short term follow-up

is recommended in hemorrhagic cysts > 5 cm.
The same follow-up is recommended in early
postmenopausal women who have a cyst with
all the characteristics of a HOC Larger hemorrhagic cysts in the early menopause and any
hemorrhagic cyst in the late menopause should
be considered possibly neoplastic and MRI or
surgical evaluation should be considered.
Hemorrhagic cyst with a clot mimicking a neoplasm.

Notice absence of flow and good through-transmission
(arrow)
Differential diagnosis
When hemorrhagic cysts present with diffuse
low-level echoes, their appearance can be similar to that of endometriomas.
In the acute phase a hemorrhagic cyst may be
completely filled with low-level echoes, simulating a solid mass (5).
Clot in a hemorrhagic cyst may occasionally
mimic a solid nodule in a neoplasm. Clot, however, often has concave borders due to retraction, while a true mural nodule has outwardly
convex borders.
In both cases there will be no internal flow at
Doppler US and there will be good throughtransmission.
Hemorrhagic cysts typically resolve within 8
weeks.
The ultrasound image shows multiple simple
and one complex right ovarian cyst, with diffuse
low-level echos and absence of flow on Doppler
US.
Note that there is good through-transmission,
also through the complex cyst (blue arrow).
On the T1 with fatsat the lesion remains bright,
ruling out a fatty lesion.
After Gd administration there is no enhancement, confirming that this is a cystic hemorrhagic lesion, most likely a hemorrhagic ovarian
cyst, although your differential may include an
endometrioma.
Hemorrhagic ovarian cyst
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Endometrioma
US findings that allow a confident diagnosis of
an endometrioma are:
Homogeneous and hypoechoic mass
Diffuse low-level echoes (ground-glass)
No internal flow at color Doppler
No enhancing nodules or solid masses
In 30% echogenic foci are seen within cyst
wall
In women of any age, probable endometriomas

require initial 6-12 week follow-up to rule out a
hemorrhagic cyst.
Until surgically removed, endometriomas require
follow-up with ultrasound, for example on a
yearly basis.
This image from a vaginal ultrasound shows a
large hypoechoic, cystic lesion with diffuse
low-level echoes and two small echogenic foci.
These have been postulated to be cholesterol
deposits, but may also constitute small blood
clots or debris.
It is important to differentiate these echogenic
foci from true wall nodules.
Finding these echogenic foci makes the diagnosis of an endometrioma very likely.
Endometrioma
Mature cystic teratoma

US findings that are characteristic of a mature
cystic teratoma are:
Hypoechoic mass with hyperechoic nodule
(Rokitansky nodule or dermoid plug)
Usually unilocular (90%)
May contain calcifications (30%)
May contain hyperechoic lines caused by
floating hair
May contain a fat-fluid level, i.e. fat
floating on aqueous fluid
Shown are transvaginal ultrasound images of

two patients that demonstrate the 'tip-ofthe-iceberg' sign: acoustic shadowing from the
hyperechoic part of the dermoid cyst (arrow).
When misinterpreted as bowel gas, the lesion
may be overlooked.
Mature cystic teratoma
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Any other cyst - possible neoplasm

All other cystic lesions are regarded as possibly
neoplastic and therefore possibly malignant.
Surgical resection is needed by an oncologic gynaecologist, who may request prior imaging-based staging.
Findings indicating possible neoplasm:

Large size
While benign lesions can be very large, the
likelihood that a lesion is neoplastic
increases with size.
Also the likelihood that a neoplastic lesion
is malignant, increases with the size of the
lesion.
Vascularized septations
The presence of septations indicates a
possible neoplasm. When septations have
a thickness of more than 3mm and are
well-vascularized - while non-specific both increase the likelihood that a
neoplasm is malignant.
Vascularized solid components
Vascularized nodularities, papillary
projections, or frank solid masses all
increase the likelihood of a neoplastic
nature.
Vascularized thick, irregular wall
Lesions with thin walls are more often
benign and lesions with thick, irregular
walls are more often malignant. However,
there is some overlap, making wall
thickness a less useful criterion. For
example a corpus luteum cyst may also
have a thickened, vascularized wall.
Secondary findings associated with
malignant lesions:
Large quantities of ascites,
lymphadenopathy and peritoneal deposits
are strongly associated with an increased
likelihood of malignancy.
Benign cystic ovarian neoplasms
Malignant cystic ovarian neoplasms
Low-risk or High-risk
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Once we have determined a cystic ovarian lesion

is either a probable simple cyst, hemorrhagic
cyst, endometrioma or mature cystic teratoma,
or is indeterminate, the next step is to place the
patient in a low-risk or high-risk group (table).
The final decision to ignore, follow or excise a
cystic ovarian lesion is based on:
Morphology of the lesion on US, CT or MRI
Risk group (low versus high)
Symptomatic lesion versus incidental
finding
Additional findings such as ascites,
lymphadenopathy or peritoneal implants
That said, the great majority of cystic ovarian

lesions is benign.
While the risk of malignancy does increase with
age, even in post-menopausal women the risk
of malignancy in a simple ovarian cyst Although
complex ovarian cysts in post-menopausal
women are also most often benign, they do require further work-up, because of the chance of
malignancy.
'the Roadmap'
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The natural history of incidentally detected

pelvic masses with benign US morpgology is not
known and therefore the optimal management
is also unknown.
The roadmap is based on the 2010 Consensus
Guidelines published in (1) and (2) and on the
findings in (3) and (4).
The mentioned size cut-offs and follow-up frequencies are accepted practices but not ironclad
rules.
Local guidelines may differ based on the clinical
scenario and institutional practice preferences.
Many of the imaging criteria described in this
article are the same for ultrasound, CT and MRI,
although of course not every feature is equally
detectable on all modalities.
Risk factors
Age is the most important risk factor for all
women.
Lesions
in
pre-menopausal
and
post-menopausal women are managed differently.
Several other factors (see table) may place a
woman in a higher risk category.
Concordantly, the roadmap shows two pathways, one for lower-risk and one for higher-risk
patients.
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MRI protocol - which sequences, and why

MRI protocol
There are many possible 'Pelvic/Ovarian mass'
protocols.
The basic building blocks are simple and are the
same for all protocols:
High-resolution, T2W sequence without
fatsat, in at least 2 planes -> anatomy
T1W sequence without fatsat, or
preferably a T1W opposed-phase sequence
-> detection of fat, in teratoma
T1W sequence with fatsat -> mainly for
the identification of blood products and for
correlation to post-contrast T1W images
A Proton-Density or T1W sequence
extending to the upper abdomen -> nodal
disease. Some institutions may prefer to
skip this sequence in favor of a staging CT
or PET/CT.
A T1W sequence with fatsat after
administration of Gadolinium ->
enhancement of solid lesions or lesion
components.
A diffusion-weighted sequence with a
highest b-value of 500- 1000 s/mm2 ->
detection (not staging) of lymph nodes
and detection of peritoneal deposits.
A very short protocol may consist of only 1, 2

and 3 (e.g., when the request is to 'rule out an
ovarian mass').
Many radiologists prefer a slightly more comprehensive protocol including 4, and often 5.
When the clinical setting is characterization or
staging of a known ovarian lesion, 4 (or CT) and
5 should always be included.
The role of diffusion-weighted MRI is yet to be
determined, but DWI is a useful aid in the detection of lymph nodes, tumors and peritoneal
deposits.
For the purpose of detection, the DW images
are sometimes fused with (superimposed on)
anatomical T2W images.
DWI cannot discriminate benign from metastatic
lymph nodes.
Further differences in protocols all arise as variations on this simple theme.
For example:
T2W images in more than 2 planes, or
obliquely angled orthogonal to the
anatomic structure of interest, are often
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useful for cervical or uterine-body

pathology. Variations in FOV, with a larger FOV to
cover the whole pelvis and a smaller FOV
centered on the lesion of interest.
Post-contrast images in 2 or even 3
planes.
Sagittal T2W cine acquisition for recording
uterine wall contractions.
MR imaging is a valuable adjunct to US, as it allows identification of blood products within hemorrhagic masses that may mimic solid tumor at
US.
Fat-suppressed T1-weighted MR images may reveal small amounts of fat, which allows the diagnosis of a mature teratoma ('dermoid').
Contrast-enhanced T1-weighted MR imaging depicts features of malignancy such as enhancing
mural nodules and/or enhancing solid areas with
or without necrosis (3).
These MR images show a lesion with high signal

on T1.
This indicates either blood, other high protein
content or fat.
On the image with fat-saturation there is suppression of the signal.
This means that we are dealing with a fat-containig lesion, i.e. a mature cystic teratoma.
The US image shows an echogenic lesion.
The corresponding lesion has a high signal on
the T1-weighted MR image. This indicates either
blood, high protein or fat.
On the image with fat-saturation there is no
suppression of the signal.
This means that we are dealing with a bloodcontainig lesion, i.e. most likely a hemorrhagic
cyst.
1. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in
Ultrasound Consensus Conference Statement
by Deborah Levine et al
September 2010 Radiology, 256, 943-954.
2. ESUR guidelines for MR imaging of the sonographically indeterminate adnexal mass: an algorithmic
approach
by Spencer JA et al
Eur Radiol. 2010 Jan;20(1):25-35.
3. MR Imaging of the Sonographically Indeterminate Adnexal Mass
by John A. Spencer et al
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September 2010 Radiology, 256, 677-694.

4. Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter
by Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr.
Obstet Gynecol. 2003 Sep;102(3):594-9.
5. Adnexal Masses: US Characterization and Reporting
by Douglas L. Brown, MD, Kika M. Dudiak, MD and Faye C. Laing, MD
February 2010 Radiology, 254, 342-354.
6. Nonovarian Cystic Lesions of the Pelvis
by Penelope L. Moyle et al
July 2010 RadioGraphics, 30, 921-938.
7. Endometriosis: Radiologic-Pathologic Correlation
by Paula J. Woodward et al
RadioGraphics 2001; 21:193-216.
8. Magnetic resonance imaging of adnexal masses
by Rajkotia K, Veeramani M, Macura KJ
Top Magn Reson Imaging 2006; 17:379-97
9. Clinical Decision Making Using Ovarian Cancer Risk Assessment
by Michael P. Stany et al
AJR 2010; 194:337-342
10. The Likelihood Ratio of Sonographic Findings for the Diagnosis of Hemorrhagic Ovarian Cysts
by Maitray D. Patel, MD, Vickie A. Feldstein, MD and Roy A. Filly, MD
2005 J Ultrasound Med 24:607-614
11. Role of Transvaginal Sonography in the Diagnosis of Peritoneal Inclusion Cysts
by Stefano Guerriero et al
2004 J Ultrasound Med 23:1193-1200
12. Sonographic Spectrum of Hemorrhagic Ovarian Cysts
by Kiran A. Jain
J Ultrasound Med 21:879-886
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Diagnostic Work Up of Ovarian Cysts

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The Radiology Assistant : Diagnostic Work up of Ovarian Cysts