Normal ovary contains >2 mil primary oocytes at birth; 10 mature each menstrual cycle. Of the 10 that mature, only 1 becomes dominant and grows to size of 18-20 mm by mid-cycle when it ruptures to release the oocyte. Other 9 follicles become atretic and fibrous.

Some ovaries can be avidly PET positive depending on date of cycle; must correlate with hx to r/u adnexal neoplasm. Ideally, schedule FED-PET in first week of cycle. 

Defined as 1 year or more of amenorrhea; avg age 51-53 in USA. 

Ovaries are generally smaller and gradually stop forming Graafian follicles. Follicular cysts may persist several years after menopause.

• Essentially a functional ovarian cyst >6mm that doesn't resolve (stable or increase in size)

• 84% of simple adnexal cysts in postmeno women are SC

• 12-20% bilateral; avg size 10 cm; usually unilocular but can be multiloculated

• US: anechoic, unilocular, thin-walled cyst w posterior acoustic enhancement (PAE)

• MR: cyst contents are fluid SI; papillary projections enhance if present.

• 80% of all ovarian mucinous tumors; 10-15% of ovarian neoplasms. Can occur at any age but rare in young women and children; increased incident in Peutz-Jeghers syndrome.

• Larger, unilateral (95%), multiloculated w/ stain glass window appearance (loculi of different densities/SI 2/2 mucinous debris and hemorrhage) and thin cyst wall/septations (<3mm). More likely to have mural calcification.

• Can be very large and fill entire pelvis; no solid components. Papillary projections are less common than SC.

• Bilateral MC (mets?), solid components or papillary projects suggest borderline/malignant tumor.

• Surgical excision is curative and typically performed due to large size at presentation in order to exclude malignancy an prevent torsion.

Borderline features rather than benign: 

• More and smaller loculi; high SI on T1WI and low SI on T2WI 2/2; thickened septa/wall (>5mm), vegetations (>5 mm)

• Ancillary features: ascites, spread to peritoneum/omentum/mesentery; LAD

60% of malignant ovarian tumors. 

Characterized lace-like or labyrinthine pattern (focal or diffuse) w/ extensive bridging and coalescence of papillae

• Frequently bilateral; typically mixed solid/cystic masses.

• solid portions enhancement avidly. Often concomitant ascites.

• Elevated CA 125 in majority of cases

Low grade: predominantly cystic masses w septations and papillary solid components.

High grade: complex cystic mass w large solid components; can also appear entirely solid.

Bilaterality and peritoneal carcinomatosis is seen more frequently in serous than in mucinous cystadenocarcinoma.

Multilocular cystic/solid mass w/ variable cystic components.; Almost always unilateral and large (6-40 cm) with enhancing thick septa and mural nodules.

Must differentiate b/n expansile and infiltrative subtypes:

• Expansile: Lower mets potential; extremely low risk of relapse w stage I dz, peritoneal spread is rare.

• Infiltrative: more aggressive, nodal mets are detected in stage I dz, CA at early stages have often fatal relapses.

All bilateral mucinous carcinomas of ovary and all unilateral carcinomas <13 cm are likely metastatic. Most mets are solid or mix solid/cystic.

Simple cyst separate from the ovary thought to be developmental in origin.

Considered normal if <5 cm.

DDX: ovarian cyst

• Ovarian cysts should be reported and followed if >3 cm, while paraovarian cysts do not be followed unless >5cm. TVUS can help confirm extra-ovarian location via gentle pressure by the transducer which displaces it away from the ovary.

PIC is a septated fluid collection formed by adhesions, almost always related to prior surgery. Ovary is closely associated w PIC, either trapped w/n or adjacent to it.

• Important NOT t orecommend surgery for tx of PIC, as it is benign and further surgery may create additional adhesions.

• DDX: cystadenoma which has thick sepatations and tends to exert mass effect.