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Any Problem? ? Mural Nodule Ovarian Neoplasms Approach to
There is a Mass in the Adnexa What Does That Mean? Any Problem? Left Ovarian Cyst Mimics Bladder!!! Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses ? Mural Nodule Ovarian Neoplasms • Ovarian cancer is less common than either cervical or endometrial cancer, but it is the leading cause of death related to GYN malignancies because it tends to be diagnosed at a more advanced stage • 80% of ovarian tumors are benign • 40% of tumors in postmenopausal women are malignant Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Question 1 - Is it ovarian or extra-ovarian in origin? Approach to Adnexal Masses “4 Questions” 1. Is it ovarian or extra-ovarian in origin? Do not assume adnexal = ovarian 2. Is it one of the “Big 5”? 3. Does clinical situation suggest the diagnosis? 4. Is it mostly cystic or solid? Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Approach to Adnexal Masses Ovarian • Look for some ovarian tissue • Small follicles around it Non-ovarian • Separate from ovary • Gentle pressure with transducer and/or hand on abdomen to show separation Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 1 Diagnostic Challenge Diagnostic Challenge ? ? Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Paraovarian / Paratubal Cyst • • • • • • • Specific Dx if see separate ipsilateral ovary 10% of all adnexal masses Adjacent to ovary Do not regress over time If > 5 cm may lead to torsion Rarely malignant They may be complicated by • Bleeding Usually no F/U needed • Rupture Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses • • Torsion Infection Exophytic vs. Paraovarian? Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Paraovarian Cyst • Clear plane between cyst and ovary Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Diagnostic Challenge Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 2 Peritoneal Inclusion Cysts Diagnostic Challenge • Clinical history – Prior pelvic surgery/inflammation • Pathophysiology – Fluid trapped between pelvic adhesions • Ultrasound findings – Variable sized cysts – Complex appearing cysts – Ovary is within or at periphery of the cyst Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Kim et al. radiology 1997; 204:481 Peritoneal Inclusion Cyst Cystadenoma Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Question 2 Is it one of the “Big 5” • Common, benign ovarian masses • Account for the majority of masses seen in most clinical practice • Often have a typical appearance that strongly suggest the diagnosis • The “bread & butter” of ovarian masses • • • • • Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Follicular Cysts • • • • Is it one of the “Big 5” < 2.5 cm in diameter Thin walled and unilocular Usually unilateral Can be multiple and bilateral Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Just report ovary as normal Corpus luteum cyst Simple cyst Hemorrhagic cyst Endometrioma Dermoid (mature cystic teratoma) Follicular Cysts • 4-5 days before ovulation, the dominate follicle grows at a rate of 2-3 mm/day to reach the maximum diameter • Cumulus oophorus may be seen 24 hrs before ovulation Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 3 Corpus Luteum Cyst • The CL of menstruation increase in size until the nd day of the menstrual 22nd cycle and then regresses slowly • The CL of pregnancy reaches maximum size approximately 8-10 weeks after ovulation and begins to decrease significantly in size between 12-16 weeks Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Simple Cysts • • • • < 3cm Thin septation with no blood flow No internal nodularity Malignancy is rare Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Simple Cysts Don’t Get Fooled By Poor Technique • More likely malignant when – Larger cyst – Older / post menopausal • Recognize that one can miss subtle nodularity when cyst is large • Image cyst wall well – Do TVUS Pay Attention to Focal Zone Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Don’t Get Fooled By Poor Technique Postmenopausal Simple Ovarian Cysts • 3-18% of post menopausal women • Serial sonograms – 25-70% disappear – 12-50% persist unchanged – 3-11% increase in size < 5 cm • Of those with surgical correlation – Most (50-85%) are serous cystadenoma Gain -12dB Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Gain 9dB Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 4 Hemorrhagic Cyst Hemorrhagic Cyst Variety of sonographic findings depending on the amount and age of clot • Thin, regular wall • Vary in size • Diffuse, low level echoes Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Changes over time – “Evolving Appearance” Hemorrhagic Cyst Hemorrhagic Cyst • Most hemorrhagic ovarian cysts resolve spontaneously after one or two menstrual cycles Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Hemorrhagic Cyst • Ultimately resolves Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Hemorrhagic Cyst • Acute clot appears solid & intensely echogenic – homogeneous low level internal echoes – lace-like pattern of internal echoes / septations – clot retracting against the wall Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 5 Hemorrhagic Cyst Hemorrhagic Cyst • No internal vascularity • No internal vascularity Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mural Nodule vs. Clot Ovarian Cyst Rupture • Crenated cyst – +/- internal debris Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Cyst Rupture Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ruptured Hemorrhagic Cyst • Crenated cyst – +/- internal debris • Free fluid – Around ovary, cul de sac – Morrison’s pouch Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 6 25 year old woman, sharp shooting pelvic pain, difficulty taking deep breaths, started suddenly p sexual intercourse, HCG (-) Endometrioma Note: echoes in fluid OV Referred Pain Cystic pelvic mass with homogeneous low-level echoes Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Dx: Ruptured hemorrhagic cyst with hemoperitoneum Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Endometrioma Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Society of Radiologists in Ultrasound Consensus Statement Endometrioma Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses F/U of Adnexal Cysts - Premenopausal Simple Cyst Management of Asymptomatic Ovarian and Other Adnexal Cysts Radiology: Volume 256: Number 3 - September 2010 Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses – < 3cm, generally no need for F/U Hemorrhagic Cyst – < 3cm, generally no need for F/U – > 3cm, F/U in 6-12 weeks • in size, no need for F/U • in size & complexity, recommend surgical consult Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 7 F/U of Simple Adnexal Cysts Postmenopauasal Simple Cyst • < 1cm, generally no need for F/U • < 1-5 cm – F/U 3 months Cystic Lesions of Any Size • • • • Thick wall or septations Internal nodularity or papillary Internal blood flow Recommend surgical consult • in size, no need for F/U • No change, F/U 6, 12, months post initial scan, then yearly • > 5cm, recommend surgery consult Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Diagnostic Challenge Theca Luteal Cyst • Largest of the functional cyst group • Associated with high levels of human chorionic gonadotropin (hCG) – Multiple gestations – Gestational trophoblastic disease – Ovarian hyperstimulation syndrome – Pregnancies complicated by hydrops fetalis High hCG levels Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Theca Luteal Cyst Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Polycystic Ovarian Disease • Complex masses with thick irregular walls, most often bilateral and multilocular • These cysts involute when the source of hCG is removed by elimination or excision • Also called Stein Leventhal Syndrome Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 1935 Recognized 8 Polycystic Ovarian Disease Polycystic Ovarian Disease • Women age group 15-30 years • Round rather than ellipsoidal in shape • Bilaterally enlarged ovaries – > 12 peripheral cysts – 2-9 mm diameter – (volume > 10cc) • An imbalance of LH & FSH results in abnormal estrogen & androgen production • Diagnosis is usually made biochemically Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Polycystic Ovarian Disease Numerous small (< 1cm) peripherally located cysts Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses LO – 14 cc RO - 13 cc Polycystic Ovarian Disease May have hyperechogenic / vascular stroma Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses What other pts have ovaries like this (small follicles) ? Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 9 32-year old women complained of vague lower abdominal discomfort. A mass was palpable on pelvic examination Cystic Teratoma Echogenic mass with posterior sound attenuation Fat-fluid level Echogenic linear speckles (dermoid mesh) Mural nodules, +/- Ca++ (dermoid plug) Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Cystic Teratoma Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses The shadowing caused by the dermal plug reflects its composition as a mixture of hair & sebum as well as fragments of bone or teeth Cystic Teratoma Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 10 Cystic Teratoma Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion – US Findings Cystic Teratoma Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion – US Findings • Unilateral ovarian enlargement (+/- focal mass) – Right ovary is more commonly involved • Most common: – Prepubertal & adolescent • • • • • Heterogeneous central stroma +/- peripheral cysts +/- absent blood flow +/- free fluid in the cul-de-sac Unusually positioned ovary Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion – US Findings • Look for torsed pedicle Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Clue to Diagnosis Unusual location of ovary!! Anterior to uterus Ovarian Torsion – US Findings • Look for torsed pedicle “Whirlpool Sign” Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 11 Ovarian Torsion • Massive edema and/or hemorrhage within the ovary (younger (younger patients) patients) – Vasodilatation with leakage of blood into the ovarian interstitium combined with hindered venous outflow – Ovarian vein thrombus Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion – Doppler Findings • Variable – dual blood supply – varying degrees of torsion • Lymphatic obstruction • Decreased or absent venous flow • Decreased arterial flow • Reversed diastolic flow • Complete absence of arterial flow Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 12 Ovarian Torsion Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion / Infarction Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Torsion Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Tubal Torsion Tubal Torsion • Women who have undergone tubal ligation • The ligated tubal segment may become filled with fluid and be predisposed to torsion Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 13 Unilateral Tubal Torsion Pelvic Inflammatory Disease • Usually due to STD – Chlamydia Trachomonas / Neisseria Gonorrhea • Other less common causes Fusiform mass with thickened wall 43 year-old woman who experienced with RLQ pain several days prior to admission. She had undergone bilateral tubal ligation 8 years previously Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Pelvic Inflammatory Disease – – – – – Direct extension from appendiceal Diverticular Post-surgical abscesses that have ruptured into the pelvis Post-abortion complications Rarely a TOA develops 200 to direct spread of infection from bowel to ovary Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Endometritis – US Findings Progression of the disease • Endometritis • Salpingitis • Oophoritis • Peritonitis • Pelvic Abscess • Indistinct, thickened endometrial stripe Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Endometritis – US Findings – +/- fluid, air • Diffuse increased vascularity – low resistance arterial waveform Uterus - Serositis • Indistinct serosal surface • Hypoechoic rim around uterus Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 14 Uterus - Serositis • Adhesions to ovary (+/- mass) Pelvic Inflammatory Disease • Variable sonographic appearance – Nonspecific Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Pelvic Inflammatory Disease Pelvic Inflammatory Disease • Most patient demonstrate bilateral but asymmetric involvement • Enlarged, ill-defined ovaries, cystic or complex adnexal masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Hydrosalpinx Hydrosalpinx • Dilated, tubular, anechoic structure between uterus and ovary • Acute – Thickening of the tube wall of > 5mm Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 15 Hydrosalpinx • Cogwheel appearance – “Plica” • “Beads on a string” (multiple 2-3 mm nodules) Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses How to distinguish between wall irregularity and small papillary projections? Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Cystic Ovarian Masses • Papillary projections: – Small solid areas that protrude 3mm or more from the cyst wall Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Hydrosalpinx • Incomplete septa, correlating with folds or kinks in the dilated tube Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Hydrosalpinx Diagnostic Challenge May be sonolucent Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 16 Diagnostic Challenge Hydrosalpinx • Echogenic fat – Infection causes inflammatory changes in the fat in the adnexa Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Pelvic Inflammatory Disease Pyosalpinx May contain low-level echoes Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses + Pregnancy Test Symptomatic on the Left Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Tubo-ovarian Abscess • Inflamed fallopian tube and ovary that are often fixed • Appear as an ill-defined and enlarged adnexal mass in which it is not possible to distinguish between the two structure Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 17 Tubo-ovarian Abscess Tubo-ovarian Abscess Vascularity Tenderness Often bilateral Ovarian margins may be indistinct • Complex, multilocular, thick walled mass, internal echoes • • • • Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Ovarian Echogenic Foci (1-3mm) Ovarian Echogenic Foci (1-3mm) !! Y R OR W TO T NO • Etiology – Calcification in inclusion cysts (reminence (reminence of of past past ovulations) ovulations) – Corpora albicans with hemosiderin To worry….? Or ….not to worry? Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Features of Malignant Ovarian Neoplasms When determining the risk of malignancy for an ovarian mass, consideration should also be given to factors other than imaging findings • Patient age • Menopausal status • Personal or family history of breast or ovarian cancer • Serum CA-125 level Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Brown et al. JUM 2004; 23:307 • Classification is based on histologic features – – – – Epithelial (90%) Germ cell Sex cord stromal Metastatic • Us features – – – Solid component (particularly if there is visible flow) Thick septa Ascites Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 18 Ovarian Cancer Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Cystic Ovarian Masses Mucinous Cystadenoma Serous Cystadenoma Mucinous Cystadeno CA Serous Cystadeno CA Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Conclusion Benign: • Purely cystic • Thin walls • Well-defined borders • Thin septations • No papillae • Usually unilocular • Usually < 5cm Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Malignant: • Solid or complex cystic with solid component • Thicker walls • Irregular borders • Thick & irregular septations • Papillary/nodularity projections • Multilocular • > 5cm • Free fluid –– –– –– Omentum Omentum Peritoneal Peritoneal Periphery Periphery of of liver liver Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses Thank You Mani Mani Montazemi, Montazemi, RDMS RDMS Adnexal Adnexal Masses Masses 19
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