Chapter 18: Ovaries and Tubes

Sertoli-Leydig Cell Tumors

"Androblastoma" sex cord-stromal ovarian neoplasm associated with VIRILIZATION - AUB and hirsutism -seen mostly in women younger than 30 - solid, hypoechoic complex or partially cystic mass

Yolk Sac Tumor

"Endodermal Sinus Tumor" - 2nd most common malignant germ cell tumor - RAPID GROWTH - elevation in serum ALPHA-FETOPROTEIN *****(patients younger than 20--poor prognosis) - varying sonographic appearances

Cystic Teratoma

"dermoid" - MOST COMMON benign ovarian tumor - result from unfertilized ovum retention that differentiates into 3 germ cells layers (ecto, meso and endoderm) - can have bone, fat, sebum, teeth, cartilage in it - commonly found in reproductive age, but can appear in post-menopausal

Isthmus (tubes)

"means bridge" short, narrow segment of fallopian tube that lies between the interstitial and ampulla

Mittelschmerz

"middle pain" pain at time of ovulation, typically on side of dominant follicle for that cycle

Fallopian tubes

"oviducts, uterine tubes, salpinges" - provide an area for fertilization and a means of transportation for products of conception to reach uterus

Theca Lutein Cysts

*elevated Hcg (100,000mIU/mL) - largest and least common functional cyst -large, bilateral and multiloculated ovarian benign cystic masses (up to 15 cm) -regress after Hcg levels diminish Increased Hcg can be also from (concurrent syndromes associated with theca lutein cysts): - ovarian hyperstimulation syndrome (fertility treatment) - gestational trophoblastic disease (molar pregnancy) - multiple gestation pregnancy (incr. Hcg) *all increase the likelihood of developing theca lutein cysts -all benign ovarian tumors are asymptomatic except for this one!!

Cystic Teratoma Clinical Symptoms

- asymptomatic but may suffer pain from rupture or torsion that can lead to peritonitis (inflammation of peritoneum) - capability of developing into cancer, but very RARE

Thecoma

- benign ESTROGEN producing tumor associated with Meig's syndrome - common in postmenopausal women - sex cord-stromal tumor (arising from gonadal ridges) -postmenopausal bleeding or AUB - hypoechoic, solid mass - no posterior enhancement - of large, may mimic pedunculated leiomyoma *very similar to fibroma

Cystic Teratoma/Dermoid Sonographic Symptoms

- complex, partially cystic mass that includes one or more echogenic structure - "TIP OF THE ICEBERG" sign: only the anterior part of the mass is seen, while the posterior is obscured by shadowing -"dermoid plug": contains components that will posterior shadow - "dermoid mesh" contains hair that will be seen as numerous linear interfaces within cystic mass

Mucinous Cystadenoma

- larger than serous, can reach up to 50 cm - complaints of pelvic pressure and swelling - often unilateral with septations and/or papillary projections - may contain internal debris

Mucinous cystadenocarcinoma

- malignant LARGE multilocular cyst with thick papillary projections and sepatations with echogenic debris - Pseudomyxoma peritonei (complex ascites from mucinous tumor) Symptoms: - weight loss, pelvic pressure and swelling, AUB, GI symptoms, acute abd pain with torsion and rupture - elevated CA-125

Serous cystadenocarcinoma

- malignant bilateral multilocular cystic masses with more prominent papillary projections and thicker septations with ascites Symptoms: - weight loss, pelvic pressure and swelling, AUB, GI symptoms, acute abd pain with torsion and rupture - elevated CA-125

Corpus luteum cyst of pregnancy

- most common pelvic mass in 1st trimester scan - may reach up to 10 cm - most resolve by 16 WEEKS GESTATION and do not exceed 3 cm

Serous Cystadenoma

- occurs most often in women in their 40s-50s and during pregnancy - often asymptomatic and bilateral - predominantly anechoic lesion that contains septations or papillary projections

Fibroma

- sex cord-stromal benign ovarian tumor associated with MEIGS - found in middle-aged women - hypoechoic, solid mass with posterior shadowing - may mimic pedunculated fibroid

Granulosa Cell Tumor

- sex cord-stromal tumor ESTROGEN producing - most common estrogenic tumor - UNILATERAL and most common in postmenopausal, if seen in adolescents = pseudoprecocious puberty - symptoms: vaginal bleeding - can reach up to 40 cm, be solid or complex, and develop into malignant endometrial carcinoma

Brenner Tumor

- transitional cell tumor - associated with MEIGS - small, solid hypoechoic unilateral tumors that can contain calcs - (may look similar to fibroid, thecoma, fibroma --SMALL)

Endometrioma

-chocolate cyst - benign, blood-containing tumor from implantation of ectopic endometrial tissue - hormones of menstruation act on this functional tissue causing it to hemorrhage that turn into bloody tumors called "endometriomas" - most often multiple and seen in reproductive years - can be located anywhere outside of endometrial cavity - Symptoms: pelvic pain ,menorrhagia, dyspareunia, painful bowel movements, infertility, may be asymptomatic

Ovulation occurs approximately on day ____ and results in:

14 of menstrual cycle - rupture of dominant follicle releasing mature ovum into peritoneal cavity

Size of fallopian tubes

7-12 cm

Cancer of fallopian tubes appearance:

Adenocarcinoma - fallopian tube carcinoma is seen as a solid mass within the adnexa

Where does fertilization occur in the tube?

Ampulla - area where ectopic pregnancies can sometimes embed

Malignant ovarian neoplasms (5)

Cystadenocarcinoma, krukenberg, sertoli-leydig, dysgerminoma, yolk sac tumor

Stage 4

Distant metastasis outside of peritoneal cavity

What are the 11 benign ovarian tumors?

Follicular Cysts, corpus luteum, theca lutein, paraovarian, cystic teratoma(dermoid), thecoma, granulosa cell, fibroma, brenner(transitional cell), endometrioma (chocolate cyst), cystadenoma

Follicular Cysts

If the graafian follicle doesn't rupture/ovulate it continues to enlarge into a follicular cyst (can be 3-8 cm) *benign ovarian cyst

If there is no arterial flow seen on doppler of ovary does that mean there is complete occlusion of blood supply?

No, ovaries also get blood supply from the uterine artery, so it may still be patent

3 layers of fallopian tubes

Outer serosa Middle muscular Inner mucosal

Pyosalpinx

Pus within fallopian tube (complex w/septations)

What is the most common malignancy of the ovary?

Serous cystadenocarcinoma

Symptoms and Findings of Ovarian Torsion

Symptoms: acute unilateral abdominal pain, nausea, vomiting Sonographic: enlarged ovary, lack or diminished flow patterns compared to the nonaffected ovary

Stage 3

Tumor involves one or both ovaries with confirmed peritoneal metastasis outside of pelvis with lymph node involvement

Are follicles normal to see during neonatal, prepubertal ages?

Yes - normal to see them in ovary in reproductive years also

Cumulus oophorus

a part of the dominant follicle where the ovum (egg) is contained *appears as a daughter cyst (cyst within a cyst)

Ovaries form in the ________ and are _______glands producing _________ and _____________

abdomen and descend into the pelvis endocrine (hormone) estrogen and progesterone

Follicular cyst appearance

anechoic, thin-walled, and unilocular(one cavity), then normally regress and are asymptomatic but can lead to pain

Hematosalpinx

blood within the fallopian tube ( complex)

Most common sites of ovarian metastases are tumors of the:

breast and GI tract

Ovarian Medulla

contains ovarian vasculature and lymphatics

Problems from corpus luteum not regressing if not fertilized:

continues to enlarge (may reach 8 cm) - symptoms: pain with enlargement, rupture, hemorrhage - if the cyst is large, can lead to ovarian torsion

2 parts of ovary

cortex and medulla

Infundibulum (tubes)

distal portion of fallopian tube that provide an opening into the peritoneal cavity

Fimbria

fingerlike projections that extend from the infundibulum and draw the unfertilized egg into the tube

Hemorrhagic cyst

follicular cyst that contains blood - appears complex with mixed echogenicity - pain associated with hemorrhage and cyst enlargement

endoderm

germ cell layer of embryo that develops into the GI and respiratory tracts

mesoderm

germ cell layer of embryo that develops into the circulatory, muscles, reproductive system

Corpus luteum

graafian follicle -> corpus luteum - produces progesterone the rest of the cycle (luteal phase) to maintain endometrium during early pregnancy to prepare for implantation - if fertilization occurs, corpus luteum is maintained

Cilia

hair-like projections within the fallopian tubes that shift with peristalsis and offer a path for the fertilized ovum

Doppler of Malignant ovarian masses

high diastolic flow, low resistant waveform

Clinical symptoms of patient with high Hcg levels

hyperemesis, pelvic fullness

corpus albicans

if fertilization does not occur, corpus luteum regresses and becomes this - may sometimes be seen in ovary as small echogenic structure

Salpingitis

infection/inflammation of fallopian tubes normally caused by PID hyperemic fallopian tube

Ampulla (tubes)

longest and most tortuous portion of fallopian tube

Krunkenberg tumor

malignant METASTATIC ovarian tumor metastasized from the GI tract, most frequently the stomach - asymptomatic, possible weight loss, pelvic pain - bilateral, smooth-walled, hypoechoic ovarian mass - characterized by mucin-filled signet-ring cells (moth-eaten like cyst formation) - "carcinoma mucocellulare" - may have ascites

High Resistant ovarian flow phase

menstrual and proliferative phase

Low resistant ovarian flow phase

mid cycle (when there is a dominant follicle (before ruptures)

Dysgerminoma

most common malignant germ cell tumor of the ovary - tumor marker used is elevation in serum LACTATE DEHYRDOGENASE -seen in younger than 30 and can be found during pregnancy - children; precocious puberty with elevated hCG - ovoid, solid echogenic mass with some cystic components (testicular equivalent in seminoma)

Corpus luteum of ECTOPIC pregnancy

normally thick-walled and complex corpus luteum cysts resemble ectopic pregnancies

Ovarian cancer is more common in women that are

nulliparous or have had miscarraiges

Graafian follicle

only follicle that doesn't atrophy. becomes dominant follicle

ectoderm

outer germ cell layer that develops into skin, hair, nails

Ovarian hyperstimulation syndrome can lead to

ovarian torsion b/c of cystic enlargement from estrogen production

Ovarian torsion

ovary twisting on its own mesenteric connection cutting off blood supply

Ovary Location

posterior to ureter and internal iliac artery, superior to external iliac

Fluid from ruptured follicle will accumulate in:

pouch of douglas - most dependent portion of peritoneal cavity

Sonohysterography

procedure where saline is injected into the endometrial cavity and fallopian tubes to observe any abnormalities

hysterosalpinography

radiographic procedure that uses dye injected into the endometrial cavity and fallopian tubes

Ovarian cystectomy

removal of ovarian cyst/follicle

Ovarian hyperstimulation syndrome

results from fertility treatment - development of multiple, enlarged follicular cysts

Ovarian torsion most commonly occurs on _______ side as a result from:

right side benign cystic teratoma or paraovarian cyst

Interstitial (tubes)

segment of fallopian tube that lies within the uterine horn (cornua)

What tumors comprise most neoplasms of the ovary?

serous cystadenomas and cystic teratomas

Hydrosalpinx

simple serous fluid within the fallopian tube (anechoic)

Paraovarian cysts

small cysts adjacent to ovary - may be hemorrhagic with septations - if large, pelvic pain

Follicle-stimulating hormone

stimulates the ovaries - develops multiple follicles during 1st half menstrual cycle (follicular phase) - released by the anterior pituitary gland *Cells surrounding ovarian follicles produce estrogen (stimulates the endometrium to thicken)

Ovarian cortex

the majority of ovary, site of oogenesis (creation of ovum)

Stage 2

tumor involves one or both ovaries with pelvic extension

Stage 1 ovarian cancer

tumor is confined to ovary

Ovary size

varies b/c age volume = length x width x height x .5233.2 typical size: 3-5cm cubed