Pathology of the ovaries Flashcards
for a normal ovary, will you see blood flow IN it?
Yes…not just on the periphery on a normal ovary
Where do the ovaries lie in an anteflexed uterus position?
lateral or posteriolateral
review cyclic changes of the ovary
do it now!
3 phases of menstrual cycle
menstrual days 1-6
proliferative days 7-14
secretory days 15-28
What is the cumulus oophorus?
visualization of the cumulus oophorus within the mature follicle
gts this
when will you find fluid in the cul-de-sac during the menstrual month?
commonly seen after the ovulation and peaks in early luteal phase
what is the normal ovarian volume for a menstruating female?
large as 22 cc
mean: 9.8+/- 5.8 cc
What is a simple cystic mass on the ovary?
larger than 2.5 cm
What is a complex cystic structure in the ovary?
when you see an abnormal unruptured follicle
size 1-10cm
complex echogenicity
What is the most common pathology of the ovary?
simple cyst
When is surgery considered on a simple cyst?
when it’s >6m and persists for more than 8 weeks
check slide 18
What do postmenopausal ovaries look like?
small anechoic cysts may be seen
can disappear or change in size over time
What happens if you see a cyst that is > than 5cm on a postmenopausal woman?
surgery generally recommended
for those containing internal septations and/or soild nodules
When would you do serial sonographic studies on a postmenopausal patient?
when a cyst starts to change or is too large to begin with
will want to document any changes
larger is a problem not smaller
ovarian masses usually grow ______?
quickly
WHat is the most common mass you will see on an ovary?
follicular cyst
What is a complex mass?
not completely anechoic
has debris
solid portions in it
can be predominantly cystic but has other stuff in it
When does a simple cyst become complex?
when it hemorrhages as it involutes
What are classic differential considerations of complex adnexal masses?
ectopic pregnancy (with positive pregnancy test, but nothing in uterus)
endometriosis
pelvic inflammartory disease
What can a dermoid appear as?
complex mass on the ovary
most masses on the ovary are _____?
benign
What are the complex masses?
cystadenoma
dermoid cyst
tubo-ovarian abscess
ectopic pregnancy
granulosa cell tumor
if you do not have a completely anechoic structure you need to identify it ______?
accurately - it matters as does a complete patient history
these things will sway the doctor one direction or another
What age frames would you most likely find solid tumors?
during peak fertile years: only 1 in 15 malignant
after age 40: ratio becomes 1 in 3
Mixed solid to cystic ovarian masses typical of all __________ovarian tumors.
epithelial
how can you tell a solid mass from gas?
can you reproduce it at different times in the scan in two planes
does it move?
a solid mass won’t move
What are the keys to malignancies?
ascites
complex-ness of mass
age of patient
The more sonographically ________the tumor, the more likely to be ________.
complex
malignant
especially with ascites
What are the symptoms of ovarian cancer?
typically asymptomatic until its too late
When would you consider a large ovary abnormal?
when it is twice the volume of the opposite ovary
When you see a pedunculated fibroid what do you need to do?
investigate…you have to be able to determine where and what it is!
why would you use doppler on the ovary?
to differentiate potential cysts from adjacent vascular structures
What can be obtained on all ovarian masses?
localized flow with pulsed doppler
What is performed to determine resistive index or pulsatility index?
Pulsed doppler
interrogation of adnexal branch of uterine artery, ovarian artery, intratumoral flow
What are some doppler signs that might be worrisome for malignancy?
intratumoral vessels
low-resistance flow
absence of normal diastolic notch in doppler waveform
What are the cut-off values for PI and RI?
PI: 1.0
RI: 0.4
if a mass shows complete absence or minimal diastolic flow is it malignant or benign?
typically benign
What are functional cysts?
result from normal function of the ovary
What is the most common cause of ovarian enlargement in young women?
functional cysts
What do functional cysts include?
follicular
corpus luteum
hemorrhagic
theca-lutein cysts
When does a follicular cysts occur?
when the dominant follicle does not succeed in ovulating na dremains active through immature
Are follicular cysts unilateral?
yes, usually
What are thin-walled, translucent, have watery fluid and may project above or within surface of ovary?
folllicular cysts
How large can a follicular cyst grow?
1-8cm
How do you treat a follicular cyst?
usually disappears spontaneously by resorption or rupture
What are the clinical signs or a follicular cyst?
asymptomatic to dull
adnexal pressure and pain
abnormal ovarian function
torsion of ovary resulting in severe pain
What is a corpus luteum cyst?
result from hemorrhage within persistently mature corpus luteum
What is a corpus luteum cyst filled with?
blood and cystic fluid
How large to corpus luteum cysts grow?
may grow 1-10cm in size
often complex
What may accompany a corpus luteum cyst/
intrauterine pregnancy (IUP)
What are hemorrhagic cysts?
a cyst that has bled into itself
could have debris or fluid level in it
may occur in follicular cysts or MORE COMMONLY in corpus luteal cysts
What are the clinical signs for a hemorrhagic cyst?
acute onset of pelvic pain
What are theca-lutein cysts?
large, bilateral, multiloculated cysts
high levels of hCG
seen in 30% of patients with trophoblastic disease
clinical: nausea and vomiting
sonographic: multilocular cysts in both ovaries
What are the ovarian syndromes?
ovarian hyperstimulation
polycystic ovarian syndrome
ovarian remnant
What is ovarian hyperstimulation syndrome?
OHS is frequent iatrogenic complication of ovulation induction
in mild form: patient presents with pelvic discomfort but no significant weight gain
ovaries enlarged, measure < 5cm in diameter
how does a patient present with severe OHS?
severe pelvic pain
abd distention
notably enlarged ovaries measuring >10cm in diameter
associated ascites, pleural effusions, numerous large thin walled cysts thoughout the
What is polycystic ovarian syndrome?
Stein-Leventhal Syndrome*
bilaterally enlarged polycystic ovaries
occurs in late teens through 20’s
may have endocrine imbalance
clinical: amenorrhea, obesity, infertility, hirsutism
sonographic: multiple tiny cysts around periphery of ovary, ovary may be normal size or enlarged
CLASSIC SIGN: STRING OF PEARLS **
WHAT ARE THE BENIGN OVARIAN CYSTS?
peritoneal inclusion cysts
paraovarian cysts
fluid collections in adhesions
benign cysts in fetuses
What are para-ovarian cysts?
usually simple
can bleed or torse
woliffian duct remnants
10% of all adnexal masses
located in broad ligament
clinical: asymptmatic
sonographic: simple cyst adjacent to ovary
what is endometriosis?
functioning endometrial tissue outside the uterus (can be any where)
may be found anywhere in the pelvis: ovary, Fallopian tube, broad ligament, cul-de-sacs
dependant on hormonal stimulation causes discomfort where ever this tissue is
affects women in the 3rd and 4th decades
what does endometriosis look like in its diffuse form?
leads to disorganization of pelvic anatomy with appearance similar to PID or chronic ectopic pregnancy
two forms: diffuse and localized (endometrioma)
What is endometriosis diagnosis based on?
patient history of symptoms
a normal pelvic ultrasound does not exclude the presence of endometriosis
what is ovarian torsion?
is caused by partial or complete rotation of ovarian pedicle on its axis
produces enlarged edematous ovary…usually >4cm in diameter
What does ovarian torsion classically look like?
multiple tiny follicles around hypoechoic mass to completely solid adnexal mass
free fluid often present
doppler examination usually reveals absent blood flow to torsed ovary.
When would you look for ovarian torsion?
when patient presents with acute, severe abd pain
medical emergency
venous drainage goes first, artery flow second
in the ovaries, which side typically has torsion first?
right side
what percentage of ovarian cysts <5cm are malignant?
3%
neoplasm is __________?
excessive growth….not necessarily cancer
What is Meigs syndrome frequently associated with?
fibroma
ovarian Ca
What volume of the ovary is abnormal for a post menopausal woman?
8.0 cc
The ovary synthesizes __________ and converts them to ________.
androgens
estrogens
Name the 5 complex masses
cystadenoma
dermoid cyst
tubo-ovarian abscess
ectopic pregnancy
granulosa cell tumor
What are the 7 common cystic or complex ovarian masses?
follicular cyst
corpus luteum cyst of pregnancy
cystic teratoma
paraovarian cyst
hydrosalpinx
endometrioma (low level echoes)
hemorrhagic cyst
an ovary with volume twice that of the opposite side generally considered ________
abnormal
What are the 6 common solid masses?
solid teratoma
adenocarcinoma
arrhenoblastoma
fibroma
dysgerminoma
torsion
What can be obtained on all ovarian masses?
localized flow with pulsed doppler
Why would you doppler the ovary?
to differentiate potential cysts form adjacent vascular structures
What are some doppler signs that raise concern for malignancy?
intratumoral vessels
low-resistance flow
absence of normal diastolic notch in doppler waveform
What is NOT a senstitive indicator of malignancy?
RI
What are some masses that cause abnormal waveforms on doppler?
inflammatory masses
metabolically active masses (including ectopic pregnancy)
corpus luteum cysts
What does increased diastolic flow suggest?
neovascularity and the likelihood of malignancy
masses showing complete absence or minimal diastolic flow (very elevated RI and PI values) usually means what?
the mass is benign
What is a sign of benign disease in early diastole?
diastolic notch
What are functional cysts a result of?
normal function of ovary
What is the most common cause of ovarian enlargement in young women?
functional cysts
What are the four cysts that are included in functional cysts?
follicular
corpus luteum
hemorrhagic
theca-lutein cysts
What are the three ovarian syndromes?
ovarian hyperstimulation
polycystic ovarian syndrome
ovarian remnant
What are the two non-functioning cysts?
para-ovarian cysts
endometrioma
