Reproductive: Random Ovarian Pathology

Question 1

What is the most sensitive finding for ovarian torsion?

Answer 1

Enlarged ovary (>4 cm in length)

Question 2

Answer 2

Think hydrosalpinx

Question 3

What imaging features are suggestive of hydrosalpinx?

Answer 3

• Serpiginous tubular cystic structure
• Cogwheel appearance (due to thickened longitudinal folds)
• String sign (incomplete septae)

Question 4

Imaging findings of pelvic inflammatory disease

Answer 4

• Hydrosalpinx
• Ill-defined border of the uterus

Note: Pt will be in severe pain during transvaginal ultrasound exam (e.g. chandelier sign).

Question 5

Pathophysiology of a paraovarian cyst

Answer 5

Congenital remnant that arises from the Wolffian duct

Question 6

What is the key imaging finding for a paraovarian cyst?

Answer 6

That it is external to the ovary (separable from it)

Question 7

Postpartum female with acute pelvic pain and fever

Answer 7

Ovarian vein thrombophlebitis

Question 8

Ovarian vein thrombophlebitis is more common on the…

Answer 8

Right (80%)

Question 9

What is the dreaded complication of ovarian vein thrombophlebitis?

Answer 9

Pulmonary embolism

Question 10

Pelvic pain in a female pt with remote history of multiple pelvic surgeries

Answer 10

Think peritoneal inclusion cyst

Note: These occur when an ovary is encased within pelvic adhesions, resulting in the accumulation of fluid because adhesions can’t absorb the fluid like normal peritoneal lining can.

Question 11

Pelvic pain in a female pt with a remote history of pelvic inflammatory disease

Answer 11

Think peritoneal inclusion cyst

Note: Multilocular cyst containing the right ovary in a pt with high risk for pelvic adhesions (which can’t absorb normal ovarian fluid like normal peritoneal lining can).

Question 12

What are the key imaging features of a peritoneal inclusion cyst?

Answer 12

• Lack of “walls” (leading to a passive shape that conforms to all surrounding structures making it not mass-like)
• Entrapment of an ovary within the fluid collection or at its periphery

Question 13

New pelvic pain in a female pt with a remote history of pelvic inflammatory disease requiring oophorectomy

Answer 13

Think peritoneal inclusion cyst

Question 14

Massively enlarged, heterogeneous and cystic endometrium in a 45 y/o pt presenting with persistent vomiting…

Answer 14

Think gestational trophoblastic disease

Note: Beta-hCG should be severely elevated.

Question 15

What is the most common form of gestational trophoblastic disease?

Answer 15

Hydatidiform mole: complete (70%) or partial (30%)

Question 16

Complete molar pregnancy

Answer 16

Neoplasia of the entire placenta (there will be no fetus)

Question 17

Karyotype of a complete molar pregnancy

Answer 17

Diploid

Note: This due to fertilization of an egg with too few chromosomes (e.g. 46XX).

Question 18

42 y/o pt wit massively elevated beta-hCG

Answer 18

Think complete hydatidiform mole

Note: Heterogeneous cystic and hypervascular mass replacing the endometrium.

Question 19

First trimester ultrasound

Answer 19

Think complete hydatidiform mole

Note: This is the “snowstorm” appearance that is common in the first trimester. In the second trimester, the appearance is usually more cystic, “bunch of grapes”.

Question 20

Partial hydatidiform mole

Answer 20

Neoplasia of only a portion of the placenta (there is a fetus, but not a normal one)

Question 21

Karyotype of a partial hydatidiform mole

Answer 21

Triploid

Note: This is due to fertilization of an ovum by two sperm (e.g. 69XXY)

Question 22

Hyperemesis gravidarum

Answer 22

Partial hydatidiform mole

Note: Abnormal fetus and enlarged, cystic placenta.

Question 23

What type of ovarian cysts are common in molar pregnancies?

Answer 23

Theca lutein cysts (many, large ovarian cysts bilaterally)

Question 24

At what point does a molar pregnancy become invasive?

Answer 24

When the molar tissue invades the myometrium (best seen on MRI)

Question 25

Beta-hCG level is 90,000

Answer 25

Invasive molar pregnancy

Question 26

What percentage of hydatidiform molar pregnancies become invasive?

Answer 26

Approximately 10%

Note: This usually happens after treatment for the molar pregnancy.

Question 27

Rising serum beta-hCG levels following dilation and evacuation of a molar pregnancy

Answer 27

Choriocarcinoma

Note: This is a very aggressive malignancy that only forms trophoblasts, no villous structure.

Question 28

How does choriocarcinoma tend to spread?

Answer 28

First, local spread (invasion of the myometrium/parametrium)

Then, hematogenous spread to any site in the body

Note: These tumors tend to bleed a lot.

Question 29

Rising serum beta-hCG levels following treatment for a molar pregnancy

Answer 29

Choriocarcinoma

Question 30

Treatment for choriocarcinoma

Answer 30

Chemotherapy (including methotrexate)

Note: Gestational trophoblastic disease is uniquely sensitive to chemotherapy.