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