 I want to insist what our duty really is, is do we need to give a specific diagnosis when possible because this really helps guide management. And what we need to consider in addition to, of course, the sonographic characteristics is the age and menopause status of the woman, a potential risk factor for ovarian cancer, such as, for instance, familial history of ovarian cancer or Lynch syndrome, identical symptoms, and also lab abnormalities such as CA-125. So we really need to have a global picture of the patient. And so when we talk about evaluation of adnexal mass, ultrasound is widely accepted as a first imaging modality. It will involve not just transabdominal, of course, endovaginal and color-empowered Doppler. And several studies have shown that expert sonographic interpretation is highly accurate in differentiating benign or leave a long lesion from potential malignant masses with a high negative predictive value. So we leave MR for characterization of adnexal masses that are indeterminate ultrasounds. It's a problem-solving modality which has high sensitivity as well as specificity for identifying malignant and benign masses. CT really doesn't play a role except perhaps for characterization of dermoids in the characterization of adnexal masses. But of course, many are found on CT and it's really important, of course, in the staging of cancer. So what we'll talk about is illustrative key sonographic character, is it of benign lesions that we can readily diagnose? And with use sonographic criteria that will help answer the question, is this mass likely to be an aggressive or invasive ovarian cancer or is it likely benign? And we'll discuss some indeterminate masses because all this is really important in terms of allowing us to formally declare a conclusion and offer appropriate recommendations and I will discuss them as we go along. These are the simple rules from IOTA, the international variant tumor analysis. The SRU is more focusing on the nexal cyst in their more recent paper. And then there is finally the ORADS from the American College of Radiology which tries to be a very comprehensive management strategy to classify risk of ovarian or nexal mass being malignant. And so I would encourage everybody to adopt at least some of them to try to make it to uniform throughout your practice, especially if you have a very large number of radiology such as we have at NYU or we had at Hopkins. Because that will allow you to offer recommendation for management based on current evidence-based practice. Of course, we do that after discussion with the referring clinicians, but that will allow us to minimize unnecessary follow-up imaging and also refer to the appropriate specialist. So let's first talk about benign and nexal masses then we can readily diagnose. And the first one is an ovarian cyst in the premenopausal women which is ovarian lesion, I should say not really mass. And you have simple cysts which is basically a failure of the follicle to involute or hemorrhagic cysts which is thought to be failure of the corpus luteum to involute. These tend to be symptomatic. And then of course, I think I'll need to insist in cases of hypostimulation or gestational trophoblastic diseases. So this is the most common lesion in 50 or younger women, a simple anechoic cyst. And the recommendation has changed a little bit recently. So if it's less than three centimeter it's basically considered normal. Between three and five centimeters, the SRE guidelines suggest that you don't really need to do a follow-up in this premenopausal women. Between five and seven centimeters, if it's really simple or you can think about it but most will recommend a follow-up in two to six months. And over seven centimeter definitely a follow-up and possibly suggesting another imaging modality because above this size is really difficult for ultrasound to be sure that this isn't simple cyst. And this is just an example of a corpus luteum which is, you know, Floyd, vascularity around it that we all know about. And, you know, this because of this vascularity that they can, you know, sometimes bleed and become hemorrhagic cysts. Now in the older women, it's a little bit different. So this is a 76-year-old woman which has an edexal mass. You see this about four and a half centimeter. It's also completely anechoic with a thin wall. So it's a simple cyst. And if provided that it's unilocular, that has thin wall, there is no color dropper or just high resistance for at the edge of the cyst, we've seen that many of these women, you know, screening of asymptomatic postmenopausal women about 3.3 to 15% will have this cyst. And particularly 10% of postmenopausal women on tamoxifen will develop cysts. So it becomes a dilemma, what to do with this? When do we need to worry about them? When we need to follow them? So the recommendations are that you check the C8125. It's normal. If it's less than three centimeter and your comfortable is a simple cyst, you probably don't need to follow. Above three centimeter, you do three to six months for characterization and then six to 12 months for growth. And then yearly afterwards, at least until stability is assured is what the general recommendation is because the natural history of the cysts is either they remain stable or they resolve over time. Now, if there is any of these, the cyst and loges or there are mural nodules or thick septations, then I would recommend perhaps before surgery at least to get an MR with contrast or also in cases where the patient's really anxious or unable to undergo regular ultrasound, then you need to maybe have MR or even laparoscopy. And in those patients that have this cyst, we move some of the path findings that have been reported as serous or musinocystidinomas, perovirion or endometriosis that have done dormant in this postmenopausal woman or hydrocell banks. The only thing I would say is be very careful when you call this a simple cyst, especially in older women because you can have reverberation artifact near the near wall and that's fine. But sometimes this can hide nodule. If you see in this case, this is not just reverberation because you shouldn't have reverberation artifact in that corner. And if you turn on it actually in the corner, you see that there is a mural nodule. And this turned out to be a small ovarian cancer in the patient that had an elevated CA125. So we really have to be careful before we call something a simple cyst. Now, sometimes if the cystic mass is more than 10 centimeters and both the aorta and the ovarians will talk about size and generally when the cyst is more than 10 centimeters then something else needs to be done about it. But if you assist at large with some of these features predominantly cystic mass, no septations or a few very thin septations, no mural thickening, no flow or high resistance flow, then this is likely that it's at least very likely to be benign and this patient may undergo an MR and then a G1 surgery. And this turned out to be just a very large benign silver cyst adenoma. So these are some of those features that in the cystic region would favor the fact that this is going to be a benign cystic neoplasm. Now we're all familiar with the next very common the nexomass, which is a hemorrhagic cyst. If you see a retracting clot with these acute angles or if you see this lace-like or fishnet appearance they will have, they will be avascular of course because this is just a blood clot with maybe some flow at the edge of the lesion. And sometimes they can have a fluid fluid level and in these cases it's very easy straightforward diagnosis. If they're five centimeters smaller there is really no need to follow up. If they're larger perhaps you want to follow up in six to 12 weeks to make sure they resolve. And it's the same rule if you see an ovarian cyst on CT in a young woman you basically apply the same rule. You don't really need to get an ultrasound to follow up. If they have an atypical appearance such as this one which looks more solid then of course you'll get a follow up and you can see that this patient came a little bit earlier than we suggested but anyway it had already resolved. Another lesion we can diagnose with confidence is endometrioma which is basically functional endometriotic tissue outside the uterus. And there's a diffuse form that basically forms cart tissue but the chocolate cyst is what we're talking about here which is a localized endometriosis of the ovary and they have a very typical appearance. They can be multilocular or unilocular but they all have this diffuse ground glass low level echoes. They can have septations but the other thing to look for is this ecogenic foci in the wall. That's very characteristic of endometriomas. It's basically probably debris from hemocidurin from the hemorrhage. So then look for that if you think something is an endometrioma. And of course if it's a large cyst such as this one is more than seven centimeter you can see again that this has a typical ground glass appearance then you may want to do an MR just to confirm and basically they will be high signal intensity on T1 because of their blood content and there's a characteristic tissue shading that you see again due to the hemocidurin content of these lesions. Now be careful again because this lesion if you look very quickly also looks like there are diffuse low level echoes however this one has nodules. So there are nodules like these soft tissue nodules and this is not an endometrioma and this turned out to be a borderline serous tumor. Now another lesion that we can readily diagnose is this one. This was a 56 year old woman with breast cancer so you can imagine that she was very anxious but we can reassure her because this is indeed an ovarian mass more solid appearing but it has these typical ecogenic lines within it which is characteristic of a cystic teratoma dermoid and this is the dermoid mesh. Now these are quite common probably one of the most common ovarian neoplasm they can be bilateral. They mostly are seen in younger adult and pregnant women but eight to 10% are found in post menopausal women. They contain derivatives from all three germ layers. They are very characteristic ultrasound features. Dermoid mesh or ecogenic mass with shadowing and this is another that's the only solid mass if there is shadowing within a solid mass this is part of the iota simple rule that will also be a dermoid. They may have calcifications and they may have some other appearance such as a fat fluid level or floating ecogenic balls and if you have two or more of this sign this is a really old paper but this whole tool this is 100% positive predictive value for the lesion being a cystic teratoma. So this is a small ecogenic mass in the ovary. This is a lesion that's why this has we have talked about a tip of the iceberg sign because there is so much shadowing and the shadowing in this case is probably from fat mixed with hair we don't see the borders of the lesion that's why it's called a tip of the iceberg. Now sometimes they have less different appearance so this is a lesion that has a fat fluid level with a hairball that floats at the fat fluid interface and also the Wachitansky nodule here and the CT confirms the presence of actually bilateral dermoids. This one is very large but again it has these floating hairballs and this one also has these characters six shadowing so we can be pretty confident that this is going to be a cystic teratoma and this large size perhaps might not be a better idea just to get another study such and more to confirm plus as we'll see in another chart there at Whisper torsion. And this is however a very typical appearance this patient had pain and really in this mass it's a solid appearing mass and there is no shadowing so really in this particular case we cannot be comfortable that this is a dermoid and so we're going to get a CT but also an MR with fat saturation the T1 with fat that confirms that this is fat in this lesion and this is indeed a cystic teratoma but this is an atypical lesion you would not be able to make a comfortable diagnosis on ultrasound. Now again be careful because the nodule if it's a cystic mass and there are ecogenic nodules you want to make sure that there is shadowing to call it a cystic teratoma in this particular case there is no shadowing and this was a high-grade ovarian cancer. Now another lesion we can comfortably diagnose is a hydrocell things by its tubular appearance and when you look at it on cross-section you can see the thick and fimbria so that's an easy diagnosis to make. Now again you can get a sense that it's tubular even though a portion of the fallopian tube is more distended and this patient did have an MR that confirms the diagnosis and she was 56 years old so we wanted to make sure but this is another comfortable diagnosis you can make. Another one is a pair ovarian cysts which is a simple cyst probably from one of these embryologic remnants in the broad ligaments so it's separate from the ovary and of course it is important to recognize that they are separate from the ovary because they're not going to change they're not functional cysts so you just have to call it a simple pair ovarian cyst. And then finally peritoneal inclusion cyst is also a lesion that we can often comfortably diagnose when it is basically strapped peritoneal fluid because the ovary will secrete some fluid and because of adhesions around the ovary the fluid will not get resolved and will be trapped. Usually this patient has a history of prior surgery pelvic inflammatory disease or endometriosis the usually a lesion of premenopausal women with active ovaries and the important thing to recognize is that they have a passive shape they don't create mass effect they tend to surround the ovary as you can see here. So to summarize these are benign lesions we can diagnose with certainty we can put it in our report and basically reassure the patient.