Things i think i should know 5A-5B Flashcards
What are some symptoms of PCOS?
chronic anovulation
• serum LH level is elevated
• FSH level depressed
• results in abnormal oestrogen and androgen production
• excessive androgen production causes symptoms;
o greasy skin
o Acne
o hirsutism (= growth of terminal hair on the body of a woman in the same patterns and sequence as that which develops in the normal post-pubertal male)
o androgenetic alopecia
What is PCOS associated with?
• Associated with
o obesity
o abnormal carbohydrate metabolism
o disturbance of lipid profile
What are women with PCOS t increased risk of?
o endometrial carcinoma
o ovarian carcinoma
o diabetes
o cardiovascular disease
What is the sonographic appearance of PCOS?
- bilaterally enlarged ovaries (>10mL)
- containing multiple small, 2- to 9-mm follicles (at least 20)
- Above criteria are not considered valid if the patient is taking oral contraceptives or has a dominant follicle greater than 10 mm
- increased stromal echogenicity
- Ovaries are a rounded shape
- follicles usually located peripherally (“string of pearls”)
What are the three categories of functional cysts?
o follicular
o corpus luteum
o theca lutein cysts
When does a follicular cyst develop?
when a mature follicle fails to ovulate or to involute and becomes large than 2.5cm
When can you use the term corpus lutein cyst?
When it is greater than 4cm
What is a theca lutein cyst?
• associated with high beta–human chorionic gonadotropin (B-hCG) levels
• the largest of the functional ovarian cysts
• increasing the risk of ovarian torsion
• typically occur in patients with gestational trophoblastic disease
- can also be seen as a complication of drug therapy for infertility causing ovarian hyperstimulation syndrome.
What does a theca lutein cyst look like on sonography?
o Bilateral
o Multilocular
o very large.
o Similar to other functional cysts, they may undergo hemorrhage or rupture.
What is the most common presentation of a haemorrhagic cyst?
• Common presentation is with acute onset pelvic pain
What helps to confirm the diagnosis of a ruptured haemorrhagic cyst?
The presence of echogenic, free intraperitoneal fluid in the cul-de-sac helps confirm the diagnosis of a leaking or ruptured hemorrhagic cyst.
What is ovarian remnant syndrome?
- cystic mass may be encountered in a patient who has undergone bilateral oophorectomy
- due to a small amount of residual ovarian tissue has been unintentionally left behind.
List the pregnancy associated ovarian lesions?
o hyperstimulated ovaries o ovarian hyperstimulation syndrome o theca lutein cysts o hyperreactio luteinalis o the rare luteoma of pregnancy
What are hyper stimulated ovaries?
- a normal response to elevated circulating levels of hCG
- most common in women undergoing ovulation induction
- the ovaries are enlarged with multiple cysts
- some of which may be hemorrhagic
What is ovarian hyperstimulation syndrome?
• used when the hyperstimulation is accompanied by fluid shifts
What are the different forms of OHS?
- The mild form
- Moderate OHS
- severe OHS
What is mild OHS?
o associated with lower abdominal discomfort
o no significant weight gain
o ovaries are enlarged, but less than 5 cm in average diameter
What is moderate OHS?
o presents with weight gain of 5 to 10 pounds
o ovarian enlargement 5 to 12 cm
o patient may have nausea and vomiting
What is severe OHS?
o weight gain of more than 10 pounds
o typically severe abdominal pain and distention.
o The ovaries are greatly enlarged (>12 cm in diameter)
o contain numerous large, thin-walled cysts, which may replace most of the ovary.
o The associated ascites and pleural effusions may lead to
depletion of intravascular fluids and electrolytes
resulting in hemoconcentration with hypotension, oliguria, and electrolyte imbalanceevere
What is hyperreactio luteinalis and when does it occur?
• caused by an abnormal response to circulating hCG in the absence of ovulation induction therapy
• incidence of hyperreactio luteinalis increases in women with polycystic ovarian disease
• In contrast to OHS, body fluid shifts are rare.
• Sonographically, there are;
o bilaterally enlarged ovaries with multiple cysts similar to OHS
o the ovaries tend not to be as large
o occurs later in pregnancy.
When should you suspect a luteoma of pregnancy?
• Most patients are asymptomatic, although maternal virilization may occur in up to 30%
• 50% risk of virilization of the female fetus
• Sonographically;
o luteomas usually present as nonspecific
o heterogeneous
o predominantly hypoechoic masses
o may be highly vascular.
• An ovarian mass in a pregnant patient with signs of virilization should suggest this diagnosis, because luteoma is the most common cause of maternal virilization during pregnancy.
IN what circumstances do you see peritoneal inclusion cysts?
- seen in patients with peritoneal adhesions
- occurring mostly in premenopausal women with a history of previous abdominal surgery
- may also be seen in patients with a history of trauma, PID, or endometriosis
How do peritoneal inclusion cysts occur?
• fluid produced by the ovary (which is the main producer of peritoneal fluid in women) accumulates within the adhesions and entraps the ovaries
• This results in an adnexal mass
Most patients present with pain and/or a pelvic mass
How do peritoneal inclusion cysts appear on sonography/
- multiloculated cystic adnexal masses
- often with a bizarre shape frequently described as a spider web pattern
- The diagnostic finding is the presence of an intact ovary positioned eccentrically amid septations and fluid
Why is diagnosis of peritoneal inclusion cysts important?
- Accurate diagnosis of peritoneal inclusion cysts is important because the risk of recurrence after surgical resection is 30% to 50%
- Conservative therapy, such as ovarian suppression with oral contraceptives or fluid aspiration, is recommended.
What age group does ovarian torsion predominantly effect?
Women of reproductive age or younger
Why are there so many differentials to torsion and what are they?
- Multiple due to the only consistent symptom being intense progressibe abdominal pain localised to the lower quadrants.
- PID
- ovarian cysts
- ectopic pregnancy
- as well as nongynecologic causes
- A right-sided predominance also exists that may mimic appendicitis.
How does torsion appear on sonography?
- enlarged edematous ovary
- or ovarian complex of ovary and adnexal mass
- Lack of arterial and venous Doppler flow should enable confident diagnosis
- presence of Doppler signal cannot eliminate the diagnosis
What are the four types of ovarian neoplasms?
- Epithelial-stromal tumours 65-75%
- Germ cell tumours: 15-20%
- Sex cord-stromal tumours: 5-10%
- Metastatic tumours: 5-10%
What are the different types of epithelial stromal tumours?
Serous cystadenoma Serous cystadenocarcinoma Mucinous cystadenoma Mucinous cystadenocarcinoma Endometrioid tumour Clear cell tumour Transitional cell tumour
What are the different types of germ cell tumour?
Teratoma
Dysgerminoma
Yolk sac tumour
What are the different types of sex cord-stromal tumours?
Granulosa cell tumour
Sertoli-Leydig cell tumour
Thecoma and fibroma
What do ovarian neoplastic lesions look like on sonography and how do they present?
• usually presents as an adnexal mass. • Can also present as ascites, abdominal pain and vaginal bleeding. • Well-defined anechoic cysts are more likely to be benign • Malignant lesions o irregular walls o thick irregular septations o mural nodules, o solid elements with flow o more likely to be malignant
How can colour be used in differentiating neoplasms?
- Not reliable for differentiation
- Malignant lesions may have a low PI and RI
- Malignant lesions tend to have central flow
- Doppler ultrasound is likely valuable in assessing the mass that is morphologically indeterminate or suggestive of malignancy.
- Doppler findings should be combined with morphologic assessment, clinical findings, patient age, and phase of menstrual cycle for optimal evaluation of an adnexal mass
What is the usual order of ovarian cancer spread?
- local invasion in the pelvis
- peritoneal seeding across the abdominal cavity
- lymphatic embolisation to:
o para-aortic nodes
o uterus
o other ovary - blood-borne metastasis to liver, lungs, brain, bone
What are the most common epithelial-stromal tumours?
Serous Cystadenoma and Cystadenocarcinoma
How do Serous Cystadenoma and Cystadenocarcinoma appear on ultrasound?
Serous cystadenoma • large • thin-walled cysts • typically unilocular • may contain thin septations • Papillary projections are occasionally seen Bilateral 20%
Serous cystadenocarcinomas
o may be quite large
o usually present as multilocular cystic masses
o containing multiple papillary projections arising from the cyst walls and septa
o septa and walls may be thick
o Echogenic solid material may be seen within the loculations.
o Papillary projections may form on the surface of the cyst and surrounding organs, resulting in fixation of the mass.
o Ascites is frequently seen.
bilateral 50%
What is the demographic for Serous Cystadenoma and Cystadenocarcinoma?
Peri and post meopausal
What are the second most common epithelial-stromal tumours?
Mucinous Cystadenoma and Cystadenocarcinoma
How do Mucinous Cystadenoma and Cystadenocarcinoma appear on ultrasound?
Both less likely to be bilateral than their serous counterparts
Mucinous Cystadenoma
• huge cystic masses
• up 30 cm and filling the entire pelvis and abdomen
• Multiple thin septa are present
• low-level echoes caused by the mucoid material may be seen in the loculations.
• Papillary projections are less frequently seen than in the serous counterpart.
Mucinous cystadenocarcinomas
o usually large
o multiloculated cystic masses
o containing papillary projections and echogenic material
o generally have a sonographic appearance similar to that of serous cystadenocarcinomas
What can happen if a mucinous tumour is ruptured?
may lead to intraperitoneal spread of mucin-secreting cells that fill the peritoneal cavity with a gelatinous material
• known as pseudomyxoma peritonei
• A ruptured mucocele of the appendix and mucinous tumors of the appendix and colon can also lead to pseudomyxoma peritonei
What demographic are Mucinous Cystadenoma and Cystadenocarcinoma seen in?
3rd to 7th decade
Are endometrioid tumours malignant or benign?
almost always malignant
What is the demographic for endometrioid tumours?
5th and 6th decade. Post menopausal.
How do endometrioid tumours present sonographically?
• usually presents as a cystic mass containing papillary projections
Are clear cell tumours malignant or benign?
Almost always malignant
What is the demographic for clear cell tumours?
5th to 7th decade. Post menopausal.
How do clear cell tumours present sonographically?
• usually presents as a nonspecific, complex, predominantly cystic mass
What are clear cell tumours associated with?
- Associated pelvic endometriosis is present in 50% to 70% of clear cell carcinomas,
- approximately one-third arise within the lining of endometriomas
Whats another name for a transitional cell tumour?
Brenner tumour
Are transitional cell tumours malignant or benign?
Almost always benign
How do transitional cell tumours appear sonographiclly?
- hypoechoic solid masses
- Calcification may occur in the outer wall
- cystic component is uncommon
- when present, usually results from a coexistent cystadenoma
What is the most common germ cell tumour?
Benign cystic teratoma (95%)
What demographic are the malignant yolk sac (endodermal sinus) and dysgerminoma tumour most commonly found in?
Children and young adults
What demographic are germ cell tumours in general usually found in?
Children and young adults
How do cystic teratomas usually present?
- may present as a palpable mass.
- usually asymptomatic and often are discovered incidentally during sonography
- Torsion is the most common complication
How do teratomas appear sonographically?
• variable appearance ranging from completely anechoic to completely hyperechoic
What are the features considered specific to dermoids?
Dermoid plug
tip of the iceberg sign
dermoid mesh
fat fluid or hair fluid level
What does a dermoid plug look like?
o a predominantly cystic mass with a highly echogenic mural nodule,
o usually contains hair, teeth, or fat and frequently casts an acoustic shadow.
o In many cases the cystic component is pure sebum (which is liquid at body temperature) rather than simple fluid.
What does the tip of the ice berg sign look like?
o A mixture of matted hair and sebum is highly echogenic because of multiple tissue interfaces
o produces poorly defined acoustic shadowing that obscures the posterior wall of the lesion
What does dermoid mesh look like?
o Highly echogenic foci with well-defined acoustic shadowing may arise from other elements, including teeth and bone.
o Multiple linear hyperechogenic interfaces, often described as lines and dots, may be seen floating within the cyst and have been shown to be hair fibers.
How does a dermoid appear on colour Doppler?
benign teratoma may show peripheral flow, but malignancy should be considered if flow is seen centrally and/or within solid areas.
What are some differential pitfalls?
- Other pitfalls include pedunculated fibroids, especially lipoleiomyomas, and perforated appendicitis with an appendicolith.
- An echogenic dermoid may appear similar to bowel gas and may be overlooked.
How do dysgerminomas appear on ultrasound?
• solid masses
• predominantly echogenic
• may contain small anechoic areas caused by hemorrhage or necrosis
prominent arterial flow within the fibrovascular septa of a multilobulated, solid, echogenic mass.
What serum marker can be raised in a yolk sac/endodermal sinus tumour?
alfa feta protein AFP
How do yolk sac/endodermal sinus tumours appear on sonography?
Similar to dysgerminomas
IN what demographic to granulosa cell tumours usually occur?
Post menopausal
How do GCC appear on sonography?
• variable appearance o small solid masses to tumors o variable degrees of hemorrhage o or fibrotic changes o or multilocular cystic lesions.
What demographic do sertoli-leydig tumours usually occur in?
women younger than 30 years of age
Are sertoli-leydig tumours malignant or benign?
Mostly benign. 20% malignant
How do sertoli-leydig tumours present?
- Clinically, signs and symptoms of virilization occur in about 30% of patients
- half will have no endocrine manifestations
- Occasionally, these tumors may be associated with estrogen production.
How do sertoli-leydig tumours appear on ultrasound?
solid hypoechoic masses or may be similar in appearance to granulosa cell tumors
How do metastatic tumours of the ovary appear on ultrasound?
- usually bilateral solid masses
- may become necrotic
- may have a complex, predominantly cystic appearance that simulates primary cystadenocarcinoma
- almost all ovarian metastases from primary tumors of the breast, stomach, and uterus were solid
- those from the colon and rectum were more heterogeneous
What are some clinical presentations of endometriosis?
- Chronic pelvic pain
- pain with periods (dysmenorrhea)
- pain with sex (dyspareunia)
- bowel pain during periods (dyschezia)
- infertility
- Abnormal bleeding
- Pain on urination (dysuria)
- Pain on ovulation
- Fatigue
- Clinical examination may reveal localised tenderness of nodules in the vagina
What is endometriosis?
- the presence of functioning endometrial tissue outside the uterus.
- main mechanism believed responsible is retrograde menstruation
- endometrial cells implant in the pelvis and give rise to endometriosis lesions
How can endometriosis manifest?
o superficial (peritoneal) disease o ovarian disease (endometriomas) o deep infiltrating endometriosis, which is the most complex and surgically challenging form.
When can a endometrioma (chocolate cyst) be confidently diagnosed?
If associated DIE is found
If you see an endometrioma and no other features of endometriosis are present what might you suspect instead?
- haemorrhagic corpus luteum
- dermoid cyst
- mucinous cystadenoma.
What is the most important role of sonography concerning endometriosis?
Identifying if DIE is present as that changes the surgery
What is the main sign of DIE?
Main sign - presence of severe adenomyosis in a uterus that is anteverted but fixed retroflexed.
How do endometriomas appear on ultrasound?
o Ground glass appearance o Thick walls o Uni- or multilocular o Multiple lesions o Kissing ovaries o Hyperechogenic wall foci o Wall nodularities o Acoustic enhancement o Absence of internal vascularity o ‘shifting’ content o Often there is no acoustic streaming (when a colour box is put over the content, the particles are not seen to move downwards o The cyst does not regress
Why should a potential endometrioma prompt a thorough search for DIE?
They occur in isolation only 1% of the time
If no DIE is found what should be your differential for an endometrioma?
Dermoid
haemorrhagic cyst
Mucinous cystadenoma
What is PID?
Pelvic inflammatory disease a broad term that covers infection involving the tubes, ovaries, parametrium and pelvic peritoneum
What are most cases of PID caused by?
chlamydia or gonnoreah
How does PID manifest?
by tubo-ovarian complexes, peritonitis, and abscess formation and is usually bilateral.
How is PID related to ectopic pregnancy?
a major cause of tubal (ectopic) pregnancy. An ectopic pregnancy can occur when untreated PID has caused scar tissue to develop in the fallopian tubes. The scar tissue prevents the fertilized egg from making its way through the fallopian tube to implant in the uterus
How is PID related to infertility?
One in 10 women with PID becomes infertile. PID can cause scarring of the fallopian tubes. This scarring can block the tubes and prevent an egg from being fertilized
What are the clinical presentations of PID?
- pain
- fever
- cervical motion tenderness
- vaginal discharge
- A pelvic mass may be palpated.
How can acute PID manifest on ultrasound?
- Endometritis (endometrial thickening, intracavity fluid)
- Purulent material in POD
• salpingitis
• pyosalpinx,
• tubo-ovarian complex
• tubo-ovarian abscess
How does salpingitis appear on sonography?
• Tube becomes ovoid or pear shape (as distal end occluded)
• Fluid may be anechoic (hydrosalpinx) or echogenic (pyosalpinx)
• Thickened walls (5mm or more)
• Incomplete septi are common (tube folding back on itself)
• Cog wheel sign when tube seen in cross section
• Fluid debris levels
- hyperaemia in wall
How does tubo ovarian abscess appear on ultrasound?
- Complete breakdown of ovarian and tubal architecture
- Separate structures are no longer identified
- multiloculated mass
- incomplete septations
- irregular margins
- low-level internal echoes
- The sonographic appearance may be indistinguishable from other benign and malignant adnexal masses.
How does chronic PID manifest?
• Typically results in hydrosalpinx
o Differentiated from other adnexal lesions by
o Anechoic
o More tubular
o Incomplete septa
o Thin wall <5mm
o ‘beads on a string’ 2- to 3-mm hyperechoic nodules projecting from the wall, representing remnants of the endosalpingeal folds
o Colour flow (if detected) is less exuberant than acute phase
o May have a peritoneal inclusion cyst (ovary is surrounded by a loculated fluid collection with thin septations)
What are the most common differentials for PID?
The most common alternative diagnoses with findings that simulate PID by the presence of an indistinct uterus and complex pelvic fluid,
- ruptured endometrioma
- hemorrhagic cyst
- perforated appendicitis.
