4. Ovary/Adnexa Flashcards
Few general tips
- Never biopsy or recommend biopsy of an ovary
- If you can’t find the ovary on CT, follow the gonadal vein
- Hemorrhage in a cystic mass = benign
Normal ovarian size =
15 ml
Post menopausal ovary should NOT be larger than
6 cc
What phase?
Follicular phase
Corpus luteum
Follicles seen during the early menstrual cycle are typically small = ___ mm in diamater
< 5 mm
The LH surge causes the dominant follicle to
Rupture, releasing the egg
After the egg is relaesed, what happens to the follice?
Regrss in size, forming a Corpeus Luteum
Premenopausal ovarian cyst.
< 1 cm =
1-2 cm =
> 3 cm =
< 1 cm = Follicle
1-2 cm = Dominant follicle
> 3 cm. = Cyst
Cumulus Oophorus
It is a collection of cells in a mature dominant follicle that protrudes into the follicular cavity
signals imminent ovulation
this is a type of functional cyst (more on that below), related to overstimulation from b-HCG
Theca Lutein Cysts
Theca Lutein cysts
see are large cysts (~ 2-3 cm) and the ovary has a typical multilocular cystic “spoke- wheel” appearance.
Multifetal pregnancy + Gestational Trophoblastic Disease (moles) + Ovaryian Hyperstiumlation Syndrome =
Theca Lutein Cysts
Theca lutein cysts + Ascites + Pleural effusion + pericardial effusion + risk for ovarian torsion and hypovolemic shock
Ovarian Hyperstimulation Syndrome
complication associated with fertility therapy (occurs in like 5%)
Cyst that is in the adnexa but not within the ovary. Instead these things are located adjacent to the ovary or tube. If the cyst is simple (not septated or nodular) and clearly not ovarian they will not need followup — is doesn’t matter how big it is, as they have incredibly low rate o f malignancy.
Paraovarian (Paratubal Cyst)
maximum ovarian volume in a post menopausal woman
6 ml
Unlike premenopausal ovaries, post menopausal ovaries should show these feature on PET
should NOT be hot on PET.
Incidental Simple Appearing Ovarian Cyst -Shown on CT-
PreMenopausal: < 3 cm =
PreMenopausal: > 3 cm =
PostMenopausal: < 1cm =
PostMenopausal: > 1cm =
PreMenopausal: < 3 cm = Call it Normal Follicle PreMenopausal: > 3 cm = Get an US
PostMenopausal: < 1cm = Call it Normal Cyst PostMenopausal: > 1cm = Get an US
Incidental Simple Appearing Ovarian Cyst -Shown on US-
PreMenopausal: < 7 cm =
PreMenopausal: > 7 cm =
PostMenopausal: < 5 cm =
PostMenopausal: > 5 cm =
PreMenopausal: < 7 cm = No Follow Up
PreMenopausal: > 7 cm = Follow Up (3 months)
PostMenopausal: < 5 cm = No Follow Up
PostMenopausal: > 5 cm = Follow Up (3 months)
The Sinister Six of Ovarian MAsses
Physiologic and functioning follicles
Corpora lutea
Hemorrhagic cysts
Endometriomas
Benign cystic teratomas (dermoids)
Polycystic ovaries
These cysts are benign and usually 25 mm or less in diameter. They will usually change / disappear in 6 weeks. =
If it persists? =
Functioning Ovarian Cysts
Non functioning if it persists (Not under hormonal control)
Simple cysts > 7 cm =
MRI
+ risk of torsion
Corpus Luteum VS Ectopic Pregnancy
moves WITH the ovary =
Move SEPARATE from the ovary =
Corpus luteum = Moves with the ovary
Ectopic pregnancy = Moves separate from the ovary
Triad:
Infertility + Dysmenorrhea + Dyspareunia (painful sex)
Endometrioma
Endometrioma
ounded mass with homogeneous low level internal echoes and increased through transmission (seen in 95% of cases).
+/- Fluid-fluid levels and internal septations
Looks like hemorrhagic cysts sometimes
the more unusual or varied the echogenicity and the more ovoid or irregular the shape, the more likelv the mass is
and endometrioma
What is the most sensitive imaging feature on MRI for the diagnosis of malignancy in an endometrioma ?
An enhancing mural nodule
complications of endometriosis
Bowel obstruction
infertility
= Due to a fibortic reaction associated with the implant.
The most common location for solid endometriosis
uterosacral ligaments
Other locations of endometriosis
CS scars
Endometrioma
“Dropped implants”
Do Endometriomas Ever Become Cancer?
About 1% - usually Clear Cell
Malignancy is very rare in endometriomas smaller than 6 cm. They usually have to be bigger than
> 9 cm
69?? nyaha
Risk factors for endometrioma turning into cancer =
a. > 45 y.o.
b. Bigger than 6-9 cm.
a solid nodule with blood flow in an endometrioma of a pregnant girl
“decidualized endometrioma. ”
Endometrioma
“Shading” - T2 shortening (getting dark) of a lesion that is T1 bright
Bright T1
Dark T2 (iron)
No fat supression (not a teratoma)
sometimes a ruptured follicle bleeds internally and re- expands. The result =
homogenous mass with enhanced through transmission (tumor won’t do that) with a very similar look to an endometrioma
Hemorrhagic cyst
“Fishnet appearance”
Endometrioma vs Hemorrhagic Cyst
Hemorrhagic cyst with go away in 1-2 menstrual cycles (so repeat 6-12 weeks)
Hemorrhagic cyst + post menopausal ladies =
follow-up 6-12 weeks
Hemorrhagic cyst + Very old ladies =
Consider cancer till proven otherwise
most common ovarian neoplasm in patients younger than 20
Dermoid
Dermoid
“Tip of the iceberg sign”
absorption of most of the US beam at the top of the mass
cystic mass, with a hyperechoic solid mural nodule
Dermoid
Rokitansky nodule or dermoid plug
Cystic mass + Nodule + bright T1/T2 + Fat suppression
Dermoid
Do Dermoids Ever Become Cancer?
1% - Squamous cell
Gross Fat containing ovarian mass on CT =
Dermoid
Hair within a cyst =
“Dot-dash” pattern
Overweight girl + infertility + acne + Pencil mustache
Polycystic ovarian Syndrome
imaging criteria of PCO
10 or more peripheral simple cysts ( < 5mm)
“string of pearls”
Enlarged ovaries (>10 cc)
