Imaging Pearls ❯ Incidentaloma ❯ Ovary
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- Revised in 2020 (from 2013)
- “Incidental adnexal findings are commonly identified in women on CT and MR studies that include the pelvis. Normal physiologic changes in premenopausal women include monthly development of a dominant follicle and subsequent corpus luteum, resulting in a potential incidental CT or MR finding in many premenopausal women. Nonneoplastic cysts that may wax and wane in size are also common in postmenopausal women; in a large series of postmenopausal women, 14% had cysts on an initial ultrasound examination, with 32% resolving but 8% developing a new cyst at 1-year follow-up.”
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. - “An extensive body of ultrasound-based imaging literature in surgical and clinically followed cohorts shows that the risk of malignancy in simple cysts identified sonographically is negligible in both premenopausal and postmenopausal women, a conclusion confirmed by recent large studies showing no increased risk of malignancy in women with sonographically identified simple adnexal cysts irrespective of cyst size.”
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. - “The revised SRU consensus recommendations have increased some size thresholds for surveillance, now stating that simple cysts characterized with standard ultrasound quality do not require ultrasound follow-up when 5 cm in premenopausal women and 3 cm in postmenopausal women. When there is exceptional quality and documentation that the cyst is simple, the SRU panel opines that these thresholds are justifiably increased to 7 cm in premenopausal women and 5 cm in postmenopausal women, because the risk of mischaracterization is reduced.”
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. - The following four elements should be reported when an incidental adnexal mass is detected on CT or MRI:
1. Mass characteristics (ie, simple-appearing cyst, features indicating a specific diagnosis, indeterminate features)
2. Size (largest diameter)
3. Technical considerations
4. Known or presumed menopausal status
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. - “It is important that radiologists who report CT or MR studies of the pelvis be familiar with the features of adnexal masses that enable confident benign or malignant diagnosis, so that those features can be described in the reporting of these masses the risk of mischaracterization is reduced.”
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. 
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254.
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254.
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254.- “The algorithm does not apply to any CT or MR adnexal finding that is unchanged in appearance over 2 or more years, because malignancy is effectively excluded by this stability. The algorithm is not intended for use in women at high genetic risk for ovarian cancer, in whom lower size thresholds for sonographic characterization of adnexal cysts may be justified. The algorithm is aborted when a patient develops symptoms potentially related to a mass being followed; an asymptomatic cyst may become painful because of internal hemorrhage, rupture, or torsion, with symptoms justifying immediate imaging attention.”
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. - “Baheti et al evaluated the agreement between contrast-enhanced CT and ultrasound in characterizing adnexal masses and showed that simple appearing cysts on CT correspond to simple cysts on ultrasound . A subsequent investigation also showed that simple-appearing cysts on CT had no risk of malignancy. Thus, although there is far more evidence confirming the absence of increased malignancy risk in sonographically characterized simple adnexal cysts, based on the available current evidence, it is reasonable to assume that simpleappearing cysts on CT or MR are similarly benign.”
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. - “Small, incidental, simple-appearing adnexal cysts on CT or MR do not justify sonographic characterization even when assessment is limited. Paralleling the revised SRU consensus recommendations for incidental simple cysts on ultrasound, our committee consensus uses 3 cm (postmenopausal) and 5 cm (premenopausal) as the default threshold for not pursuing follow-up of incidental simple-appearing cysts on CT or MR [7]. Because many adnexal cysts are 5 cm in premenopausal women and 3 cm in postmenopausal women, the mere existence of a small (ie, below size threshold) simple-appearing cyst with limited assessment is not enough to justify sonographic recharacterization or follow-up when it is an incidental finding. O cysts on CT or MR are similarly benign.”
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. - “When an incidental simple-appearing cyst is adequately characterized by CT or MR but justifies sonographic follow-up because of its size, the sonographic evaluation is reasonably delayed by 6 to 12 months to provide evidence regarding the cyst growth rate. By delaying the sonographic follow-up by 6 to 12 months instead of immediately recharacterizing the cyst with ultrasound, the cyst has a chance to resolve or involute, allowing for diagnosis as a nonneoplastic cyst that requires no further follow-up, or to grow, favoring a benign cystic neoplasm.”
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254. - • Incidental adnexal findings on CT and MR examinations of the female pelvis are common; we provide an algorithm to guide management of the incidental adnexal mass based on whether the mass is (1) a simple-appearing cyst; (2) has reasonably diagnostic imaging features; or (3) has an uncertain diagnosis.
• Simple-appearing cysts on CT or MR have very low risk of malignancy. Imaging follow-up is justified only when the cyst is relatively large for the patient’s menopausal status. The primary goals of imaging follow-up are to limit the risk of cyst mischaracterization and to understand the rate of cyst growth, which may inform subsequent clinical decision making.
• Recommendations regarding the optimal timing of sonographic follow-up for a large simple-appearing cyst balances the small potential risk of CT or MR mischaracterization against the desire to gain information about cyst growth using as few imaging studies as possible.
Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee
Patel MD et al.
J Am Coll Radiol 2020;17:248-254.