Sonographic Features of Ovarian Remnants Jean Simpson, MD

Sonographic Features of Ovarian Remnants
Arthur C. Fleischer, MD, David Tait, MD, Jack Mayo, MD, Lonnie Burnett, MD,
Jean Simpson, MD
Ovarian remnants occur after a portion of ovarian
tissue is left behind unintentionally after oophorectomy. The ovarian remnant may be functional and cystic, producing pelvic pain and, in some patients,
extrinsic compression of the distal ureter. Ovarian
remnants frequently are associated with adhesions
from previous pelvic surgery for endometriosis or
pelvic inflammatory disease. Ovarian remnants also
may be included within pelvic peritoneal inclusion
cysts. In this retrospective study, the sonographic
features of ovarian remnants in 10 patients with surgical proof or clinical follow-up data are described.
Most ovarian remnants were simple cysts (seven of
10), three had multiple septations, and six had a rim
of presumably ovarian tissue with arterial and
venous flow. Three patients with ovarian remnant
masses that were aspirated had symptomatic relief
O
varian remnant syndrome is a known but
relatively uncommon complication of difficult bilateral oophorectomy.1,2 The remnant of ovarian tissue left behind after surgical
removal can become functional and cystic, producing pelvic pain or extrinsic compression of the distal ureter, or both. The presence of a cystic mass in
the pelvis in a woman with a history of bilateral
Received February 19, 1998, from the Departments of Radiology
and Radiological Sciences (A.C.F., J.M.), Obstetrics and Gynecology
(D.T., L.B.), and Pathology (J.S.), Vanderbilt University Medical
Center, Nashville, Tennessee. Revised manuscript accepted for publication June 14, 1998.
Address correspondence and reprint requests to Arthur C.
Fleischer, MD, Department of Radiology and Radiological Sciences,
RR-1213 MCN, Vanderbilt University Medical Center, 21st Avenue
South and Garland, Nashville, TN 37232–2675.
without recurrence. In one patient, guided aspiration
was unsuccessful, probably owing to the presence of
organized hemorrhage within the mass. Extrinsic
compression of the distal ureter was observed in one
patient, who was treated with gonadotropin releasing hormone agonist (Lupron). The sonographic
findings of a completely cystic or multiseptated
pelvic mass with a rim of vascularized solid tissue in
a postoophorectomy patient, although such cases are
rare, suggest the diagnosis of an ovarian remnant. If
the diagnosis can be established with a high degree
of certainty, sonographically guided aspiration may
be attempted in an effort to provide symptomatic
relief. Otherwise, sonography is useful in serial
assessment of these masses in patients receiving
medical treatment. KEY WORDS: Ovary, remnant;
Transvaginal sonography; Remnant, ovarian.
salpingo-oophorectomy is suggestive of an ovarian
remnant. Ovarian remnants may become incorporated within a peritoneal cyst. Ovarian remnants
commonly are described as a sequela of pelvic
surgery for endometriosis or pelvic inflammatory
disease.
Ovarian remnant syndrome should be considered
distinct from residual ovary syndrome, in which
pelvic symptoms originate from the ovaries preserved
at the time of hysterectomy. The theoretical basis for
ovarian remnant syndrome was revealed by the
work of Shemwell and Weed,3 who showed that
ovarian tissue implanted onto the peritoneum of
cats could survive after separation from its blood
supply. This development of parasitic blood supply
allows the ovarian tissue to remain responsive to
the hypothalmic-pituitary-ovarian axis.
 1998 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 17:551–555, 1998 • 0278-4297/98/$3.50
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OVARIAN REMNANTS
J Ultrasound Med 17:551–555, 1998
The present study describes the sonographic features of ovarian remnants as well as the therapeutic
outcome in a small number of patients whose mass
was aspirated using sonographic guidance.
MATERIALS AND METHODS
The case material from a group of 10 women with
surgically proved ovarian remnant syndrome (seven
surgically proved and three clinically presumed on
the basis of analysis of aspirated fluid) that had been
collected over a 7 year period was analyzed retrospectively. The women’s ages, surgical histories, and
sonographic features are listed in Table 1.
Both transabdominal sonography and transvaginal sonography were performed in all cases. Color
Doppler interrogation was performed in six patients.
Standard scanning protocols were used.
RESULTS
This study consisted of 10 women ranging in age
from 35 to 70 years (average, 53 years). All had undergone total abdominal hysterectomy and bilateral
salpingo-oophorectomy. Their clinical data are listed
in Table 1. Three women had a history of endometriosis, three had bowel disorders, one had had a mucinous cystadenoma removed, one had von Willebrand
disease, and one had non-Hodgkin lymphoma. The
length of time after surgery until the patient came for
evaluation ranged from 5 months to 50 years (average, 16 years). All patients complained of pelvic pain.
The masses ranged from 2 to 10 cm in average
dimension (Figs. 1 to 6). Most lesions (seven of 10)
had smooth walls, three had septa, and six had a rim
of presumably ovarian tissue. Of the four masses
with a focal area of solid tissue, three had arterial and
venous flow within the solid area on transvaginal
color Doppler sonography. In one patient with a
dense area of fibrosis found later at surgery, no flow
was detected.
Table 1: Clinical and Sonographic Findings
Patient Figure
History
Sonographic Features
Other Findings
1*
1
35 yr old, 7 yr post TAH
and 2 yr post BSO, with pain
3 cm multiloculated hemorrhagic mass
Serum FSH = 2 mIU/ml;
LH = 1.6 pg/ml
2*
2
53 yr old, 3 yr post TAH
and BSO, with
mucinous cystadenoma
3 × 5 cm fusiform cystic mass
Aspirated fluid; E2 =
15 pg/ml; no recurrence
3*
3
60 yr old, 30 yr post TAH
and BSO, with von Willebrand
disease
3 × 4 cm multiloculated cystic mass
Aspirated; no recurrence
4
4
34 yr old, 6 months post TAH
and BSO
10 cm multiseptated, partially solid mass;
arterial flow in wall
Aspiration attempted but
unsuccessful
5
5
45 yr old, 12 yr post TAH and
BSO, history of Crohn disease
8 × 10 cm smooth-walled cyst with
arterial flow in wall
Aspirated; no recurrence
6*
6
74 yr old, 33 yr post TAH and
BSO, with diffuse pelvoabdominal pain
10 × 12 cm cystic mass with arterial
and venous flow within ovarian remnant
7*
41 yr old, 20 yr post TAH and
BSO, with history of endometriosis,
five laparotomies for pelvic cysts
2 cm smooth-walled cyst with arterial flow
in wall
8*
35 yr old, 9 yr post TAH and BSO
2 × 3 cm irregularly shaped cyst
9*
37 yr old, 5 yr post TAH/BSO;
history of endometriosis
3 × 4 cm solid mass with venous flow
10
70 yr old, 27 yr post TAH and
BSO, with non-Hodgkin
lymphoma
5 × 7 cm septated mass with
arterial and venous flow in
wall
*Surgical proof.
TAH, Total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; FSH, follicle stimulating hormone; LH, luteinizing
hormone; E2, estradiol.
J Ultrasound Med 17:551–555, 1998
FLEISCHER ET AL
553
Figure 1 Transabdominal color Doppler sonogram from a
35 year old woman with acute pelvic pain who had had total
abdominal hysterectomy and bilateral salpingo-oophorectomy.
A partially cystic structure containing fine strands is seen
within a mass that has a well vascularized wall. This was
found to represent a hemorrhagic corpus luteum within an
ovarian remnant.
Figure 2 Transvaginal sonography in a 53 year old woman
with acute pelvic pain who had undergone total abdominal
hysterectomy and bilateral salpingo-oophorectomy 3 years
ago. A fusiform cystic mass that was nonvascular is present in
the left adnexa. At surgery, the distal portion of the left tube
was found to be obstructed by adhesions crossing the ovarian
fossa, accounting for its fusiform shape. A small remnant of
ovarian tissue was found near the fimbriated end of the tube.
Of the seven patients who underwent reoperation, all had histologically proven ovarian tissue.
Three patients had a presumptive diagnosis of
ovarian remnant on the basis of aspiration of fluid
and clinical follow-up results.
Of the four patients whose masses were aspirated
with sonographic guidance, three reported immediate symptomatic relief. The cytologic findings on
the aspirated fluid in all patients indicated a benign
lesion. The aspirated fluid from one patient’s mass
had an estradiol value of 15 pg/ml. Another patient’s aspirated fluid showed a follicle-stimulating
hormone level of 2 mIU/ml and luteinizing hormone level of 16 pg/ml, indicating ovarian
origin. In one patient with a probable endometrioma with organized hemorrhage, aspiration was
unsuccessful. In three patients, the mass had not
recurred on follow-up scans obtained 5 to 15
months after aspiration. In one patient, the mass
persisted and was removed surgically.
Figure 3 Transvaginal sonography in a 60 year old woman
who had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy 30 years ago and also had
von Willebrand disease. A multiloculated cystic mass is seen
within the ovarian remnant. Eight milliliters of clear fluid was
aspirated with alleviation of symptoms.
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OVARIAN REMNANTS
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A
B
Figure 4 Transvaginal sonogram from a 34 year old woman with complex pelvic mass with septa and solid tissue, who had a
history of endometriosis and who had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy 3 years
ago. A, Arterial and venous flow was present in the solid area. Sonographically guided aspiration was unsuccessful even though
the needle tip was properly placed within the mass. B, Follow-up sonogram 6 months later shows evolution of hemorrhagic area
within the ovarian remnant.
DISCUSSION
The sonographic appearance of ovarian remnants
varies from small to relatively large cystic or multiseptated masses that contain a rim of vascularized
ovarian tissue. Ovarian remnants can be differentiated from peritoneal cysts by documenting the presence of ovarian tissue in the wall of a mass. Because of
the limited numbers in our series we were not able to
estimate the prevalence of vascular versus hypovascular ovarian tissue or the specificity of this finding.
Although color Doppler sonography can suggest the
existence of functional ovarian tissue by the presence
of flow, it cannot always allow distinction between
areas of fibrosis and scarring that may appear as a rim
of vascularized solid tissue. The surrounding wall of
a peritoneal inclusion cyst that involves an ovarian
remnant is derived from the mesothelium of the peritoneum, which is usually avascular.4
Sonographically guided aspiration may provide a
means for symptomatic relief through nonsurgical
decompression of the mass. If the mass contains
functioning ovarian tissue, masses may enlarge or
regress, depending on the presence of follicular or
luteal cysts. On the basis of results from our limited
series, it seems appropriate to attempt to provide
symptomatic relief in some patients by sonographically guided aspiration.
On sonography, peritoneal inclusion cysts can be
distinguished from ovarian remnants by careful
evaluation of the rim of such masses.4 Peritoneal
cysts may contain a normal ovary inside an anechoic
cyst, whereas only a thin rim of ovarian tissue can be
seen in an ovarian remnant. The existence of arterial
and venous flow within the solid tissue usually indicates that vascularized ovarian tissue is present.
The majority of patients in this series had pelvic
pain many years after initial surgery (total abdominal
hysterectomy and bilateral salpingo-oophorectomy).
Some patients had had multiple operations whereas
others had intercurrent diseases, such as endometriosis, which may increase the likelihood of
adhesions surrounding the ovary.
Figure 5 Transvaginal color Doppler sonogram from a 45 year
old woman with a cystic mass who had had a total abdominal hysterectomy and bilateral salpingo-oophorectomy 12
years ago. Arterial flow is evident within the presumed ovarian remnant.
J Ultrasound Med 17:551–555, 1998
Sonography provides important data concerning
the size and accessibility of the mass to sonographically guided aspiration. In our limited experience,
sonographically guided aspiration provided symptomatic relief and may offer the patient an alternative to
repeat surgery in some cases. Medical pretreatment
with gonadotropin releasing hormone agonists
(Lupron) also may be used to shrink ovarian remnants, particularly those causing extrinsic compression of the ureter.5 Lupron therapy is both therapeutic
and diagnostic, as resolution of the cyst after administratration of this agent confirms the presence of ovarian tissue. Documentation of flow with an ovarian
remnant by color Doppler sonography may be helpful
in predicting which masses are vascularized and
therefore most amenable to medical management.
Sonography has an important role in the management of cases of suspected ovarian remnant syndrome. Even though the treatment of each patient
needs to be tailored to her specific clinical concerns,
women under the age of 45 years with suspected
ovarian remnant may be considered for an initial
trial of medical therapy followed by sonographically guided aspiration should the medical treatment fail or symptoms persist. Owing to the
increased prevalence of ovarian cancer in women
older than 45 to 50 years, surgical treatment may be
indicated. Sonographically guided aspiration may
be useful in women who are poor surgical candidates.
Figure 6 Transvaginal color Doppler sonogram from a 74 year
old woman with a cystic left adnexal mass who had undergone a total abdominal hysterectomy and bilateral salpingooophorectomy. Arterial and venous flow is present within the
ovarian remnant.
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