Table 1

Clinical and ultrasound features typical of different histological sub-types of adnexal tumor

Category/typeAge (years)LateralityAppearanceTypical featuresColor scorePictureRef
Endometriosis-related tumors  
 EndometriomaMedian, 34Uni/biUni- or multilocular (1–4 locules)Groundglass content; papillations in 10%, but most often without internal blood flow; premenopausal patient; raised CA 125 (median 44 U/mL)1/2/(3)Embedded Image171
Benign tumors  
Sex cord-stromal tumor  
 Fibroma/ fibrothecoma (65%)Median, 50; 65% postmenopausalUniRegular round, oval or slightly lobulated solid tumors; sometimes multilocular-solid (15–20%)Fan-shaped shadowing; often raised CA 125 (34%) and/or ascites(1)/2/3Embedded Image172
 Sertoli cell tumor (most benign)≤30 (75%)UniSolid; median diameter 90 mmHormonally inactive or estrogen-producing (abnormal bleeding)3/4Embedded Image173
 Leydig cell tumor (almost all benign)Median, 58UniSolid; median diameter 24 mmEndocrine symptoms (75% virilization); testosterone/androstenedione3/4Embedded Image173
Germ cell tumor  
 Mature cystic teratoma (dermoid)Median, 33Uni (88%)Uni- (58%) or multilocular (or uni-/multilocular-solid)Mixed echogenicity/white ball and stripes/shadowing; CA 19-9 elevated in 30%1/2/(3)Embedded Image†
 Struma ovarii (entirely or predominantly thyroid tissue); 3% of all ovarian teratomasMedian, 40Uni/biMultilocular/multilocular-solid; rarely, papillations; fluid anechoic or low-level‘Struma pearl’: smooth; roundish solid area; thyrotoxicosis may occur1/2/3Embedded Image174
Epithelial  
 Serous cystadenoma40–60Uni (80–90%)Uni- or multilocular (2–10 locules)Anechoic cystic fluid; often papillations without internal blood flow1/2Embedded Image‡
 Serous cystadenofibroma40–60Uni (84%)Multilocular-solid (37%), unilocular-solid (30%), multilocular (19%) or unilocular (13%); median diameter 50–80 mm1 (52%), 2 (17%) or 3 (13%) papillations; absent color Doppler signals (80%) and shadows behind papillations (40%)1/2Embedded Image175
 Mucinous cystadenomaMedian, 50Uni (95%)Multilocular (65%) >10 locules; sometimes unilocular (18%) or multilocular-solid (16%); median diameter 112 mmSometimes ‘honeycomb nodule’1/2/(3)Embedded Image176
 Brenner tumor (99% benign)30–70UniSmall solid tumors, 20–80 mm; often extensive calcifications; sometimes multilocular-solidSmall cysts often seen in solid tumors; shadowing; CA 125 raised in 10%1/2/(3)Embedded Image177 178
Tumor-like lesions  
Infection  
 Abscess16–50Uni/biUni-/multilocularCogwheel appearance; mixed echogenicity; acute pain; raised CA 1253/4Embedded Image178
Malignant tumors  
Epithelial  
 Borderline serousMedian, 42;
30% <40		Uni (73%)/bi (27%)Unilocular-solid (55%) or multilocular-solid (30%); cystic fluid anechoic (47%) or low-level>3 irregular papillations (81%) with internal blood flow and anechoic spaces; no shadowing2/3Embedded Image179 180 181 182
 Borderline mucinous (intestinal type)
 (30–50%)		Median, 50UniMultilocular (80%) or unilocular (15%); very large tumor (median diameter 195 mm)Multiple small loculi, often ‘honeycomb nodule’; no papillations; cystic fluid low-level2/3Embedded Image176 180
 Borderline mucinous (endocervical type)30–40UniUnilocular-solid; sometimes multilocular-solid; median diameter 37 mmPapillations (60%); cystic fluid low-level or ground-glass2/3Embedded Image176 180
 Borderline seromucinous
 (new category)		Median, 42UniContain endometrioid-, indifferent- and squamous-type epitheliumFrequently associated with endometriosis—176 180
 Low-grade serous carcinomaMedian, 53Bi (60%)Multilocular-solid (55%) or solid (32%)Small calcifications in solid tissue; papillations (32%)2/3/4Embedded Image181
 High-grade serous carcinoma55–65Bi (50%)Solid (64%) or multilocular-solid (33%)Areas of necrosis in solid tissue; rarely, papillations (7%)2/3/4Embedded Image181
 Mucinous carcinoma (3%)Median, 53Uni (80%)Multilocular-solid (55%), multilocular or solidVery large tumor (median diameter 197 mm); cystic fluid low-level2/3/(4)Embedded Image176
 Endometrioid carcinoma
 (10–15%)		Median, 55Uni (79%); co-exist with endometrial carcinoma (20%)Multilocular-solid (48%) with low-level (53%) or ground-glass (16%) cystic fluid, or solid (34%); median diameter 102 mmCockade-like appearance; papillations in 29%; 20% develop from endometriosis(2)/3/4Embedded Image183
 Clear cell carcinoma (5–25%)Median, 55Uni (85%)Multilocular-solid (41%) or unilocular-solid (35%) with low-level (44%) or ground-glass (22%) cystic fluid, or solid (24%); median diameter 117 mmSolid nodules; papillations in 38%; 20–30% develop from endometriosis(2)/3/4Embedded Image184
 CarcinosarcomaMedian, 66 (range 33–91)Bi (50%)Solid (72.5%); multilocular-solid (24.5%); median diameter 100 mmMost tumors solid with irregular margins and cystic areas3/4Embedded Image§
Sex cord-stromal tumor  
 Granulosa cell tumor (70%)50% premenopausal; 3–10% prepubertal (juvenile type)UniLarge multilocular-solid/solid; median diameter 100 mm; heterogeneous solid tissue with areas of necrosis and hemorrhage; echogenicity of fluid mixed or low-level; rarely, papillations‘Swiss cheese’ pattern; hyper-estrogenic (abnormal bleeding, thick endometrium); CA 125 normal; estradiol elevated in postmenopause3/4Embedded Image185
 Sertoli-Leydig-cell tumor≤30 (75%)Uni (100%)Large multilocular-solid or solid; median diameter 50–150 mmEndocrine symptoms (one-third virilization); testosterone/androstenedione3/4Embedded Image173
Germ cell tumor  
 DysgerminomaMedian, 20 (range 16–31)UniHighly vascularized, purely solid tumors with heterogeneous internal echogenicity divided into several lobules; smooth and sometimes lobulated contour; well-defined relative to surrounding organsInternal lobular appearance; raised LDH, sometimes AFP3/4Embedded Image186
 Yolk sac tumor*20–30UniLarge and irregular multilocular-solid/solid (100–200 mm)Fine-textured slightly hyperechoic solid tissue; raised AFP3/4Embedded Image187 188
 Immature teratoma15–30UniLarge, predominantly solidVery inhomogeneous solid tissue with hyper-reflective areas; raised AFP2/3/4Embedded Image
 ChoriocarcinomaMedian, 36UniLarge, solid (inhomogeneous echogenicity) with small and irregular cystic spacesRaised hCG(3)/4Embedded Image189
 Embryonal carcinoma14–20UniLarge, solid (inhomogeneous echogenicity) with small and irregular cystic spacesRaised hCG and AFP(3)/4Embedded Image189
 Malignant mixed germ cell tumorMedian, 18UniLarge, solid (inhomogeneous echogenicity) with small and irregular cystic spacesRaised hCG/LDH/AFP(3)/4Embedded Image189
Secondary metastatic  
 Breast, stomach, lymphoma or uterusMedian, 56Bi (50–75%)/uniSolid; median diameter 70 mm‘Lead-vessel’ sign; CA 125 moderately raised in 75%; CA 15-3 raised (breast)3/4Embedded Image190
 Colon, rectum, appendix or biliary tractMedian, 56; appendix younger25–50Bi (50–75%)/uniMultilocular/multilocular-solid; median diameter 120 mm; many locules; irregular; papillationsCA 125 moderately raised in 75%; CEA raised (colon, rectum); CA19-9 raised (biliary tract)(2)/3/(4)Embedded Image190
Tumor of Fallopian tube: epithelial  
 Tubal cancer55–60Uni (90%)Completely solid or with large solid component(s) and anechoic cystic fluid; average 50 mmWell-vascularized ovoid or sausage-shaped structure; normal ovarian tissue adjacent in 50%3/4Embedded Image191

  • All example images in this table are reproduced from the cited references in Ultrasound in Obstetrics and Gynecology. Color score indicates amount of blood flow within lesion, classified as no detectable flow (color score, 1), minimal flow (color score, 2) moderate flow (color score, 3) or abundant flow (color score, 4); scores in parantheses are less frequent.

  • *Yolk sac tumor is also named endodermal sinus tumor.

  • †Heremans et al (personal communication).

  • ‡Virgilio et al (personal communication).

  • §Ciccarone et al (personal communication).

  • ¶Landolfo et al (personal communication).

  • AFP, alpha-fetoprotein; Bi, bilateral; hCG, human chorionic gonadoptropin; LDH, lactate dehydrogenase; postmeno, post-menopausal; premeno, pre-menopausal; Ref, reference; Uni, unilateral.