Ovarian Pathology

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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


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