Ovarian mass in an adolescent patient

Question 1

A 16-year-old patient experienced acute back pain after a sports-related injury. The back pain resolved with physical therapy; however, imaging studies obtained during her evaluation suggested an adnexal mass. Ultrasonography is performed and reveals the image shown in Figure 2-1. The most likely diagnosis is:

(A) mature cystic teratoma 
(B) endometrioma
(C) hydrosalpinx
(D) ectopic pregnancy
(E) hemorrhagic ovarian cyst

Answer 1

(A) mature cystic teratoma

Question 2

What is the most common neoplastic cyst in adolescents, and what are some of their common characteristics?

Answer 2

Dermoids/mature cystic teratoma - most common frequent germ cell tumor as well

Characteristics: benign, 7% of the time are bilateral, have cells from at least TWO germ cell layers, often contain hair/sebum/teeth

Question 3

What are some characteristic findings of dermoids on ultrasound?

Answer 3

• Shadowing echodensity
• Diffuse or regional high amplitude echoes
• Fat-fluid levels
• Intracystic floating balls

2+ characteristic signs –> high PPV for dermoid identification

On CT/MRI can also see ovarian calcification

Question 4

How do dermoids present and how should they be managed?

Answer 4

Presentation: asymptomatic OR dull abdominal pain OR torsion (d/t weight of contents, rapid enlargement, “floating” location in pelvis due to high fat content)

Management: if small, can monitor with USN; if large should surgically intervene (usually with cystectomy for fertility-sparing) - want to avoid spill because of chemical peritonitis, foreign body reaction, or dense adhesions

Question 5

How does an endometrioma present by ultrasound and how is it managed?

Answer 5

USN: low, homogeneous echogenicity - “ground glass”

Management: fertility-sparing surgical removal with COMPLETE removal of cyst wall to prevent recurrence

Question 6

How does a hydrosalpinx present on ultrasound, and how is it managed?

Answer 6

USN: dilated FT that folds on itself (usually postinflammatory - the proximal and distal ends of the tube become scarred and serous fluid can accumulate in the tube lumen and cause swelling)

Management: pts usually asymptomatic; can just observe

Question 7

How does a hemorrhagic ovarian cyst present on ultrasound, and how should it be managed?

Answer 7

USN: complex cyst that resolves over time

Management: USN monitoring unless intraperitoneal bleeding seen

Question 8

How does an ectopic pregnancy present on ultrasound?

Answer 8

Extrauterine embryo with cardiac activity, adnexal fluid with a yolk sac or embryo, tubal ring, or complex or solid adnexal masses