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GENITOURINARY IMAGING 1047

CME FEATURE
See www.rsna
.org/education
/rg_cme.html
LEARNING
OBJECTIVES
FOR TEST 3
After completing this
journal-based CME
activity, participants
will be able to:
■■List the poten-
tial causes of T2-
hypointense adnexal
lesions.
■■Discuss the differ-
ential diagnosis and
characteristic MR
imaging findings
for T2-hypointense
adnexal lesions.
■■Describe an imag-
ing algorithm for
these lesions that is
based on a multi-
sequential MR im-
aging and multimo-
dality approach.
T2-Hypointense Adnexal
Lesions: An Imaging
Algorithm1
Alla Khashper, MD • Helen C. Addley, MRCP, FRCR • Nesreen Abourokbah,
MD • Stephanie Nougaret, MD • Evis Sala, MD, PhD, FRCR • Caroline
Reinhold, MD, MSc
T2-weighted sequences are an integral part of magnetic resonance
(MR) imaging performed for the characterization of adnexal lesions.
A relatively small number of these lesions demonstrate low signal
intensity on T2-weighted MR images. In the majority of cases, a spe-
cific diagnosis can be made by interpreting the signal intensity of the
lesion with respect to certain pathologic correlates, including blood
products, smooth muscle, fibrous tissue, and calcification, as well as
high lesion cellularity. For example, lesions that are at least as dark
as skeletal muscle are almost always benign, whereas those whose T2
signal intensity is higher than that of skeletal muscle constitute a more
heterogeneous group composed of benign, borderline, and malignant
disease entities. The authors propose a diagnostic algorithm that takes
these features into account, as well as the appearances of the lesion
with additional pulse sequences, to aid in the correct interpretation of
T2-hypointense adnexal lesions. Knowledge of the anatomy, the T1-
weighted imaging features, and the enhancement characteristics of ad-
nexal lesions allows accurate characterization of these lesions, resulting
in appropriate patient management.
©
RSNA, 2012 • radiographics.rsna.org

RadioGraphics 2012; 32:1047–1064 • Published online 10.1148/rg.324115180 • Content Codes:

1
From the Department of Radiology, McGill University Health Center, 1650 Cedar Ave, Suite C5 118, Montreal, QC, Canada H3G 1A4 (A.K., N.A.,
C.R.); Department of Radiology, Addenbrooke’s Hospital, Cambridge, England (H.C.A., E.S.); and Department of Radiology, St Eloi Hospital, CHU
Montpellier, Montpellier, France (S.N.). Recipient of a Certificate of Merit award for an education exhibit at the 2010 RSNA Annual Meeting. Received
November 22, 2011; revision requested December 14 and received March 1, 2012; accepted March 2. For this journal-based CME activity, the authors,
editor, and reviewers have no relevant relationships to disclose. Address correspondence to A.K. (e-mail: khashper@yahoo.com).
©
RSNA, 2012
1048  July-August 2012 radiographics.rsna.org
Introduction
Magnetic resonance (MR) imaging is optimal
for the evaluation of adnexal masses due to its
multiplanar capability and inherent soft-tissue
contrast. The MR imaging features of inde-
terminate adnexal masses can provide unique
morphologic information regarding the lesion,
including its location, size, and cystic-solid
composition (1). T2-weighted sequences are an
integral part of MR imaging performed for the
characterization of adnexal masses. The major-
ity of adnexal lesions contain cystic compo-
nents, which demonstrate high signal intensity
on T2-weighted images. The finding of a T2-
hypointense adnexal lesion is less common and
should be interpreted with respect to specific
pathologic correlates, including blood products,
smooth muscle, fibrous tissue, and calcification,
as well as high lesion cellularity. In this article,
we discuss the differential diagnosis for T2-hy-
pointense adnexal lesions and describe imaging
features that allow a more specific diagnosis. In
addition, we propose a diagnostic algorithm that
takes these features into account, as well as the
appearances of the lesion with additional pulse
sequences, to aid in the correct interpretation of
T2-hypointense adnexal lesions.
Normal Anatomy
of the Adnexa Uteri
To accurately characterize indeterminate adnexal
lesions, it is important to first be familiar with
their normal appearance and to assess the relation-
ship of the lesion to the pelvic organs. The adnexa
include the fallopian tubes and the ovaries as well
as structures that originate from the uterus and
its supporting ligaments. Identifying the anatomic
origin of an adnexal lesion aids in characterizing
the lesion and narrowing the differential diagnosis.
The imaging appearance of the ovaries will vary
depending on the patient’s physiologic state (stage
of menstrual cycle, age, pregnancy status) or previ-
ous treatment and procedures. The fallopian tube
is a serpentine structure filled with interdigitating
plicae, and typically no lumen is visualized (2).
The identification of a tubal structure separate
from the ovary aids in making the diagnosis. Al-
though multiplanar MR imaging is superior to
other imaging techniques in demonstrating the
pelvic anatomy, identification of specific anatomic
structures and of the origin of the lesion can re-
main a diagnostic challenge in some cases.
Location of T2-
Hypointense Adnexal Lesions
When a parauterine adnexal mass is visualized,
verification of the origin of the mass is essential
for appropriate patient management. If the go-
nadal vessels lead to the lesion and no ipsilateral
ovary is visualized, an ovarian lesion is considered
to be a possibility. On the other hand, visualiza-
tion of both ovaries as separate and distinct from
the lesion confirms that the lesion is extraovarian
in origin. Visualization of hyperintense ovarian
follicles or of a functional cyst at T2-weighted
imaging helps identify the ovaries. The presence
of a pedicle between the uterus and the lesion
indicates that the lesion arises from the uterus.
Dynamic ultrasonography (US) may be helpful
for demonstrating movement of the mass with
the uterus; however, the pedicle of a subserosal
pedunculated leiomyoma can be very narrow and
is more easily identified at MR imaging (3). The
“bridging vessel” sign represents tortuous vas-
cular structures passing between the uterus and
the lesion and may be seen at US; however, this
sign is most clearly depicted at gadolinium-based
contrast material–enhanced T1-weighted imaging
or T2-weighted imaging, which nicely demon-
strate vascular flow voids (3). The bridging vessel
sign confirms that the lesion originates from the
uterus and excludes an ovarian origin (Fig 1),
although intravenous administration of contrast
material can be helpful in confirming an ovarian
vascular supply to the mass (4).
In the setting of an adnexal mass that is neither
ovarian nor uterine in origin, the possibility of
tubal disease must be considered. Tubal masses
are separate from the uterus as well as the ovary,
although they may be attached to the ovary by
adhesions. The most common T2-hypointense
tubal lesion is hematosalpinx (discussed later), fol-
lowed by tubal leiomyoma, fibroma, and abscess.
Although extrauterine leiomyomas are uncom-
mon, they can arise from a fallopian tube or round
ligament. Endovaginal US may provide assurance
RG  •  Volume 32  Number 4 Khashper et al  1049

Figure 1.  Exophytic subserosal leiomyoma in a 47-year-old woman. (a) Endovaginal Doppler US
image shows the bridging vessel sign (arrow) between the uterus (Ut) and a mass. (b) Short-axis
T2-weighted MR image shows a heterogeneous, predominantly hypointense mass, with vascular
flow voids (arrows) between the uterus and the mass. (c) Coronal T2-weighted MR image shows
splitting of the myometrium toward the mass (arrows), as well as a separate and distinct normal left
ovary (arrowheads).

of separation of the uterus and ovaries from the
mass. MR imaging is extremely useful due to its
superb multiplanar capability and its capacity to
demonstrate the typical signal characteristics of
leiomyoma (see “Smooth Muscle”) (5).
Signal Characteristics of
T2-Hypointense Adnexal Lesions
Tissue characterization at MR imaging is based
primarily on differences in longitudinal (T1) and
transverse (T2) relaxation times (6). The majority
of adnexal lesions contain cystic components and
are, therefore, T2 hyperintense. However, there
are a few distinctive histologic and morphologic
entities that result in shortening of T2 relaxation
time and hence manifest with low signal intensity
at T2-weighted imaging, including blood products,
muscle, fibrous tissue, calcification, air or flow-
related artifact, and paramagnetic substances such
as melanin (7). For the purposes of this article, T2-
hypointense adnexal masses are grouped according
to their predominant component (Table 1).
1050  July-August 2012 radiographics.rsna.org

We divide T2-hypointense adnexal lesions into

Table 1
two subgroups. The first subgroup includes masses Classification of T2-Hypointense Adnexal Masses
that are as dark as or darker than skeletal muscle according to Predominant Component
on T2-weighted MR images, whereas the second
Blood products
subgroup contains lesions whose T2 signal inten-
 Endometrioma
sity is higher than that of skeletal muscle (Table 2).
  Hemorrhagic cyst
T2-hypointense adnexal lesions that are at least as  Hematosalpinx
dark as skeletal muscle help narrow the differential   Cystic adenomyosis
diagnosis and improve specificity. Nearly all of Smooth muscle
these lesions are benign nonaggressive entities. Ad-   Uterine leiomyoma
nexal lesions that are hypointense on T2-weighted Fibrous tissue
MR images, but whose signal intensity is higher  Fibroma
than that of skeletal muscle, are a more heteroge-  Fibrothecoma
neous group composed of benign, borderline, and  Cystadenofibroma
malignant disease entities. In the appropriate clini- Mixed cellularity
cal context, these entities should be included in   Brenner tumor
the differential diagnosis for lesions that are not as   Struma ovarii
hypointense as skeletal muscle.   Krukenberg tumor

Pathologic Correlates
Blood Products
The signal characteristics of a hemorrhagic le-
sion at MR imaging depend on the age of the
hemorrhage and whether the blood products are
intracellular or extracellular in location (Table 3),
even though time-related changes in hemorrhage
are not as predictable for extracranial bleeding as
for intracranial bleeding. Intracellular deoxyhe-
moglobin (acute hemorrhage) and intracellular
methemoglobin (early subacute hemorrhage)
result in T2 shortening and are, therefore, T2
hypointense. Intracellular deposits of ferritin or
hemosiderin in the wall of a mature hematoma
also lead to decreased T2 signal intensity due to
magnetic susceptibility effects. In contrast, extra-
cellular methemoglobin (late subacute hemor-
rhage) is T2 hyperintense, whereas intracellular
methemoglobin results in high T1 values due to
paramagnetic effects (7).
Endometrioma.—At US, an endometrioma typi-
cally appears as a homogeneous hypoechoic mass
with low-level echoes. MR imaging has been
shown to be more specific than US or computed
tomography (CT) for the diagnosis of endometri-
oma (9). Iron overload (10), a high concentration
of protein, and increased viscosity over time are
well-recognized characteristics of endometriomas
due to repeated bleeding and degradation of old
blood products, resulting in low T2 signal inten-
sity (11). Diagnostic MR imaging criteria with a
high specificity for endometriosis include multiple
hyperintense cysts on fat-suppressed T1-weighted
Table 2
Classification of T2-Hypointense Lesions
according to Degree of Signal Loss
T2 isointense relative to muscle
 Endometrioma
  Cystic adenomyosis
 Hematosalpinx
 Leiomyoma
 Fibroma
 Fibrothecoma
 Cystadenofibroma
  Struma ovarii
T2 hypointense relative to muscle
  Hemorrhagic cyst
  Malignant transformation of endometrioma
  Mucinous cystic neoplasm
  Krukenberg tumor
images (Fig 2) and, in the case of a solitary lesion,
a T1-hyperintense and T2-hypointense cyst (Fig
3) (12). Homogeneous T2 shading is a character-
istic feature of endometrioma. The term shading
refers to signal loss on T2-weighted MR images in
an ovarian cyst that appears hyperintense on T1-
weighted images (13). Hemorrhage-containing
lesions that (like skeletal muscle) are markedly
hypointense on T2-weighted images are highly
specific for endometriomas. However, not all en-
dometriomas show this degree of T2 shortening,
depending on their age, the amount of hemosid-
erin, and the protein concentration. Dependent
layering and a hypointense fluid level representing
different-aged blood products can be seen within
an endometrioma. A hypointense peripheral ring
caused by hemosiderin staining may be seen in
RG  •  Volume 32  Number 4 Khashper et al  1051

Figure 2.  Endometriomas in a 26-year-old woman. Axial

fat-saturated T1-weighted MR image reveals multiple bilat-
eral hyperintense ovarian cysts, findings that are compatible
with endometriomas. Bilateral ovarian cysts were also seen
at abdominal US.

Figure 3.  Solitary endometrioma in a 48-year-old woman. (a) Axial fat-saturated T1-weighted MR image shows
a hyperintense lesion (arrow) in the left ovary. (b) Axial T2-weighted MR image demonstrates homogeneous loss of
signal within the lesion (arrow), a finding that represents the “shading” sign.

Table 3
Signal Intensity Characteristics of Hemorrhagic Lesions at MR Imaging

T1 T2 Signal
Principal Component Time Range Age of Hemorrhage Signal Intensity Intensity
Intracellular oxyhemoglobin Hyperacute Minutes–24 h Low-intermediate High
Intracellular deoxyhemoglobin Acute 1–3 d Low Low
Intracellular methemoglobin Early subacute 3–7 d High Low
Extracellular methemoglobin Late subacute 1 wk–months High High
Hemosiderin and ferritin Chronic Months–years Very low Very low
Source: Reference 8.

chronic lesions (14). Margins that are slightly
angled or distorted and not completely round due
to adjacent scarring and fibrosis are also charac-
teristic of endometriomas.
Malignant transformation is a rare complica-
tion of endometriosis and is estimated to occur
in about 1% of patients (15). The most common
histologic subtypes include endometrioid and
clear cell carcinoma (16). Suspicious features
include a large or growing endometrioma and
lack of the characteristic shading on T2-weighted
images. Loss of T2 shading following malignant
1052  July-August 2012 radiographics.rsna.org

Figure 4.  Malignant transformation of an endometrioma in a 37-year-old woman. (a) Axial fat-saturated T1-weighted
MR image shows a unilocular, homogeneously hyperintense left ovarian lesion containing hypointense nodules (arrows).
(b) On an axial T2-weighted MR image, the mass is intermediately hypointense and contains hyperintense nodules
(arrows) but nevertheless has higher signal intensity than does skeletal muscle (*). (c) Axial contrast-enhanced T1-
weighted MR image demonstrates enhancing solid mural nodules. (d) Subtraction T1-weighted MR image more
clearly depicts the nodules (arrows). Endometrioid carcinoma was proved at pathologic analysis.

transformation of an endometrioma is thought to
be related to dilution of the hemorrhagic content
by tumor secretion (Fig 4) (17).
In these cases, careful assessment for the
presence of an enhancing mural nodule must
be made. Solid mural nodules seem to be the
most valuable imaging finding in suggesting
malignant transformation of an endometrioma
(18). Positive enhancement of the nodule is
best appreciated on dynamic contrast-enhanced
subtraction T1-weighted MR images (19), on
which the nodule is clearly highlighted on a
background of unchanged signal intensity in the
rest of the lesion.
Hemorrhagic Ovarian Cyst.—Functional hem-
orrhagic ovarian cysts, including follicular cysts
(usually <1 cm) and corpus luteal cysts (often
>1 cm) (20), are related to ovulation and are
typically not seen after menopause (21). Dis-
tinguishing between a hemorrhagic cyst and an
endometrioma remains a diagnostic problem in
some cases (22). Both entities may have similar
US features and appear hyperintense on fat-sup-
pressed T1-weighted MR images. Frequently,
endometriomas will have a very bright “light
bulb” appearance, which can help differenti-
ate them from hemorrhagic cysts. Hemorrhagic
cysts may also be hypointense on T2-weighted
MR images, although they are more commonly
hyperintense. Hemorrhagic cysts show hetero-
geneous and relatively mild signal loss with no
shading on T2-weighted images, whereas en-
dometriomas show marked T2 signal loss. This
is due to the absence of repeated bleeding and,
therefore, a lower concentration of blood prod-
ucts and viscosity in hemorrhagic cysts than in
endometriomas (Fig 5).
RG  •  Volume 32  Number 4 Khashper et al  1053

Figure 5.  Hemorrhagic right ovarian cyst in a 39-year-old woman. (a) Short-axis fat-saturated T1-
weighted MR image shows a predominantly hyperintense right ovarian lesion (arrow). (b) On an axial T2-
weighted MR image, the lesion (white arrow) demonstrates mild signal loss relative to skeletal muscle (*)
and typical endometrioma (cf Fig 3). Note the functional simple cyst (black arrow) in the left ovary.

Figure 6.  Endometriosis in a 33-year-old woman with hematosalpinx. (a) Axial fat-saturated T1-weighted
MR image demonstrates bilateral hyperintense serpentine structures (arrows) and the waist sign (arrow-
heads), findings that are compatible with hematosalpinx. (b) Axial T2-weighted MR image reveals hypoin-
tense blood contents (arrows) in the fallopian tubes. The presence of hypointense irregular plaque in the
cul-de-sac (arrowhead) associated with bowel tethering confirms the diagnosis of pelvic endometriosis.

Functional hemorrhagic ovarian cysts are more
commonly unilateral than bilateral and show a
thin, well-defined smooth wall. Hemorrhagic cysts
frequently contain heterogeneous contents due to
clot formation and retraction. At follow-up imag-
ing performed after a few physiologic cycles, a
hemorrhagic cyst will demonstrate complete or
partial resolution, whereas an endometrioma usu-
ally has a stable and persistent appearance.
Hematosalpinx.—A hematosalpinx can be rec-
ognized at both US and MR imaging as a tubu-
lar or corkscrew-shaped structure centered in
the fallopian tube. The most helpful and specific
findings of a hematosalpinx are T2 hypointen-
sity, a tubular shape with small round projec-
tions, and diametrically opposed indentations
in the walls resulting in the “waist” sign, which
reflects a tubular cystic structure with a folded
configuration (23). Hematosalpinx may be the
only imaging finding of pelvic endometriosis
(24). However, it may in fact be associated with
endometriosis; therefore, detection of a hema-
tosalpinx should prompt careful evaluation for
endometrial deposits and endometriomas, and
vice versa (Fig 6).
1054  July-August 2012 radiographics.rsna.org

Figure 7.  Cystic adenomyosis in a 26-year-old woman.

(a) Endovaginal US image shows an apparent cyst
with low-level echoes (arrow) to the left of the uterus
(Ut), a finding that suggests a left-sided endome-
trioma. (b) Axial fat-saturated T1-weighted MR image
shows a hyperintense hemorrhagic lesion (arrow) in the
left cornu surrounded by myometrium. The left ovary
(arrowheads) appears separate and distinct. (c) Axial
T2-weighted MR image helps confirm a uterine lesion
(arrow) with very low signal intensity comparable to
that of skeletal muscle (*). These findings are consistent
with cystic adenomyosis. Arrowheads = left ovary.

Cystic Adenomyosis.—Subserosal cystic adeno-
myosis of the uterus may also mimic a T2-hy-
pointense adnexal lesion (25). It is characterized
by a cystic myometrial lesion with extensive glan-
dular changes and hemorrhage. The hemorrhage
can be seen at different stages of organization,
from subacute blood to hemosiderin deposits in
the wall of the adenomyotic cyst, and thus can
appear similar to an endometriotic cyst (26).
The uterine origin of cystic adenomyosis can be
confirmed on the basis of (a) the presence of
myometrial splaying around the lesion, (b) visu-
alization of the bridging vessel sign, and (c) iden-
tification of the ovaries as separate and distinct
entities (Fig 7) (27).
Smooth Muscle
Compared with other soft tissues in the body, both
smooth muscle and skeletal muscle demonstrate
lower signal intensity on T2-weighted MR im-
ages, which results from the T2 shortening effects
of intramuscular actin, myosin, and collagen, as
well as decreased extracellular fluid relative to sur-
rounding tissues (28). Normal pelvic structures
that demonstrate very low signal intensity on T2-
weighted MR images include the junctional zone
of the uterus; the vaginal, urethral, and rectal mus-
cularis; and the bladder detrusor muscle (7). Uter-
ine leiomyoma represents the classic example of a
pelvic neoplasm that is composed predominantly
of smooth muscle and therefore typically demon-
strates low signal intensity on T2-weighted MR
images and low to intermediate signal intensity on
T1-weighted images (Fig 8). This characteristic
signal intensity aids in making the diagnosis and is
seen in up to 60% of uterine leiomyomas, showing
a hyaline subtype of degeneration. The T2 signal of
leiomyomas may vary in less common subtypes of
degeneration (cystic, myxoid, and red) due to the
presence of specific components (edema, hemor-
rhage, necrosis, and calcification) or in unusual
subtypes (lipoleiomyoma and myxoid leiomyoma)
RG  •  Volume 32  Number 4 Khashper et al  1055

Figure 8.  Multiple uterine leiomyomas in a 66-year-old woman. (a) Coronal T2-weighted MR image
depicts predominantly hypointense intramuscular (white arrow) and exophytic (black arrow) subserosal
leiomyomas. The exophytic leiomyoma should be differentiated from an adnexal mass. (b) On an axial fat-
saturated T1-weighted image, the leiomyomas (arrows) are isointense relative to uterine myometrium (*).

(29), resulting in a heterogeneous “cobblestone”
appearance. Exophytic uterine leiomyomas may
mimic adnexal masses in some cases. In these
instances, determining the origin of the mass will
allow a correct diagnosis to be made.
Extrauterine leiomyomas are rare and often
pose a significant diagnostic challenge. These
masses may originate from the adnexa, including
the ovaries, fallopian tubes, and round ligament.
Parasitic leiomyoma arises from the broad liga-
ment of the uterus and, unlike other leiomyomas,
can grow after hysterectomy. Primary ovarian
leiomyoma is a very rare pathologic entity, with
less than 80 cases having been reported in the
literature. .Ovarian leiomyoma coexists with uter-
ine leiomyoma in 80% of cases, with typical MR
imaging characteristics similar to those of smooth
muscle (5). Because leiomyomas are the most
common gynecologic tumors and are usually be-
nign, they should be included in the differential
diagnosis given the characteristic T2 hypointen-
sity of smooth muscle tumors.
Fibrous Tissue
Fibrous tissue represents low-cellularity or acellu-
lar material in combination with spindle, oval, or
round cells that result in collagen formation. Fi-
brosis typically demonstrates intermediate signal
intensity on T1-weighted MR images and very
low signal intensity on T2-weighted images (7).
The solid fibrous component of fibroma, fibro­
thecoma, and cystadenofibroma characteristically
demonstrates very low T2 signal intensity, allow-
ing the differentiation of these benign tumors
from malignant solid ovarian lesions.
Although MR imaging criteria for malignant
ovarian tumors include visualization of a solid
mass or a large solid component in association
with a cystic mass, awareness of the typical MR
imaging characteristics of fiber-containing tu-
mors allows the diagnosis of benign ovarian dis-
ease to be made.
Fibroma and Fibrothecoma.—Fibroma and
fibrothecoma represent a spectrum of benign
stromal ovarian tumors composed of fibrous
tissue and theca cells. Fibromas can be as-
sociated with ascites and pleural effusions in
classic Meigs syndrome (30), or with elevated
carcinogenic antigen levels (31). These solid
tumors have a variable appearance at US and
not uncommonly remain indeterminate. With
T1-weighted sequences, fibrothecomas demon-
strate nonspecific hypo- to isointensity with mild
enhancement following the intravenous adminis-
tration of a gadolinium chelate.
Therefore, identification of the characteristic
predominantly low signal intensity of fibromas
at T2-weighted imaging allows their differentia-
tion from other solid ovarian masses (32) (Fig 9).
1056  July-August 2012 radiographics.rsna.org

Figure 9.  Ovarian fibroma in a 71-year-old woman. (a) Sagittal T2-weighted MR image demonstrates a very low-
signal-intensity ovarian mass (arrow), a finding that is typical of fibroma. The presence of a few simple cysts (arrow-
head) helps verify the ovarian origin of the lesion. (b) On a sagittal contrast-enhanced T1-weighted MR image, the
fibroma (arrow) shows mild enhancement.

Figure 10.  Left ovarian fibrothecoma in a 65-year-old

woman. (a) Axial T2-weighted MR image shows a het-
erogeneously hypointense ovarian mass, with the most
hypointense components (arrowheads) representing
fibrous tissue. Ut = uterus. (b) Short-axis T2-weighted
MR image shows an endometrial polyp (arrow) and a
uterus (Ut) that is hyperstimulated for the patient’s age.
(c) Postcontrast T1-weighted MR image demonstrates
multifocal endometrial enhancement (arrow) as well as
mild enhancement of the fibrothecoma (arrowheads).
Ut = uterus.

Fibrothecomas are responsible for the endocrine

activity that results in endometrial hyperplasia
and polyps in some cases (33). Visualization of
a thickened endometrium or endometrial polyp
associated with a hypointense ovarian mass at
T2-weighted imaging favors the diagnosis of a
fibrothecoma (Fig 10). In larger lesions, vari- fibrous components can be seen in associa-
ous combinations of T2-hypointense theca and tion with T2-bright edema and cysts, resulting
in mixed low to high signal intensity on T2-
weighted MR images (32).
RG  •  Volume 32  Number 4 Khashper et al  1057

Figures 11, 12.  (11) Ovarian cystadeno-

fibroma in a 74-year-old woman. (a) Endo-
vaginal Doppler US image depicts an indeter-
minate cystic ovarian mass with a thick wall.
(b) On an axial T2-weighted MR image, the
fibroid solid component in the cystic wall has
the typical very low-signal-intensity appear-
ance (arrows). (c) Axial contrast-enhanced
subtraction T1-weighted MR image shows
mild enhancement of the fibroid solid compo-
nent (arrows). (12) Ovarian cystadenofibroma
in a 65-year-old woman. Coronal T2-weighted
MR image shows a left ovarian mass (arrow)
that is partially multicystic and partially solid.
The solid component has considerable hypoin-
tense signal, similar to skeletal muscle (*).

ing. The imaging appearance of cystadenofibro-

Cystadenofibroma.—Cystadenofibroma is an-
other example of a usually benign ovarian tumor
that contains fibrous stroma in combination
with an epithelial cystic component. These tu-
mors are classified according to epithelial cell
type into serous, endometrioid, mucinous, clear
cell, and mixed subtypes, whereas the relation-
ship between epithelial proliferation and the
stromal component of the tumor is used to clas-
sify tumors as benign, borderline, or malignant
(34). At MR imaging, a cystadenofibroma typi-
cally appears as a multiloculated cystic mass,
with a solid fibrous component that demon-
strates low signal intensity at T2-weighted imag-
mas varies depending on whether the cystic or
fibrous component predominates (Figs 11, 12).
In patients with primarily cystic cystadenofi-
bromas, the solid fibrous component may result
in irregular wall thickening (possibly >3 mm)
with mild enhancement on postcontrast im-
ages. Therefore, recognition of the typical very
low-signal-intensity appearance of the solid fi-
brous component at T2-weighted imaging plays
a crucial role in assessing for possible ovarian
malignancy (35). Although most ovarian cystad-
enofibromas are benign, they do have malignant
potential and therefore are removed surgically.
However, making the correct diagnosis of cyst-
adenofibroma may help avoid unnecessary ex-
tensive surgery.
1058  July-August 2012 radiographics.rsna.org

Figure 13.  Brenner tumor in a 77-year-old woman.

(a) Axial T2-weighted MR image shows a complex left
ovarian mass with a significantly hypointense solid
component dorsally (arrowheads) and a multicystic
component with hypointense septa ventrally (arrows).
(b) Corresponding axial contrast-enhanced T1-weighted
MR image shows mild enhancement of the dorsal solid
component (arrowheads) as well as septal enhancement
within the multicystic component (arrows). (c) Contrast-
enhanced CT scan reveals coarse calcifications dorsally
(arrow), in addition to a few cysts. Pathologic analysis
demonstrated Brenner tumor in the dorsal aspect of the
lesion as well as an associated cystadenofibroma ventrally.

Mixed-Cellularity Tumors

Brenner Tumor.—Brenner tumor is an uncom-

mon epithelial-stromal tumor that represents
about 2% of ovarian neoplasms and typically
contains a fibrous stromal component in associa-
tion with calcifications and transitional cells that
are histologically similar to urothelial epithelium
(36). The fibrous components, as well as calcifi-
cations (when present), are markedly hypointense
on T2-weighted MR images. Brenner tumors
are usually discovered incidentally at pathologic
analysis, and up to 20% of these tumors are as-
sociated with mucinous cystadenomas or other
epithelial neoplasms (37). In these cases, the le-
sion has a complex cystic and solid appearance,
with the Brenner tumor (representing the solid
part) characteristically demonstrating very low
signal intensity at T2-weighted imaging (Fig 13).
Although the T2-weighted imaging findings of
Brenner tumors overlap with those of fibrotheco-
mas, Brenner tumors typically demonstrate at
least moderate enhancement after contrast mate-
rial administration, whereas fibrothecomas are
hypovascular. The presence of calcification and
coexisting epithelial neoplasms favors a diagno-
sis of Brenner tumor over fibrothecoma. In rare
cases, benign Brenner tumor shows “borderline”
characteristics or even malignant transformation
to transitional cell carcinoma (38). According to
a few MR imaging studies, borderline Brenner
tumors typically manifest as cystic masses with
papillary and solid elements (38), whereas ma-
lignant Brenner tumors typically manifest as
multilocular cystic masses with large solid com-
ponents. In such borderline or even malignant
tumors, a solid component composed of poorly
differentiated cells demonstrates iso- to hyperin-
tensity at T2-weighted MR imaging, as opposed
to the marked T2 hypointensity of the fibrous
stromal component seen in the more typical be-
nign Brenner tumors (39).
Struma Ovarii.—Struma ovarii is a rare type of
ovarian lesion that accounts for 0.30%–0.65%
of ovarian tumors and 2% of ovarian teratomas
(40). Struma ovarii is a highly specialized form
RG  •  Volume 32  Number 4 Khashper et al  1059

Figure 14.  Struma ovarii in a 59-year-old woman. (a) Sagittal T2-weighted MR image shows a multiloculated,
heterogeneous left ovarian lesion with very low signal intensity (arrow). (b, c) Corresponding axial in-phase (b)
and opposed-phase (c) T1-weighted MR images reveal a hypointense mass with chemical shift artifact in its ventral
aspect (arrowhead), a finding that is compatible with a small amount of fat. (d) Axial postcontrast T1-weighted MR
image shows significant enhancement of the ovarian lesion (arrow) with sparing of its inferior aspect.

of ovarian teratoma and is composed entirely or
predominantly of thyroid tissue with large fol-
licles containing colloid material (41). About
5% of patients with struma ovarii develop clini-
cal evidence of hyperthyroidism (42). At US,
struma ovarii has a nonspecific solid and cystic
appearance. High-attenuation cystic compo-
nents and calcifications may be recognized at
CT. MR imaging demonstrates a loculated
cystic mass with variable signal characteristics.
Cystic spaces may show marked hypointensity
at T2-weighted imaging and intermediate sig-
nal intensity at T1-weighted imaging due to the
thick, gelatinous colloid of the struma, whereas
other locules are T1 hyperintense owing to
hemorrhage (43). Some locules may contain
microscopic fat, as indicated by signal drop-off
and surrounding chemical shift artifact on op-
posed-phase T1-weighted MR images. Struma
ovarii typically demonstrates strong enhance-
ment of the solid components on postcontrast
T1-weighted images (Fig 14). At times, it can be
difficult to distinguish these lesions from border-
line mucinous epithelial ovarian lesions. In mu-
cinous lesions, the T1 and T2 relaxation times
are shortened owing to the high protein content
and viscosity of the mucinous tumor, with high
signal intensity on T1-weighted images and low
signal intensity on T2-weighted images (44). In
addition, mucinous ovarian neoplasms (Fig 15)
1060  July-August 2012 radiographics.rsna.org

Figure 15.  Borderline mucinous ovarian neoplasm in a 52-year-old woman. (a) Axial T2-weighted MR image de-
picts a multicystic septated lesion (arrowheads) with mixed hypo- and hyperintensity, although the hypointense
aspect of the mass demonstrates relatively mild signal loss compared to skeletal muscle (*). (b) Axial fat-saturated
T1-weighted MR image shows the lesion (arrowheads) with heterogeneous mixed hyper- and hypointensity, a com-
mon characteristic of mucinous tumor.

Figure 16.  Metastatic right ovarian Krukenberg tumor in a 48-year-old woman with gastric cancer. (a) Axial T2-
weighted MR image shows a hypointense right ovarian lesion (arrows) that nonetheless appears less dark than adjacent
muscle (*) or the uterus (Ut). (b) On a corresponding axial contrast-enhanced T1-weighted MR image, the ovarian
mass (arrows) demonstrates marked enhancement.

are typically less hypointense than struma ovarii
on T2-weighted MR images. Struma ovarii are
benign in 95% of cases and usually occur in
premenopausal women; therefore, preoperative
diagnosis is essential to avoid unnecessary radi-
cal surgery (45).
Krukenberg Tumor.—Krukenberg tumors are
metastatic ovarian adenocarcinomas that most
commonly originate from the stomach (70% of
cases), followed by the breast, colon, and appen-
dix. Krukenberg tumors account for 1%–2% of
all ovarian tumors worldwide and are bilateral in
60%–80% of patients (46). The ovaries are usually
not recognized. Krukenberg tumors commonly
appear as solid masses with well-demarcated or
RG  •  Volume 32  Number 4 Khashper et al  1061

Figure 17.  Diagram illustrates a diagnostic algorithm for T2-hypointense adnexal masses. ↑T1 SI = high signal in-
tensity on T1-weighted images, ↓T1 SI = hypo- or isointensity on T1-weighted images, + enhancement = enhanced
solid component, − enhancement = no enhancement detected.

(owing to cystic necrosis or hemorrhage) ill-de- mass is visualized, an algorithmic approach to

fined intratumoral cysts. They often demonstrate
variable hypointensity on T2-weighted images due
to the presence of metastatic mucin-filled signet-
ring cells in the ovarian stroma and abundant
collagen formation (Fig 16) (47). Moderate to
marked enhancement of the solid component and
pericystic rim is noted, a finding that is unusual
in other solid ovarian lesions (48). Krukenberg
tumor is a rare but significant malignancy that
should be included in the differential diagnosis for
T2-hypointense adnexal masses in the appropriate
clinical context. For differential purposes, the pos-
sibility of Krukenberg tumors may be considered
in cases of heterogeneous solid and cystic bilateral
ovarian masses that show at least moderate en-
hancement, as well as T2 hypointensity of the solid
component that is relatively mild compared with
the signal intensity of skeletal muscle.
Diagnostic Workup of
T2-Hypointense Adnexal Lesions
Both benign and malignant adnexal masses show
variable signal intensity on T2-weighted MR im-
ages. However, when a T2-hypointense adnexal
image analysis can help significantly narrow the
differential diagnosis (Fig 17).
First, the radiologist should exclude a uterine
origin for the lesion by assessing for the bridging
vessel sign, splaying of the myometrium, and sep-
arate identification of the ovaries on T2-weighted
and postcontrast T1-weighted MR images. Exo-
phytic pedunculated leiomyoma and cystic ad-
enomyosis are the most common T2-hypointense
uterine lesions that can mimic an ovarian mass.
When a uterine source for an adnexal lesion
is ruled out, attention should be paid to the de-
gree of signal loss on T2-weighted MR images.
Endometrioma, leiomyoma, fibrous lesions, he-
matosalpinx, and struma ovarii can all show very
low signal intensity on T2-weighted images that
is comparable to that of skeletal muscle (7). Ap-
plying this criterion results in very high specificity
for a benign lesion, allowing appropriate conser-
vative or (if surgical removal is indicated) lapa-
roscopic management. When an adnexal lesion
is hypointense on T2-weighted images but has a
1062  July-August 2012 radiographics.rsna.org

Table 4
Diagnostic Workup of T2-Hypointense Adnexal Masses

Helpful
Type of Mass Key Features Imaging Examinations
Uterine origin
  Uterine leiomyoma, Visualization of ovaries as separate and distinct T2W, C+ T1W
cystic adenomyosis entities, splitting of myometrium, bridging vessel
sign (vascular flow voids)
Hemorrhagic
 Endometrioma Hyperintensity remaining after fat saturation, FS T1W
“multiplicity” sign
Adhesions T2W, C+ T1W
  Malignant transformation Loss of shading T2W
of endometrioma Solid nodule C+ subtraction T1W
 Hematosalpinx Hyperintense serpentine structure FS T1W
Fibrotic
 Fibrothecoma Endometrial thickening or polyps T2W, C+ T1W
 Cystadenofibroma Hypointense thick walls of the cyst US, T2W
Mixed cellularity
  Brenner tumor Coarse calcifications CT
Associated neoplasm US, CT, MR imaging
  Struma ovarii Calcifications CT
Strong enhancement C+ T1W
Note.—C+ = contrast-enhanced, FS = fat-saturated, T1W = T1-weighted MR imaging, T2W = T2-weighted
MR imaging.

signal intensity that is clearly higher than that of
skeletal muscle, the specificity for benign disease
decreases and there is greater overlap with findings
for malignant lesions. Lesions within this group
include both benign and malignant entities (eg,
hemorrhagic cyst, malignant transformation of an
endometriotic cyst, mucinous epithelial neoplasm,
and Krukenberg tumor) (Table 2). Therefore, the
degree of signal loss relative to skeletal muscle at
T2-weighted imaging provides an additional crite-
rion for characterizing adnexal lesions.
The classic imaging features of the lesion at
MR imaging performed with additional sequences
as outlined earlier help further characterize T2-
hypointense adnexal masses (Table 4). Hemor-
rhagic adnexal lesions, particularly those with
recurrent bleeding, are typically hyperintense on
fat-saturated T1-weighted MR images and include
endometrioma, cystic adenomyosis, and hemato-
salpinx. Mucinous epithelial neoplasms may also
be T2 hypointense and T1 hyperintense, although
to a lesser extent.
Loss of shading on T2-weighted MR images
compared with prior images, and visualization of
an enhancing mural nodule within an endometri-
otic cyst on postcontrast T1-weighted images, are
highly suggestive of malignant transformation of
the endometrioma.
Visualization of a thickened endometrium or
an endometrial polyp associated with a signifi-
cantly T2-hypointense ovarian mass would favor
the diagnosis of a fibrothecoma. A Brenner tumor
can be diagnosed in the setting of a markedly T2-
hypointense ovarian mass that shows moderate
vascularity, is associated with an epithelial neo-
plasm, and contains coarse calcifications (better
appreciated at CT). A multiloculated cyst with
thick, markedly T2-hypointense walls is sugges-
RG  •  Volume 32  Number 4 Khashper et al  1063
tive of a cystadenofibroma. A heterogeneous but
significantly T2-hypointense ovarian mass with
marked enhancement may represent a struma
ovarii in certain clinical contexts, whereas a bor-
derline mucinous neoplasm shows only a mild
degree of T2 hypointensity. In addition, micro-
scopic fat can be found in struma ovarii, in keep-
ing with signal drop-off on in-phase and out-of-
phase T1-weighted images.
This diagnostic algorithm, coupled with ap-
propriate clinical information, should allow an
accurate diagnosis to be made in the majority of
T2-hypointense adnexal masses.
Conclusions
Identification of T2-hypointense adnexal masses
at MR imaging is an important diagnostic crite-
rion that can help narrow the differential diagno-
sis. In masses with signal intensity comparable to
that of skeletal muscle on T2-weighted images, a
diagnosis of a benign disease entity can be made
with a high degree of confidence. Knowledge of
the anatomy, the T1-weighted imaging features
and enhancement characteristics of the lesion,
and the various physical entities that cause T2
shortening should allow the radiologist to accu-
rately characterize the lesion, resulting in appro-
priate patient management.
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Teaching Points July-August Issue 2012

T2-Hypointense Adnexal Lesions: An Imaging Algorithm

Alla Khashper, MD • Helen C. Addley, MRCP, FRCR • Nesreen Abourokbah, MD • Stephanie Nougaret, MD •
Evis Sala, MD, PhD, FRCR • Caroline Reinhold, MD, MSc
RadioGraphics 2012; 32:1047–1064 • Published online 10.1148/rg.324115180 • Content Codes:

Page 1048
The “bridging vessel” sign represents tortuous vascular structures passing between the uterus and the
lesion and may be seen at US; however, this sign is most clearly depicted at gadolinium-based contrast
material–enhanced T1-weighted imaging or T2-weighted imaging, which nicely demonstrate vascular
flow voids (3).

Page 1050
T2-hypointense adnexal lesions that are at least as dark as skeletal muscle help narrow the differential diag-
nosis and improve specificity.

Page 1050
The term shading refers to signal loss on T2-weighted MR images in an ovarian cyst that appears hyperin-
tense on T1-weighted images (13).

Page 1052
Hemorrhagic cysts show heterogeneous and relatively mild signal loss with no shading on T2-weighted
images, whereas endometriomas show marked T2 signal loss.

Page 1055
The solid fibrous component of fibroma, fibro­thecoma, and cystadenofibroma characteristically demon-
strates very low T2 signal intensity, allowing the differentiation of these benign tumors from malignant
solid ovarian lesions.