Differential Diagnosis of The Adnexal Mass

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Differential diagnosis of the adnexal mass

Authors: Mitchel S Hoffman, MD, Lauri Hochberg, MD
Section Editors: Deborah Levine, MD, Barbara Goff, MD
Deputy Editor: Alana Chakrabarti, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2020. | This topic last updated: Oct 24, 2019.
INTRODUCTION
An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a common gynecologic problem. In the United
States, it is estimated that there is a 5 to 10 percent lifetime risk for women undergoing surgery for a suspected ovarian neoplasm [1].
Adnexal masses may be found in females of all ages, from fetuses to older adults, and there is a wide variety of types of masses. Pathology
in this area may also arise from the uterus, bowel, retroperitoneum, or metastatic disease from another site, such as the gastrointestinal tract
or breast.
Evaluation of an adnexal mass relies primarily on pelvic ultrasound, with additional information from history, physical examination, and
laboratory tests; patients may require surgical evaluation or treatment.
The different types of adnexal masses are reviewed here. Diagnosis and management of an adnexal mass and other related topics are
discussed separately:
● (See "Approach to the patient with an adnexal mass".)

● (See "Ultrasound differentiation of benign versus malignant adnexal masses".)
● (See "Serum biomarkers for evaluation of an adnexal mass for epithelial carcinoma of the ovary, fallopian tube, or peritoneum".)
● (See "Management of an adnexal mass".)
● (See "Ovarian cysts and neoplasms in infants, children, and adolescents".)
CLINICAL APPROACH
A mass in the adnexa may be symptomatic or discovered incidentally on pelvic examination or imaging. There are many different types of
adnexal masses. The type of mass is identified with pelvic imaging, use of biomarkers, and/or surgical exploration and pathologic evaluation.
Most adnexal masses arise from the ovary or fallopian tube. However, other gynecologic structures may give rise to an adnexal mass,
including the mesovarium or mesosalpinx (eg, paratubal cysts). Uterine leiomyomas may protrude toward the adnexa and be palpated or
visualized as an adnexal mass. In addition, adnexal masses may arise from other proximal structures, including the urinary tract (eg, bladder
diverticulum), bowel (eg, appendiceal abscess, diverticular abscess, bowel neoplasm), or pelvic connective tissue (eg, peritoneal cyst) or
nerves (nerve sheath tumor). The types of adnexal masses are shown in the table (table 1).
In terms of frequency, the distribution of histologic types of adnexal masses in an international cross-section study from the International
Ovarian Tumor Analysis (IOTA) group of over 4848 women is shown in the table (table 2) [2].
Some adnexal masses require immediate attention; these include ectopic pregnancy, adnexal torsion, a ruptured ovarian cyst with
hemorrhage, or a tubo-ovarian abscess. (See "Approach to the patient with an adnexal mass", section on 'Evaluation for urgent conditions'.)
A serious concern when an adnexal mass is discovered is the possibility that it is malignant. The differential diagnosis of benign and
malignant neoplastic masses is discussed below. The evaluation for a malignant neoplasm in an adnexal mass, including the sonographic
features of malignant neoplasms and use of biomarkers, is discussed in detail separately. A consensus paper from the Society of
Radiologists in Ultrasound in 2010 indicated that transvaginal ultrasound, supplemented by transabdominal ultrasound, was the best
technique for imaging and characterizing an adnexal cyst [3]. The first international consensus report on adnexal masses reviewed the
current state of the science and reported recommendations for assessment and management of adnexal masses [4]. This report described
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two approaches to the assessment of adnexal masses. The first is using pattern recognition seen on ultrasound to create a simple risk
assessment stratification profile. The second approach is to use risk prediction models with an emphasis on the IOTA Simple Rules [5].
There are also recommendations for indeterminant masses with regard to when to refer to an expert sonologist and gynecologic oncologist.
(See "Approach to the patient with an adnexal mass", section on 'Evaluation for malignancy' and "Serum biomarkers for evaluation of an
adnexal mass for epithelial carcinoma of the ovary, fallopian tube, or peritoneum" and "Ultrasound differentiation of benign versus malignant
adnexal masses".)
ANATOMY AND HISTOLOGY
Gross anatomy — The uterine adnexa consist of the ovaries, fallopian tubes, and surrounding vascular, lymphatic, and connective tissues
(figure 1).
The ovaries are suspended lateral and/or posterior to the uterus. The supporting structures of the ovaries include the utero-ovarian ligament
that attaches the ovary to the uterus; the infundibulopelvic ligament (also referred to as the suspensory ligament of the ovary), through which
the ovarian vessels travel, that attaches the ovary to the pelvic sidewall; and the broad ligament, which condenses to form the mesovarium. It
is also attached to the broad ligament through the mesovarium.
The ovary consists of an outer cortex, where the ova and follicles are located, and a medulla, where the blood vessels and connective tissue
compose a fibromuscular tissue layer (figure 2).
The fallopian tubes arise from the uterine corpus posterior and superior to the round ligaments. The broad ligaments support the tubes with a
condensation of connective tissue called the mesosalpinx.
Histology — The ovary includes several different tissue types. The most common neoplasms are epithelial. These derive from the stem cells
that would typically give rise to fallopian tube epithelium (most high-grade serous carcinomas), or ovarian surface epithelium and inclusions
(eg, cystadenomas). Ovarian germ cell tumors are derived from primordial germ cells of the ovary (figure 3). Ovarian sex cord-stromal tumors
derive from stem cells that would normally give rise to supporting epithelial cells, including ovarian stroma (eg, fibromas) and follicles (eg,
granulosa cell tumors, Sertoli-Leydig cell tumors).
The fallopian tubes consist of an outer muscularis layer of the tube with longitudinal smooth muscle fibers and an inner layer with circular
fibers. The fallopian tube mucosa is composed of numerous delicate papillary folds (plica) consisting of three cell types: ciliated columnar
cells; nonciliated, columnar secretory cells; and intercalated cells, which may simply represent inactive secretory cells [6].
Pelvic anatomy and histology is discussed in detail separately. (See "Surgical female pelvic anatomy".)
GYNECOLOGIC TRACT MASSES
There are many different types of adnexal masses (table 1). The likely etiology of an adnexal mass differs by age and reproductive status.
This is because some masses are stimulated by reproductive hormones.
Fetuses, children, and adolescents — Follicular ovarian cysts are common in fetuses and increase in frequency with advancing gestational
age and with some maternal complications (eg, diabetes mellitus, preeclampsia, Rh isoimmunization).
A pelvic mass in a newborn is most likely a physiologic cyst that initially arose due to maternal hormonal stimulation in utero. The differential
diagnosis of an intra-abdominal mass in fetuses or neonates includes genitourinary tract disorders (eg, reproductive tract anomalies, urinary
tract obstruction, urachal cyst), gastrointestinal tract disorders (eg, mesenteric or omental cyst, volvulus, colonic atresia, intestinal
duplication), or miscellaneous disorders (eg, choledochal, splenic, or pancreatic cyst, lymphangioma).
Between the neonatal period and puberty, physiologic cysts are uncommon because gonadotropin ovarian stimulation decreases in infancy
and early childhood and then increases during puberty. Nevertheless, most simple ovarian cysts in children are physiologic and result from
enlargement of a cystic follicle.
Girls between menarche and 18 years of age constitute an age group in which the development of both simple and complex cysts is quite
common. Adolescent ovaries may contain multiple follicles in different stages of development. Most simple cysts result from failure of the
maturing follicle to ovulate and involute.

Ovarian neoplasms (benign and malignant) account for approximately 1 percent of all tumors in children and adolescents. Most ovarian
masses are physiologic or benign neoplasms; fewer than 5 percent of ovarian cancers occur in this age group.
Ovarian cancer is the most common gynecologic malignancy in women ≤25 years of age, and germ cell tumors are the most common
histology [7]. Germ cell tumors compose one-half to two-thirds of ovarian neoplasms in girls up to 18 years of age compared with 20 percent
of ovarian neoplasms in adult women. In girls younger than nine years of age, approximately 80 percent of ovarian neoplasms are malignant.
Epithelial neoplasms are rare in the prepubertal age group.
The etiology, diagnosis, and management of ovarian neoplasms from the fetal to adolescent age group are reviewed separately. (See
"Ovarian cysts and neoplasms in infants, children, and adolescents".)
Premenopausal women — There is a broad differential diagnosis of an adnexal mass in women of reproductive age. Adnexal masses
stimulated by reproductive hormones are found almost exclusively in this age group. These include physiologic cysts, endometriomas, and
leiomyomas. Ovarian or tubal malignant neoplasms are uncommon in this age group, although the peak age for ovarian germ cell tumors is
between ages 10 and 30 years.
Adnexal masses in the reproductive-age women that are associated with reproductive hormones include some that result from an aspect of
the menstrual cycle, including:
● Functional/physiologic cysts
● Corpus luteal cyst
● Theca lutein cyst
● Polycystic ovaries
Other types of masses are stimulated by reproductive hormones:
● Endometrioma
● Uterine leiomyoma
Premenopausal women may develop benign or malignant neoplastic adnexal masses. These occur most commonly in the ovary but may
develop in the fallopian tube.
Common benign neoplasms include mature teratomas and cystadenomas. In general, ovarian or tubal cancers increase in incidence with
increasing age and so are more common in postmenopausal women. However, ovarian germ cell tumors (eg, teratomas) arise primarily in
young women between 10 and 30 years of age; they represent 70 percent of ovarian neoplasms in this age group [8].
Ovulatory — Some adnexal masses are associated with normal or abnormal ovulatory function.
Functional or corpus luteal cysts — In the process of normal ovulation, a follicle develops to maturity and then ruptures to release an
ovum; this is followed by formation and subsequent involution of the corpus luteum (figure 4). (See "Physiology of the normal menstrual
cycle".)
Follicular cysts (also referred to as physiologic cysts) arise when rupture does not occur and the follicle continues to grow; corpus luteal cysts
occur when the corpus luteum fails to involute and continues to enlarge after ovulation (the corpus luteum enlarges for the first six weeks of
pregnancy and doubles its prepregnancy size [9]). These cysts are therefore called physiologic or functional. Either type may become
hemorrhagic.
Follicular cysts appear smooth, thin walled, and unilocular on ultrasound examination (image 1), while corpus luteum cysts can look complex
and grossly are yellow (image 2). Simple cysts <3 cm in diameter are considered to be normal physiologic cysts. Physiologic cysts can
become quite large but are usually less than 10 cm in size. Although simple cysts are most likely benign, there are no data to support which
asymptomatic simple cysts are to be followed and which can be ignored. The Society of Radiologists in Ultrasound Consensus Conference
Statement has developed guidelines to address this topic [3]. (See "Ultrasound differentiation of benign versus malignant adnexal masses",
section on 'Step one: Is it a simple cyst?'.)
Corpus luteal cysts in the normal menstrual cycle may have a variety of appearances on ultrasound. They can be simple or complex,
containing internal debris (hemorrhage) and thick walls. They can also be enlarged, up to 8 cm, but typically resolve spontaneously [10].

An early intrauterine pregnancy is always associated with a corpus luteum cyst, which is typically <2.5 cm in diameter. However, the corpus
luteum may occasionally become enlarged and painful due to hemorrhage.
Functional and corpus luteal cysts are generally asymptomatic unless they rupture, they become hemorrhagic, or torsion occurs. Most
spontaneously resolve within a few weeks, but some persist for several months. (See "Evaluation and management of ruptured ovarian cyst"
and "Ovarian and fallopian tube torsion".)
Theca lutein cysts — Theca lutein cysts (also called lutein cysts or hyperreactio luteinalis) are luteinized follicle cysts that form as a
result of overstimulation from high human chorionic gonadotropin (hCG) levels or extreme sensitivity to hCG.
Bilateral multiseptated cystic adnexal masses in a woman with gestational trophoblastic disease, multiple gestation, ovarian hyperstimulation,
or a pregnancy complicated by fetal hydrops are likely to be theca lutein cysts rather than malignant neoplasms. This type of cyst can also
occur in a normal pregnancy due to hypersensitivity to normal levels of hCG. (See "Adnexal mass in pregnancy", section on 'Types of
adnexal masses in pregnant women' and "Hydatidiform mole: Epidemiology, clinical features, and diagnosis", section on 'Ovarian theca lutein
cysts'.)
Most theca lutein cysts are asymptomatic, but maternal virilization, hyperemesis gravidarum, preeclampsia, or thyroid dysfunction may occur.
The cysts gradually resolve weeks to months after the source of hCG is eliminated. (See "Gestational hyperandrogenism".)
Polycystic ovaries — Polycystic ovary syndrome (PCOS) results in enlarged ovaries with multiple small follicular cysts in some
women (image 3). Although the ovaries are enlarged, patients with PCOS rarely present with an adnexal mass.
The classic phenotype of PCOS is a woman who is obese, hirsute, and anovulatory. Ultrasound criteria (used for the Rotterdam criteria)
considered to have sufficient specificity and sensitivity to define PCOS are the presence of 12 or more follicles in each ovary measuring 2 to
9 mm in diameter and/or increased ovarian volume (>10 mL, calculated using the formula 0.5 x length x width x thickness). (See "Clinical
manifestations of polycystic ovary syndrome in adults", section on 'Ultrasound appearance'.)
PCOS is treated to manage abnormal uterine bleeding, infertility, insulin resistance, obesity, and hirsutism. The polycystic ovaries themselves
do not require treatment. (See "Treatment of polycystic ovary syndrome in adults".)
Pregnancy-related — Some types of adnexal mass are found only in pregnant women.
Corpus luteum of pregnancy — An early intrauterine pregnancy is always associated with a corpus luteum cyst. (See 'Functional or
corpus luteal cysts' above.)
Luteoma — Luteoma is a non-neoplastic ovarian mass associated with pregnancy; it is essentially a corpus luteum that is solid rather
than cystic. A luteoma is sometimes mistaken for a neoplasm on clinical, gross, or microscopic examination [11]. Luteomas involute
spontaneously after delivery or are adequately treated by a conservative surgical approach. The diagnosis should be suspected in the
presence of a solid adnexal mass and maternal hirsutism or virilization. (See "Gestational hyperandrogenism".)
Decidualization of endometrioma — Endometriomas may become decidualized during pregnancy. This can raise suspicion of a
malignant mass due to the presence of a solid element with flow. (See 'Endometrioma' below.)
Ectopic pregnancy — An ectopic pregnancy may present as an adnexal mass noted on pelvic examination or ultrasound. Signs and
symptoms suggestive of ectopic pregnancy include a history of a missed menstrual period, abdominopelvic pain, and vaginal bleeding. An
ectopic pregnancy is potentially life-threatening, and any woman with a possible ectopic pregnancy should be evaluated immediately. (See
"Ectopic pregnancy: Clinical manifestations and diagnosis" and "Ultrasonography of pregnancy of unknown location".)
Stimulated by reproductive hormones — Adnexal masses that are stimulated by reproductive hormones tend to regress and become
asymptomatic after menopause.
Endometrioma — An endometrioma is a benign cause of an adnexal mass arising from the ectopic growth of endometrial tissue.
Patients with endometriosis often complain of pelvic pain, dysmenorrhea, and dyspareunia. An endometrioma, or "chocolate cyst," appears
as a complex mass on ultrasound, typically containing homogeneous internal echoes. The ultrasound appearance of an endometrioma is
often described as containing "ground glass" internal echoes (image 4). The chocolate-colored fluid, or old blood contained in the cyst, has a
classic appearance. (See "Endometriosis: Pathogenesis, clinical features, and diagnosis" and "Endometriosis: Management of ovarian
endometriomas".)

Leiomyoma — A leiomyoma (fibroid) is a benign neoplasm of smooth muscle origin, which usually arises from the uterus but may also
be found in the broad ligament (picture 1).
Most women with symptomatic fibroids are in their 30s or 40s. Myomas are clinically apparent in approximately 25 percent of reproductive-
age women and noted on pathologic examination in approximately 80 percent of surgically excised uteri. (See "Uterine fibroids (leiomyomas):
Epidemiology, clinical features, diagnosis, and natural history".)
Depending on the size and location of the leiomyoma, patients often present with complaints of pelvic pressure, pain, heavy menstrual
bleeding, and/or dysmenorrhea. Physical examination usually reveals an enlarged, irregularly shaped uterus that appears as a solid uterine
tumor or tumors on ultrasound examination.
A fibroid arising from the posterior uterus and projecting into the posterior cul-de-sac (pouch of Douglas) or coming from the fundus as a
pedunculated mass can be confused with an ovarian neoplasm (picture 1). Cystic degeneration of a fibroid can result in the appearance of a
complex mass on ultrasound. This, coupled with the fact that fibroids can cause an elevation in the serum cancer antigen (CA) 125
concentration, results in further concern that the mass may be a malignant ovarian neoplasm. Transvaginal imaging is key to differentiating
between a leiomyoma in the adnexa from a solid ovarian tumor. First, the ovary must be found intact, normal, and completely separate from
the leiomyoma. Also, Doppler flow can be used to see the vascular communication between the uterus and the pedunculated leiomyoma.
Infectious or inflammatory
Tubo-ovarian abscess — A tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian tube, ovary, and,
occasionally, other adjacent pelvic organs (eg, bowel, bladder). This may manifest as a tubo-ovarian complex (an agglutination of those
structures) or a collection of pus (TOA). These abscesses are found most commonly in reproductive-age women and typically result from
upper genital tract infection. TOA is usually a complication of pelvic inflammatory disease (PID).
Findings of abdominopelvic pain, fever, purulent cervical discharge, and cervical motion tenderness in association with an adnexal mass
suggest a diagnosis of TOA. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)
Hydrosalpinx — Untreated or undertreated cases of PID result in scarring or "clubbing" of the tubal fimbriae. This leads to a collection
of either tubal secretions or pus, resulting in a hydrosalpinx or pyosalpinx, respectively.
After acute infection has resolved, a hydrosalpinx may remain. The tubal function is often compromised, and this may contribute to infertility.
(See "Long-term complications of pelvic inflammatory disease", section on 'Hydrosalpinx'.)
A hydrosalpinx should be suspected when a dilated, tubular cystic structure is seen adjacent to the ovary. Hydrosalpinges often have
incomplete septations. Three-dimensional ultrasound using sectional planes is useful to visually reconstruct the hydrosalpinx (image 5).
Luminal contents vary from serous (hydrosalpinx) to blood (hematosalpinx) or pus (pyosalpinx).
Benign neoplasms — Ovarian/tubal neoplasms may arise from stem cells, which typically give rise to the surface epithelium, fallopian
tube epithelium, germ cells, or sex cord-stromal cells (figure 3 and image 6). The most common types of benign neoplasms in reproductive-
age women are mature cystic teratoma (dermoid cyst) followed by serous cystadenoma and then mucinous cystadenoma [2,12]. Mature
cystic teratomas are a type of germ cell tumor; these ovarian neoplasms are found most commonly in women ages 10 to 30 years [13].
Serous or mucinous cystadenoma — Serous and mucinous cystadenomas are among the most common benign ovarian neoplasms.
They are thin walled, uni- or multilocular, and range in size from 5 to <20 cm.
Compared with serous cystadenomas, mucinous cystadenomas occur less frequently, are more likely to be multiloculated, are larger (they
can attain an enormous size), and are less often bilateral (less than 5 versus 20 to 25 percent) (table 3). A definitive diagnosis depends on
pathologic evaluation to determine the cell type lining the cysts. Serous lining is similar to fallopian tube lining, and mucinous lining cells
collect mucin in their cytoplasm and resemble either endocervical or gastrointestinal epithelium.
Many of these tumors are asymptomatic and found incidentally on pelvic examination or with ultrasound. As the masses grow, they can
cause pressure or pain, bloating, and urinary symptoms and can present with ovarian torsion.
Benign-appearing masses that are persistently symptomatic should be removed. There are no data regarding the decision to observe or
remove these benign-appearing cystic masses if they are asymptomatic. In our experience, several factors play a role in this important
treatment decision, including age, size of the mass, ultrasound appearance, family history or other risk factors for ovarian cancer, and
medical comorbidities. If the patient is a good candidate for surgery, it is reasonable to remove such masses due to uncertain future behavior.

If the patient is not a good candidate for surgery or removal is not felt to be strongly indicated due to the other factors discussed above, then
observation may be considered with serial ultrasound examinations to assess for stability and changes suspicious for malignant
transformation.
There are no data to support the frequency of repeat ultrasound examinations if the management plan is observation. A repeat ultrasound in
six months is reasonable and then yearly thereafter if the mass is stable with benign features. The International Ovarian Tumor Analysis
group (IOTA) is collecting data for part 5 of a large prospective international observational study to evaluate this question. Data collection
began in 2012 and is ongoing, and benign-appearing adnexal masses will be observed with transvaginal ultrasound with the goal of
collecting data that will allow development of a protocol regarding observation of benign-appearing adnexal masses.
An interim analysis of the IOTA 5 study was presented at the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)
conference in 2017 [14]. Data were presented regarding 2623 patients with an adnexal lesion presumed to be benign by subjective
assessment of the ultrasound investigator and were followed for a mean of 22 months. The probability of observing a malignant tumor,
torsion, and cyst rupture at two years was 0.7, 0.4, and 0.2 percent, respectively. The conclusion of this interim analysis is that conservative
management for these patients seems to be safe. The plan is to continue observation with interval ultrasound examinations for a total of five
years. (See "Management of an adnexal mass", section on 'Surveillance'.)
Mature cystic teratoma — A mature cystic teratoma (dermoid cyst) is a benign germ cell tumor and is the most common ovarian
neoplasm in the second and third decades of life [13]. Mature teratomas can contain elements differentiated to all three germ cell layers:
ectodermal (eg, skin, hair follicles, sebaceous glands), mesodermal (eg, muscle, urinary), and endodermal origin (eg, lung, gastrointestinal).
Transvaginal ultrasound usually reveals a complex mass, which can contain hyperechoic contents, hyperechoic lines or dots, fluid, and areas
of acoustic shadowing. Mature teratomas may have a variety of appearances depending on their content (image 7 and image 8). The tumors
are bilateral in 10 to 15 percent of patients (table 3) [15]. (See "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations,
and diagnosis", section on 'Mature teratoma (dermoid)'.)
Endosalpingiosis — Endosalpingiosis is the presence of non-neoplastic, ectopic, cystic glands outside the fallopian tube that are lined
with fallopian tube-type ciliated epithelium [16]. Endosalpingiosis may occur in pelvic organs, including ovaries, fallopian tube serosa, uterine
serosa, myometrium, or pelvic peritoneum. It may also occur in the bladder or in a retroperitoneal or axillary lymph node [17].
Endosalpingiosis is not well studied, and the clinical features remain uncertain. Similar Müllerian inclusions occur less frequently and may be
lined by mucinous or endometrioid epithelium.
Rarely, endosalpingiosis presents as large, tumor-like cystic masses involving the uterine serosa (figure 5) or bladder epithelium (picture 2)
[18,19].
Paraovarian/paratubal cysts and tubal and broad ligament neoplasms — Neoplasms arising from the fallopian tube or broad
ligament (figure 6 and picture 3A-B) are rare, although it is now believed that most high-grade serous carcinomas in the adnexa arise in the
fallopian tubes. Since the tubes and broad ligaments are not usually visualized on ultrasound examination, the source of these tumors may
be erroneously attributed to the ovary or uterus, which are more common sites for neoplasms.
The most common findings in this area are simple cysts that originate from the remnants of paramesonephric (Müllerian) or mesonephric
(Wolffian) ducts that are present during urogenital embryologic development (picture 3A) [20,21]. These are not neoplastic. The histology of
these lesions may also be mesothelial. Paramesonephric cysts are most common, in particular the hydatid cyst of Morgagni [22,23]. A
hydatid cyst of Morgagni is attached to the tubal fimbriae and contains serous fluid surrounded by a translucent wall. These are non-
neoplastic cysts lined by either mesothelium or fallopian tube-like epithelium.
Neoplasms may also present as paratubal or paraovarian masses. In a retrospective study of 59 women who underwent surgery for cystic
paraovarian lesions, 75 percent had simple cysts and 25 percent had neoplastic lesions (seven cystadenomas and eight cystadenofibromas);
there were no malignant neoplasms [24]. A primary malignancy deriving from the paratubal or paraovarian lesions is rare; a literature review
found 14 reports of malignant or borderline paraovarian epithelial neoplasms [25]; however, metastatic malignancies often involve the
paraovarian or paratubal tissues.
These cysts are usually discovered incidentally during pelvic sonography or surgery. There are no data regarding whether these cysts, either
benign or malignant, are more common in pre- or postmenopausal women. The key to diagnosis is a simple cyst seen adjacent to a normal
ovary. In women with paratubal or paraovarian cysts that are asymptomatic, appear simple on ultrasound, and are <10 cm in diameter, no
intervention or continuing surveillance is needed.

When a paratubal or paraovarian cyst is symptomatic, it most commonly presents as dull unilateral pelvic pain [21]. Surgery is usually not
necessary unless symptoms become severe. If the cyst is large or symptomatic, it should be removed surgically. This can typically be
achieved laparoscopically. As with larger ovarian cysts, a paratubal cyst may result in torsion of the adnexa and acute severe pain requiring
emergent surgical intervention (picture 3B).
It is often difficult to distinguish between a paratubal cyst and an exophytic simple ovarian cyst as they can look similar on ultrasound. It is not
clinically relevant to distinguish them as both are benign cysts and can be managed similarly.
Women with complex paratubal/paraovarian cysts should be managed in the same manner as women with complex ovarian cysts. (See
"Approach to the patient with an adnexal mass".)
Rarely, a leiomyoma may arise in the fallopian tube or broad ligament. An adenomatoid "tumor" may arise in the fallopian tube. It is unclear
whether such a tumor is neoplastic. It is a benign mesothelial proliferation that grossly resembles a leiomyoma and histologically may be
confused with a carcinoma [26].
Malignant neoplasms — The incidence of ovarian malignant neoplasms in women of this age group with an adnexal mass ranges from 6
to 11 percent [27]. Most primary ovarian neoplasms are partially cystic and derive from epithelial cells, although they can also arise from
other cell types, such as germ cell, sex cord-stromal, and mixed cell types. Germ cell tumors are the second most common type of ovarian
neoplasm in females younger than 30 years old, but they become rare after this age. (See "Epithelial carcinoma of the ovary, fallopian tube,
and peritoneum: Clinical features and diagnosis" and "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and
diagnosis" and "Sex cord-stromal tumors of the ovary: Epidemiology, clinical features, and diagnosis in adults" and "Ovarian cysts and
neoplasms in infants, children, and adolescents".)
The ovary can also be involved by metastatic malignant neoplasms forming in the gynecologic tract or nongynecologic primary sites
("Krukenberg tumor"), especially from endometrial carcinoma or gastrointestinal tract or breast cancer. (See 'Metastatic disease' below.)
Postmenopausal women — Most adnexal cysts in postmenopausal women are benign, but the incidence of ovarian cancer increases with
advancing age; at least 30 percent of ovarian masses in women over age 50 are malignant neoplasms [27]. Malignant adnexal masses
include those of primary ovarian or tubal origin or metastatic lesions from other primary malignant neoplasms (eg, endometrial, breast, or
gastrointestinal tract).
Nonmalignant etiologies of an adnexal mass in postmenopausal women include many of those also seen in patients of reproductive age,
such as cystadenoma, paraovarian cyst, or hydrosalpinx. Leiomyomas or endometriomas are stimulated by estrogen, serum levels of which
decrease significantly after menopause. Thus, these lesions typically decrease in size in postmenopausal women but may remain as smaller
masses.
Simple cysts are common in this age group. They most commonly represent either persistent physiologic/functional cysts from the
premenopausal period, or nonovulatory ovarian activity, or paraovarian or paratubal cysts/hydrosalpinx [28-30].
Neoplastic
Epithelial neoplasms — Benign or borderline ovarian epithelial neoplasms may also occur in postmenopausal women. These include
serous or mucinous cystadenomas or serous, mucinous, or endometrioid borderline neoplasms. (See 'Serous or mucinous cystadenoma'
above and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Histopathology", section on 'Overview of borderline
neoplasms'.)
Epithelial carcinoma is the most common histologic type of cancer of the ovary, fallopian tube, and peritoneum, accounting for 90 percent of
all cancers at these sites [31,32]. Ovarian carcinoma is traditionally referred to as a single entity, but it consists of a heterogeneous group of
neoplasms with multiple histologic subtypes [33].
Based upon histopathology, immunohistochemistry, and molecular genetic analysis, the five main subtypes of epithelial ovarian, fallopian
tubal, and peritoneal carcinomas and their relative proportions are [33]:
● High-grade serous carcinoma (HGSC; 70 to 80 percent)

● Endometrioid carcinoma (10 percent)
● Clear cell carcinomas (10 percent)
● Mucinous carcinoma (3 percent)

● Low-grade serous carcinoma (LGSC; <5 percent)
The different subtypes also differ in risk factors and clinical behavior. It has been proposed that what had been diagnosed as ovarian or
peritoneal serous carcinomas (HGSC and LGSC) may originate from fallopian tube precursors, serous tubal intraepithelial
neoplasia/carcinoma in the case of HGSC, and endosalpingiosis/Müllerian rests in the case of LGSC [34-41]. The histopathology, risk
factors, and diagnosis of serous ovarian, fallopian tubal, and peritoneal carcinomas are discussed separately. (See "Epithelial carcinoma of
the ovary, fallopian tube, and peritoneum: Histopathology" and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Incidence
and risk factors".)
High-grade tubal intraepithelial neoplasia/carcinoma is typically seen either associated with an ovarian or tubal mass or as a pathology result
after risk-reducing salpingo-oophorectomy in a patient with a BRCA mutation. These are microscopic lesions and do not present as a mass.
The average age at diagnosis of ovarian, tubal, or peritoneal carcinoma is approximately 60-years old. Patients often present with vague
gastrointestinal symptoms including dyspepsia, early satiety, anorexia, constipation, and bloating; these nonspecific complaints are
associated with advanced disease. Physical findings may include an adnexal or abdominopelvic mass, abdominal distention with ascites,
and/or pleural effusion. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section on
'Clinical presentation'.)
Pelvic ultrasound findings in women with epithelial ovarian cancer usually include a complex adnexal mass, either unilateral or bilateral, often
accompanied by ascites (image 9) [5]. (See "Ultrasound differentiation of benign versus malignant adnexal masses".)
Germ cell tumors — Ovarian germ cell tumors are derived from primordial germ cells of the ovary (figure 3). They may be benign or
malignant. In our experience, the most common germ cell tumor in postmenopausal women is malignant degeneration of a teratoma. These
neoplasms comprise approximately 20 to 25 percent of ovarian neoplasms overall but account for only approximately 5 percent of all
malignant ovarian neoplasms [42-44]. Ovarian germ cell tumors arise primarily in young women between 10 and 30 years of age and
represent 70 percent of ovarian neoplasms in this age group [8]. Mature teratomas are sometimes seen in postmenopausal women, but
malignant germ cell tumors are exceedingly rare in the postmenopausal age group. (See "Ovarian germ cell tumors: Pathology,
epidemiology, clinical manifestations, and diagnosis".)
Sex cord-stromal tumors — Ovarian sex cord-stromal tumors are a heterogeneous group of benign or malignant neoplasms that
develop from the dividing cell population that would normally give rise to cells surrounding the oocytes (the nongerm cell and nonepithelial
components of the gonads) (figure 3) [45]. These neoplasms are rare, comprising only 1.2 percent of all primary ovarian cancers (malignant
neoplasms) [46]. The average age at diagnosis is approximately 50 years.
The histologic types of sex cord-stromal tumors include granulosa-stromal cell (eg, granulosa cell tumor, fibroma, thecoma), Sertoli-stromal
(eg, Sertoli-Leydig cell tumor), and granulosa and Sertoli-Leydig elements (eg, gynandroblastoma).
Sex cord-stromal tumors are often comprised of cells that produce ovarian hormones, including estrogen and androgens. These may result in
symptoms of estrogen excess or other effects, and measurement of these and other tumor markers may play a role in diagnosis (table 4).
They rarely may be associated with Meigs syndrome. Meigs syndrome includes findings of an adnexal mass, ascites, and pleural effusions
[47].
Ovarian sex cord-stromal tumors are discussed in detail separately. (See "Sex cord-stromal tumors of the ovary: Epidemiology, clinical
features, and diagnosis in adults".)
Simple ovarian cysts — Simple (anechoic) ovarian cysts are common in postmenopausal women. Simple cysts often resolve
spontaneously but require surveillance to detect malignancy. If a simple cyst develops complex features or is accompanied by an elevated
tumor marker level, surgery is required to exclude ovarian cancer. (See "Management of an adnexal mass", section on 'Postmenopausal
women'.)
Simple cysts that develop during menopause probably represent either persistent physiologic/functional cysts from the premenopausal period
or nonovulatory ovarian activity [28-30]. High levels of gonadotropins or androgens may cause small, epithelial-lined structures in the ovary to
secrete fluid into their inner cavity and enlarge to become cysts. This is not uncommon, especially in the first few years after menopause [28-
30,48].
The prevalence of a simple unilocular cyst in postmenopausal women ranges from 2.5 to 18 percent, depending upon the population and
criteria used (eg, <5 or <10 cm) [48,49]. The risk of ovarian cancer in a woman with a simple cyst on a high-quality sonogram is exceedingly

low [50]:
● The largest study to-date was a population-based study of a large health care group including 72,093 women who underwent pelvic
ultrasound from 1997 to 2008 [51]. Simple ovarian cysts were found in 23.8 percent of women <50 years old, and no ovarian cancers
were found in women with a simple cyst; 49 ovarian cancers were diagnosed in this age group overall. In women ≥50 years, 13.4
percent had simple cysts, and one of these women was diagnosed with a metastatic peritoneal malignancy, presumed to be an ovarian
primary; there were 161 ovarian cancers in this age group overall. A nested case-control analysis found that, compared with a normal-
appearing ovary, the risk of ovarian cancer for an ovarian cyst was <50 years (simple cyst: odds ratio [OR] 0 because there were no
cases; complex cyst: OR 24.7, 95% CI 6.8-90.0) and ≥50 years (simple cyst: OR 0.17, 95% CI 0.02-1.30; complex cyst: OR 23.1, 95%
CI 9.8-54.1). In women ≥50 years with a simple cyst, the three-year risk of ovarian cancer was 0.5 per 1000 women. This study
confirmed the low rate of ovarian cancer associated with an ultrasound finding of a simple cyst. The case-control design allowed
calculation of the comparative risks of ovarian cancer across age groups and ultrasound findings.
● In an ovarian cancer screening trial, more than 15,000 women over 55-years old underwent annual transvaginal sonography for three
years [52]. Simple cysts were seen in 14 percent of women on the first ultrasound. At one-year follow-up, the incidence of new simple
cysts was 8 percent. Among ovaries with one simple cyst at the first screen, 32 percent had no ovarian mass, 62 percent had one or
more simple cysts, and 6 percent had a complex or solid mass (not necessarily arising from the simple cyst).
● In a series of 8794 asymptomatic postmenopausal women offered transvaginal sonography at the time of a routine gynecologic check-
up, 2.5 percent (215 patients) had a simple unilocular adnexal cyst; 84 percent were ≤5 cm and 88 percent were missed on pelvic
examination [28]. Complete follow-up information was available for 149 of these patients:
• Forty-five women underwent surgery for cyst size ≥10 cm, CA 125 ≥35 international units/mL, or patient preference, and the
following diagnoses were found: serous cystadenoma (41), mucinous cystadenoma (3), cystadenofibroma (3), paraovarian cyst (1),
and ovarian cancer (1). The ovarian cancer occurred in a 3-cm cyst associated with a CA 125 of 45 international units/mL.
• Among the 104 patients followed conservatively, 44 percent had cyst resolution (median time to resolution 15 months, range 6 to 54
months), although some of these women subsequently developed new cysts. The remaining patients had persistent cysts
throughout the study with a median follow-up of 48 months.
● A series of 15,106 asymptomatic women ≥50 years of age reported a unilocular ovarian cyst in 18 percent [48]. Approximately 70
percent of these cysts spontaneously resolved, most within three months, but 6.8 percent persisted >12 months. No woman with an
isolated unilocular ovarian cyst developed ovarian cancer.
● An autopsy study of 234 postmenopausal women (median age 75) who died of nongynecologic disease found ovarian cysts in 36 (15
percent) [30]. Cyst size ranged from 5 to 75 mm; all were benign except for one case of bilateral serous cystadenomas of low malignant
potential. In addition, 11 women had paraovarian cysts.
The management of simple ovarian cysts is discussed in detail separately. (See "Ultrasound differentiation of benign versus malignant
adnexal masses", section on 'Step one: Is it a simple cyst?'.)
Other gynecologic etiologies — Leiomyomata may persist into the menopausal years, but new myomas typically do not develop.
Similarly, endometriomas that developed prior to menopause may remain on/in the ovary. Previous imaging should be reviewed to determine
whether an adnexal mass is a new mass that developed after menopause. (See 'Leiomyoma' above and 'Endometrioma' above and "Uterine
fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Postmenopausal women' and
"Endometriosis: Management of ovarian endometriomas".)
NONGYNECOLOGIC MASSES
Metastatic disease — The ovaries and fallopian tubes are common sites of metastases of endometrial, breast, and some gastrointestinal
malignant neoplasms. In studies of 50 or more cases of metastatic neoplasms to the ovary, the sites of primary tumors included colon cancer
(15 to 32 percent), breast (8 to 28 percent), gastric (6 to 22 percent), and appendix (2 to 20 percent) [53-55]. Rarely, lymphoma or sarcomas
may metastasize to the ovary and present as ovarian masses. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum:
Clinical features and diagnosis", section on 'Excluding an extraovarian primary cancer'.)

Abdominopelvic abscess — Infectious or inflammatory causes of an adnexal mass that are not derived from the gynecologic tract include
lesions of the gastrointestinal tract (especially diverticulitis and, less often, appendicitis) or any other type of pelvic abscess. (See
"Posthysterectomy pelvic abscess" and "Clinical manifestations and diagnosis of acute diverticulitis in adults" and "Acute appendicitis in
adults: Clinical manifestations and differential diagnosis".)
The prevalence of diverticular disease in the general population is age dependent, increasing from less than 5 percent at age 40, to 30
percent by age 60, and 65 percent by age 85. During an episode of diverticulitis, a tender mass is palpable in approximately 20 percent, and
abdominal distention is common. Symptoms include fever, abdominal pain (usually left lower quadrant), nausea and vomiting, constipation,
diarrhea, and urinary symptoms. Diverticular disease should be considered in the older woman who presents with fever, left-sided pelvic
pain, and a pelvic mass on pelvic or ultrasound examination.
In a patient with constipation, a somewhat firm, usually mobile adnexal mass may be palpated on pelvic examination. However, this resolves
if the constipation is treated.
Examples of other bowel masses that may present as an adnexal mass include: appendiceal tumor or inflammatory mass, a tumor arising
from a Meckel's diverticulum, and gastrointestinal stromal tumors of the small and large intestine.
Urinary tract masses — Urinary tract masses that may present as an adnexal mass on pelvic examination or imaging include bladder
diverticulum, ureteral diverticulum, and pelvic kidney. (See "Renal ectopic and fusion anomalies".)
Other masses — Other types of abdominopelvic masses that may present as an adnexal mass on pelvic examination or imaging include
peritoneal and omental cysts, intraligamentous masses, and various retroperitoneal lesions.
A peritoneal inclusion cyst may occur as a result of pelvic adhesions. The typical presentation is a patient with prior surgery (especially
hysterectomy) or history of inflammation (pelvic inflammatory disease) with a cystic mass seen on transvaginal ultrasound that is not clearly
palpable. The ultrasound appearance includes pockets of fluid in the pelvis separated by filmy adhesions that can move ("flapping sails"
sign). Often the ovary, if present, is contained within the loculated fluid, which conforms to surrounding pelvic structures and sidewalls. There
is generally an irregular-shaped exterior border rather than a round cyst [3]. If the clinical scenario and findings on imaging are consistent
with a peritoneal inclusion cyst, then no intervention is indicated and surveillance with serial imaging may be performed. Resolution of the
loculated fluid or reduction of the volume may be seen over time as this is peritoneal fluid trapped within filmy adhesions.
Malignant peritoneal mesothelioma is a rare neoplasm of the serosal membranes of the pleura, peritoneum, pericardium, or tunica vaginalis
testes. The disease distribution is typically diffuse, but localized disease may occur and could potentially be detected as an adnexal mass.
There are no signs or symptoms that are specific for malignant peritoneal mesothelioma. The most frequent symptoms are abdominal
distention/pain, weight loss, dyspnea, and chest pain. (See "Malignant peritoneal mesothelioma: Epidemiology, risk factors, clinical
presentation, diagnosis, and staging".)
ADNEXAL MASS COMPLICATIONS
In addition to the presence of an adnexal mass, complications may occur that have characteristic symptoms, patterns, or findings on pelvic
imaging.
Hemorrhagic ovarian cyst — An ovarian cyst may become hemorrhagic (ie, there may be bleeding within the cyst). Women with a
hemorrhagic cyst may be asymptomatic or may present with mild to severe pelvic pain. If the patient is stable and bleeding is not ongoing,
then the patient may be managed expectantly. Ultrasound features typically include a cystic mass with internal echoes, which vary depending
on the evolution of a blood clot. There may be a fluid level if there has been fresh bleeding or a blood clot that appears as an avascular solid
internal mass. Or there can be "cobweb" internal echoes as the blood clot resolves. Hemorrhagic cysts or hemorrhagic corpus luteum cysts
usually occur with ovulatory dysfunction. Patients who are on anticoagulation are at increased risk. (See "Ultrasound differentiation of benign
versus malignant adnexal masses", section on 'Step two: Is there a physiologic process that can account for potentially confusing findings?'
and "Management of an adnexal mass", section on 'Ruptured or hemorrhagic ovarian cyst'.)
Ruptured ovarian cyst — An ovarian cyst may rupture. This is typically accompanied by the sudden onset of moderate to severe pelvic
pain. Ruptured ovarian cysts may cause bleeding. Most may be managed expectantly, but some surgical management is required in some
cases. (See "Evaluation and management of ruptured ovarian cyst".)
https://sibib2.ucm.cl:2141/contents/differential-diagnosis-of-the-adnexal-mass/print?search=patologia anexial&source=search_result&selectedTitle=… 10/38

Adnexal torsion — Ovarian torsion refers to the complete or partial rotation of the ovary on its ligamentous supports, often resulting in
ischemia. The fallopian tube often twists along with the ovary; when this occurs, it is referred to as adnexal torsion. The primary risk factor for
ovarian torsion is an ovarian mass and is most common if the ovary is 5 cm or larger.
Pelvic ultrasound is the first-line imaging study for patients with suspected ovarian torsion and will identify a mass or cyst that is usually 5 to
10 cm. Power Doppler can be used to evaluate blood flow to the ovary, but the diagnosis and decision for surgery is a clinical one. Blood flow
will be seen unless the torsion involves complete obstruction of the supplying vessels, so observing blood flow to the ovary does not rule out
adnexal torsion. A definitive diagnosis of ovarian torsion is made by direct visualization of a rotated ovary at the time of surgical evaluation.
(See "Ovarian and fallopian tube torsion".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See
"Society guideline links: Ovarian and fallopian tubal disease".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a
given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You
can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Ovarian cysts (The Basics)")
● Beyond the Basics topic (see "Patient education: Ovarian cysts (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a common gynecologic problem. Adnexal
masses may be found in females of all ages, from fetuses to older adults. (See 'Introduction' above.)
● A mass in the adnexa may be symptomatic or discovered incidentally on pelvic examination or imaging. The type of mass is determined
with pelvic imaging, use of biomarkers, and/or surgical exploration and pathologic evaluation. Some adnexal masses require immediate
attention; these include ectopic pregnancy, adnexal torsion, a ruptured ovarian cyst with hemorrhage, or a tubo-ovarian abscess. A
serious concern is the possibility that an adnexal mass is malignant neoplasm. (See 'Clinical approach' above.)
● The etiology is usually a primary process of the ovary or fallopian tube but may involve the broad ligament, uterus, bowel, or
retroperitoneum, or metastatic neoplasm or infection from another site, such as the breast or gastrointestinal tract. Adnexal masses may
be benign or malignant neoplasms or non-neoplastic. The differential diagnosis of an adnexal mass varies according to age and
menopausal status (table 1). (See 'Clinical approach' above.)
● Ovarian neoplasms derive from the three different ovarian cell types. The most common ovarian neoplasms are epithelial. These derive
from the stem cells that would typically give rise to fallopian tube epithelium (most high-grade serous carcinomas), or ovarian surface
epithelium and inclusions (eg, cystadenomas). Ovarian germ cell tumors are derived from primordial germ cells of the ovary (figure 3).
Ovarian sex cord-stromal tumors derive from stem cells that would normally give rise to supporting epithelial cells, including ovarian
stroma (eg, fibromas) and follicles (eg, granulosa cell tumors, Sertoli-Leydig cell tumors). (See 'Histology' above.)
● Ovarian neoplasms (benign and malignant) account for approximately 1 percent of all tumors in children and adolescents. Most ovarian
masses are physiologic or benign neoplasms; fewer than 5 percent of ovarian cancers occur in this age group. Germ cell tumors are the
most common histologic type of ovarian cancer in children and adolescents. (See 'Fetuses, children, and adolescents' above.)

● There is a broad differential diagnosis of an adnexal mass in women of reproductive age. Adnexal masses stimulated by reproductive
hormones are found almost exclusively in this age group. These include physiologic cysts (eg, follicular cyst, corpus luteal cyst),
endometriomas, and leiomyomas. Ovarian or tubal malignant neoplasms are uncommon in this age group, although the peak age for
ovarian germ cell tumors is between ages 10 and 30 years. (See 'Premenopausal women' above.)
● There is a high index of suspicion for ovarian cancer in postmenopausal women with an adnexal mass. At least 30 percent of ovarian
masses in women over age 50 are malignant neoplasms. Nonmalignant etiologies of an adnexal mass in postmenopausal women
include many of those also seen in patients of reproductive age. Simple cysts are common in this age group and are rarely malignant.
(See 'Postmenopausal women' above.)
● Nongynecologic sources of adnexal masses include metastatic disease from nongynecologic primary sites (eg, gastrointestinal, breast),
pelvic abscess, and other pelvic or retroperitoneal masses (eg, peritoneal inclusion cyst, nerve sheath tumor, bladder diverticulum). (See
'Nongynecologic masses' above.)
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Topic 3204 Version 34.0

GRAPHICS
Differential diagnosis of an adnexal mass
Gynecologic: Extraovarian
Gynecologic: Ovarian Gynecologic: Tubal Nongynecologic
and extratubal
Benign
Functional (physiologic) cyst Ectopic pregnancy Paraovarian cyst Constipation

Corpus luteal cyst Hydrosalpinx Paratubal cyst Appendiceal abscess
Luteoma of pregnancy Uterine leiomyoma (pedunculated or Diverticular abscess
Theca lutein cyst cervical) Pelvic abscess
Polycystic ovaries Tubo-ovarian abscess Bladder diverticulum
Endometrioma Ureteral diverticulum
Cystadenoma Pelvic kidney
Benign ovarian germ cell tumor Peritoneal cyst
(eg, mature teratoma) Nerve sheath tumor
Benign sex cord-stromal tumor
Malignant or borderline
Epithelial carcinoma Epithelial carcinoma Metastatic endometrial carcinoma Appendiceal neoplasm

Epithelial borderline neoplasm Serous tubal intraepithelial neoplasia Bowel neoplasm
Malignant ovarian germ cell tumor Metastasis (eg, breast, colon,
Malignant sex cord-stromal tumor lymphoma)
Retroperitoneal sarcoma
Modified from: Rauh-Hain JA, Melamed A, Buskwofie A, Schorge JO. Adnexal mass in the postmenopausal patient. Clin Obstet Gynecol 2015; 58:53.
Graphic 107713 Version 4.0

Prevalence of specific adnexal mass pathologies in patients in the International Ovarian Tumor Analysis group (IOTA)
study (n = 4848)
Patients from oncology Patients from other hospitals,

Tumor pathology All patients, n (%)
centers, n (%) n (%)
All benign pathologies 3183 (65.7) 1861 (57.0) 1322 (83.4)
Endometrioma 845 (17.4) 456 (14.0) 389 (24.5)
Benign teratoma (dermoid) 512 (10.6) 334 (10.2) 178 (11.2)
Simple/parasalpingeal cyst 285 (5.9) 147 (4.5) 138 (8.7)
Functional cyst 128 (2.6) 69 (2.1) 59 (3.7)
Hydrosalpinx 112 (2.3) 53 (1.6) 59 (3.7)
Peritoneal pseudocyst 34 (0.7) 21 (0.6) 13 (0.8)
Abscess 45 (0.9) 34 (1.0) 11 (0.7)
Fibroma 245 (5.1) 168 (5.1) 77 (4.9)
Serous cystadenoma 543 (11.2) 326 (10.0) 217 (13.7)
Mucinous cystadenoma 359 (7.4) 203 (6.2) 156 (9.8)
Rare benign pathologies 75 (1.5) 50 (1.5) 25 (1.6)
All malignant pathologies 1665 (34.3) 1402 (43.0) 263 (16.6)
Primary invasive stage I 222 (4.6) 184 (5.6) 38 (2.4)
Primary invasive stage II 82 (1.7) 64 (2.0) 18 (1.1)
Primary invasive stage III 658 (13.6) 579 (17.7) 79 (5.0)
Primary invasive stage IV 102 (2.1) 88 (2.7) 14 (0.9)
Rare primary invasive pathologies* 113 (2.3) 80 (2.5) 33 (2.1)
Borderline stage I 249 (5.1) 197 (6.0) 52 (3.3)
Borderline stage II 9 (0.2) 6 (0.2) 3 (0.2)
Borderline stage III 25 (0.5) 23 (0.7) 2 (0.1)
Borderline stage IV 1 (0.02) 1 (0.03) 0
Secondary metastatic cancer 204 (4.2) 180 (5.5) 24 (1.5)
* Including malignant sex cord-stromal tumors, germ cell tumors, mesenchymal tumors, lymphomas, and rare malignant epithelial tumors (eg, malignant Brenner tumor).
Reproduced from: Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian
Tumor Analysis group. Am J Obstet Gynecol 2016; 214:424. Table used with the permission of Elsevier Inc. All rights reserved.

Normal female reproductive anatomy

Ovarian anatomy
This figure shows the ovary, fallopian tube, and follicles (cysts).
Reproduced with permission from: Anatomical Chart Company, General Anatomy. Copyright ©2008
Anatomical Chart Company.

Origins of ovarian tumors
Many epithelial ovarian carcinomas, such as high-grade serous

carcinomas, originate in the fallopian tube epithelium.

Menstrual cycle

Ovarian follicle on ultrasound
Three-dimensional transvaginal ultrasound image of the left ovary containing a normal dominant follicle. The follicle is round, contains
clear fluid, and is surrounded by normal ovarian tissue. The thick arrow is pointing to the follicle in one dimension.
Courtesy of Lauri Hochberg, MD.

Ovarian corpus luteum on ultrasound
Power Doppler outlines the single peripheral vessel that is seen typically in a corpus luteum. The corpus luteum has scalloped edges and can have internal echoes,
hemorrhage, or a blood clot.

Polycystic ovary on ultrasound
Three-dimensional transvaginal ultrasound image of a polycystic ovary. There are typical features present, including multiple (>10)
small peripheral follicles <1 cm in diameter ("string of pearls" sign). There is also typically increased central stroma, and overall
volume of the ovary is increased to greater than 10 cc.

Ovarian endometrioma on ultrasound
Transvaginal ultrasound image of an endometrioma containing homogeneous internal echoes, which look like "ground glass." Ovarian crescent sign present.

Uterine leiomyomata
Gross intraoperative photograph of multiple uterine leiomyomata.
Courtesy of Mitchel Hoffman, MD.

Fallopian tube hydrosalpinx on ultrasound
Transvaginal ultrasound three-dimensional image of a hydrosalpinx. Features that suggest this entity include a cystic mass adjacent to the normal intact
ovary, incomplete septations, and the mass is tubular in shape.

Ovarian fibrothecoma on ultrasound
(A through C) Ultrasound image of a smooth solid benign ovarian tumor, a fibrothecoma, which is a type of sex cord-stromal tumor.

Bilaterality of ovarian neoplasms
Ovarian tumor histology Incidence of bilaterality

(World Health Organization classification) (approximate %)
Serous cystadenoma 12 to 23
Serous borderline tumor 55
Serous carcinoma 60
Mucinous cystadenoma 5
Mucinous borderline tumor 5
Mucinous carcinoma 5
Mature cystic teratoma (dermoid) 15
Dysgerminoma 15
Other malignant germ cell tumors 1
Granulosa-stroma cell tumor 5
Secondary tumors 70
Data from: Kurman RJ, Ellenson LH, Ronnett B. Blaustein's Pathology of the Female Genital Tract, 6th ed, Springer, 2011.

Benign mature ovarian teratoma (dermoid cyst) on ultrasound
Transvaginal ultrasound image of a benign teratoma that features heterogeneous contents, smooth outer surface. The arrow points to lines that are hair. There are
hyperechoic portions and homogeneous echoes (mucin).

Benign mature ovarian teratoma (dermoid cyst) on ultrasound
Transvaginal ultrasound of a mature teratoma in the ovary containing heterogeneous contents, which often shadow. It is round and well circumscribed. This image
contains the "ovarian crescent" sign, which is a rim of normal-appearing ovary with follicles. These features suggest a benign cyst.

Endosalpingiosis: Pelvic cysts
Transvaginal ultrasound showed cystic formations in the areas of the right fallopian tube (A) and fundus uteri (B). The
maximum diameter of the cysts was 7.5 cm. Laparoscopic presentation of the cystic mass (C); uterus (front) with right tube
and right abdominal wall (background).
Reproduced from: Scheel AH, Frasunek J, Meyer W, Strobel P. Cystic endosalpingiosis presenting as chronic back pain, a case report.
Diagn Pathol 2013; 8:196. Copyright © 2013 Scheel et al; licensed by BioMed Central Ltd. This is an Open Access article distributed
under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.

Endosalpingiosis: Bladder cyst
Cystoscopic findings showing a soft sessile polypoid lesion in the posterior wall of the urinary bladder.
Reproduced with permission from: Maeda K, Kojima F, Ishida M, et al. Case report: Müllerianosis and
endosalpingiosis of the urinary bladder: Report of two cases with review of the literature. Int J Clin Exp Pathol
2014; 7:4408. Copyright © 2014 International Journal of Clinical and Experimental Pathology. All rights
reserved.

Anatomic locations of paratubal and paraovarian cysts
(1) A hydatid cyst of Morgagni arises from the hydatid of Morgagni, which is a remnant of the
paramesonephric duct.
(2) A Kobelt cyst arises from the appendix vesiculosa, which is a remnant of the mesonephric
duct.
(3) A cyst of the epoophoron arises from the epoophoron, which is a remnant of the
mesonephric tubules.
(4) A cyst of the paroophoron arises from the paroophoron, which is a remnant of the
mesonephric tubules.
(5) A Gartner duct cyst arises from the duct of Gartner, which is a remnant of the
mesonephric duct.
Modified from: Janovski NA, Paramanandhan TL. Ovarian Tumors: Major Problems in Obstetrics and
Gynecology, WB Saunders, Philadelphia 1973.

Paratubal cysts
(A) A hydatid cyst of Morgagni dangles from its stalk near the fimbriated end of
this formalin-fixed fallopian tube.
(B) A paratubal cyst bulges from one aspect of the fallopian tube in this fresh
specimen. A portion of the fimbriated end of the tube is at top.
Reproduced with permission from: Reichert RA. Diagnostic Gynecologic and Obstetric
Pathology: An Atlas and Text, Lippincott Williams & Wilkins, Philadelphia 2012.
Copyright © 2012 Lippincott Williams & Wilkins. www.lww.com.

Torsion of paratubal cyst (fallopian tube)
Courtesy of Mitchel Hoffman, MD.

Malignant ovarian mass
Ultrasound image of a complex, malignant ovarian mass (arrowhead).
Courtesy of Jorge Londono, MD.

Markers that may be secreted by germ cell and sex cord-stromal tumors of the ovary
AFP hCG LDH E2 Inhibin* T A4 DHEA AMH
Germ cell tumors
Dysgerminoma –¶ ±Δ + ± – – – – –
Embryonal ± + ± ± – – – – –
Immature teratoma ± – ± ± – – – ± –
Choriocarcinoma – + ± – – – – – –
Yolk sac tumor + – + – – – – – –

(endodermal sinus tumor)
Gonadoblastoma ◊ – – – ± ± ± ± ± –
Polyembryona ± + – – – – – – –
Mixed germ cell ± ± ± ± – – – – –
Sex cord-stromal tumors
Thecoma-fibroma – – – – – – – – –
Thecoma – – – ± ± – – – –
Granulosa cell – – – ± + ± – – +
Sex cord tumor with – – – + – – – – –

annular tubules
Sertoli-Leydig ± – – ± ± ± ± ± –
Sertoli – – – – ± ± – – –
AFP: alpha-fetoprotein; hCG: human chorionic gonadotropin; LDH: lactate dehydrogenase; E2: estradiol; T: testosterone; A4: androstenedione; DHEA:
dehydroepiandrostenedione; AMH: anti-müllerian hormone.
* Both inhibin A and inhibin B levels should be determined (tumors might over secrete A or B).
¶ Borderline elevations in case reports (<16 ng/mL).
Δ Low level seen in dysgerminomas with either nondysgerminomatous elements of syncytiotrophoblastic cells.
◊ Type of germ cell sex cord-stromal tumor consisting of neoplastic germ cells and sex cord-stromal derivatives.

Contributor Disclosures
Mitchel S Hoffman, MD Nothing to disclose Lauri Hochberg, MD Nothing to disclose Deborah Levine, MD Nothing to disclose Barbara Goff,
MD Employment (Spouse): Lilly [General oncology] - No relevant conflict on topics. Alana Chakrabarti, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review
process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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17-05-2020 Differential diagnosis of the adnexal mass - UpToDate

Official reprint from UpToDate®

● (See "Approach to the patient with an adnexal mass".)

ANATOMY AND HISTOLOGY

GYNECOLOGIC TRACT MASSES

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Other types of masses are stimulated by reproductive hormones:

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● High-grade serous carcinoma (HGSC; 70 to 80 percent)

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ADNEXAL MASS COMPLICATIONS

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SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

● Basics topic (see "Patient education: Ovarian cysts (The Basics)")

SUMMARY AND RECOMMENDATIONS

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5. https://www.iotagroup.org/iota-models-software/iota-simple-rules-and-srrisk-calculator-diagnose-ovarian-cancer (Accessed on March 2

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Topic 3204 Version 34.0

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Differential diagnosis of an adnexal mass

Functional (physiologic) cyst Ectopic pregnancy Paraovarian cyst Constipation

Epithelial carcinoma Epithelial carcinoma Metastatic endometrial carcinoma Appendiceal neoplasm

Graphic 107713 Version 4.0

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Patients from oncology Patients from other hospitals,

All benign pathologies 3183 (65.7) 1861 (57.0) 1322 (83.4)

Endometrioma 845 (17.4) 456 (14.0) 389 (24.5)

Benign teratoma (dermoid) 512 (10.6) 334 (10.2) 178 (11.2)

Simple/parasalpingeal cyst 285 (5.9) 147 (4.5) 138 (8.7)

Functional cyst 128 (2.6) 69 (2.1) 59 (3.7)

Hydrosalpinx 112 (2.3) 53 (1.6) 59 (3.7)

Peritoneal pseudocyst 34 (0.7) 21 (0.6) 13 (0.8)

Abscess 45 (0.9) 34 (1.0) 11 (0.7)

Fibroma 245 (5.1) 168 (5.1) 77 (4.9)

Serous cystadenoma 543 (11.2) 326 (10.0) 217 (13.7)

Mucinous cystadenoma 359 (7.4) 203 (6.2) 156 (9.8)

Rare benign pathologies 75 (1.5) 50 (1.5) 25 (1.6)

All malignant pathologies 1665 (34.3) 1402 (43.0) 263 (16.6)

Primary invasive stage I 222 (4.6) 184 (5.6) 38 (2.4)

Primary invasive stage II 82 (1.7) 64 (2.0) 18 (1.1)

Primary invasive stage III 658 (13.6) 579 (17.7) 79 (5.0)

Primary invasive stage IV 102 (2.1) 88 (2.7) 14 (0.9)

Rare primary invasive pathologies* 113 (2.3) 80 (2.5) 33 (2.1)

Borderline stage I 249 (5.1) 197 (6.0) 52 (3.3)

Borderline stage II 9 (0.2) 6 (0.2) 3 (0.2)

Borderline stage III 25 (0.5) 23 (0.7) 2 (0.1)

Borderline stage IV 1 (0.02) 1 (0.03) 0

Secondary metastatic cancer 204 (4.2) 180 (5.5) 24 (1.5)

Graphic 109383 Version 1.0