Solid hypoechoic masses with smooth margins and acoustic shadowing and minimal Doppler flow are characteristic features of ovarian thecoma-fibroma group tumors, sex cord stromal neoplasms most commonly seen in the postmenopausal patient [91]. In a small study of 99 benign-appearing smooth purely solid masses, those with IOTA color score of 1 or 2, the risk of malignancy at 3 year follow-up was low, at 2%, suggesting conservative management may be an option for some patients with serial US imaging follow-up [92]. MRI may be able to assign a specific benign diagnosis or stratify for risk of malignancy, which may alter further imaging follow-up intervals [17,73]. If not requiring surgical management, indeterminate lesions that are well seen on US may be followed sonographically. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is not useful for further characterization of a suspicious adnexal lesion. Although not supported by the existing literature, CT of the pelvis without and with IV contrast may be potentially useful to determine if a suspected solid component within an adnexal lesion demonstrates enhancement. CT Pelvis Without IV Contrast CT pelvis without IV contrast is not useful for further characterization of a suspicious adnexal lesion. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is useful for staging of ovarian cancer, specifically for identifying other sites of disease, and with better detection of lymph node metastasis than conventional CT [93]. MRI Pelvis Without and With IV Contrast On US, solid adnexal lesions with irregular contour are highly suspicious for malignancy with a 93% PPV for malignancy [24]. Similarly, lesions with >4 papillary structures or solid tissue with increased color or spectral Doppler flow are concerning for malignancy [34,37,62].
Clinically Suspected Adnexal Mass No Acute Symptoms. Solid hypoechoic masses with smooth margins and acoustic shadowing and minimal Doppler flow are characteristic features of ovarian thecoma-fibroma group tumors, sex cord stromal neoplasms most commonly seen in the postmenopausal patient [91]. In a small study of 99 benign-appearing smooth purely solid masses, those with IOTA color score of 1 or 2, the risk of malignancy at 3 year follow-up was low, at 2%, suggesting conservative management may be an option for some patients with serial US imaging follow-up [92]. MRI may be able to assign a specific benign diagnosis or stratify for risk of malignancy, which may alter further imaging follow-up intervals [17,73]. If not requiring surgical management, indeterminate lesions that are well seen on US may be followed sonographically. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is not useful for further characterization of a suspicious adnexal lesion. Although not supported by the existing literature, CT of the pelvis without and with IV contrast may be potentially useful to determine if a suspected solid component within an adnexal lesion demonstrates enhancement. CT Pelvis Without IV Contrast CT pelvis without IV contrast is not useful for further characterization of a suspicious adnexal lesion. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is useful for staging of ovarian cancer, specifically for identifying other sites of disease, and with better detection of lymph node metastasis than conventional CT [93]. MRI Pelvis Without and With IV Contrast On US, solid adnexal lesions with irregular contour are highly suspicious for malignancy with a 93% PPV for malignancy [24]. Similarly, lesions with >4 papillary structures or solid tissue with increased color or spectral Doppler flow are concerning for malignancy [34,37,62].