Diagnostic Ultrasound - Abdomen and Pelvis

Solid Adnexal Mass
1032
Differential Diagnoses: Female Pelvis
DIFFERENTIAL DIAGNOSIS
Common
• Leiomyoma
• Ectopic Pregnancy
• Mature Teratoma (Dermoid)
Less Common
• Adnexal Torsion
• Metastases, Ovary
• Ovarian Fibroma
• Solid Adnexal Mass (Mimics)
○ Hemorrhagic Ovarian Cyst
○ Endometrioma
○ Obstructed Uterine Duplication
○ Pelvic Kidney
○ Rectosigmoid Carcinoma
• Primary Ovarian Malignancy
○ Mucinous Cystadenocarcinoma
○ Serous Cystadenocarcinoma
○ Endometrioid Carcinoma
Rare but Important
• Ovarian Lymphoma
• Tubo-Ovarian Abscess
• Tubal Carcinoma
• Luteoma of Pregnancy
• Adenofibroma
• Granulosa Cell Tumor
• Brenner Tumor
• Atypical Germ Cell Tumors
○ Immature Teratoma
○ Dysgerminoma
○ Choriocarcinoma
• Massive Ovarian Edema and Fibromatosis
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
• Understanding typical appearance of benign lesions and
mimics of malignant solid masses is important to avoid
unnecessary work-up or surgery
• Ovaries visualized separate from mass suggests nonovarian
etiology
• If mass appears fibrotic with shadowing, tends to be benign
fibrous lesions
○ Pedunculated or broad ligament leiomyoma
○ Ovarian fibroma
○ Adenofibroma
• Bilateral lesions
○ Primary ovarian malignancy
○ Metastases
○ Endometrioid carcinoma
○ Lymphoma
• Hormonally active lesion
○ Thecoma
○ Granulosa cell tumor
Helpful Clues for Common Diagnoses
• Leiomyoma
○ May be subserosal, exophytic, pedunculated
○ Ovaries are seen separate from mass
– Using transducer pressure to push away ovary can
confirm this
○ Fibrous appearance with edge shadowing
○ Blood flow is seen connecting mass to uterus
○ MR helpful in establishing etiology if uncertain
(leiomyoma vs. fibrous ovarian tumor)
○ Can grow/degenerate during pregnancy due to
hormonal stimulation
– Causes pain
– Appears as growing, solid adnexal mass
• Ectopic Pregnancy
○ Always should be suspected in premenopausal woman
with pelvic pain and adnexal mass
○ Typically, small round adnexal mass (tubal ring) separate
from ovary
– With absent intrauterine pregnancy
– Hypervascular rim on color Doppler
□ Do not confuse with increased flow around corpus
luteum
○ May see yolk sac or fetal pole but typically do not
○ When ruptured, if adherent, adnexal clot can be
confused for large solid adnexal mass
– Ovary and tubal pregnancy may not be seen
separately from clot
• Mature Teratoma (Dermoid)
○ Cystic mass with variety of imaging appearances that can
mimic solid lesion
– Typical: Heterogeneous cystic ovarian mass with
echogenic shadowing mural nodule (Rokitansky
nodule)
– Posterior "dirty" shadowing, tip of iceberg sign
– ± fat-fluid level
– Dot-dash sign from hair
– Rarely entirely echogenic and solid appearing but
should lack central Doppler flow
□ Beware of twinkling artifact mimicking true flow;
use pulsed Doppler if unsure
Helpful Clues for Less Common Diagnoses
• Adnexal Torsion
○ Unilateral lesion in patient with severe ipsilateral pain
○ Enlarged ovary
○ Multiple, small, peripheral follicles or mass acting as lead
point
○ Blood flow may be absent on affected side, but not all
cases of torsion have abnormal blood flow
• Metastases, Ovary
○ Patient with known primary carcinoma, most commonly
from colon, gastric, breast, lung, or contralateral ovary
○ Krukenberg tumors are metastatic ovarian tumors that
contain mucin-secreting signet-ring cells, usually of GI
origin
• Ovarian Fibroma
○ Typically seen in women age 40-60
○ May be associated with hirsutism and amenorrhea if it
secretes androgen
○ May be associated with endometrial thickening if it
secretes estrogen
• Solid Adnexal Mass (Mimics)
○ Hemorrhagic Ovarian Cyst