ORIGINAL ARTICLE
Primary Fallopian Tube Carcinoma: Correlation Between
Magnetic Resonance and Diffuse Weighted Imaging
Characteristics and Histopathologic Findings
Song Qi Cai, MD,* Feng Hua Ma, MD,* Jin Wei Qiang, MD, PhD,* Shu Hui Zhao, MD,*
Guo Fu Zhang, MD, PhD, and Ya Min Rao, MD
Objective: The aim of this study was to investigate the magnetic
resonance (MR) and diffusion-weighted (DW) imaging characteristics of
primary fallopian tube carcinoma (PFTC).
Methods: The clinical, MR, and DW imaging characteristics and
pathologic findings of 23 patients with 27 tumors were studied retro-
spectively. The MR and DW imaging appearance of tumors including
laterality, size and shape, architecture, signal intensity, apparent diffusion
coefficient (ADC) value, enhancement pattern, hydrosalpinx, and
intrauterine fluid collection were evaluated and correlated with pathologic
findings.
Results: Histopathologically, all 27 tumors were serous carcinoma with a
unilateral tumor in 19 patients and bilateral tumors in 4 patients. Thirteen
patients (57%) with PFTC were misdiagnosed preoperatively, 10 of which
as epithelial ovarian carcinoma. The mean (SD) largest diameter was 61 (7)
mm. The tumor shape was fusiform, sausagelike, or serpentine in 19 pa-
tients (70%) and nodular or irregular in 8 patients (30%). Twenty (74%)
of the 27 tumors were solid, and 7 (26%) were cystic-solid. The solid
components showed hypointensity to isointensity on T1-weighted imaging,
and isointensity to slight hyperintensity on T2-weighted imaging. There
were obvious hyperintensity on DW imaging; obvious hypointensity on
ADC maps with a mean (SD) ADC value of 0.79 (0.22)  103 mm2;
and mild (8/27, 30%), moderate (13/27, 48%), and marked (6/27, 22%)
enhancement on contrast-enhanced imaging. Ipsilateral hydrosalpinx,
intrauterine fluid collection, and ascites were found in 14 tumors (52%)
and 7 (30%) and 5 (22%) patients, respectively.
Conclusions: The PFTC has some characteristic MR imaging features.
The DW imaging, ADC maps, and ADC values are helpful for the detec-
tion and differentiation of PFTC from other pelvic masses.
Key Words: primary fallopian tube carcinoma, magnetic resonance
imaging, diffusion-weighted imaging, pathology
(J Comput Assist Tomogr 2015;39: 270275)
P rimary fallopian tube carcinoma (PFTC) most commonly
occurs in postmenopausal women and is a rare tumor that
accounts for 0.4% to 1.1% of all gynecological malignancies.1
Recently, several studies have reported an increase in the
incidence of PFTC.2 Because of the insidious and nonspecific
presentation and significant distant and lymph node metastases,
the overall survival rate for patients with PFTC is generally
low.3 Although a few case reports and a small series of ultrasound
From the *Department of Radiology, Jinshan Hospital, and Departments of
Radiology and Pathology, Obstetrics & Gynecology Hospital, Shanghai
Medical College, Fudan University, Shanghai, China.
Received for publication July 28, 2014; accepted October 7, 2014.
Reprints: Jin Wei Qiang, MD, PhD, Department of Radiology, Jinshan Hospital,
Shanghai Medical College, Fudan University, Shanghai 201508, China
(email: dr.jinweiqiang@163.com).
Supported by grants from Shanghai Municipal Commission of Science &
Technology (no. 124119a3300) and Shanghai Municipal Commission of
Health and Family Planning (nos. 2013SY075 and ZK2012A16).
The authors declare no conflict of interest.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
270 www.jcat.org
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
and computed tomography studies of PFTC are available, due to
the complex and variable morphology of tumor, the preoperative
misdiagnosis rate is rather high.47 Therefore, further study on
the imaging of PFTC, especially appearance on magnetic
resonance (MR) imaging, is needed. In addition, to the best of
our knowledge, no study regarding the diffusion-weighted (DW)
imaging characteristics of PFTC has been reported. The purpose
of this study was to investigate the clinical, MR, and DW imaging
characteristics of 23 patients with PFTC by correlating these
characteristics with pathological findings, to improve the accuracy
of preoperative diagnosis and the prognosis of PFTC patients.
MATERIALS AND METHODS
Patients
This retrospective study was approved by the institutional
review boards of Jinshan Hospital and Obstetrics & Gynecology
Hospital of Fudan University, Shanghai, China, and informed
consent was waived. We searched for the data of patients with
fallopian tube cancer (FTC) from February 2008 to May 2014 at
hospital information system and picture archiving and commu-
nication system. Sixty-six patients with FTC were found. We
excluded 37 patients with secondary FTC and 6 patients with
extensive FTC and ovarian cancer whose primary site could not
be confirmed by surgery and histopathology. The remaining 23
patients had PFTC, proven by surgery and histopathology in
accordance with one of the following criteria modified by Sedlis8:
(1) the main tumor arises from the endosalpinx, (2) the histol-
ogical pattern reproduces the epithelium of tubal mucosa, (3) tran-
sition from benign to malignant tubal epithelium is demonstrable,
and (4) the ovaries or endometrium are either normal or contain a
tumor that is smaller than the tumor in the tube.
The patients' age ranged from 42 to 81 years (mean [SD] age,
56.9 [1.6] years). Eleven patients presented with vaginal watery
discharge and bleeding, 7 patients presented with abdominal pain
and swelling, and the remaining 5 patients were asymptomatic;
PFTC was found during a routine physical examination. The
serum CA-125 antigen level was elevated in 14 of the 18 patients
based on CA-125 assay. The clinical data in 23 patients with
PFTC are summarized in Table 1.
MR and DW Imaging Scan
All scans were performed with 1.5-T MR imaging scanners
(Avanto or Symphony; Siemens, Erlangen, Germany) using a
pelvic phased-array coil with the patient supine and free breathing.
The following sequences were obtained: spin echo (SE) axial T1-
weighted imaging (T1WI) (time of repetition [TR]/time of echo
[TE], 340/10 ms], turbo SE T2-weighted imaging (T2WI) with
and without fat saturation (TR/TE, 8000/83 and 4000/98 ms,
respectively), and sagittal and coronal turbo SE T2WI (TR/TE,
8000/98 ms). Axial DW imaging was obtained using the
J Comput Assist Tomogr Volume 39, Number 2, March/April 2015
J Comput Assist Tomogr Volume 39, Number 2, March/April 2015 Primary Fallopian Tube Carcinoma

tumor was heterogeneous; and (6) hydrosalpinx, intrauterine fluid

TABLE 1. Clinical and Pathological Features of 23 Patients With collection, ascites, peritoneal implant, and lymphadenopathy. At
PFTC
least 3 measurements were obtained and averaged.
Clinical Features Patients, n %
RESULTS
Menstruation status
Histopathologically, all 27 tumors were high-grade serous
Postmenopausal 15 65 carcinoma, with 11 (41%) occurring in ampulla, 7 (26%)
Premenopausal 8 35 occurring in fimbria, and 9 (33%) extensively involving both the
Symptoms ampulla and fimbria. Ten tumors involved the ipsilateral ovary,
Abnormal vaginal bleeding or watery discharge 11 48 forming a large cystic mass in 3 cases, which resulted from the
Abdominal pain or swelling 7 30 adhesion of the fimbrial end and ovary. According to International
Asymptomatic 5 22 Federation of Gynecology and Obstetrics staging, 6 patients
Serum CA-125 elevation 14* 78 (26%) were at stage I, 11 (48%) were at stage II, 5 (22%) were
FIGO stage at stage III, and 1 (4%) was at stage IV (Table 1). An associated
I 6 26 ovarian sarcoma and tubo-ovarian abscess were found in 1 patient.
Thirteen patients (57%) with PFTC were misdiagnosed preopera-
II 11 48
tively, 10 of which as epithelial ovarian carcinoma, one as sex
III 5 22 cord-stromal ovarian tumor, and one as uterine leiomyoma. One
IV 1 4 patient with an associated tubo-ovarian abscess was missed.
Histological type A total of 27 masses were found in the 23 patients; with a
Serous carcinoma 23 100 unilateral tumor in 19 patients (15 left and 4 right) and bilateral
Other 0 0 tumors in 4 patients. The size of the tumor ranged from 14 to
Location 120 mm, with the mean (SD) largest diameter of 61 (7) mm.
Unilateral 19 83 Twenty (74%) of the 27 tumors were solid, and the remaining
Bilateral 4 22 7 (26%) were cystic-solid. The shape of the solid tumors was
Ampulla 11 41 fusiform or sausagelike in 16 cases (80%) and nodular or irregular
in 4 cases (20%). Three cystic-solid tumors appeared as tubular or
Fimbria 7 26
serpentine-shaped (Fig. 1), and the remaining 4 were irregular.
Ampulla and fimbria 9 33 The solid components of 27 tumors showed hypointensity to
*Eighteen of the 23 patients had CA-125 results. isointensity on T1WI; isointensity to slight hyperintensity on
Number of tumors. T2WI; and mild enhancement in 8 (30%), moderate in 13
FIGO, International Federation of Gynecology and Obstetrics.
(48%), and marked in 6 (22%) on contrast-enhanced T1WI
(Table 2). The signal intensity of cystic components was the same
as that of urine, except 1 hydrosalpinx that displayed high
following parameters: echo planar imaging (TR/TE, 3100/81 ms); intensity on both T1WI and T2WI. The solid components of
b factors, 0 and 800 s/mm2; 5-mm slice thickness; 1.5-mm gap; tumors demonstrated obvious hyperintensity on DW images and
296  320 matrix; 270  320-mm field of view; 4 excitations; obvious hypointensity on ADC maps (Figs. 2, 3). The mean
and scan time of 1.24 minutes. The contrast-enhanced FLASH (SD) ADC value was 0.79 (0.22)  103 mm2. The ipsilateral
two-dimensional T1WI with fat saturation (TR/TE, 196/2.9 ms) hydrosalpinx was found in 14 tumors (52%). Intrauterine fluid
was performed in the axial, ,sagittal and coronal planes right collection and ascites were found in 7 (30%) and 5 (22%) patients,
after intravenous administration of gadopentetate dimeglumine respectively. The peritoneal implant at the rectouterine pouch was
(Magnevist; Bayer Schering, Guangzhou, China) at a dose of seen in 2 cases and extensively at mesentery, omentum, and
0.1 mmol/kg of body weight and a rate of 2 mL/s. The scanning diaphragm in 5 cases. Pelvic lymphadenopathy was seen and
parameters were as follows: 5-mm slice thickness, 1.5-mm gap, pathologically confirmed in 4 cases.
256  256 matrix, 200250  340-mm field of view, and 4 exci-
tations. The scanning range was from the inferior pubic DISCUSSION
symphysis to the renal hilum and extended beyond the dome of
Traditionally, PFTC is thought of as a rare gynecological
the tumor in the cases with huge masses.
malignancy. However, the true incidence of PFTC may have been
underestimated because available evidence suggests that the
MR and DW Imaging Analysis fimbrial end of the fallopian tube is a precursor of some ovarian
The MR images were reviewed independently by 2 radio- serous neoplasms.9,10 The PFTC commonly affects post-
logists (S.Q.C. and F.H.M. with 4 and 10 years of experience in menopausal women. So far, there is no effective screening method
abdominal imaging, respectively). Their interpretations were for patients with early PFTC. However, intermittent vaginal
confirmed by the third radiologist (J.W.Q. with 30 years of watery discharge and bleeding are considered to be relatively
experience in abdominal imaging). The following features of specific symptoms, and elevation of serum CA-125 level is
tumor were evaluated: (1) laterality, size, and shape; (2) frequently found in patients with PFTC and those with a
architecture (cystic or solid components); (3) signal intensity recurrence. Therefore, PFTC tends to be more frequently
(referring to myometrium and fat); (4) apparent diffusion diagnosed at an early stage and thereby has a better prognosis in
coefficient (ADC) value being measured on ADC maps with a contrast to epithelial ovarian cancer (EOC).
30-pixel region of interest placed at solid targeted areas, which In our series, postmenopausal patients accounted for 65% of
had homogeneous signal on conventional MR images; (5) contrast the cohort, vaginal watery discharge or bleeding occurred in 48%,
enhancement (mild, moderate, or marked enhancement referring and elevated CA-125 level was found in 78% patients, which is in
to the inner and outer myometrium)the predominant signal accordance with the results of previous studies.2,3 Seventy-four
intensity was taken to represent the tumor's signal, where the percent of patients were at stages I and II, which is higher than that

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Cai et al J Comput Assist Tomogr Volume 39, Number 2, March/April 2015

FIGURE 1. A 53-year-old woman with postmenopausal vaginal bleeding for 8 months and elevated CA-125 level (61 [<35]U/mL). Axial
fat-saturated T1WI (A) and T2WI (B) show an adnexal cystic-solid mass with isointensity on T1WI, slight hyperintensity on T2WI, and a
serpentine shape on sagittal T2WI (C). The solid component (arrow) of tumor is markedly enhanced compared with the myometrium
(arrowhead) (D).

reported by previous studies, possibly owing to improved medical the fimbria have a worse prognosis, due to the easy occlusion of
conditions and state-of-the-art imaging tools. the fimbrial end and extension to the ovary.10,11 In our series,
The most frequent origination of PFTC is the ampulla, 11 (41%) of the 27 tumors derived from the ampulla, 7 tumors
followed by the fimbria. Patients with PFTC originating from (26%) derived from the fimbria, and the remaining 9 (33%)
extensively involved the fallopian tube, of which the origin was
TABLE 2. MR Imaging Features of 23 Patients With PFTC difficult to identify. Ten tumors extended to the ovaries. Compared
with the reported size of EOC, which ranges from 90 to
MR Imaging Features Patients/Tumors, n % 118 mm,1214 the size of PFTC in our series was significantly
smaller.
Shape Serous carcinoma is the most common pathologic type,
Fusiform/sausagelike/serpentine 19 70 accounting for approximately 45% to 90%, followed by endo-
Nodular/irregular 8 30 metrial carcinoma, undifferentiated carcinoma, and clear cell
Architecture carcinoma.3 In our series, all 27 tumors were high-grade serous
Solid 20 74 carcinoma. At the early stage, PFTC is confined to the tube with
Cystic-solid 7 26 a nodular, papillary, infiltrative, or massive growth pattern. The
SI of solid component fallopian tube is distended to a fusiform, sausage, or serpentine
Hypointense/isointense on T1WI 27 100 shape, which is the characteristic imaging feature for the detection
and differentiation of PFTC from other pelvic masses. Serous
Isointense/slight hyperintense on T2WI 27 100
fluid secreted by the tumor accumulates and distends the tube
Obvious hyperintense on DWI 27 100 resulting in hydrosalpinx, or it may result in a mixed cystic-solid
Obvious hypointense on ADC maps 27 100 configuration. Fluid may decompress through the uterus or
SI of cystic component fimbria resulting in intrauterine fluid collection or ascites. There-
Hypointense on T1WI 6 86 fore, hydrosalpinx is an indirect characteristic imaging feature. In
Hyperintense on T1WI 1 14 our series, 22 (81%) of the 27 tumors had a characteristic imaging
Obvious hyperintense on T2WI 7 100 finding: a fusiform, sausage, or serpentine mass in 19 tumors and
Enhancement of solid components a nodular or irregular mass with an associated hydrosalpinx in 3
Mild 8 30 tumors. After administration of contrast medium, 78% of the
Moderate 13 48 masses were mildly-to-moderately enhanced, whereas most EOCs
were markedly enhanced in previous studies.15,16
Marked 6 22
Some DW imaging studies of EOC have been reported
Hydrosalpinx 14 52 recently1720; however, no DW imaging report concerning PFTC
Intrauterine fluid collection 7 30 has been published. The value of DW imaging for pelvic tumors
Ascites 5 22 lies in the following aspects: (1) identifying small lesions by pro-
SI indicates signal intensity. viding a high contrast-to-noise ratio, (2) sensitivity in identifying
the depth of invasion, (3) assessment of the differentiation of tumors,

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J Comput Assist Tomogr Volume 39, Number 2, March/April 2015 Primary Fallopian Tube Carcinoma

FIGURE 2. A 63-year-old woman with postmenopausal vaginal watery discharge for 4 months. Axial fat-saturated T1WI (A) and T2WI
(B) show a sausagelike, solid, isointense mass (arrow) at the left side of the uterus (arrow head). The mass demonstrates mild enhancement
on contrast-enhanced T1WI (C), obvious hyperintensity on DW image (b = 800 s/mm2) (D), and obvious hypointensity on ADC maps (E).
The ADC value is 0.688  103 mm2/s.

and (4) monitoring treatment response.17 In our series, the solid
component of PFTC demonstrated obvious high signal intensity
on DW images and very low signal intensity on ADC maps.
The mean (SD) ADC value was 0.79 (0.22)  103 mm2, which
was much smaller than those of ovarian malignancies reported in
the literatures, in which ADC values ranged from 1.03 (0.19) 
103 to 2.006 (0.53)  103 mm2/s.1820
Further study will be necessary to confirm the difference by
comparing PFTC with EOC using the same DW imaging para-
meters. In addition, on conventional MR imaging, PFTC is often
surrounded and obscured by the bowel, which demonstrates varia-
ble signal intensity. The DW imaging, however, can be helpful for
identifying PFTC, with an obvious high signal on DW images and
a low signal on ADC maps. In our series, 3 tumors, which were
difficult to differentiate from the surrounding bowel on conven-
tional MR images, were clearly demonstrated on DW images.
Distinguishing between PFTC and EOC is often difficult.4
In our series, the misdiagnosis rate of PFTC was as high as 48%
(13/27), in which 10 cases were diagnosed as EOC. The EOC
typically manifests as a large multilocular cystic mass with a
variable amount of solid component, which is usually markedly
enhanced. In addition, rare hydrosalpinx, intrauterine fluid col-
lection, and vaginal watery discharge or bleeding may be found.
The PFTC shares a similar appearance with granulosa cell tumors
and fibrothecomas, which often have estrogen-related symptoms
or demonstrate low signal intensity on T2WI because of the
fibrotic component.21 The PFTC may be misinterpreted as uterine
leiomyoma when it is adjacent to the uterus. However, leiomyoma
typically shows characteristic low signal intensity on T2WI and
marked enhancement. The PFTC may present as tubo-ovarian
abscess and should be considered in the differential diagnosis of
acute pelvic peritonitis such as a tubo-ovarian abscess.22,23 Our
series had 1 patient with PFTC and associated tubo-ovarian
abscess, which had not been reported radiologically. Only the
tubo-ovarian abscess was diagnosed preoperatively. Whether
tubal inflammation induces PFTC or the reverse has not yet been
determined. Both PFTC and tubo-ovarian abscess appear with
high signal intensity on T2WI and DW images and low signal
intensity on ADC maps. However, PFTC can be enhanced
compared with nonenhanced abscess cavity. The combination of
conventional preenhanced and postenhanced MR images and
DW images is crucial for the accurate preoperative diagnosis.
In conclusion, MR imaging characteristics of PFTC are the
fusiform, sausage- or serpentine-shaped, solid or mixed cystic-
solid, and mild-to-moderate enhanced mass, with hydrosalpinx
or intrauterine fluid collection. In addition, PFTC has an obvious

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Cai et al J Comput Assist Tomogr Volume 39, Number 2, March/April 2015

FIGURE 3. A 54-year-old woman with abdominal pain, elevated CA-125 level (94.6 [<35]U/ml), and white blood cell count
(81.81% [43%76%]). Axial fat-saturated T1WI (A) and T2WI (B) show a sausage-shaped solid mass (black arrow) with isointensity
and slight hyperintensity, respectively, in the left adnexal area. The mass demonstrates slight enhancement at the center and marked
enhancement at the periphery on contrast-enhanced T1WI (C). At the upper section, an associated tubo-ovarian abscess with avidly
enhanced and thickened wall (white arrow) is seen (D). The tumor demonstrates obvious hyperintensity on DW image (b = 800 s/mm2)
(E) and obvious hypointensity on ADC maps (F). The ADC value is 0.748  103 mm2/s. Microscopically, neutrophils are numerous in stroma
(black arrowhead), and clusters of poorly differentiated serous tumor cells appear as a glandlike solid structure (white arrowhead)
(G, hematoxylin & eosin 100). Figure 3 can be viewed online in color at www.jcat.org.

high signal intensity on DW images and a low signal intensity and
low ADC value on ADC maps.
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