Ovarian Pathology
Give the formula for ovarian volume
.523 X length X width X height
List 2 possible sonographic differences between follicular cysts and corpus luteal cysts
1. Follicular are thin walled and unilocular 2. CL are crenated inner wall pattern, presence of internal echos due to hemorrhage
What are the criteria for a simple cyst
1. anechoic 2. smooth/ thin/ round walls 3. PAE
List the 3 characteristics of a solid ovarian mass
1. distal acoustic shadowing 2. irregular, poorly defined walls 3. echo-filled inferior
Which 2 ovarian masses are associated with endometrial cancer?
1. endometroid 2. granulose cell tumor
Theca lutein ovarian cysts are typically seen with
1. gestational trophoblastic disease 2. multiple gestational pregancy 3. infertility treatment- ovarian hyperstimulation
List the 2 ovarian tumors that are associated with changes in a patients secondary sex characteristics
1. granulose cell tumor 2. sertoli-leydig
Given a pediatric pt who has multiple ovarian cysts, what may be the problem
1. precocious puberty 2. juvenile hypothyroidism dysfunciton
List the characteristics of dysgerminoma
1. rare malignant germ cell tumor 2. may occur at any age, but occurs predominantly in women under 30 and may be found in pregnancy 3. most common germ cell tumor 4. elevated LDH/hCG
How many weeks does it take for theca lutein cysts to regress after molar evacuation
10-12 wks
Convert 20mm to ________ cm.
2
What size must a follicular cyst be before it can be diagnosed as a cyst
2.5cm
At what size can a follicle be identified ?
4-5 mm
Precocious puberty is defined as the development of pubic hair, breasts, and the genitals before the age of
8
How would a sonographer differential between a hemorrhagic cyst and an endometrioma
A hemorrhagic cyst decreases in size over the next few menstrual cycles, but an endometrioma does not change in size.
Germ cell tumors are associated with elevated levels of ________ and ________.
AFP, bhCG
Rare, masculinizing tumor
Androblastoma
List the clinical signs of Meigs syndrome
Ascites, pleural effusion, benign ovarian tumor
Assisted reproductive therapy can result in all of the following except a. heterotypic pregnancy b. multiple gestations c. ovarian hyperstimulation d. Asherman syndrome
Asherman syndrome
What is the sonographic appearance of an ovary that is under oral contraceptive stimulation
Atretic and irregular follicles, no dominate follicle developes
What lab is extremely elevated with theca lutein cysts
B-hCG
Describe the waveforms associated with both benign and malignant tumors
Benign- high resistive Malignant- low resistive
Describe the sonographic appearance of PCOS
Bilaterally enlarged round ovaries with multiple follicles around the periphery (11-15), referred to as the "string of pearls" sign
Benign tumor that often occurs along cystadenoma
Brenner tumor
It is an uncommon solid mass that resembles a fibroma. It is rarely malignant. Typically it is well encapsulated, unilateral, maybe in conjunction with a mucinous cystadeoma. It may be hypoechoic or may have calcifications in the outer wall
Brenner tumor
____________ this ovarian pathology is an uncommon solid mass arising from surface epithelium resembling a fibroma and thecoma .Sonographic appearance is hypechoic solid mass with possible calcifications in the otter wall.
Brenner tumor
What is the biological tumor marker found in the blood of approximately 75% of women with ovarian cancer
CA-125
Ovarian cyst that form in the place of a ruptured dominant follicle and regresses 9-11 days after ovulation if pregnancy does not occur
CL of menstruation
What occurs in place of a ruptured dominant follicle
CL of menstruation or pregnancy (if implantation occurs)
Ovarian cyst that continues as a result of pregnancy
CL of pregnancy
It is thought to be from Mullerian duct origin and a variant of endometroid carcinoma. The sonographic appearance is nonspecific and can be complex, or predominantly cystic mass.
Clear cell carcinoma
Brenner tumors may be seen in conjunction with what ovarian tumor
Coexistent cystadenoma
Of the 4 types of functional cysts which is more susceptible to hemorrhage
Corpus luteum
What is the differential of Krukenberg's tumor
Cystadenocarcinoma
A 25 year old patient presents to the ultrasound department complaining of pelvic pain, dyspareunia, and oligomenorrhea. An ovarian mass, though to be a chocolate cyst, is noted during the examination. Wha tis the sonographic appearance of a chocolate cyst?
Cystic mass with low level echos
Usually located anterior and superior to the uterus. It is typically round and well circumscribed. It can be cystic with echogenic mural focus or complex with cystic areas
Dermoid
List the Germ cell tumors
Dermoid (benign cyst teratoma) Immature teratoma Dysgerminoma Yolk Sac Tumor
Tumor composed of various body tissues
Dermoid tumor
What is the most common malignant germ cell tumor
Dysgerminoma
What is the most common of all malignant neoplasms
Dysgerminoma
Blood-filled cyst associated with endometriosis
Endometrioma
__________ is the 2nd most common epithelial malignant and is associated with endometrial cancer as an independent primary
Endometroid
What 2 hormones stimulate follicular development of ovulation
FSH/ LH
Mucinous cyst adenomas are mostly bilateral (T/F)
False
Meigs syndrome is associated with what ovarian tumor?
Fibroma
_________________ comprise 4% of ovarian neoplasms. They are benign and unilateral. Most commonly found in postmenopausal and menopausal women. Rarely associated with estrogen production and are frequently asymptomatic despite their large size. Ascites is present is up in 50% of patients when tumor is larger than 5cm
Fibroma
List of sex cord tumors
Fibroma Thecoma Granulosa cell tumor Sertoli - Leydig cell tumor
Thecoma tumors are similar to appearance to which ovarian pathology? Are thecoma tumors benign or malignant
Fibromas, benign
Name the 4 functional cysts
Follicular corpus luteum hemorrhagic theca lutein
Give the common primaries of Krukenberg tumors
GI and breast
Which ovarian malignant is the most common malignancy of childhood, adolescence, and young adults
Germ cell tumors
What are the two causes of theca lutein cysts
Gestational trophoblastic disease Multiple gestations (associated with high levels of bHcG)
The dominant follicle prior to ovulation is termed the
Graafian follicle
Hormonal tumor with feminizing characteristics
Granulosa cell tumor
List the sex-cord stromal tumors
Granulose cell tumor thecoma fibroma sertoli-leydig cell tumor (androblastoma/arrhenoblastoma)
Describe the "dermoid mesh" appearance of a dermoid tumor
Hair that appears as numerous linear interfaces floating within the cyst areas of the mass
Normal ovarian flow is said to be
High resistant during menstruation and low resistant at the time of ovulation
What usually causes ovarian torsion
It is caused secondary to an ovarian mass
The malignant ovarian tumor with gastrointestinal origin is the
Krukenberg Tumor
If a pt has a prior hx of ca and presents with a pelvic mass, what ovarian pathology must be present
Krukenberg tumor
Ovarian tumor caused by metastatic disease
Krukenberg's Tumor
PCOS is caused by an imbalance of which 2 hormones? What is the nature of the imbalance
LH/FHS LH is high FSH is low
What are follicular cyst
Mature follicles that failed to ovulate or involute
Krukenberg's tumor is associated with what other pathology findings
Mets, cancer from the stomach, GI tract, biliary tract, GB, pancreas, breast, and lung
Describe the complications of mild vs severe forms of ovarian hyperstimulation syndrome
Mild: pelvic discomfort, no significant weight gain, enlarged ovaries measuring no greater than 5cm Severe: severe pelvic pain, abdominal pain, abdonmial distention, enlarged ovaries greater than 10cm, associated with ascites, pleural effusion, numerous large thin walled cysts around periphery
Is it sure that a corpus luteum are follicles that have failed to ovulate? If no, what is the cause of corpus luteum cysts?
No. CL cysts are caused from failure of reabsorption or from excess bleeding into the CL
Describe the tip of the iceberg sign
Only the anterior element of the mass is seen while an ill defined shadow from a mixture of matted hair and sebum obscures the greater part of the mass is obscured by shadowing
Explain the tip of the iceberg sign
Only the anterior element of the mass is seen while an ill defined shadow from a mixture of matted hair and sebum obscures the greater part of the pelvis
A female patient presents to the ultrasound department with a clinical history of Clomid treatment. She is complaining of nausea, vomiting, and abdominal dissension. What circumstances is most likely causing her clinical symptoms?
Ovarian hyperstimulation syndrome
A 39 year old pt comes to the us department for lt sided pain. She tells you she has endometriosis and has had her uterus and both ovaries removed 6 months ago. You see a cyst in her lt adnexa. what is a possible diagnosis
Ovarian remnant syndrome
A 24-year-old-female patient presents to the emergency department with severe left lower quadrant pain, nausea, and vomiting. The sonographic examination reveals an enlarged ovary with no detectable Doppler signal. What is the most likely diagnosis ?
Ovarian torsion
Multiple cysts associated with with Stein Leventhal syndrome
PCOS
Sonographically presents as bilateral enlarged ovaries with multiple follicles demonstrating increased ovarian echogencity
PCOS
The sonographic "string of pearls" sign is indicative of
PCOS
Which ovarian condition is described by having bilaterally enlarged ovaries and multiple small peripheral cysts? Also called the "string of pearl" sign
PCOS
During a pelvic sonogram you visualize a small cyst located adjacent to the ovary. What is the most likely etiology is this cyst?
Paraovarian Cyst
Which ovarian cyst is usually located superior to the uterine fundus? Is it functional or non-functional?
Parovarian/ non-functional
What can cause Pseudomyxoma peritonei
Penetration or rupture of the tumor capsule leading to the intraperitoneal spread of mucinin secreting cells that fill the peritoneal cavity with gelatinous material
Cause of female infertility include all of the following except: a. previous intrauterine device use b. PCOS c. Asherman syndrome d. Endometriosis
Previous intrauterine device use
__________ is penetration of tumor capsule that leads to intraperitoneal spread of mutinous secretions
Pseudomyxoma peritonei
List the sonographic patterns of dermoid tumors
Range in size from small to 40cm Unilateral, round, oval mass Located anterior and superior to the uterus
How are the symptoms of Meigs syndrome relieved
Removal of the ovarian tumor
Accounts for 60-80% of all ovarian carcinomas. They vary in size, but tend to be smaller than mucinous cysts. They are larger than their benign counterpart. They are multilocular cystic masses with internal papillary projections. They may have thick walls and septa. they may also present with ascites
Serous cystadenocarcinoma
___________ are malignant epithelial tumors that can become quite large and likely to rupture. They tend to have thick, irregular walls septations with papillary projections and echogenic material.
Serous cystadenocarcinoma
Usually found in women between ages 13-45. They contain thicker mucinous fluid. These are unusually large masses filling the entire pelvis and abdomen. Simple or septet thin walled, multilocular cysts
Serous cystadenoma
List the epithelial ovarian tumors
Serous cystadenoma / serous cystadenocarcinoma mucinous cystadenoma/ mucinous cystadenocarcinoma endometroid brenner tumor (transitional cell) clear cell carcinoma
List the symptoms of ovarian torsion
Severe acute unilateral pelvic pain fever N/V palpable adnexal mass
Amenorrhea, hirsutism, and obesity describe
Stein-Levanthal
PCOS is associated with
Stein-Leventhal sydnrome
Excessive hair growth in women in areas where hair growth is normally negligible would be seen with
Stein-Leventhal syndrome
What treatment is the most effective for ovarian remnant syndrome
Surgery
List the germ cell tumors
Teratomas (mature and immature) Dysgerminoma Yolk Sac Tumor (AKA: Endodermal Sinus Tumor)
Multiple cysts associated with GTD
Theca lutein cyst
Ovarian hyperstimulation syndrome causes multiple large follicles to develop on the ovary termed
Theca lutein cyst
What is the largest of the functional cyst
Theca-lutein
What is associated with excessive levels of B-hCGand nausea
Theca-lutein cyst/ gestational trophoblastic disease/ multiple gestations
_____________ comprise approximately 1% of all ovarian neoplasms. 70% occur in postmenopausal women. They are unilateral and almost always benign. They are associated with estrogen production
Thecoma
Describe the appearance of a follicular cyst
Thin walled, unilocular, unilateral, range in size from 1-20cm, diagnosed when greater than 2.5 cm
Thecomas are almost always benign (T/F)
True
Describe the sonographic appearance of an androblastoma tumor and list its clinical symptoms
Unilateral, between 5-15cm, solid/ hypoechoic mass or complex partially cystic mass Asymptomatic, sometimes estrogen producing, increased testosterone (hirsutism/ abnormal menstruation)
Describe the sonographic appearance of a torsed ovary
Variable depending upon the duration and degree of torsion, enlarged hypoechoic ovary with multiple cortical follicles, reduced color flow
Why do follicular cysts form
When mature follicles fail to ovulate or involute post ovulation
What are the differentials of a fibroma
a. Brenner tumor b. Pedunculated fibroid
Describe the sonographic appearance of acute and chronic hemorrhagic cysts
acute- hyperechoic - mimics a solid mass, PAE chronic- hypoechoic, complex, reticular pattern of internal echos and septations within the cyst, possible fluid/fluid level
The longest and most tortuous segment segment of the Fallopian tube is the
ampulla
The segment of the Fallopian tube where fertilization typically occurs is the
ampulla
What are the general symptoms of an ovarian mass
asymptomatic, pain, adnexal fullness, tenderness, ovarian enlargement
Are theca lutein cysts bilateral or unilateral
bilateral
Is PCOS bilateral, unilateral, or have the possibility to be both?
bilateral
Is a theca lutein cyst bilateral, unilateral, or have the possibility to be both?
bilateral
is PCOS unilateral ot bilateral finding
bilateral
How is PCOS diagnosed
biochemically (FSH and LH levels)
Is a Brenner tumor bilateral, unilateral, or have the possibility to be both?
both
Is a mucinous cystadenocarcinoma bilateral, unilateral, or have the possibility to be both?
both
Is a mucinous cystadenoma bilateral, unilateral, or have the possibility to be both?
both
Is a serous cystadenocarcinoma bilateral, unilateral, or have the possibility to be both?
both
Is a serous cystadenoma bilateral, unilateral, or have the possibility to be both?
both
Is a teratoma bilateral, unilateral, or have the possibility to be both?
both
Is an endometrioid bilateral, unilateral, or have the possibility to be both?
both
Is clear cell carcinoma bilateral, unilateral, or have the possibility to be both?
both
Malignant gestational trophoblastic disease
choriocarcinoma
Hairlike projections within the Fallopian tube are called
cilia
List the signs of ovarian malignancy
complex ovarian mass irregular thick walls thick irregular septations (greater than 3mm) solid echogenic elements blood flow within septations/walls/or nodules low RI pattern Malignant ascites Mixed tumors Mulilocular Thickly seperated masses Solid mural nodules with cystic masses Bilateral tumors Fixed tumors
Lis the signs of malignancy
complex ovarian mass irregular thick walls, poorly defined margins Thick irregular septations (greater than 3mm) Solid echogenic elements Blood flow within sepations/nodules/walls Low RI pattern Malignant ascites Bilateral or fixed tumors
Cyst that develops with pregnancy
corpus lutein cyst
After the Graafian follicle ruptures, the remaining structure is termed the
corpus luteum
The cystic mass commonly noted with a pregnancy is the
corpus luteum
What forms in place of a ruptured Graafian follicle
corpus luteum
A corpus luteum cyst can be differentiated from a follicular cyst by observing a
crenelated inner wall pattern and the presence of internal echos
The most common benign ovarian tumor is the
cystic teratoma
The ovarian mass that contains fat, sebum, and teeth is
cystic teratoma
What benign ovarian tumor contains elements of all 3 embryonic layers
dermoid
Solid, malignant germ cell tumor
dysgerminoma
The ovarian tumor associated with an elevated serum locate dehydrogenase is the
dysgerminoma
______________ and ___________ are the most common ovarian neoplasms seen in pregnancy
dysgerminoma, serous cystadenoma
Which of the following is a tumor of ectopic endometrial tissue
endometrioma
What is the name of the ovarian cyst seen in association with endometriosis
endometrioma (chocolate cyst)
Nearly all are malignant. Appears to be a cyst mass containing papillary projections or may be a solid mass that may contain areas of hemorrhage. It is associated with endometrial carcinoma
endometroid
All of the following ovarian tumors are associated with estrogen production except a. fibroma b. thecoma c. granulsoa cell d. androblastoma
fibroma
Benign, connective tissue tumor
fibroma
The finger like extensions of the Fallopian tubes are called
fimbria
List the 4 functional cyst
follicular theca lutein corpus luteum hemorrhagic
Mature follicle that fails to ovulate
follicular cyst
Persistent functional cysts
follicular cysts
Ovarian cysts that are hormonally affected
functional cyst
What is the most common cause of ovarian enlargement in young women
functional cyst
What ovarian cyst is the most common cause of ovarian enlargement in young women
functional cyst
Gonadoblastoma and embryonal cell carcinoma are _________ tumors
germ cell
What type of patients do you see theca lutein cysts in
gestational trophoblastic disease and multiple birth gestation due to excessive b-hCG, infertility patients
What pathologies are found in teratomas
glandular thyroid, hair, teeth, bone, sebum,, cartilage, digestive elements
Blood within the Fallopian tube is termed
hematosalpinx
What is the physiologic process of polycystic ovarian syndrome
imbalance of FSH and LH (FHS is low, LH is high)
Increased AFP levels are seen with which two germ cell tumors
immature teratoma and yolk sac tumor
List the 4 clinical signs of Stein-Leventhal syndrome
infertility oligomenorrhea hirsutism obesity
Stein-Leventhal syndrome is related to
infertility, anovulatory cycles, hirsutism
The most distal part of the Fallopian tube is the
infundibulum
The short and narrow segment of the Fallopian tube distal to the interstitial segment is the
isthmus
What is the formula for calculating ovarian volume?
length X width X height X .5233
The parovarian cyst is usually of __________ or _______ origin
mesothelial, paramesonephric
Makes up 5-10% of malignant ovarian neoplasms. Composed of large multilocular cystic masses with papillary projections and echogenic material. They are filled with gelatinous material
mucinous cystadenocarcinoma
Large, benign cyst filled with thick fluid
mucinous cystadenoma
The inner of the wall of the Fallopian tube is the
mucosal layer
The malignant ovarian mass that is associated with pseudomyxoma peritonea is the
mutinous cystadenocarcinoma
Give the 4 patient characteristics of PCOS
obesity hirsutism oligomenorrhea infertility
When in live is a paraovarian cyst more common
occurs at any age- but more common in the 3rd and 4th decades of life
Sonographic findings of ovarian hyperstimulation syndrome include all of the following except: a. cystic enlargement of the ovaries b. ascites c. pleural effusions d. oligouria
oligouria
What is the second most common gynecological malignancy and the 4th leading cause of cancer death
ovarian cancer
What is a frequency iatrogenic complication of ovulation induction
ovarian hyperstimualtion syndrome
Occur when both ovaries are removed but a small amount of ovarian tissue remains
ovarian remnant
What syndrome can occur when pt has undergone a technically difficult oophorectomy in which anatomy was distorted due to conditions such as PID or endometriosis
ovarian remnant syndrome
Large, painful, unilateral, complex adnexal cyst
ovarian torsion
Patients with ovarian hyperstimulation syndrome are at increased risk for
ovarian torsion
What are the symptoms of a functional cyst
pain, menstrual irregularity
All of the following adnexal masses may appear sonographically similar to a uterine leiomyoma except: a. thecoma b. parovarian cyst c. fibroma d. granulose cell tumor
paraovarian cyst
Remnant of the Wolffian duct. They are cystic structures found in the broad ligament. Frequently seen superior to the uterine fundus
paraovarian cyst
Which cyst is found in the broad ligament
parovarian cyst
While scanning a 45 yr old pt you see a cyst superior to the uterine fundus in the rt adnexa separate from the ovary. What is a possible diagnosis
parovarian cyst
Cysts in the pelvic ligaments
parovarian cysts
List the clinical symptoms of Granulose Cell tumors?
precocious puberty vagional bleeding full breasts pain/ pressure/ fullness Meigs syndrome if tumor becomes torsed/ ruptures
Implants from an ovarian cystic tumor
pseudomyxoma peritonei
What it the penetration of the tumor capsule or rupture that may lead to intraperitoneal spread of mucin which leads to ascites with septations
pseudomyxoma peritonei
Pus within the fallopian tube is termed
pyosalpinx
A 55-year old patient presents to the ultrasound department with a history of pelvic pressure, abdominal swelling, and abdominal bleeding, A pelvic sonogram, reveals a large, muliloculated cystic mass with papillary projections. What is the most likely diagnosis?
serous cystadenocarcinoma
Large, malignant tumor with multiple septaitons
serous cystadenocarcinoma
Large, benign, separated cysts
serous cystadenoma
What benign ovarian neoplasm is associated with peritoneal ascites
serous cystadenoma
List the epithelial tumors
serous cystadenoma, serous cystadenocarcinoma mucinous cystadenoma, mucinous cystadenocarcinoma endometriod brenner tumor (transitional cell) clear cell carcinoma
Which two ovarian tumors secretes a male sex hormone and causes secondary male sex characteristics in the female
sertoli-leydig cell tumor PCOS cysts
Are serous cyst adenomas smaller or larger than mutinous cysts
smaller
Describe sonographic appearance of dysgerminoma
solid hyperechoic mass with areas of hemorrhage or necrosis, varies in size (a few cm to 50cm), unilateral, may undergo torsion due to rapid growth, prominent arterial flow, may contain a speckled pattern of calcifications, METS may occur due to perforations of the capsule and spread via the lypmh system
The most common location for a dermoid cyst is
superior to the fundus
The ovarian cyst associated with distinctly elevated levels of human chorionic gonadotropin is the
theca lutein cyst
The ovarian cyst associated with gestational trophoblastic disease is the
theca lutein cyst
These are the largest of the functional cysts. They are seen in association with excessive levels of BhCG. They are very large, multilocular cysts that may undergo rupture, hemorrhage or torsion
theca lutein cysts
Which of the following would be described as functional cysts that are found in the presence of elevated levels of human chorionic gonadotropin?
theca lutein cysts
Ovarian tumor with prominent shadowing
thecoma
Which of the following is an estrogen-producing ovarian tumor? a. Brenner tumor b. fibroma c. thecoma d. endometrioma
thecoma
What is another name for Brenner tumor
transitional cell
Are corpus luteum cyst of pregnancy bilateral, unilateral, or have the possibility to be both?
unilateral
Are corpus luteum cysts of menstruation bilateral, unilateral, or have the possibility to be both?
unilateral
Are follicular cysts bilateral or unilateral
unilateral
Are functional cyst bilateral, unilateral, or have the possibility to be both?
unilateral
Is a follicular cyst bilateral, unilateral, or have the possibility to be both?
unilateral
Is a paraovarian cyst bilateral, unilateral, or have the possibility to be both?
unilateral
Is an ovarian remnant cyst bilateral, unilateral, or have the possibility to be both?
unilateral
Is the corpus lutetium unilateral or bilateral
unilateral
Describe the appearance of endometriomas (chocolate cysts)
unilateral or bilateral rage from anechoic to solid- depending upon the amount of blood and its organizaiton well defined unilocular or multilocular cystic mass with diffuse homogenous low level internal echos fluid-fluid level can be commonly seen
List the risk factors of ovarian malignancy
women who have had breast or colon cancer family hx of ovarian or breast ca (strongest risk) increased age nullparity infertility uninterrupted ovulation late menopause
Hysterosalpingography utilizes what substance for the visualization of the uterine cavity and fallopian tubes
x-ray dye
A pt with an ovarian mass presents with an elevated serum alpha-fetoprotein. Which of the following would be the most likely? a. ovarian fibroma b. ovarian thecoma c. cystic teratoma d. yolk-sac tumor
yolk sac tumor