OBGYN 1 - Chapter 44 - Part 1

Common Solid Masses

-solid teratoma -adenocarcinoma -arrhenoblastoma -fibroma -dysgerminoma -torsion

Doppler of the Ovary Cont. 2

Abnormal waveforms can be seen in inflammatory masses, metabolicaly active masses including ectopic pregnancy, and corpus luteum cysts RI is not a sensitive indicator of malignancy

Ovarian Torsion Cont. 2

Accounts for 3% gyn. operative emergencies Acute abd. condition requiring prompt diagnosis and surgical intervention Ovarian pedicle partially or completely rotates on its axis, compromising lymphatic and venous drainage

Hemorrhagic Cysts Cont.

Acute hemorrhagic cyst usually hyperechoic, may mimic solid mass Usually smooth post. wall and shows post. acoustic enhancement indicating cystic component Diffuse low level echoes may be seen but are commonly seen in endometriomas Internal pattern becomes more complex

Normal Sonographic Appearance of Ovaries Cont. 8

After hysterectomy, ovaries can be difficult to visualize w/ US Use of both TA and TV approaches increases chance of visualization

Complex Masses

Any simple cyst that hemorrhages as it involutes may appear as complex mass In pts. of reproductive age, classic differential considerations of complex adnexal mass are ectopic pregnancy, endometriosis, and PID Dermoids and other benign tumors can appear in similar fashion

Ovarian Torsion

Caused by partial or complete rotation of ovarian pedicle on its axis Produces enlarged endematous ovary, usually >4cm diameter

Ovarian Torsion Cont.

Classical: multiple tiny follicles around hypoechoic mass to completely solid adnexal mass Free fluid often present in pelvis Doppler exam usually reveals absent blood flow to torsed ovary

Ovarian Torsion Cont. 4

Clinical - acute severe unilateral pain Intermittent pain mat precede acute pain by weeks Symptoms mimicked by many other pelvic or lower abd. processes and frequently torsion part of differential diagnostic list

Polycystic Ovarian Syndrome Cont.

Clinical: amenorrhea, obesity, infertility, hirsutism Sonographic Findings: multiple tiny cysts around ovary periphery, ovary may be normal size or enlarged

Follicular Cysts Cont.

Clinical: asymptomatic to dull, adnexal pressure and pain, abnormal ovarian function, torsion of ovary results in severe pain Sonographic findings of simple cyst

Corpus Luteum Cysts Cont.

Clinical: irregular menstural cycle, pain, mimic ectopic pregnancy, rupture Sono Findings: cystic type of lesion, may have internal echoes secondary to hemorrhage and increased color

Endometriosis

Common condition which functioning endometrial tissue present outside uterus Ectopic tissue can be found almost anywhere in pelvis, including ovary/fallopian tube/broad ligament/ external surface of uterus/ scattered over peritoneum/ cul de sac/ bladder

Normal Sonographic Appearance of Ovaries Cont. 2

Cumulus oophorus may occasionally be detected as eccentrically located, cystlike, 1 mm internal mural protrusion Visualization of cumulus indicates mature follicle and imminent ovulation - no reproducible sonographic sign reliable Other follicles become atretic

Common Complex Masses

Cystadenoma Dermoid cyst Tubo-ovarian abscess Ectopic pregnancy Granulosa cell tumor

Endometriosis Cont.

Diffuse form more common and consists of endometrial plantings within peritoneum Rarely diagnosed by sonography Localized form consists of discrete mass called endometrioma or chocolate cyst and frequently found in multiple sites

Normal Sonographic Appearance Ovaries Cont.

During reproductive years, three phases recognized sonographically during each menstrual cycle During early proliferative phase, many follicles develop and increase in size until day 8-9 due to stimulation by both FSH and LH At that time one follicle becomes dominant, reaching up to 2-2.5cm at time of ovulation

Simple Cystic Masses Cont.

Finally produces progesterone after ovulation to sustain early pregnancy until placenta can do so at 10-12 weeks gestation

Common Cystic or Complex Ovarian Mass

Follicular cyst Corpus luteum cyst of pregnancy Cystic teratoma Paraovarian Cyst Hydrosalphinx Endometrioma - low level echoes Hemorrhagic Cyst

Normal Sonographic Appearance Cont. 3

Follicular cyst develops if fluid in nondominant follicles not reabsorbed Dominant follicle usually disappears immediatly after rupture at ovulation Occasionally follicle decreases in size and develops a wall that appears crenulated/scalloped

Normal Sonographic Appearance of Ovaries Cont. 7

Following menopause, ovary atrophies and follicles disappear w/ increasing age Postmenopausal ovary difficult to visualize in US b/c of smaller size and lack of discrete follicles Stationary Loop of bowel may mimic small shrunken ovary - look for peristalsis in bowel

Functional Ovarian Cysts

Functional cysts result from normal function of ovary Most common cause of ovarian enlargement in young women Functional cysts include follicular, corpus luteum, hemorrhagic, theca-lutein cysts

Normal Sonographic Appearance Ovaries

Homogenous echotexture May exhibit central more echogenic medulla Small anechoic or cystic follicles may be seen peripherally in cortex Appearance varies w/ age and menstural cycle

Functional Ovarian Cysts Cont.

Hormonal therapy sometimes administered to suppress cyst Most cysts measure <5 cm in diameter and regress during subsequent menstrual cycle Follow up sonographic exam in 6 weeks usually documents change in size

Simple Cystic Masses Cont. 3

If cyst >6cm persists more than 8 weeks, surgical intervention may be considered US guided needle aspiration has become another option for reducing recurrent simple ovarian cysts in carefully selected cases

Ovarian Volume

In adult mensturating female, normal ovary may have volume as large as 22cc w/ mean volume 9.8 +/- 5.8 cc Volume more than 8.0 cc considered abnormal for post menopausal pt

Polycystic Ovarian Syndrome

Includes Stein-Leventhal Syndrome Bilaterally enlarged polycystic ovaries Occurs in late teens - 20s May have endocrine imbalance Spectrum of sonographic appearances

Hemorrhagic cysts

Internal hemorrhage may occur in follicular cysts or more commonly in corpus luteal cysts Pt. may present w/ acute onset of pelvic pain

Theca Lutein Cysts

Large, bilateral, multiloculated cysts Associated w/ high levels of HCG Seen in 30% pts. w/ trophoblastic disease Clincally - N and V Sono - multilocular cysts in both ovaries

Normal Sonographic Appearance of Ovaries Cont. 5

Less frequent appearances include typical ring color Doppler pattern around wall of isoechoic corpus luteum In absence of fertilization, corpus luteum begins to undergo involutional changes on postovulatory days 8-9 - disappears shortly before or with onset of mensturation

Simple Cystic Masses Cont. 4

Majority of ovarian masses simple cysts, most of which are benign US criteria for simple cysts include thin smooth wall, anechoic contents, and acoustic enhancement

Solid Tumors

Mixed solid to cystic ovarian masses typical of all epithelial ovarian tumors Most common are serous types, cystadenoma and cystadenocarcinoma During peak fertile years, only 1 in 15 malignant, ratio becomes 1 in 3 after age 40

Solid Tumors Cont.

More sonographically complex the tumor, more likely to be malignant, especially if associated w/ ascites Epithelium of serous tumors tubal in type - may be one or multiple cysts 1/4 bilateral - most occur in women >40 - large and often fill pelvic cavity

Normal Sonographic Appearance of Ovaries Cont. 6

Multiple small penctate echogenic foci commonly seen in normal ovary Foci reported to be common finding w/ TVS Generally very small 1-2mm and located in periphery Focci are nonshadowing and can be multiple

Ovarian Hyperstimulation Syndrome

OHS frequenct iatrogenic complication of ovulation iduction In mild form, pt. presents w/ pelvic discomfort, but no significant weight gain Ovaries enlarged, measure <5cm diameter

Follicular Cysts

Occur when dominant follicle does not succeed in ovulating and remains active though immature Usually unilateral Thin walled translucent, have watery fluid, may project above/within surface of ovary May grow 1-8 cm Usually disappear spontaneously by resorption or rupture

Normal Sonographic Appearance Ovaries Cont. 4

Occurrence of fluid in cul-de-sac commonly seen after ovulation and peaks in early luteal phase Following ovulation in luteal phase, mature corpus luteum develops and may be identified sonographically as small hypoechoic/isoechoic structure peripherally in ovary May appear irregular w/ echogenic crenulated walls and contain low level echoes

Simple Cystic Masses

Ovary function is to mature oocytes until ovulation under influence of LH and FSH from pituitary At same time ovary synthesizes androgens (male hormones) and converts them to estrogens (female hormones)

Solid Tumors Cont. 2

Ovary w/ volume twice that of opposite side generally considered abnormal When solid mass found, care taken to identify connection w/ uterus to differentiate ovarian lesion from pedunculated fibroid Color doppler helpful by using color to identify vascular pedicle between uterus and mass as can often be identified w/ pedunculation

Ovarian Torsion Cont. 5

Pt. has fever, nausea, vomiting Palpable mass felt in more than 50% pts. Rt ovary 3x more likely to torse than left

Corpus Luteum Cysts

Result from hemorrhage within persistently mature corpus luteum Filled w/ blood and cystic fluid May grow 1-10cm in size May accompany intrauterine pregnancy IUP

Simple Cystic Masses Cont. 5

Small anechoic cysts may be seen in postmenopausal ovaries Can disappear or change in size over time - serial studies can monitor size and document changes Surgery generally recommended for postmenopausal cysts >5cm and for those containing internal septations and/or solid nodules

Doppler of the Ovary

Suspected cystic lesion: color Doppler helpful in differentiating potential cyst from adjacent vascular structures Color can be used to localize flow to further determine flow velocity w/ pulsed Doppler - can be obtained on all ovarian masses Pulsed doppler interrogation of adnexal branch of uterine artery, ovarian arter, intratumoral flow performed to determine resistive index or pulsatility index

Ovarian Torsion Cont. 7

Torsed masses often large >4cm diameter Vary in appearance from cystic to solid, vary in echogenecity from relatively anechoic to markedly hyperechoic Palpable mass may be present Torsion occurs more frequently on rt. side, and pain may mimic acute appendicitis

Ovarian Torsion Cont. 6

Torsed ovary typically enlarged and heterogenous in appearance, owing to edema, homorrhage, and/or necrosis Is often a lead mass, but in some cases mass not appreciated b/c mixed in w/ necrosis and hemorrhage of torsed mass

Ovarian Torsion Cont. 3

Usually associated w/ mass Hypoechoic enlarged ovary, w/ or w/o peripheral follicles Absent blood flood on Doppler exam Free fluid in cul de sac Surgical emergency

Simple Cystic Masses Cont. 2

Usually one follicle enlarges from 3mm to approx. 24mm over about 10 days mid and late follicular phases Followed by ovulation Resulting corpus luteum or abnormal unruptured follicle can persist as simple or complex cystic structure from 1-10cm

Paraovarian Cysts

Usually simple Can bleed or torse Wolffian duct remnants 10% of all adnexal masses Located in broad ligament Clinical - asymptomatic Sono - simple cyst adjacent to ovary

Ovarian Volume Cont.

Volume of more an twice that of opposite side should be considered abnormal regardless of size

Ovarian Hyperstimulation Syndrome Cont.

W/ severe hyperstimulation, pt. has severe pelvic pain, abd. distension and notable enlarged ovaries measuring >10cm diameter Associated ascites, pleural effusions, numerous large thin walled cysts through periphery When treated condition resolved in 2-3 weeks usually

Endometrioma

Well defined unilocular or multilocular Predominantly cystic mass Containing diffuse homogenous low level internal echoes

Doppler of the Ovary Cont.

What is the value of RI in distinguishing between benign and malignant adnexal masses? Largest study uses cutoff of > 0.4 as normal RI in nonfunctioning ovary Other investigators use PI of >1 normal Signs that may be malignant: intratumoral vessels, low resistance flow, absence of normal diastolic notch in doppler waveform