Chapter 42: Pathology of Ovaries Flashcards
Where are the ovaries found following a hysterectomy?
medially, directly superior to the vaginal cuff
Where are ovaries located when difficult to see transvaginally?
extremely laterally or superiorly
The cumulous oophorus may be detected as
cystlike, 1mm internal protrusion
When will a follicular cyst develop?
if the fluid In the nondominant follicles is not reabsorbed
When does the dominant follicle usually disappear?
immediately after rupture with ovulation
How does a corpus luteum appear?
irregular and contains low echoes
T/F: normal small, punctate, echogenic foci are found in the ovary
true, they are nonshadowing and can be multiple
T/F: ovaries synthesize androgens and convert them to estrogens
True, at the same time of ovulation
The majority of ovarian masses are
simple cysts (benign)
In premenopausal women, ovarian simple cysts are usually
functional
What are the differential considerations of simple adnexal cysts?
- functional cyst
- paraovarian cyst
- cystadenoma
- cystic teratoma
- endometrioma
- rarely tubo-ovarian abscess
What kind of cysts in postmenopausal women can be fixed with surgery?
greater than 5cm and for those containing internal septations and/or solid nodules
In patients of reproductive age, the classic differential considerations of a complex adnexal mass are:
- ectopic pregnancy
- endometriosis
- PID
The differential considerations of a solid-appearing adnexal mass include?
- pedunculated fibroid
- dermoid
- fibroma
- thecoma
- granulosa cell tumor
- Brenner tumor
What may appear to be a solid mass in the adnexa?
- tubo-ovarian abscess
- ovarian torsion
- hemorrhagic cysts
- ectopic pregnancy
Patients with normal menstrual cycles are best scanned for Doppler studies in the first ___ days of the cycle to avoid confusion with normal changes in the luteal phase
10
What is a normal RI in a nonfunctioning ovary?
greater than 0.4, or greater than 1
What Doppler signs are worrisome for malignancy in the ovary?
- intratumoral vessels
- low-resistance flow-absence of normal diastolic notch in waveform
Whats the most significant problem with RI ?
not a sensitive indicator of malignancy
What are the 4 types of functional cysts?
- follicular
- corpus luteum
- hemorrhagic
- theca-lutein
What is sometimes given to suppress an ovarian cyst?
hormonal therapy
Most ovarian cysts measure less than ____ cm and regress during the subsequent menstrual cycle
5
A follow-up U/S in ___ weeks is usually scheduled to document a change in ovarian cyst size
6
When do follicular cysts form?
when a mature follicle fails to ovulate or involute
Describe a follicular cyst
- usually unilateral
- asymptomatic
- <2cm
- can be as large as 20cm
Corpus luteum cysts result from what
failure of absorption or from excess bleeding into the corpus luteum
Describe corpus luteum cysts:
- usually <4cm
- unilateral
- prone to hemorrhage and rupture
- usually resolves by 16 weeks with pregnancy
Internal hemorrhage may occur in _____ cysts, or more commonly in _____ cysts
follicular, corpus luteal
How does an acute hemorrhagic cyst appear sonographically?
hyperechoic and may mimic a solid mass..usually has a smooth posterior wall and show post. enhancement
After time how does a hemorrhagic cyst appear ?
internal pattern becomes more complex, the clotted blood becomes more echogenic and may show a fluid level
What are the largest functional cysts?
theca-lutein cysts
How do theca-lutein cysts appear?
very large, bilateral, multiloculated cystic masses
What are theca-lutein cysts associated with?
high levels of hCG, and seen most frequently in association with gestational trophoblastic desease
What is ovarian hyperstimulation syndrome?
a frequent iatrogenic complication of ovulation induction, can result in mild-sever forms
What can occur in severe cases of ovarian hyperstimulation syndrome?
severe pelvic pain, abdominal distention, notably enlarge ovaries (>10cm)
What is PCOS?
an endocrine disorder associated with chronic anovulation
PCOS includes what syndrome?
Stein-Leventhal syndrome
What is seen with Stein-Leventhal syndrome?
- infertility
- oligomenorrhea
- hirsuitism
- obesity
WHEN does PCOS typically occur?
late teens and twenties
Clinical signs of PCOS:
- amenorrhea
- obesity
- infertility
- hirsutism
- early pregnancy loss
Son findings of PCOS:
- multiple tiny cysts around periphery of ovary
- can be normal sized or enlarged
What is ovarian remnant syndrome?
When a cystic mass is seen in the adnexa after an oophorectomy..typically after technically difficult surgery when not all ovarian tissue is removed. This tissue becomes functional and produces cysts with a thin rim of ovarian tissue in the wall
Describe peritoneal inclusion cysts:
lined with mesothelial cells and are formed when adhesions trap peritoneal fluid around the ovaries, resulting in large adnexal masses..sonographically they appear as multiloculated cystic adnexal masses
What accounts for 10% of adnexal masses?
paraovarian cysts
Where do paraovarian cysts arise from?
the broad ligament and usually are of mesothelial or para mesonephric origin
What age is most common for paraovarian cysts?
30-40
When can a specific diagnosis of paraovarian cyst be made?
only by demonstrating a normal ipsilaterl ovary close to, but separate from, the cyst..may contain small nodular areas and have septations
Where are omental cysts found?
higher in the abdomen
Where are urachal cysts found?
midline in the anterior abdominal wall
In premenarchal girls, small follicles of what size are common?
less than 9mm
Small simple cysts of postmenopausal ovaries are how common?
15% of time, and commonly change in size and dissapear
Where can endometriosis be found?
- ovary
- fallopian tube
- broad ligament
- external surface of uterus
- scattered over peritoneum
- cul-de-sac
- bladder
What does the localized form of endometriosis consist of’?
discrete mass(endometrioma/chocolate cyst) that can be found in multiple sites
T/F: endometriomas are typically symptomatic?
false, they are asymptomatic
Sonographic appearance of endometrioma?
well-defined, unilocular of multilocular, predominantly cystic mass containing diffuse homogenous, low-level internal echoes
With ovarian torsion, what is often found in the pelvis?
free fluid
What accounts for 3% of gynecologic operative emergencies?
ovarian torsion
Ovarian torsion often involves what?
fallopian tube
Clinical findings of ovarian torsion:
- acute severe unilateral pain
- fever
- nausea
- vomiting
- palp mass felt 50% of time
The right ovary is __ times more likely to torse than the left?
3
Describe ovarian torsion sonographically?
- typically enlarged ovary
- heterogenous in appearance(edema, hemorrhage, necrosis)
- may vary in size
A combination of what three things leads to ovarian carcinoma detection
- physical exam
- lab
- imaging
What is the fourth leading cause of cancer death?
ovarian cancer
What is the leading cause of death from gynecologic malignancy in the US? What %?
ovarian carcinoma, 25%
_____% of ovarian malignancies occur in women between 40-60 years of age
60%
About ____% of ovarian cancers involve women over 60, with risk increasing with age
80%
At the time of initial detection, 50% of women present with stage __ of ovarian cancer
stage 3
What blood chemistry test MAY be helpful in detecting ovarian cancer?
CA 125
Ovarian cancer most commonly presents as _____, but can also appear as what?
predominantly cystic;
complex, cystic or solid mass
Differential diagnoses of ovarian carcinoma Include:
- endometriosis
- hemorrhagic cyst
- ovarian torsion
- PID
- benign ovarian neoplasms
Masses less than ___ cm in their longest axis are much more likely to be benign, whereas masses larger than ____ cm are much more likely to be malignant
5; 10
Increasing age correlates with ______ incidence of ovarian malignancy?
increased
What cancers increase risk of ovarian cancer?
breast and colon…because of genetic mutations in the BRCA1 and BRCA2 genes
What is the strongest risk factor of ovarian cancer?
family history of ovary cancer
Risk factors of ovarian cancer include (6):
- family history
- increasing age
- nulliparity
- infertility
- uninterrupted ovulation
- late menopause
Clinical symptoms of ovarian cancer include (6):
- vague abdominal pain
- swelling
- indigestion
- frequent urination
- constipation
- weight change (ascites)
Describe Stage 1 of ovarian cancer?
limited to ovary
Describe Stage 2 of ovarian cancer?
limited to pelvis
Describe Stage 3 of ovarian cancer?
limited to abdomen-intraabdominal extension outside pelvis/retroperitoneal nodes/extension to small bowel/omentum
Describe Stage 4 of ovarian cancer?
hematogenous disease (liver parenchyma)/ spread beyond abdomen
How does ovarian cancer appear sonographically?
- presents with adnexal mass
- lesions with irregular walls
- thick , irregular septations
- mural nodules and
- solid echogenic elements
What are surface epithelial-stromal tumors?
gynecologic tumors that arise from the surface epithelium and cover the ovary and the underlying stroma
What are the most common of all ovarian neoplasms and malignancies?
surface epithelial-stromal tumors
Epithelial tumors account for ___% of all ovarian neoplasms and ____% of all ovarian malignancies
65-75%
80-90%
Epithelial tumors can be divided into 5 categories:
- serous
- mucinous
- endometroid
- clear cell
- transitional cell (Brenner)
What is the most common kind of epithelial tumor?
serous tumor, accounting for 30% of all ovarian neoplasms
Mucinous tumors account for ___-___% of ovarian neoplasms
20-25%
The benign or low-malignancy potential form of epithelial tumors is
adenoma
The malignant form of epithelial tumors is termed
adenocarcinoma
T/F: Serous and mucinous tumors vary greatly In size, and may be found to fill the pelvis and extend into the abdomen?
True
In general, are the serous tumors bigger or smaller than mucinous tumors?
smaller
What is pseudomyxoma peritonei*?
penetration or rupture of the tumor capsule of an epithelial tumor may lead to intraperitoneal spread of mucin-secreting cells that fill the peritoneal cavity with a gelatinous material
Pseudomyxoma peritonei may be sonographically similar to what?
ascites or it may contain multiple septations in the fluid that fills much of the pelvis and abdomen
Describe mucinous cystadenoma
- unusually large (can be 15-30cm)
- -most common cystic tumor
- usually unilateral
- cyst filled with sticky, gelatin-like substance
- multilocular cystic space
What is the most common cystic tumor of the ovaries?
mucinous cystadenoma
What are the clinical findings of mucinous cystadenoma?
- pressure
- pain
- increased abdominal girth
What are the sonographic findings of mucinous cystadenoma?
simple or septate thin-walled multilocular cysts
Mucinous cystadenocarcinomas are ___% bilateral when malignant?
15-20%
Mucinous cystadenocarcinomas most frequently occur in women of what age range?
40-70 years
T/F: mucinous cystadenocarcinomas are likely to rupture and cause ascites?
true
What are clinical indications of mucinous cystadenocarcinomas?
pelvic pressure and pain when ruptured
What are sonographic findings of mucinous cystadenocarcinomas?
ascites with bright punctate echoes, thick, irregular walls and septations
What is the second most common benign tumor of the ovary?
serous cystadenoma
Describe serous cystadenomas
- unilateral
- smaller than mucinous cysts
- unilocular or multilocular cysts with septations
Clinical findings of serous cystadenomas
- pelvic pressure
- bloating
Sonographic finding of serous cystadenomas are what?
multilocular cyst that may or may not have a nodule
What are clinical findings of serous cystadenocarcinoma?
fullness and bloating
What are sonographic findings of serous cystadenocarcinoma?
multilocular cysts containing chambers of varying size with septated, internal papillary projections…solid elements or bilateral tumors suggest malignancy
What are endometrioids?
epithelial ovarian tumors
The peak age range of endometrioid tumors is what?
50-60 years
Endometrioid tumors are often associated with what?
endometrial adenocarcinoma
T/F: nearly all endometrioids are malignant?
true
___%-_____% of endometrioids are bilateral
25-30%
What are sonographic findings of endometrioids?
- cystic masses that contain papillary projections
- occasionally appear predominantly solid with areas of hemorrhage or necrosis
Clear cell tumors are of what origin?
mullerian duct, and are a variant of endometrioid carcinoma
Clear cell tumors are nearly always _____ and are bilateral about ___% of the time
malignant, 20% of time
What is the peak age range of clear cell tumors?
50-70 years
Brenner tumors are most often
benign
Sonographic findings of Brenner tumors:
- unilateral and small, typically less than 1-2cm
- although solid they may be hypoechoic with no posterior acoustic enhancement
- multiple calcifications may be present
Brenner tumor AKA
transitional cell tumors
How uncommon are Brenner/ Transitional Cell tumors?
2% of ovarian neoplasms
What is the age range of Brenner tumors?
40-70
T/F: Brenner tumors are symptomatic?
false, usually an incidental finding and always benign
Germ cell tumors are derived from what?
primitive germ cells of the embryonic gonad
Germ cell tumors account for __-__% of ovarian neoplasms, with approx. ___% being benign cystic teratomas
15-20%
95%
Germ cell tumors include what 5 types?
- teratomas
- dysgerminoma
- embryonal cell carcinoma
- choriocarcinoma
- transdermal sinus tumor (rare, occurring in adolescents)
What is the most common benign ovarian neoplasm (20%)?
cystic teratoma/ dermoid
Dermoids/cystic teratomas occur most frequently when?
reproductive years
What are the three layers of dermoids?
- ectoderm
- mesoderm
- endoderm
What do dermoids/cystic teratomas consist of?
- fatty sebaceous material
- hair
- cartilage
- bone’
- teeth
Clinical findings of dermoid tumors?
- asymptomatic
- abdominal pain
- enlargement and pressure
- pedunculated
- subject to torsion
Sonographic findings of dermoid tumors
- completely cystic
- cystic with echogenic mural nodule (dermoid plug)
- fat/fluid level
- high amplitude echoes with shadowing or complex mass with internal septations
Echogenic dermoids may be confused with
bowel
What is the most common ovarian malignancy occurring in childhood?
dysgerminoma
What is dysgerminoma?
rare malignant germ cell tumor that is bilateral in 15% of cases
An entirely solid ovarian mass in a woman less than 30 is usually
dysgerminoma
What are the two most common ovarian neoplasms seen in pregnancy?
- dysgerminoma
- serous cystadenoma
Children with dysgerminomas present with
precocious puberty and an elevation in serum hCG levels
*What is the tumor marker used for dysgerminoma?
an elevation in serum lactate dehydrogenase
What is the testicular equivalent to the dysgerminoma?
seminoma
How do dysgerminomas appear sonographically?
hyperechoic solid mass with areas of hemorrhage and necrosis on US, may show speckle pattern of calcifications
Endodermal sinus tumor AKA
yolk sac tumor
Describe endodermal sinus tumors
- rare
- rapidly growing
- unilateral
- women under 20
- increased serum AFP may be seen
- poor prognosis
What is the second most common malignant ovarian germ cell neoplasm?
endodermal sinus tumor AKA yolk sac tumor
What are sex cord-stromal tumors?
solid adnexal masses that arise from the sex cords of the embryonic gonadal and/or ovarian stroma
What are included in sex cord-stromal tumors? (4)
- granulosa cell tumors
- thecoma
- fibroma
- sertoli-leydig tumors
A granulosa is a feminizing neoplasm composed of what?
cells resembling a graafian follicle
What is the most common hormone-active estrogenic tumor of the ovary but is rarely found?
granulosa
What are the most common stromal tumors?
- thecomas
- fibromas
Describe thecomas and fibromas appearance and who they are found in
-benign solid hypoechoic adnexal masses occurring in middle aged women
Both thecomas and fibromas arise from
ovarian stromas
What are thecomas?
tumors with an abundance of thecal cells
Describe thecomas
- usually benign
- unilateral
- show signs of estrogen production
What are fibromas?
stromal tumors with an abundance of fibrous tissue
Fibromas are rarely associated with
estrogen production
Ascites has been reported in up to ___% of patients with fibromas larger than 5 cm
50%
What is Meigs syndrome?
associated ascites along with pleural effusion with ovarian mass … occurs in 1-3% of women with fibroma, but can occur with other neoplasms as well
T/F: Sertoli-Leydig tumors are rare
true
Sertoli-Leydig tumors generally occur in women of what age
under 30
Almost all sertoli-leydig tumors are
unilateral, with malignancy occurring in 10-20%
What is Sertoli-Leydig tumor?
sex-cord stromal ovarian lesions derived from testicular cell types, contain cells with chromosomal abnormalities and often produce testosterone
Sertoli-Leydig tumors result in virilization of how many patients?
1/3
What are symptoms of virilization?
- loss of secondary sex characteristics
- acne
- male pattern baldness
- deepening of the voice
- clitoral enlargement
- potential menstrual disorders or abdominal swelling
What are lab findings of Sertoli-Leydig tumors?
abnormal quantities of circulating hormones, particularly testosterone
What are sonographic findings of Sertoli-Leydig tumors?
- typically measure 5-15cm
- smaller tumors usually appear solid with an echo texture similar to fibroids
- larger tumors are often multiloculated with cystic components
- generally the larger the tumor the more likely a malignancy
What is arrhenoblastoma?
masculinizing ovarian tumor that occurs in females 15-65 years
What are clinical findings for arrhenoblastoma?
same as for other pelvic masses with the addition of amenorrhea and infertility
What are the sonographic findings of arrehnoblastoma
solid mass with cystic components, lobulated and well encapsulated
______ are more involved with metastatic desease than any other pelvic organ and often mimic the appearance of advanced stage 2 to 3 primary ovarian cancer
ovaries
Approximatley __% of ovarian neoplasms are metastatic in origin
5-10%
Where can ovarian metastatic disease come from?
breast, upper gi tract, other pelvic organs by direct extension or lymphatic spread
Metastatic disease to ovaries is frequently ____ and associated with _____
bilateral, ascites
How does mets appear sonographically?
usually completely solid or solid with a moth eaten cystic pattern that occurs when they become necrotic
What is Krukenberg’s tumor?
drop mets to the ovaries from the GI tract, prmiarily from the stomach, but also from the biliary tract, GB, and pancreas (typically solid)
Cystic mets masses in the ovaries tend to result more commonly from what?
rectosigmoid colon cancers
The ovary is a common site of mets from carcinoma of the ____
bowel
What are the sonographic findings of Krukenberg’s tumor?
- frequently bilateral
- often associated with ascites
- may be solid masses that diffusely infiltrate and increase the bulk of the ovarian parenchyma
What is the least common of all gynecologic malignancies?
carcinoma of the fallopian tube (1%)
Carcinoma of the fallopian tube occurs most frequently in
postmenopausal women with pain, vaginal bleeding, and a pelvic mass
How does carcinoma of the fallopian tube appear sonographically
sausage shaped, complex mass with cystic and solid components often with papillary projections..clinical and sonographic findings are similar to ovarian carcinoma
What pelvic masses can be found that are not gynecologic in origin?
- pelvic kidneys
- omental cysts
- impacted feces in colon
- colonic cancer or masses
- distended bladder
- hydroureters
- abscesses
- retroperitoneal masses
