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 Image 171
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)/2/3 Embedded Image 172
 Sertoli cell tumor (most benign)≤30 (75%)UniSolid; median diameter 90 mmHormonally inactive or estrogen-producing (abnormal bleeding)3/4 Embedded Image 173
 Leydig cell tumor (almost all benign)Median, 58UniSolid; median diameter 24 mmEndocrine symptoms (75% virilization); testosterone/androstenedione3/4 Embedded Image 173
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 occur1/2/3 Embedded Image 174
 Serous cystadenoma40–60Uni (80–90%)Uni- or multilocular (2–10 locules)Anechoic cystic fluid; often papillations without internal blood flow1/2 Embedded 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%)1/2 Embedded Image 175
 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 Image 176
 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 Image 177 178
Tumor-like lesions
 Abscess16–50Uni/biUni-/multilocularCogwheel appearance; mixed echogenicity; acute pain; raised CA 1253/4 Embedded Image 178
Malignant tumors
 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 shadowing2/3 Embedded Image 179 180 181 182
 Borderline mucinous (intestinal type)
Median, 50UniMultilocular (80%) or unilocular (15%); very large tumor (median diameter 195 mm)Multiple small loculi, often ‘honeycomb nodule’; no papillations; cystic fluid low-level2/3 Embedded Image 176 180
 Borderline mucinous (endocervical type)30–40UniUnilocular-solid; sometimes multilocular-solid; median diameter 37 mmPapillations (60%); cystic fluid low-level or ground-glass2/3 Embedded Image 176 180
 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%)2/3/4 Embedded Image 181
 High-grade serous carcinoma55–65Bi (50%)Solid (64%) or multilocular-solid (33%)Areas of necrosis in solid tissue; rarely, papillations (7%)2/3/4 Embedded Image 181
 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 Image 176
 Endometrioid carcinoma
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)/3/4 Embedded Image 183
 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)/3/4 Embedded Image 184
 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 areas3/4 Embedded 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 postmenopause3/4 Embedded Image 185
 Sertoli-Leydig-cell tumor≤30 (75%)Uni (100%)Large multilocular-solid or solid; median diameter 50–150 mmEndocrine symptoms (one-third virilization); testosterone/androstenedione3/4 Embedded Image 173
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 AFP3/4 Embedded Image 186
 Yolk sac tumor*20–30UniLarge and irregular multilocular-solid/solid (100–200 mm)Fine-textured slightly hyperechoic solid tissue; raised AFP3/4 Embedded Image 187 188
 Immature teratoma15–30UniLarge, predominantly solidVery inhomogeneous solid tissue with hyper-reflective areas; raised AFP2/3/4 Embedded Image
 ChoriocarcinomaMedian, 36UniLarge, solid (inhomogeneous echogenicity) with small and irregular cystic spacesRaised hCG(3)/4 Embedded Image 189
 Embryonal carcinoma14–20UniLarge, solid (inhomogeneous echogenicity) with small and irregular cystic spacesRaised hCG and AFP(3)/4 Embedded Image 189
 Malignant mixed germ cell tumorMedian, 18UniLarge, solid (inhomogeneous echogenicity) with small and irregular cystic spacesRaised hCG/LDH/AFP(3)/4 Embedded Image 189
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)3/4 Embedded Image 190
 Colon, rectum, appendix or biliary tractMedian, 56; appendix younger25–50 Bi (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 Image 190
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%3/4 Embedded Image 191
  • 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.