ADNEXA/OVARIES Flashcards
Diffuse disease of the female pelvic cavity
PID
ENDOMETRIOSIS
Most commonlyPID caused by
Uncommonly reason
Sexual disease
Genera
Chlamydia
Un. Ruptured appendix peritonitis
Early stage of endometriosis and PID may mimic
Functional bowel disease
Pelvic infection PID:
Endemetritis
Salpingitis
Hydrosalpinx
Pyosalpinx
Periovarian inflammation
Tubo ovarian complex
Tubo ovarian abscess
Parametritis
Infection found in uterine serosa and broad ligaments
Oophoritis
Ovary infection
Most common location
Oviduct
Salpingitis
Us in chronic Pid
Dilated fallopian tubes
Hydrosalpinx
Pyosalpinx
Abscess
Complex fluid intraperitoneal
PID clinical symptoms
Large palpable bilateral complex mass
Ovary separate from mass
free fluid in cul-de-sac
Doppler increase vasicularity
Infertility
Endometritis
Intensive pervic pain and tenderness described as dull aching
constant vaginal discharge
Fever
Pain in right upper abdomen
Mistral irregular bleeding
Painfull intercourse
Fitz-hugh- Curtis syndrome
Perihepatic inflammation
Along liver margin
Hypoechoic rim between liver and
Adjacent rib
PID lab test
I WBC
Caused by chlamydia
Way be asymptomatic
Differential consideration
Hematoma
Dermoid cyst
Ovarian neoplasm
Endometritis
Us if endometritis
Periovarian inflammation
Thickening or fluid endometrium
Periviovarian inflammation
Enlarged ovaries with multiple cysts
Indistinct margin
Us salpingitis
Clinical
Nodular thickening
Irregularity of tube with diverticle
Dilated tube
Tortuous
Low-grade fever
Asymptomatic
Pelvis fullness
Unilateral or bilateral
Us pyosalpinx or
Hydrosalpinx
Fluid-filled
Regular fallopian tide
With or without echo
Us
Tube- ovarian abscess
Complex mass
With septarian
Irregular margins
Internal echoes
Usually in Incul-de-sac
Acute salpangitis
The tube is enlarged
Distended with echoes pus appears
Thickwall
Hydrosalpinx
Reasons
PID
Endomeíritis
Post operative adhesions
Hydrosalpinx
Clinical
Us
A symptomatic
Pelvic fullness
Law grade fever
Wall thin ia dilatio
Multi cystic or fusi form mass
Dilated tube from fundus of uterus
Bilateral
Ampulary more dilated then interstitial
Pointed beak at swan end of tube near isthmus
Peritoneal psedocyst
With hemorrhagic mesotherial cyst appearance
Right lower pain in some patient
Fluid filled mass and separations in cul-de-sac
Tube-ovarian
Abscess
Complex
Adhesive
Edemarous
Inflamedserosa
May adhere ovary
And other peritoneal surfaces
Distort anatomy
Periovarian adhesion
Ovary cannon be separated from dilated tube
Tube - ovarian complex
Response to -o
Sono guidance for drainage
Peritonitis
Inflammation of peritoneum
Pelvic peritonitis
If infection spreads to involve bladder
Ureter
Bowel
Adnexal area
US in peritonitis
.gas forming bubbles
Located areas of fluid within pelvis
Parabolic gutters
Mesentric reflections
Evaluation space btw right kidney and liver
Left kicky spleen
Endemetritis division
Obstetric. Immediate Post partum
NONObstetric _PID or IU
Most common cause E of fever in Post partum
‘endometritis
Normal thickness of endemiritis
If more than
20mm
More than
Endometritis
hemorrhage
Retained products of pregnancy
Risk increases
Prom
Retained clot
Prolonged labor
Endometriosis
Presence of functionalendometrial tissue in abnormal locations
Anywhere
Especially more dependent Parts of pelvic
Cut de sac
Clinical finding endomeírisis
Severe diysmenorrhea
Chronic pelvic pain
Adhesion
Bleeding
Dysparenuia during sexual intercourse
Types of endometriosis
Internal and
External
Internal endometriosis
Within the uterus
Adenomyosis
External endometriosis
Outside the uterus
Pouch of Douglas
Surface of ovaries
Fallopian tube
Uterus broad ligaments
Rectovaginal septum
More common form of endometriosis
External or indirect
Internal or direct form of endometriosis
clinical
Adenomyosis
Invading the uterin body
Invading junction al zone and myometrium
Heavy menstrul bleeding and uterin e enlargement
C
Adenomyosis most common
Women had uterin surgery
Us endometriosis
Uterin bulbous
Myometrial cysts
Border between endometrium and myometrium is in distinct
BLUURED BORDER appearance more common in posterior of uterus
MRI more than US IN distinct
External or localized form
Discrete mass
Endometrioma
Or chocolate cyst
Asymptomatic
May enlarged
Surgical emergency
By rupture
Causing ovary twisted
Common site is ovaries chocolate cyst enlarge ovaries
External form in US
Rarely detected
Unless focal mass
Endometrioma present
Endometriomas may uni or bilateral ovarian mass
Ranging from anechoic
To solid depending on amount of blood
Ovaries adhere to pos uterine or in culled sac
Difficult to define
May be cystic mass be disseminated cancer or pelvic infection
More common form of endometriosis
Diffuse external endometriosis
Ground glass appearance
Endometrioma and mass in the ovaries fills with blood
Ovaries places
If uterus in the midline lateral or posterolateral
Uterus in one side of midline ipsilateral ovary superior to uterine fundus
In retroverted ovaries lateral and superior
Enlarge ed uterus ovaries more superior and laterally
Hysterectomy ovaries in midline superior to vaginal cuff
Or in high in pelvis or in curl de sac
TV if ovaries superiorly or extremely latterly can not be seen
Cumulus oophorus
As eccentrically located cyst like
1 mm internal mural protrusion
Mature follicle and ovulation
Crenulated
Scalloped follicles
Occasionally follicles decrease in size and develops a wall
Follicular cyst
Develops if fluid in non dominant follicles not reabsorbed
Like simple cyst
Dominant follicles disappear after ruptured at ovulation
Free fluid in the culled sac
Commonly seen in. Lute all phase after ovulation
Following ovulation in luteal phase
Mature corpus luteim
Develops and may be identified in US as small hypoechoic or isoechoic structure periphery within the ovary
May appear irregular with echo genie crenulated wall contain low level echoes
Less frequent appearance of corpus
RING OF FIRE
In Doppler around wall of the isoechoic corpus
That the same as ectopic pregnancy
Multiple small punctate
Echo genie foci commonly seen in normal ovary
Very small 1 2 mm
Periphery no shadowing
Multiple
Abnormal volum of the ovaries
22 ml in menstration mean 9;8 ml +- 5.8
In pst menopause more than 8 ml abnormal
If one side is twice of another
Majority of ovarian masses
Simple cysts benign
If in post menopause seen more than 5 cm with septation and solid echoes surgery recommended
Common cystic or complex ovarian mass
Follicular cyst
Capos luteum
Cystic teratoma
Para ovarian cyst
Hydrosalpinx
Endometrioma
Hemorrhagic cyst
Complex mass or cyst
Any simple cyst that hemorrhages as involuted برگشتن به حالت اولیه خودش
Reproductive age complex mass classic differential
Adnexal mass
Ectopic
Endometrioma
Endometriosis
PID
dermoid and other benign tumours
Cystadenoma
Granulosa cell Tumours or
Tubo ovarian abscess
Most common solid tumours of ovaries
Serous types
Cyst Adenoma
Cyst adeno carcinoma
Solid tumours
More complex the Tubo more more likely to be malignant
Especially with ascites
When solid mass found identify connections with uterus
To deferentiate ovarian lesion from pedunculated uterine fibroid
Color Doppler to see the vascular pedicle between uterus and mass
Common solid mass arising ovaries
Solid teratoma
Adenocarcinoma
Arrhenoblastoma
Fibroma
Dysgerminoma
Torsion
Doppler of the ovary
Suspected cystic lesion
In differentiating potential cyst from adjustment vascular iliac artery
Pulse Doppler for
Adnexal branch uterin artery
Ovarian artery
Intramural flow
To determine resistive index
Doppler of ovaries time
Normal men’s in first 10 days of cycle
To avoids confusion with normal changes in intraovarian blood flow because high diastolic flow occurs in luteal phase
Value for RI AND PI IN Doppler
RI > 0.4
PI > 1
Sign for malignancy
Intramural vessels
Low resistance flow
Absence of normal diastolic notch in DOPPLER
Abnormal waveform can be seen in
Inflammatory masses
Metabolically active masses ectopic pregnancy
corpus luteum cysts
RI is not the sensitive indicator of malignancy
Diastolic notch in early diastolic
Sign of benign disease
Functional ovarian cysts
Follicular
Corpus luteum
Hemorrhagic
Theca lutein cysts
Follicular cyst
When dominant follicles does not succeed in ovulating and remains active
Unilateral
Thin wallled translucent watery fluid 1- 8 cm
Disappear or rupture
Simple cyst
Corpus luteum cyst
From hemorrhage whitin mature corpus luteum that persisted
Filed with blood
1-10 cm
May accompany the intrauterine pregnancy
May mimic ectopic
Rupture
cyst type lesion internal echo
Increase color
2-hemorrhage cyst
Internal hemorrhage can occur in follicular cyst
Or corpus luteual cyst
Acute onset of the pelvic pain
Appearance:
Hemorrhagic cyst with Retracted blood clot showing reticular inner or cobweb or fishnet appearance
Indicating hemolysis of the blood
Diffuse low level echoes may be seen
In Endometriomas
Chocolate chips and ground glass
3- Theca lutein cyst
Large bilateral multiloculated cyst
With high level of bhcg
In 30% of trophoblastic molar enlarged uterus filled with grapelike clusters
Nausea vometing
In US, multilocular cyst in both ovaries
Ovarian hyper stimulation syndrome
Mild
Severe
Severe pelvic pain
Ascites
Abdominal distension
Pleural effusion
Ovaries more than 10 cm
Numerous large thin walled cyst
Ovaries no more in pelvic cavity and become abdomen organ
Polycystic ovarian syndrome
Include stein levanthal syndrome an endocrine disorder with chronic an ovulation
Bilaterally enlarge polycystic ovary
Clinical amenorrhea
Obesity
Hirsutism
Infertility
In US Multiple tiny cyst around periphery of ovary may be normal or enlarged ovary
Imbalance in FSH LH. Abnormal estrogen and progesterone characteristics finding in poly
Ovaries are rounded increase number of follicles
characteristics finding in polycystic
Imbalance in FSH LH. Abnormal estrogen and endrogen
Elevated LH / FSH ratio
Follow up polycystic patients
Unopposed esterogenic hyperplasia and endometrial carcinoma occurs in significant proportion
PCOS common cause of infertility and early pregnancy loss
Polycystic ovation appearance
Enlarge ovary with string of pearls enlarged follicles prominent follicles around peripheral ovary
Peritoneal inclusion cyst
When adhesion trap peritoneal fluid around ovaries
Resulting in large Adnexal mass
Pelvic pain pelvic mass
Para ovarian cyst
Simple
Wolfian duct remnant
Can bleed undergo torsion
In broad ligament
Asymptomatic
Simple cyst adjuscent to ovary
May completely fill the Adnexal region
Endometriosis
Endometrioma chocolate cyst
Ovarian torsion
3% of gynaecology operative emergencies
Partial or complete rotation of ovarian pedi ul on its axis
Enlarge edematose ovary more than 4 cm
Hypoechic mass
Free fluid in pelvic
Absent of blood flow to TOR sed ovary
Result in Edelman
Loss of arterial perfusion
Infarction of the ovary
Involves ovary and fallopian tube
Torsion of normal ovary usually in
In children and younger female with mobile Adnexa pre-existing ovarian cysts or mass
Or pregnancy
More often in the right side can mimic appendicitis
Abnormal ovaries suggest malignancy defined as
Enlarged echogenic ovaries
1) ovarian carcinoma
Absent of symptoms in early stage
Not detected until advanced
Having spread beyond capsule but still within pelvic stage ll
In to abdomen stage lll
Normal to slightly enlarge firm irregular ovaries to pelvic mass
Differentials
Endometriosis
Hemorrhagic ovarian cyst
Ovarian torsion
PID
Benign ovarian neoplasm
Increase age increase malignant
Less than 5 cm benign
More than 10 cm malignant
Strongest risk factor for ovarian carcinoma
Family history of ovarian and breast cancer
Other
Nulliparity
Infertility
Uninterrupted ovulation
Late menopause
Epithelial tumours
80 to 90% malignancy
65% to 75% ovarian neoplasm
Surface epithelial stromal tumours
Arise from surface epithelium cover ovary and underlying stroma
Most common types are
Serous and mucinus tumours
Serous epithelial tumours are common
Mucinous cystadenoma 20% to 25%
Benign ovarian
Mucinous cystadenocarcinoma 5%to 10% malignant ovarian neoplasm
Serous cystadenoma more common in malignancy cystadeno carcinoma
Second most common benign tumour of the ovary after dermoid 20% to 25% of all benign ovarian tumours
Serous cyst adeno carcinoma 60 to 80% ovarian carcinoma
Adenoma
Benign or low malignancy potential
Cyst add to term
Lesion cystic
Malignant form adenocarcinoma
Fibroma more than 50% of tumour fibrous
2-1 Mucinous cystadenoma
Type of epithelial tumour lined by Mucinous elements
20% to 25% benign ovarian neoplasm
Mucinous cystadenocarcinoma malignant
Cystadenocarcinoma marked sign
Septal nodularity
Large sized and septation
Mucynous cystadenomas
Benign large sized septation are characteristics in women 13 to 45
80% to 85% is benign
Very large 15-30 cm
Sonographic findings
• In 75% of patients with mucinous tumors, ultrasound examination shows simple or septate thin-walled multilocular cysts
• Contain internal echoes with compartments differing in echogenicity caused by mucoid material in dependent portions
Mucinus cyst-adenoma
• Unusually large (15 to 30 cm)
• Most common cystic tumor
• Usually, unilateral
• Cyst filled with sticky, gelatin-like material
• Multilocular cystic spaces
• Benign type more common than malignant
• Clinical: pressure, pain, increased abdominal girth
• Sonographic findings: simple or septate thin-walled multilocular cysts
Mucinous cystadenocarcinoma
• Most frequently occurs in women 40 to 70 years old
• Accounts for 5% to 10% of all primary malignant ovarian neoplasms
• 15% to 20% bilateral when malignant
Psedumixoma peritoneum
• 10% occur in menopausal women
• Can also become very large and more likely than benign form to rupture
• If tumor ruptures, associated with pseudomyxoma peritoneum
• Causes loculated ascites with mass effect
In us mucinous
Sonographic findings
• Malignant cysts tend to have thick, irregular walls and septations with papillary projections and echogenic material.
•Generally, have sonographic appearance similar to serous cystadenocarcinomas
Mucinous cystadenocarcinoma
• Bilateral
• May occur in menopausal women (10%)
• Large, likely to rupture-ascites
• Clinical: pelvic pressure; pain when ruptured
• Sonographic findings: ascites appears as hypochoic fluid with bright punctate echoes;
thick, irregular walls and septations
Serous cyst adenoma
• Second most common benign tumor of ovary (after dermoid cyst)
• Represents 20% to 25% of all benign ovarian neoplasms
• Is usually unilateral; 20% are bilateral
Serous cyst adenocarcinoma
G, H, and I are images in a single patient with a serous cystadenocarcinoma.
Extensive nodularity shows vascularity confirming the morphologic suspicion of a malignant mass.
There is high diastolic flow resulting in a low resistive index.
Serous cyst adenoma
Sonographic findings
• Usually, unilocular or multilocular with thin septations
• Smaller than mucinous cysts (up to 20 cm); borders irregular with loss of capsular definition
• Multilocular cysts contain small amount of solid tissue in chambers of varying size with occasional internal septum or mural nodules
Serous cyst adeno carcinoma
• External papillary mass adhesions and infection lead to bilateral involvement.
• Loss of capsular definition and tumor fixation;
calcifications
Peritoneal implants; ascites; metastases to omentum, lymph nodes, liver, and lungs
• Clinical: pelvic fullness, bloating
• Sonographic findings: cystic structure with septations and/or papillary projections; internal and external papillomas usually present
Germ cell tumours
• Account for 15% to 20% of ovarian neoplasms, with approximately 95% being benign cystic teratomas
• Besides teratomas, germ cell tumors include dysgerminoma, embryonal cell carcinoma, choriocarcinoma, and transdermal sinus tumor.
Associated with elevated AFP and hcg levels
• Often occur as mixed tumors with elements of two or three varieties of germ cell layers
• Associated with elevated alpha-fetoprotein
(AFP) and hCG levels
Teratoma mature benign form
Teratoma: Dermoid Tumors
• Size ranges from small to 40 cm
• Unilateral, round to oval mass
• Contains fatty, sebaceous material, hair, cartilage, bone, teeth
• Clinical: asymptomatic to abdominal pain, enlargement and pressure; pedunculated; subject to torsion
• Sonographic findings: cystic/complex/solid mass; echogenic components; acoustic
Dermoid plug
2) Cystic mass with very echogenic nodule along mural wall representing “dermoid plug”
TERATOMAS IN US
Sonography may demonstrate one of several
patterns:
1) Completely cystic mass
2) Cystic mass with very echogenic nodule along mural wall representing “dermoid plug”
3) Fat-fluid level
4) High-amplitude echoes with shadowing (e.g., teeth or bone)
5) Complex mass with internal septations
IMATURE TERATOMAS MALIGNANT FORM
• Immature teratomas uncommon; occur in girls and young women 10 to 20 years of age
• Rapidly growing, solid malignant tumors with many tiny cysts
• AFP elevated in 50% of patients
• Unilateral and small in size; may grow to larger dimension
The tip of the ice berg sign
Immature teratoma because of shadowing you cannot say how deep it is the posterior margins is not appreciated
Dermoid mesh
Hyper echo IVC lines corresponding hair in dermoid tumours TERATOMAS
small hyperechoic floating lines and dots
Dermoid plug or Rokitansky nodule
Hyperexhoic nodule situated near the wall of the cyst with posterior shadowing
Mobile spherules
Image (5).
A well-defined large complex adnexal mass lesion, with multiple large floating / mobile echogenic spherical structures (named mobile spherules) in benign cystic TERATOMAS
Benign cystic teratoma dermoid cyst appearance
Image (6).
A well-defined large cystic adnexal mass lesion, with fat-fluid level (non-dependent lower density hyperechoic fat floating over dependent higher density hypochoic fluid).
- most common ovarian neoplasms seen in pregnancy.
Dysgerminoma and serous cystadenoma are two
Dysgerminoma
Dysgerminoma
• Rare malignant germ cell tumor bilateral in 15% of
cases
• Mass constitutes 1% to 2% of primary ovarian
Dysgerminoma
• Entirely solid ovarian mass in woman <30 years of age usually dysgerminoma
Endodermal Sinus Tumor
• Endodermal sinus tumors rare rapidly growing tumors also called yolk sac tumors
• Usually occurs in women <20 years of age; is almost always unilateral
• Increased serum AFP may be seen.
Yolk sac tumor
Endodermal Sinus Tumor
Endodermal Sinus Tumor
• Endodermal sinus tumor has poor prognosis.
• Second most common malignant ovarian germ cell neoplasm after dysgerminoma
•Sonographic appearance similar to dysgerminoma
•Sonographic appearance similar to dysgerminoma
Endodermal Sinus Tumor
• Second most common malignant ovarian germ cell neoplasm after dysgerminoma
Endodermal Sinus Tumor
• Sex cord-stromal tumors
Stromal بستر
• Sex cord-stromal tumors typically solid adnexal masses that arise from sex cords of embryonic gonadal and/or ovarian stroma
• Includes granulosa cell tumor, thecoma, fibroma, and Sertoli-Leydig cell tumors (androblastoma)
• Accounts for 5% to 10% of all ovarian neoplasms and 2% of all ovarian malignancies
Fibroma and Thecoma
• Both fibroma and thecoma tumors arise from ovarian stroma;
are pathologically similar
• Tumors with abundance of thecal cells called thecomas, and those with abundance of fibrous tissue called fibromas
• Thecomas usually benign and unilateral, comprising 1% of all ovarian neoplasms;
70% occur in postmenopausal women
• Frequently show signs of estrogen production
70% occur in postmenopausal women
Fibroma and Thecoma
Fibroma
• Comprise 4% of ovarian neoplasms
• Rarely associated with estrogen production
• Clinical signs include lack of symptoms if tumor small
• If large, increasing pressure and pain apparent
• Ascites has been reported in up to 50% of patients with fibromas >5 cm in diameter
Ascites has been reported in up to 50% of patients
with fibromas >5 cm in diameter
•Meigs syndrome
Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and
pleural effusion that resolves after resection of the tumor.
Fibroma
• Associated ascites along with pleural effusion
• Referred to as Meigs syndrome; occurs in 1% to 3% of patients with fibroma
• Not specific; it can occur with other ovarian neoplasms as well
• Found in postmenopausal women
the majority of the benign tumors seen in Meigs syndrome.
Ovarian fibromas constitute the majority of the benign tumors seen in Meigs syndrome.
Granulosa Cell Tumor clinical
• Clinical symptoms of estrogen production may include precocious puberty or vaginal bleeding and full breasts.
• Pain, pressure, fullness may also be present.
• May twist on itself to cause torsion or rupture, leading to
Meigs syndrome
• Malignant transformation rare, but when it occurs, lesion spreads via lymphatics and bloodstream
Granulosa Cell Tumor
• Feminizing neoplasm composed of cells resembling graafian follicle
• Most common hormone-active estrogenic tumor of ovary
• More common after menopause (50%)
• Also seen in reproductive ages (45%) and in adolescence (5%)
• Most common hormone-active estrogenic tumor of ovary
Granulosa Cell Tumor
• More common after menopause (50%)
Granulosa Cell Tumor
Granulosa Cell Tumor
• Clinical symptoms of estrogen production may include
precocious puberty or vaginal bleeding and full breasts.
• Pain, pressure, fullness may also be present.
• Maystwist on itself to cause torsion or rupture, leading to
Meigs syndrome
• Malignant transformation rare, but when it occurs, lesion spreads via lymphatics and bloodstream
Granulosa Cell Tumor in US
Sonographic findings
• Variable appearance
• Mass without torsion
• Similar to endometrioma or cystadenoma, with low-level homogeneous echoes
• If torsion occurs, multilocular cyst containing blood or fluid
seen
• Solid masses may have echogenicity similar to uterine fibroids.
Metastatic Disease
Metastatic Disease
• Ovaries more involved with metastatic disease than any other pelvic organ
• Metastases often mimic appearance of advanced stage II to III primary ovarian cancer.
• Approximatelv 5% to 10% of ovarian nanni. metastatic in a
• Krukenberg tumors
• Krukenberg tumors “drop” metastases to ovaries from GI tract, primarily from stomach, but also from biliary tract, gallbladder, pancreas.
Sonographic findings
• Metastatic disease to ovaries
Sonographic findings
• Metastatic disease to ovaries frequently bilateral and often associated with ascites
• Metastases usually completely solid or solid with “moth-eaten” cystic pattern that occurs when nectotic
moth-eaten” cystic pattern
Metastases usually completely solid or solid with “moth-eaten” cystic pattern that occurs when nectotic
بید گاز زده
• Lymphoma
nvolving ovary usually diffuse and disseminated and frequently bilateral
• Sonographically, mass appears as solid hypochoic tumor similar to lymphoma elsewhere body.
Carcinoma of the Fallopian Tube
• Least common (<1%) of all gynecologic malignancies
• Adenocarcinoma most common histological finding
• Occurs most frequently in postmenopausal women with pain, vaginal bleeding, pelvic mass
• Usually involves distal end; may involve entire length of tube
• Least common (<1%) of all gynecologic malignancies
Carcinoma of the Fallopian Tube
Carcinoma of the Fallopian Tube most in
• Occurs most frequently in postmenopausal women with pain, vaginal bleeding, pelvic mass
Carcinoma of the Fallopian Tube in US
Sonographic findings
• Appears as sausage-shaped, complex mass, with cystic and solid components often with papillary projections
• Clinical and sonographic findings similar to those of ovarian carcinoma
• Appears as sausage-shaped, complex mass, with cystic and solid components often with papillary projections
Carcinoma of the Fallopian Tube in US
• The differential considerations of a solid-appearing adnexal mass include
pedunculated fibroid, dermoid, fibroma, the-coma, granulosa cell tumor, Brenner tumor ( a solid abnormal growth on the ovary most benign most often in women after menopause), and metastasis.
Tubo-ovarian abscess, ovarian torsion, hemorrhagic cysts, and ectopic pregnancy also may appear solid.
• Pulsed Doppler interrogation of the adnexal branch of the uterine artery, the ovarian artery, or intratumoral flow is performed to determine the resistive index or pulsatility index.
Theca-lutein cysts
are the largest of the functional cysts and appear as very large, bilateral, multiloculated cystic masses. They are associated with high levels of human chorionic gonadotropin and are seen most frequently in association with gestational trophoblastic disease.
Omental cysts tend to be higher in the abdomen, and urachal cysts are midline in the anterior abdominal wall above the bladder
Omental cysts
Germ cell tumors include
teratomas, dysgerminoma, embryonal cell carcinoma ( type of testicular cancer) ( , choriocarcinoma, and transdermal sinus tumor.
Common Cystic or Homogenous
Ovarian Masses
• Follicular cyst
• Corpus luteum cyst of pregnancy
• Cystic teratoma
• Paraovarian cyst
• Hydrosalpinx
• Endometrioma (low-level echoes)
• Hemorrhagic cyst
• Cystadenoma
• Dermoid cyst
• Tubo-ovarian abscess
• Ectopic pregnancy
• Granulosa cell tumor
Ovarian Remnant Syndrome
Ovarian Remnant Syndrome. Infrequently, a cystic mass may be seen in a patient who has a history of bilateral oopho-rectomy. This usually results in a technically difficult surgery (because of adhesions), in which a small amount of residual ovarian tissue has been unintentionally left behind. The residual ovarian tissue can become functional and produce cysts with a thin rim of ovarian tissue in the wall.
Fluid Collections in Adhesions
. Fluid collections in adhesions can create cystic structures of odd shapes throughout the abdomen. Omental cysts tend to be higher in the abdo-men, and urachal cysts are midline in the anterior abdominal wall peritoneum above the bladder. Any tumor may have cystic elements, and the sonographer should demonstrate if the tumor is a simple cyst or a complex mass.
benign Cysts in Fetuses and Adolescents.
Small simple cysts (1 to 7 mm) normally occur in fetuses and newborn girls because of stimulation by maternal hormones. In pre-menarchal girls, small follicles (less than 9 mm) are common.
Larger cysts also are seen in otherwise healthy premenarchal gis. These may be followed closely if they are regressing, as jong as the child’s growth and development appear normal.
Occasionally, ovarian cysts produce symptoms of precocious puberty in young girls. These may arise spontaneously or in association with other hormonal derangements.
Other epithelial tumors
Less common varieties of epithelial tumors are endometrioid, clear cell, Brenner (transitional cell), and undifferentiated carci-noma. Endometrioid tumors are nearly all malignant and are the second most common epithelial malignancy. Approximately 25% to 30% are bilateral and occur most frequently postmeno-pausal; peak age ranges from 50 to 60 years. Clear cell tumors are considered to be of müllerian duct origin and a variant of the endometrioid carcinoma. Clear cell tumors are nearly always malignant and are bilateral about 20% of the time. Peak age ranges from 50 to 70 years. Transitional cell tumor, also known as Brenner tumor, is uncommon. The Brenner tumor is found in 1.5% to 2.5% of patients; peak age ranges from 40 to 70 years. It is nearly always benign and 6% to 7% are bilateral; 30% are associated with cystic neoplasms in the ipsilateral ovary.
• Sonographic Findings. These types of epithelial tumors cannot be distinguished sonographically; however, they are more frequently found unilaterally. They are usually small and present as a nonspecific, complex, predominantly cystic mass. Occasionally the tumor may contain hemorrhage or necrosis. The Brenner tumors are hypochoic, solid masses that may contain calcifications in the outer wall. They are composed of dense fibrous stroma and appear similar to ovarian fibromas and thecomas.
Epithelial tumors
Serous and mucinous
Serous cystadenoma
Serous cystadenocarcinoma
Mucinous cystadenocarcinoma
Mucinous cystadenocarcinoma
Other epithelial tumors
Germ cell tumors
Teratoma
Immature and mature teratoma
Dysgerminoma
Endodermis sinus tumor
Stromal tumors
Fibroma
Thecoma
Granulosa
Sertoli leydig cell tumors
Arrhenoblastoma
Sertoli-Leydig Cell Tumor
Sertoli-Leydig cell tumors (also called androblastomas) are rare. They generally occur in women under 30 years and constitute less than 0.5% of ovarian neoplasms. Almost all are unilateral, and malignancy occurs in 10% to 20% of these tumors. Clinically, symptoms of virilization occur in about 30% of patients. Occasionally, these tumors may be associated with estrogen production.
Sonographic Findings. Sonographically, the tumor usually appears as a solid hypochoic mass.
Arrhenoblastoma
Arrhenoblastoma
Arrhenoblastoma is a masculinizing ovarian tumor that occurs in females 15 to 65 years of age, with a peak incidence at 25 to 45 years. Clinical features are the same as for other pelvic masses, with the addition of amenorrhea and infertility. This mass may undergo malignant transformation in 22% of patients.
• Sonographic Findings. The tumor is a solid mass with cystic components; it is lobulated and well encapsulated. In
Cyst Adenoma
- All of the following are solid tumors except:
A. Thecoma
B. Fibroma
C. Brenner’s tumor
D. Cystadenoma
E. Teratoma
B. Cystic and ovarian in origin
Most adnexal masses are:
A. Cystic, ovarian in origin, and malignant
B. Cystic and ovarian in origin
C. Ovarian in origin and malignant
D. Cystic and malignant
E. None of the above
Granulosa cell tumors may be discovered in patients
Benign and estrogenic.
Granulosa cell tumors may be discovered in patients of all ages, including children.
Smatiy are seen in posimenopausal parients. They are usually benign but do on malignant potential. These estrogenic hmors secrete estrogen, causing pander female characteristics thai present as precocious puberty in children and seas veginal bleding and breast dysplasia in ihe posimenopausal patient.
18. E. Leiomyoma.
€ 458. A 52-year-old female presents as postmenopausal for 5 years, G-4-PA. Her uterus is enlarged upon palpation and is irregular in contour. You suspect:
A. Endomet: ial cancer
B. Adenomyosis
C. Endometriosis
D. Hydatidiform mole
E. Leiomyoma
E
Arrhenoblastoma
- B. Arrhenoblastoma.
Arrhenoblaslomas are androgenic tumors that secrete lestosterone, causing secondary male characteristics. Female patients present with a masculine stature and male hair growth patterns on the face, abdomen, and upper thighs. After removal, female characteristics should return.
Sex cord germ cell stromal tumors
• Includes granulosa cell tumor, thecoma, fibroma, and Sertoli-Leydig cell tumors (androblastoma)
