ovarian pathology ch 44 Flashcards
Normal Sonographic Appearance
- Homogeneous echotexture
- May exhibit central, more echogenic
medulla. - Small anechoic or cystic follicles may be
seen peripherally in cortex. - Appearance varies with age and menstrual
cycle.
During early proliferative phase,
many follicles develop and increase in size until about day 8 or 9 of cycle due to stimulation by both follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
At that time, one follicle becomes dominant,
reaching up to
2.0 to 2.5 cm at time of
ovulation.
Follicular cyst develops
if fluid in
nondominant follicles not reabsorbed
Dominant follicle usually
disappears
immediately after rupture at ovulation.
Occasionally follicle decreases in
size and develops a wall that appears crenulated (scalloped).
Following menopause,
ovary atrophies and follicles disappear with
increasing age.
Postmenopausal ovaries are difficult to visualize
sonographically because of smaller size and lack of discrete follicles.
Stationary loop of bowel may
mimic small shrunken ovary; look for
peristalsis in bowel.
After hysterectomy,
ovaries can be difficult to visualize with
ultrasound.
Ovarian Volume
- In adult menstruating female, normal ovary may have volume as large as 22 cc, with mean ovarian volume of 9.8 ± 5.8 cc.
- Volume of more than 8.0 cc considered abnormal for postmenopausal patient.
- Volume of more than twice that of opposite side should also be considered abnormal, regardless of actual size.
Cystic Masses
Majority of ovarian masses simple
cysts, most of which are benign
Cystic Masses Sonographic Findings
- thin smooth wall
- anechoic contents
- acoustic enhancement
Cystic masses are
mostly fluid-filled, may
have some echoes
Common Cystic Masses
- Follicular cyst
- Corpus luteum cyst of pregnancy
- Cystic teratoma
- Paraovarian cyst
- Hydrosalpinx
- Endometrioma (low-level echoes)
- Hemorrhagic cyst
Complex masses may
have cystic and solid components, usually are cystic with many internal echoes or debris
common complex masses
- Cystadenoma
- Dermoid cyst
- Tubo-ovarian abscess
- Ectopic pregnancy
- Granulosa cell tumor
Mixed solid to cystic ovarian masses typical of all
epithelial ovarian tumors
During peak fertile years,
only 1 in 15 malignant; ratio becomes 1 in 3 after age 40
sonographically complex the mass,
more likely to be malignant, especially
if associated with ascites
solid masses
large and often fill pelvic cavity
When solid mass found,
care taken to identify connection with uterus
to differentiate ovarian lesion from pedunculated fibroid
Color Doppler helpful with solid mass by
using color to identify vascular pedicle between uterus and mass, as can often be identified with pedunculation
Solid masses are usually
hypoechoic or hyperechoic with no fluid levels, may be heterogeneous
common solid masses
- Solid teratoma
- Adenocarcinoma
- Arrhenoblastoma
- Fibroma
- Dysgerminoma
- Torsion
Suspected cystic lesion: color Doppler helpful in
differentiating potential cyst from adjacent
vascular structures
Color can be used to
localize flow to further determine flow velocity with pulsed Doppler; can
be obtained on all ovarian masses
Pulsed Doppler interrogation of adnexal branch of uterine artery, ovarian artery, intratumoral flow performed to determine
resistive index or
pulsatility index
Largest study uses cutoff of
> 0.4 as normal RI in nonfunctioning ovary.
Other investigators use PI of
> 1 as normal.
Signs that may be worrisome for malignancy:
- intratumoral vessels
- low-resistance flow
- absence of normal diastolic notch in Doppler waveform
Abnormal waveforms can be seen in
inflammatory masses, metabolically active
masses (including ectopic pregnancy), and corpus luteum cysts.
RI is not a sensitive indicator of
malignancy
Mass showing complete absence or minimal
diastolic flow (very elevated RI and PI values)
usually
benign.
Inflammatory masses, active endocrine tumors, and trophoblastic disease (ectopic pregnancies) may give low indices, mimicking
cancer.
Follicular Cysts occur when
dominant follicle does not succeed in ovulating and remains active though immature
Follicular Cysts usually
unilateral
Follicular Cysts
Thin-walled, translucent, have watery fluid; may project above or within
surface of ovary
Follicular Cysts may grow
1 to 8 cm
Follicular Cysts usually disappear
spontaneously by resorption or rupture
Clinical findings of follicular cyst
asymptomatic to dull, adnexal pressure and pain
Sonographic findings of follicular cyst
simple cyst
Corpus Luteum Cysts result from
hemorrhage within persistently mature
corpus luteum
Corpus Luteum Cysts is filled with
blood and cystic fluid
Corpus Luteum Cysts may grow
1 to 10 cm in size
Corpus Luteum Cysts may accompany
intrauterine pregnancy (IUP)
Corpus Luteum Cysts clinical findings:
- irregular menstrual cycle
- pain
- mimic ectopic pregnancy
- rupture
Corpus Luteum Cysts sonographic findings:
“cystic” type of lesion; may have internal echoes secondary to hemorrhage and increased color
Hemorrhagic Cysts internal hemorrhage may occur in
follicular cysts or, more commonly, in corpus luteal cysts.
Hemorrhagic Cysts patient may present with
acute onset of pelvic pain
acute hemorrhagic cyst usually
hyperechoic; may mimic solid mass.
Hemorrhagic Cysts usually has
smooth wall with posterior acoustic
enhancement indicating its cystic component
Hemorrhagic Cysts internal pattern becomes
more complex.
Theca-Lutein Cysts
large, bilateral, multiloculated cysts
Theca-Lutein Cysts associated with
high levels of human chorionic gonadotropin
Theca-Lutein Cysts seen in
30% of patients with trophoblastic disease
Theca-Lutein Cysts regress after
hCG levels diminish
Theca-Lutein Cysts clinical findings
nausea and vomiting
Theca-Lutein Cysts sonographic findings
multilocular cysts in both ovaries
Paraovarian Cysts located
adjacent to the ovary, but not attached
Paraovarian Cysts commonly arise from
fallopian tubes or broad ligaments
Paraovarian Cysts can range
in size and contribute to pelvic pain
Paraovarian Cysts may cause
ovarian torsion due to nature of cyst
Most common benign ovarian tumor
Cystic Teratoma (Dermoid)
Cystic Teratoma (Dermoid) Also is referred to as a
dermoid cyst
Cystic Teratoma(Dermoid)
Germ cell tumor
Cystic Teratoma (Dermoid) result from the
retention of an unfertilized
ovum
Cystic Teratoma
(Dermoid) composed of the three germ cell layers
- ectoderm
- mesoderm
- endoderm
Cystic Teratoma (Dermoid) can contain
hair, teeth, bone, cartilage, etc.
Cystic Teratoma (Dermoid) “Tip of the Iceberg” Sign due to
posterior shadowing of lesion
Polycystic Ovary Syndrome
(PCOS) AKA
Stein-Leventhal Syndrome
Polycystic Ovary Syndrome
(PCOS) bilaterally
enlarged polycystic ovaries
Polycystic Ovary Syndrome
(PCOS) occurs in
late teens through 20s
Polycystic Ovary Syndrome
(PCOS) may have
endocrine imbalance
Polycystic Ovary Syndrome
(PCOS) spectrum of
sonographic appearances
Polycystic Ovary Syndrome
(PCOS) clinical findings
- amenorrhea
- obesity
- infertility
- hirsutism
Polycystic Ovary Syndrome
(PCOS) sonographic findings
multiple tiny cysts around periphery of ovary; ovary may be normal size or enlarged
women undergoing ovulation induction by the administration of hormones are at
increased risk for
OHS
Ovarian Hyperstimulation Syndrome Ovaries can become
enlarged and measure up to 12cm.
Ovarian Hyperstimulation Syndrome ovary will also contain
multiple large follicles that could turn into theca-lutein cysts due to the patient’s hCG levels
Ovarian Hyperstimulation Syndrome clinical-
fertility treatment, electrolyte imbalance, nausea, vomiting, abdominal distension, ovarian enlargement, oliguria (low urine output)
Ovarian Hyperstimulation Syndrome sono
cystic enlargement of ovaries >5cm, ascites, possible pleural effusion
Sex cord-stromal tumors are
masses that arise from sex cords
of embryonic gonadal and/or ovarian
stroma.
Thecoma
Sex cord-stromal tumor
Thecoma often found in
postmenopausal women
Thecoma may be associated with
Meigs syndrome (having abbenign ovarian tumor with ascites and pleural effusion)
Thecoma is
estrogen-producing
Thecoma clinical
Postmenopausal bleeding
Thecoma sono:
hypoechoic, solid mass with posterior
attenuation
Granulosa Cell Tumors most common
estrogenic tumor
Granulosa Cell Tumors
Sex cord-stromal tumor
Granulosa Cell Tumors is
estrogen-producing
Granulosa Cell Tumors can be linked to
pseudoprecocious puberty
Granulosa Cell Tumors ptential for
malignancy
Granulosa Cell Tumors appearance can be
unpredictable
Fibroma
Sex cord-stromal tumor
Fibroma NOT associated with
estrogen production
Fibroma can undergo
malignant degeneration
Fibroma sono
hypoechoic, solid mass with posterior
attenuation
Fibroma appearance
similar to thecoma
Endometrioma (Chocolate Cyst)
Benign, blood-containing tumor
Endometrioma (Chocolate Cyst) associated with
endometriosis
Endometrioma (Chocolate Cyst) forms from
implantation of ectopic endometrial tissue
Endometrioma (Chocolate Cyst) can be located
anywhere outside the endometrial cavity, including any other pelvic organ
Endometrioma (Chocolate Cyst) most commonly found on the
ovary
Endometrioma (Chocolate Cyst) sono
cystic mass with low level internal echoes, may have a fluid-fluid level
Serous Cystadenoma
Epithelial tumor
Serous Cystadenoma 50-70% are
benign
Serous Cystadenoma often
large and bilateral
Serous Cystadenoma sono
mostly anechoic that contains
septations or papillary projections
Serous Cystadenoma clinical
Patients usually asymptomatic,
maybe pelvic pain
Mucinous Cystadenoma
Epithelial tumor
Mucinous Cystadenoma often
larger than serous
Mucinous Cystadenoma also have
septations and/or projections
Mucinous Cystadenoma not as often
bilateral
Mucinous Cystadenoma sono
similar appearance to serous, but presence of
internal debris distinguishing factor between the two
Mucinous Cystadenoma clinical
pelvic pressure and swelling due to large size
Ovarian Torsion also referred to
adnexal torsion, since it can involve the fallopian tube as well
Ovarian Torsion occurs most often on the
right side
Ovarian Torsion can also be detected in the
fetus
Ovarian Torsion
pedicle partially or completely rotates on its axis, compromising lymphatic and venous drainage
Ovarian Torsion clinical
acute unilateral pain, nausea and vomiting, slight leukocytosis
Ovarian Torsion sono
enlarged ovary, small peripherally located follicles, lack of or diminished
flow patterns in comparison to contralateral ovary, “whirlpool sign”, excessive free
fluid
Most common malignancy of the ovary
Serous Cystadenocarcinoma
Serous Cystadenocarcinoma frequently
bilateral
resembles the serous cystadenoma, but
has more prominent projections and thicker
septations
Serous Cystadenocarcinoma clinical
weight loss, pelvic pressure, abnormal
vaginal bleeding, gastrointestinal issues
Mucinous Cystadenocarcinoma less often
bilateral
Mucinous Cystadenocarcinoma associated with
pseudomyxoma peritonei (intraperitoneal extension of mucin-secreting cells resulting from rupture of mucinous tumor, fluid from mass resembles ascites)
Mucinous Cystadenocarcinoma clinical
similar to serous counterpart
Krukenberg Tumor that most likely metastasized from
gastrointestinal tract
Krukenberg Tumor most frequent origin is
the stomach (gastric cancer)
Krukenberg Tumor often
bilateral
Krukenberg Tumor sono
smooth-walled, hypoechoic or
hyperechoic
Krukenberg Tumor clinical
asymptomatic, hx of gastric
cancer, possible weight loss, pelvic pain
Sertoli-Leydig Cell Tumor (Androblastoma)
Sex cord-stromal tumor
Sertoli-Leydig Cell Tumor (Androblastoma) found more often in women
younger than 30.
Sertoli-Leydig Cell Tumor (Androblastoma) sono
solid hypoechoic mass, or complex mass
Sertoli-Leydig Cell Tumor (Androblastoma) clinical
virilization (development of male characteristics), abnormal menstruation, hirsutism
Ovarian cancer accounts for more
deaths than any other of the female
reproductive system.
Most common malignant germ cell tumor of
ovary
Dysgerminoma
Dysgerminoma most likely found in patients
under 30
Dysgerminoma most frequent ovarian malignancy found in
childhood
Dysgerminoma sono
ovoid, solid, echogenic mass, may have
cystic components
Dysgerminoma clinical
pseudoprecocious puberty (children), elevated serum lactate dehydrogenase,
possible elevated hCG
Yolk Sac Tumor AKA
endodermal sinus tumor
Yolk Sac Tumor
Germ cell tumor
Yolk Sac Tumor is
rapid growth, highly malignant
Yolk Sac Tumor occurs in
females younger than 20 yrs
Yolk Sac Tumor has a
Poor prognosis
Yolk Sac Tumor sono
homogeneous echogenic mass, varying
appearances
Yolk Sac Tumor clinical
Serum AFP (alpha- fetoprotein) elevated
Endometrioid Tumor (Endometrioid Carcinoma) high incidence of
malignancy
Endometrioid Tumor (Endometrioid Carcinoma) often seen in women during
their fifth and sixth decade of life
Endometrioid Tumor (Endometrioid Carcinoma) associated with
hx of endometrial cancer or endometriosis
Endometrioid Tumor (Endometrioid Carcinoma) Sono
complex mass with solid components or cystic mass with papillary projections
Ovarian Cancer STAGE I:
- Limited to ovary
- Limited to 1 ovary
- Limited to 2 ovaries
- Positive peritoneal lavage (ascites)
Ovarian Cancer STAGE II:
- Limited to pelvis
- Involvement of uterus/fallopian tubes
- Extension to other pelvic tissues
- Positive peritoneal lavage (ascites)
Ovarian Cancer STAGE III:
Limited to abdomen: intraabdominal extension outside pelvis/retroperitoneal nodes/extension to small bowel/omentum
Ovarian Cancer STAGE IV:
Hematogenous disease (liver parenchyma)/spread beyond abdomen
Carcinoma of the Fallopian Tube
Least common (<1%) of all gynecologic malignancies
Carcinoma of the Fallopian Tube Adenocarcinoma is the most common
histological finding
Carcinoma of the Fallopian Tube occurs most frequently in
postmenopausal women with pain, vaginal bleeding, pelvic mass
Carcinoma of the Fallopian Tube usually involves
distal end; may involve entire length
of tube
Carcinoma of the Fallopian Tube sono
sausage-shaped, complex mass with cystic and solid components, often with papillary projections
Carcinoma of the Fallopian Tube clinical
similar to ovarian carcinoma
