Adnexal Pathology Ovarian Neoplasms Flashcards
____ cysts are the most common ovarian physiologic ovarian cysts
functional (benign)
what type of cysts are these?
Follicular Cysts
Corpus Luteum Cysts
Hemorrhagic Cysts
what other type of cysts are there?
functional (benign)
parovarian
explain follicular development
This is text for the following diagram starting with the
early primary follicle-left upper corner on diagram &
going clockwise
Following menses 4-5 primary follicles begin to
grow. Follicle growth produces low levels of
estrogen and minute amounts of progesterone.
High amounts of estrogen is produced by the
maturing follicles thus increasing blood estrogen
levels. High estrogen levels inhibit FSHRF thus
inhibiting secretion of FSH.
The Graafian follicle is the mature dominant follicle.
Normally, only one follicle dominates and the others
decrease. The Graafian follicle produces estrogen
and increases the endometrial lining to prepare for
implantation. It also secretes a small amount of
progesterone and the ovum undergoes meiosis. The
LH surge causes ovulation. The blue area is the
degenerating follicle
what are these?
describe them sonographically
Functional Cysts - Follicular Cysts (f)
US Findings
– Usually multiple
– Thin-walled
– Unilocular
– Anechoic
(Green oval outlines theovary)
where do follicles grow? what is the f? what phase of growth is this?
Early Follicular Phase
Note all the follicles growing around the
outside / periphery of the ovary. The left
image with the ‘F’ has one that seems to
becoming dominant
what phase is this? what’s happening?
Late Follicular Phase
Dominant Follicle (note the small
calipers) will become the Graafian follicle
This follicle is getting the ovum inside ready to be
fertilized
what is the us criteria of a simple cyst?
aka benign functional cyst
Anechoic
Smooth, thin walls
Posterior enhancement (yellow lines)
The ovarian outline is green
what functional cyst has teh following clinical findings?
– Asymptomatic
– Pressure symptoms if the cyst becomes too large
Ruptured Dominant Follicle
– No longer meets simple cyst US criteria. Note the inside of the follicle does not have the classic ‘simple cyst’ appearance. The walls have collapsed (arrows) and so it is no longer a simple follicle
___________ are functional preparing for pregnancy note
the wall thickness is thicker but not as
thick as with pregnancy
Corpus luteum during a pregnancy can
measure up to 5 cm and is associated
with maintaining the1st 10 weeks of
pregnancy
– These are generally resolved by 16 weeks
GA
Functional Cysts
Corpus Luteum Cysts
what is this? describe it.
Functional Cysts
Corpus Luteum Cysts
US Findings
– Sonolucent to hypoechoic compared to ovary
– Smooth-walled
– Posterior enhancement
– Free fluid in cul-de-sac if ruptured
_____cysts occur in the initial 2-3
weeks of the cycle
________ cysts occur in the final 1-2
weeks of the cycle
Graafian follicle
Corpus luteal
Majority of functional cysts will undergo
spontaneous regression, a 6-week US
follow-up (F/U) is warranted to make sure
a suspicious cystic lesion is not
pathologic
What clinical findings are associated with the Benign Adnexal Cysts Hemorrhagic Cysts (Ovarian cysts are
commonly complicated by hemorrhage)
Clinical Findings
Pelvic pain, tenderness, may delay menstruation
Mimics ectopic pregnancy
Pain can be severe especially if cyst
– Ruptures
– Or there is torsion of the ovary with the cyst
what is the ddx of hemorrhagic cyst (benign adnexal cyst)
US Findings:
Complex mass, depending on age of
hemorrhage (any simple cyst that hemorrhages
may appear as a complex mass)
Posterior enhancement
Differential diagnosis
– PID
– Ectopic pregnancy
– Cystic teratoma or dermoid
– Use patient symptoms to help the order of your differential list.
what is this?
Acute
– Usually hyperechoic
– May mimic a solid mass
(top images – note follicles
in ovary enhancing too)
– Will have posterior
enhancement (yellow area
Hemorrhagic Cyst
Vary on amount and age
of hemorrhage
what is this?
what do you need to be aware of?
Hemorrhagic Cyst
US Example of ‘Ring of Fire’
No vascular flow within the cyst
F/U US to distinguish between an endometrioma
& a corpus luteum with hemorrhage
If the corpus luteum is examined shortly
after ovulation, a ring of vessels will be
seen called a ‘ring of fire’ which disappears
after the corpus luteum hemorrhage has
been there for a while
A hemorrhagic cyst may be surrounded by
increased vascularity, but not have flow
within the cyst
Ectopic pregnancy can have ‘ring of fire’ too
which is why it is a differential diagnosis
___ Accounts for approx. 10% of adnexal masses
Cyst involving the broad ligament
May have arisen from embryonic ducts
» Mesonephric/Wolffian
» Mesothelial
» Paramesonephric
» Hydatid of Morgagni
Paraovarian Cysts
(Benign Adnexal Cysts)
what is this?
what abou tits us findings?
Note its’ location it is separate from ovary
Typically asymptomatic
On US may be unilocular or multilocular *
terms you’ll need to know
– May resemble serous cystadenomas
Thin walled without ovarian tissue around cyst
– Cyst size does NOT change with menstrual cycle
– May be difficult to distinguish from ovarian cysts
what are teh most common clinical findings of a benign adnexal cysts?
Ovarian cysts are usually asymptomatic
They often are an incidental finding during
ultrasounds performed for other reason
Lower abdominal pain is the most common symptom
reported
Pain can be sharp, intermittent, sudden in onset, and
severe
A sudden onset of abdominal pain may suggest cyst
rupture but more serious etiologies must be
considered, including adnexal torsion, perforated
viscus, or ectopic pregnancy
It is abnormal to find a cyst in a
postmenopausal woman who is
NOT on hormone replacement therapy
Finding a palpable mass or cyst in
these women should prompt a
thorough search for the type of
ovarian neoplasm
Adnexal Cysts
Postmenopausal women
what types of tissue do the ovaries contain?
- Epithelial-Stromal cells Covers the ovary
- Germ cells Produce the ova that are formed on
the inside of the ovary - Sex-Cord Stromal cells. These produce most of the estrogen & progesterone
what are the 3 main types of ovarian tumors
- Epithelial-Stromal tumors start from the cells that cover the outer surface of the ovary. Most ovarian cancers start in this epithelial covering
- Germ Cell tumors start from the cells
that produce the ova - Sex-Cord Stromal tumors start from connective tissue cells that hold the ovary together and produce the female
hormones estrogen and progesterone
what are the 3 sub-groups for the epithelial ovarian tumors?
Benign epithelial tumors
Tumors of low malignant potential
Epithelial ovarian cancers
______ tumors are
Most common ovarian tumor type at 65-75%
what are the common varieties, less common?
epithelial-stromal tumors
Common Varieties
Serous Cystadenoma - Serous Cystadenocarcinoma
Mucinous Cystadenoma - Mucinous Cystadenocarcinoma
Less Common Varieties
Brenner Tumor / Transitional Cell Tumor
Endometrioid Carcinoma
Clear Cell Carcinoma
Serous Cystadenoma is the
__________ benign ovarian tumor
______are unilateral
Typical patient is _____years old
2nd most common (following dermoid)
70%
20-50
____ is Usually unilocular
Thin-walled, fluid filled (serous fluid)
May grow up to 20 cm
May contain low-level echoes due to debris
May have small mural nodules typically less
than mucinous cystadenoma
Anechoic
Posterior enhancement
Some may be multilocular
Septations are typically thin
Amount of septations varies
Serous Cystadenoma
what are typical findings w/ mucinous cystadenoma?
Typical patient is 20-50 years old, (13 –
45 years per Hagen-Ansert)
Benign cyst with sticky, gelatinous mucin contents
Multilocular daughter cells 10% malignant (usually after
menopause)
mucinous cystadenoma us findings:
how large can the become?
Usually unilateral
More septations than serouscystadenoma
Fluid filled mucin seen within mass
May see fluid-fluid levels of fluid-debris
separated by septa within mass
Can become extremely large 15-30 cm
what is a brenner tumor aka
what is it?
is it benign or malignant?
Transitional Cell Tumor
Relatively uncommon neoplasm
Usually appears post-menopause
Usually unilateral
Well-encapsulated solid lesion
can be either.
____ is the 2nd Most common ovarian tumor type
at 15-20%
varieties incl:
Teratoma – Benign
» Mature AKA Dermoid – Malignant
» Immature – Dysgerminoma (Malignant)
Germ Cell Tumors
_____ is Associated with increased
Alpha-fetoprotein (AFP)
Human chorionic gonadotropin (hCG)
Typically unilateral
germ cell tumors
what is a benign mature teratoma aka
is it a common ovarian neoplasm?
is it uni or bi -lateral?
dermoid
Most common ovarian neoplasm
Can be bilateral in approximately 15%
Typical patient is of childbearing age
Size variable
Can cause pain if hemorrhage cause
undergoes torsion
what do dermoid masses contain? what is it?
what do they contain?
Benign Mature Teratoma. Mass contains variety of:
Ectoderm, Mesoderm, Endoderm
A bizarre tumor in the ovary that typically contains a variety of tissues including
hair, teeth, bone, fat, thyroid, etc.
describe a dermoid on us?
what can it be confused with?
Range of appearances depends on the
amount and type of contents within the mass
– This photo shows the tumor turned inside out
bowel.
Example: This US Shows a highly echogenic intraovarian mass with no normal ovarian tissue
what is this?
Benign Mature Teratoma AKA Dermoid
Range of Appearances
– Highly echogenic areas
– Uniform echoes
Example: The small, highly echogenic, (hyperechoic to the
ovary) mass in an otherwise normal ovary
what is this?
17 year-old female with h/o
left adnexal pain for 8 months
(Selected trans-abdominal and trans-vaginal ultrasound images demonstrate a complex cystic/solid mass with the solid component predominating
A dermoid cyst was suggested in the differential diagnosis. Surgical excision and subsequent histology confirmed the diagnosis of mature cystic teratoma/dermoid cyst with ectodermal, mesodermal and endodermal derivatives
On gross examination, sebaceous material admixed with hair was seen. This may account for the “frond like” pattern seen on the transvaginal images. It is interesting to note the increased information about the internal architecture/anatomy of the mass when comparing the trans-abdominal images above with the trans-vaginal images)
dermoid.
below is known as “tip of the iceberg sign”
Example: Transverse TA image showing the uterus (U). In the right adnexal region there is a highly echogenic and attenuating mass (arrows). This is the classic ‘tip of the iceberg’ sign where the ‘top of the mass’ is seen but the mass attenuates the sound beam hiding the rest of the mass (think about the Titanic ship – the sailor saw the ‘tip of the iceberg’ but under the water the iceberg was huge and couldn’t be seen and cut a hole in the ship sinking it)
what has
Elevated AFP is ½ of patients
Typically occurs in 10 to 20 year old females
Rapid growth rate
Rare, yet ____________
Solid malignant tumor with areas of necrosis & hemorrhage seen as multiple small cysts on US
Malignant Immature Teratoma
Rare yet They are the most common
malignant germ cell ovarian carcinoma
Malignant solid tumor mostly occur in
females under 30 years of age
what is this?
dysgerminoma - solid mass, may or may not have cystic areas w/i due to hemorrhage and/or necrosis
Example: Transverse TA US in young woman shows a large, solid pelvic mass (M) adjacent to the uterus (U)
Note: The most common explanation for a solid
adnexa mass is a pedunculated uterine fibroid so it
is important to find the organ or origin for the mass
Differential most common to least common, then
add clinical findings and rearrange list.
These types of tumors tend to be
functioning and, by producing estrogens
or androgens, may have dramatic clinical presentations
Vaginal bleeding in postmenopausal women
& pre-puberty girls (breast development in young girls)
If male hormones are produced then facial & body hair may occur
Typically solid adnexal masses
Sex Cord-Stromal Tumors
what type of sex-cird stromal tumors are there?
what is the incidence
Incidence is 5-10% per Rumack
Granulosa Cell Tumor (Low Grade cancer)
Thecoma AKA Theca (Benign)
Sertoli-Leydig Cell Tumors (Low Grade
cancer) - Arrhenoblastomas, Androblastomas
Fibroma (Benign tumor that DOESN’T function)
what type of tumor is a feminizing neoplasm composed of the granulosa cells of the Graafian follicle
It is the most common of the _____ tumors of the ovaries
Estrogen is produced by these functioning tumor
Age determines clinical signs
granulosa cell tumor
hormonal
If the patient is:
Pre-menarche – Causes pseudo precocious puberty
Of reproductive age – Metrorrhagia
Post-menopausal – Abnormal uterine bleeding
they may have…
Granulosa Cell Tumor
what Benign solid functioning ovarian, rarely malignant
Typically occurs in older women with the mean age at 59
FYI 84% occur after menopause
60% have abnormal bleeding
20% have endometrial carcinoma
Thecoma / Theca Cell
what tumor is AKA Arrhenoblastomas and Androblasomas
Sertoli-Leydig Cell Tumors
describe a sertoli-leydig cell tumor (AKA Arrhenoblastomas, Androblasomas) and its
clinical findings
us findings
Solid, uncommon group of tumors
Hormonally active – producing / secreting androgens
(mainly testosterone) causing virilization
Clinical Findings
Associated with amenorrhea & infertility
May become malignant
US Findings
Unilateral
Solid tumor with cystic
components
Well encapsulated
Size can vary
what Benign, non-functioning solid lesion
90% are unilateral
is Associated with Meigs’ syndrome?
fibroma
what are the 4 characteristics meigs’ syndrome?
what type of tumor is it associated with?
Has 4 Characteristics
Ovarian mass (solid)
Ascites
Pleural effusion
Resolves following surgery
fibroma
what is this? describe it.
US Findings
Solid ovarian mass
Hypoechoic
Little to no throughtransmission
Similar to leiomyoma however it is NOT
connected to the uterus
what blood test is available to test for women at high risk of ovarian cancer?
“For women at high risk of ovarian cancer or who
have symptoms of ovarian cancer, transvaginal
sonography & CA-125 blood test, in addition to the
pelvic exam may be able to detect the disease.”
quote American Cancer Society
2010 Estimates from American Cancer Society
“New cases ____
Deaths per year ____
5 year relative survival rate for localized stage: 93%
5 year relative survival rate for all stages combined: 46%
10 year relative survival rate for ovarian cancer
patients is 38%”
21,880
13,850
“This is a cancer that mainly develops in older
women. Around two-thirds of women are 55 or
older. It is slightly more common in white women
than African-American women.” quote American
Cancer Society
______ carcinoma – resembles
low-grade transitional cell carcinoma of urinary
bladder. Newly described but patients typically present with advanced disease and have a poor prognosis.
Transitional cell (Brenner)
ovarian carcinoma
____ is the Most common malignant tumor of the ovary
Majority of ovarian cancers are serous cystadenocarcinomas (85 to 90% per cancer.org)
Occurs mostly from age 40 – 60 years, 50 - 70 years per HA and is Rare under age 35
Serous Cystadenocarcinoma
what are these US Findings associated with?
Predominately cystic with variable thick walls with solid
components inside
Usually multilocular 25 - 30% bilateral at time of
diagnosis
Ascites if metastases has occurred
Serous Cystadenocarcinoma
describe these doppler findings associated with Serous Cystadenocarcinoma
Doppler Findings
Extensive nodularity with vascularity confirms the morphologic suspicion of a malignant mass
There is high diastolic flow, low RI
what is this? how can you tell?
Mucinous Cystadenocarcinoma
US Findings
Large cystic multiloculated
Solid masses hemorrhage
and necrosis are commonly present
The image demonstrates septal nodularity (arrows)
which raises the suspicion of malignancy
This 48-year-old female (G4 P2 Ab2)
who presented with an enlarging abdominal girth over the last six months as her only complaint
At her annual exam, a pelvic mass was discovered
what is it?
Mucinous Cystadenocarcinoma
At surgery a 22 pound mass was removed
The histological diagnosis was low grade
mucinous cystadenocarcinoma
what are the 4 stages of ovarian carcinoma?
Stage I. Growth limited to ovaries
Stage II. Extension of neoplasm into the pelvis
Stage III Disease extension to abdominal cavity
Stage IV. Distant metastatic disease
what is the incidence of metastatic tumors?
where do primary ones occur?
5-10%
Uterus
Stomach
Colon
Breast
Lymphoma
____ is teh Metastatic spread from carcinoma of
the G.I. tract commonly spreads to
the ovary
Krukenberg’s Tumor
what is this? describe it.
Krukenberg’s Tumor
US Findings
Bilateral ovarian masses
Can be completely solid or solid with
‘moth-eaten’ cystic pattern
Associated ascites
