OBJECTIVE.

This article reviews the range of adnexal masses that present in pediatric females.
The preferred imaging modalities, the appearance of the normal ovaries, and the
epi- demiology of ovarian diseases and abnormalities are discussed. The illustrated
abnormalities include simple and complex ovarian and paraovarian cysts,
neoplasms, ovarian torsion, ecto- pic pregnancy, and tuboovarian abscess, with
attention to the imaging features and vascular flow patterns that help distinguish
surgical from nonsurgical cases, malignant from benign lesions, and ovarian
abnormalities from mimickers.

Adnexal abnormalities in pediatric patients are uncommon but not rare. In fact, the
breadth of adnex- al disease diagnosed in adult fe- males is seen in the pediatric
population, al- beit with a different incidence profile. Diagnosis may be more
difficult, even delayed or missed, because of low index of suspicion; nonspecific
complaints; or consideration of more common, acute abdominal processes that
mimic adnexal issues. This article will re- view the imaging options and features of
ad- nexal lesions, including neoplasms, vascular compromise, infection, and some
important paraovarian mimickers in pediatric patients.

Technique

The preferred initial imaging modality of the female pelvis remains gray-scale ul-
trasound with additional color and pulsed wave Doppler imaging. Ultrasound is safe,
inexpensive, and free of ionizing radiation. With the patients bladder distended, a
sono- graphic window is created by which the ova- ries can generally be identified.
The ovaries may be particularly prominent in infant fe- males because of the
lingering presence of maternal hormones, and small follicles are often noted even in
prepubertal girls (Fig. 1). The typical mean ovarian volume is rough- ly 1 cm3 in girls
up to 5 years old; the ova- ries at least double in size by the age of 12

years [1]. At puberty, ovaries increase in size to approximately 4 cm3 [2], with
growth par- alleling uterine maturation. When lesions are discovered, the
sonographer gathers infor- mation about the size and internal character- istics of the
lesions and presence and quality of vascular flow.

If further imaging assessment is required, both CT and MRI are available and
provide specific benefits. MRI, like ultrasound, func- tions without ionizing radiation.
It also offers superb soft-tissue contrast, including dynam- ic enhancement for
evaluation of vascular in- tegrity. However, MRI takes longer to per- form and may
require sedation of the patient, making it more cumbersome in emergency
situations. Thus, CT remains important in this setting because of its speed, spatial
res- olution, and ready global assessment of the abdomen and pelvis, especially for
surgical planning. Mimickers of adnexal abnormali- ties and diseases can be
excluded, and stag- ing of malignancy can be performed.

Ovarian Cysts

The most common adnexal abnormality in the pediatric population is an ovarian

cyst. Ovarian cysts are the most frequent cause of an abdominal mass in the fetus
and in the new- born [3]. An anechoic focus in an ovary is con- sidered a follicle if it
is smaller than 3.0 cm. A mature dominant follicle may fail to involute

appropriately and may enlarge into a functional cyst or corpus luteum. Rupture or
hemorrhage often brings these patients to medical atten- tion. Based on the degree
of complexity asso- ciated with blood products, clot formation, ly- sis, and retraction,
appearances are variable on all cross-sectional imaging modalities (Fig. 2).

Whether simple or complex, these lesions are followed with ultrasound to confirm
resolution and exclude cystic neoplasm.

Ovarian Neoplasms

Ovarian neoplasms commonly have a cys- tic component and may be benign or
malignant. The solid component is the most sta- tistically significant predictor of
malignancy [4]. Categories are defined by the cell of ori- gin: germ cell tumors,
epithelial tumors, and stromal tumors. These neoplasms general- ly present in
postpubertal girls as a result of pain, increasing abdominal girth, and symptoms
derived from hormonal effects when masses are functional. The first category of
neoplasms is germ cell tumors. Benign teratomas comprise 67% of pediatric ovarian
neoplasms and are bilat- eral in up to 25% of cases [5]. Mature teratomas contain
tissue from all three primitive linesendoderm, mesoderm, and ectoderm. The
presence of fat or calcification in the le- sion is diagnostic and easily distinguished
by CT (Fig. 3) or MRI. The diagnosis may be slightly more challenging by ultrasound
(Fig. 4), but several signs are helpful including the tip-of-the-iceberg sign (coarse,
shadow- ing calcification), dermoid mesh (linear in- terfaces representing hair), and
dermoid plug (echogenic nodule with fat, hair, and teeth). Some teratomas contain
immature elements

and have potential for recurrence and metas- tasis. This subtype may even present
in in- fants and may result in peritoneal spread of disease. Chemotherapy can lead
to matura- tion of the implants to a benign form, despite persistent bulk [6] (Fig. 5).
Other categories of germ cell tumors in- clude dysgerminoma, yolk sac tumor (Fig.
6), choriocarcinoma, and mixed varieties [7]. These tumors are indistinguishable by
imaging, but imaging features direct the op- erative approach and provide
preoperative staging. Final diagnosis and staging are the purview of pathology. The
second category of neoplasms is epi- thelial tumorscystadenomas and cystade-
nocarcinomas. Most tumors in this category are divided into serous and mucinous
sub- types, both of which are often quite large at presentation (Fig. 7). Imaging
highlights in- ternal septations, papillary projections, and/

or larger solid components. On ultrasound, mucinous tumors may have low-level

inter- nal echoes from mucoid material. The over- all rate of malignancy ranges from
7.5% to 30% [4, 8]. Imaging descriptions address the probability of malignancy,
lesion vasculari- ty, ovary of origin, and signs of lesion rup- ture. The uterus is
usually rotated toward the side of tumor origin [9]. The third category of primary
neoplasms is tumors of stromal cell origin. These tu- mors include granulosa-thecal
cell tumors, fibromas, thecomas, Sertoli-Leydig cell tu- mors, and undifferentiated
sex cord stromal tumors. Many are hormonally active and, therefore, present earlier
than those with- out function [10]. Typically, these tumors are solid, unilateral, and
contained (Fig. 8). They may appear similar to germ cell tumors without fat or
calcium, but presentation may foreshadow cell origin.

Other rare ovarian neoplasms range from aggressive malignancies, such as small
cell carcinoma (Fig. 9), which is usually associ- ated with hypercalcemia, to benign
entities, such as hemangiomas (Fig. 10). Metastat- ic disease can also involve the
ovaries, either from hematogenous or contiguous spread. Within this group of
malignancies are adeno- carcinoma of the colon, Burkitt lymphoma, alveolar
rhabdomyosarcoma, Wilms tumor, neuroblastoma, and retinoblastoma [11].

Ovarian Surgical Emergencies

Any ovarian or tubal mass predisposes a patient to ovarian torsion. Of course,

ovarian torsion can occur without a lead point second- ary to excessive mobility of
the ovary or fallo- pian tube (Fig. 11). In either situation, torsion is a high-stakes
imaging diagnosis and surgi- cal emergency. The diagnosis may be particu- larly
challenging if torsion is intermittent. The

most important finding is an enlarged, round- ed ovary compared with the

contralateral side. Follicles often migrate to the periphery, the so-called string-of-
pearls sign [12] (Fig. 12). Because a normal Doppler examination cannot exclude
early or intermittent torsion at the time of the study, abnormal ovarian mor- phology
is suspicious for intermittent torsion. Poor vascular flow or apparent lack of flow by
ultrasound without morphologic changes is indeterminate. In pediatric patients,
ultra- sound via a transabdominal approach through a distended bladder is a
complete examina- tion. If advanced imaging is required, MRI without and with
contrast material (Fig. 13) can confirm the diagnosis and may highlight any
underlying mass. Torsion can occur in utero. A nonviable ovary in an infant ranges in
appearance from a complex cystic and sol- id mass without vascular flow (Fig. 14) to
a small calcified mass visible on radiographs. A torsed ovary in an infant may lie in
the abdo- men rather than the pelvis. The other adnexal emergency, which oc- curs
in postpubertal girls, is ectopic pregnan- cyhence, the importance of the
pregnancy test in the clinical evaluation. Any complex adnexal mass with an empty
uterus and posi- tive pregnancy test is highly concerning. The presence of complex
ascites strengthens the case (Fig. 15). Risk factors include pelvic in- flammatory
disease, previous ectopic preg- nancy, intrauterine device, in vitro fertiliza- tion, and
tubal surgery [13].

Pelvic Infections

Pelvic infection may emanate from the ad- nexa or may involve the adnexal regions
from adjacent structures, creating an imaging ap- pearance similar to that of
neoplasms with

complicating features, torsion, or ectopic pregnancy. Classic imaging findings of

tubo- ovarian abscess and pyosalpinx are complex fluid collections with thick walls
and rim en- hancement or increased peripheral vascu- lar flow, often with adjacent
inflammatory change and free fluid (Fig. 16). Ultrasound depicts septations well, but
CT and MRI of- fer a global assessment, which is often re- quired preoperatively
[14]. CT and MRI are also better than ultrasound at excluding ap- pendicitis, a much
more common diagnosis in this population, and phlegmon or abscess associated
with inflammatory bowel disease. Importantly, Crohn disease without abscess may
not be treated surgically so correct diag- nosis of this entity affects management.
Other nongynecologic pelvic abnormalities are beyond the scope of this article. The
criti- cal clinical questions to the radiologist in the setting of adnexal lesions are the
site of origin, benign versus malignant features, and presence of infection or
abscess. Pairing clinical presen- tation and imaging findings will direct appro- priate
management, whether it is reassurance, follow-up imaging, or surgery. Ultrasound
re- mains the imaging workhorse for the detection and diagnosis of pediatric pelvic
abnormalities and diseases, and CT and MRI provide com- plementary information
when more detail is re- quired or when questions persist.