Ovaries and Adnexa

IOTA colour Doppler classification

1. No blood flow 2. Minimal flow 3. Moderate flow 4. Highly vascular with marked flow

Mucinous cystadenoma

25% of all benign ovarian neoplasm Often occur in the 3rd to 6th decades, can be seen in very young women Usually unilateral Sonographic Appearance Huge cystic masses, measuring up to 30cm and filling the entire pelvis and abdomen Multiple thin septa are present Low level echoes caused by mucoid material may be seen in the loculations

Mucinous cystadenocarcinoma

5%-10% of all primary malignant ovarian neoplasms Frequently occur in the 4th to 7th decades Usually unilateral Sonographic Appearance Usually large multiloculated cystic masses Contain papillary projections and echogenic material Generally have a similar appearance to serous cystadenoma Pseudomyxoma peritonei - Similar sonographic appearance to ascites - May contain multiple septations or floating debris - Caused when penetration of the tumor capsule or rupture leads to intraperitoneal spread of mucin-secreting cells that fill the peritoneal cavity with gelatinous material

IOTA Multilocular cysts

A cyst with at least one septum by no measurable solid component or papillary projection

IOTA unilocular cyst

A cyst without septa, solid parts, or papillary structures

IOTA multilocular-solid cyst

A multilocular cyst with a measurable solid component or at least one papillary projections

IOTA solid tumor

A tumour where the solid component comprises 80% or more of the tumour when assessed in 2D sections May contain papillary projections protruding into the small cysts of the solid tumour

IOTA unilocular-solid cyst

A unilocular cyst with a measurable solid component or at least one papillary structure

Postoperative pelvic masses

Abscesses - Ovoid shaped - Hypoechoic masses with thick irregular walls - Posterior acoustic enhancement - Can contain gas - Vascularity within wall of the abscess Hematomas - Have a spectrum of ultrasound findings varying with time - Initial hyperacute phase = anechoic - After organization and clot formation = highly echogenic - With lysis of the clot they are again anechoic Lymphoceles - Occur after surgical disruption of lymphatic channels - anechoic Urinomas - localized collection of urine - anechoic Seromas - localized collection of serum

Endometrioid tumour

Almost all endometrioid tumors are malignant Second most common epithelial malignancy 30% are bilateral Occur frequently in 5th and 6th decades Has better prognosis than other epithelial malignancies, probably related to diagnosis at an earlier stage Sonographic Appearance Cystic mass containing papillary projections Some are predominantly a solid mass that may contain areas of hemorrhage or necrosis

Transitional cell tumour

Also known as Brenner tumor Uncommon and almost always benign Mostly asymptomatic and found incidentally Approx. 30% are associated with cystic neoplasms Sonographic Appearance Hypoechoic solid masses Calcifications may occur in the outer wall Cystic component is uncommon, but when present usually results from a coexistent cystadenoma

IOTA cystic contents

Anechoic Ground glass Hemorrhagic Mixed echogenicity

IOTA solid papillary projections

Any solid projections into the cyst cavity from the cyst wall >3mm Described as smooth or irregular projections

Metastatic tumours

Approx. 10% of ovarian neoplasms are metastatic in origin Most common primary sites of ovarian metastases are tumors of the breast and GI tract Sonographic Appearance Bilateral solid masses May become necrotic and may have a complex predominantly cystic appearance that simulates primary cystadenocarcinoma Ascites

Sertoli-Leydig tumour

Rare Occurs in women <30yrs Malignancy occurs in 20% of theses tumors Symptoms Viralization - 30% Half will have no endocrine manifestations Occasionally associated with estrogen production Sonographic Appearance Solid, hypoechoic masses Similar in appearance to granulosa cell tumors

Yolk sac tumour

Rare Rapidly growing tumor Poor prognosis Arises from undifferentiated, multipotential embryonal carcinoma by selective differentiation toward yolk sac or vitelline structures Usually occur in women <20yrs Lab Results Increased levels of serum alpha-fetoprotien Sonographic Appearance Similar appearance to dysgerminoma Has both echogenic and hypoechoic components

Luetoma of pregnancy

Rare benign solid mass Stromal cells become hormonally active, producing androgens and replacing the normal ovarian parenchyma Symptoms Asymptomatic Maternal virilization 30% - Have 50% risk of virilization of female fetus Sonographic Appearance Nonspecific, heterogenous, predominantly hypoechoic masses May be highly vascular

Peritoneal inclusion cysts

Represent a type of pseudocyst, with fluid accumulation entrapped by peritoneal adhesions The fluid which is produced from the ovary, occurs following an insult to the peritoneum; consequently PICs are seen in patient with peritoneal adhesions, previous trauma, injury, or endometriosis Symptoms Pain Pelvic mass Sonographic Appearance Recognized on the basis of two key features - Lack of a wall o PICs typically have an irregular passive shape that conforms to and is defined by the contour of the surrounding structures - Entrapment of the ovary either within or at the periphery of the fluid collection Doppler may demonstrate vascularity within septations, at times mimicking malignancy

Hemorrhagic cyst

Results from hemorrhage into a corpus luteum or another functional cyst Typically resolve within 8-12 weeks Symptoms Acute pelvic pain Pelvic mass Asymptomatic Sonographic Appearance Can have a variety of appearances depending on the stage of evolution of the blood products and clot Echogenic Avascular Homogenous or heterogenous Nonshadowing material Lace-like reticular echoes or an intracystic solid clot - Fluid-fluid level is possible Thin wall - Clot may adhere to cyst wall mimicking a nodule, but has no blood flow on Doppler - Retracting clot may have sharp or concave borders, mural nodularity does not Posterior acoustic enhancement Free intraperitoneal fluid in posterior cul-de-sac helps confirm diagnosis of leaking or ruptured hemorrhage cyst

Adnexal torsion

Rotation of the ovary and portion of the fallopian tube supplying the vascular pedicle Can be intermittent or sustained and results in venous, arterial, and lymphatic stasis Gynecologic emergency and requires urgent surgical intervention to prevent ovarian necrosis Occurs mainly in young women 15-30yrs. Approx. 20% of cases occur during pregnancy. Causes Hypermobility of the ovary - 50% Adnexal mass - 50%-80% - Most lesions are dermoid cysts or paraovarian cysts - Large cystic ovaries undergoing ovarian hyperstimulation are at particular risk - Masses between 5-10cm are at most risk In early pregnancy a torsion can occur secondary to a corpus luteal cyst or laxity of the adjacent tissues Symptoms Severe non-specific lower abdominal and pelvic pain Either intermittent or sustained nausea and vomiting Adnexal tenderness Raised WCC Sonographic Appearance Enlarged ovary, especially when compared with contralateral ovary Ovarian oedema Variable echogenicity - hypo or hyperechoic - Long standing infarcted ovary may have a more complex appearance with cystic or haemorrhagic degeneration Peripherally displaced follicles with hyperechoic central stroma - follicular ring sign Midline ovary position Doppler findings in torsion are variable - Little or no ovarian venous flow; common - Absent arterial flow; sign of poor prognosis - Absent or reversed diastolic flow - Normal vascularity does not rule out intermittent torsion o Normal Doppler flow can also occasionally be found due to dual supply from both the ovarian and uterine arteries Whirlpool sign of twisted vascular pedicle An underlying ovarian lesion may be seen Ovary tenderness to transducer pressure Free pelvic fluid >80% of cases Urgent surgery is required to prevent ovarian necrosis Most ovaries are not salvageable, in which case a salpingo-oophorectomy is required

Serous cystadenocarcinoma

Serous cystadenocarcinomas account for all malignant ovarian neoplasms Most frequently occur in perimenopausal and postmenopausal women Approx. 50% are bilateral Sonographic Appearance Large, multilocular cystic masses Contain multiple papillary projections arising from the cyst walls and septa The septa and walls may be thick Echogenic solid material may be seen within the loculations Papillary projections may form on the surface of the cyst and surrounding organs, resulting in fixation of the mass Ascites is frequently seen

Serous cystadenoma

Serous cystadenomas account for 25% of all benign ovarian neoplasms Peak incidence in 4th and 5th decades Approx. 20% are bilateral Sonographic Appearance Large, thin walled cysts Typically unilocular May contain thin septations Papillary projections occasionally seen

IOTA incomplete septum

Strand of tissue running across the cyst from one internal surface to the contralateral side, but which is not seen in all scanning planes

Fallopian tube carcinoma

The fallopian tube is now thought to be the location of the initial development of high-grade serous cystadenocarcinomas Serous tubal intraepithelial carcinoma is too small to visualise using imaging modalities Minority of patients have a profuse watery discharge - hydrops tubae profluens Tumour usually involves the distal end, but it may involve the entire length of the tube Sonographic Appearance Sausage shaped, solid or cystic mass with papillary projections

IOTA septum

Thin strand of tissue running across the cyst cavity from one internal surface to the contralateral side

Thecoma

Tumours with an abundance of thecal cells are classified as thecomas - Predominantly occur in postmenopausal women - Unilateral - Almost always benign - Frequently show clinical signs of estrogen production Sonographic Appearance Hypoechoic mass with marked posterior attenuation Main differential diagnosis is a pedunculated uterine fibroid Can have a varied sonographic appearance

Immature teratomas

Uncommon Rapidly growing malignant tumor that most often occurs in first two decades of life Sonographic appearance - Solid mass - Cystic structures of varying sizes may be seen - Calcifications

Ovarian vein thrombosis

Uncommon Usually seen 48-96hrs postpartum Can result in PE Underlying cause is venous stasis and spread of bacterial infection from endometritis Right ovarian vein is involved 90% of cases Symptoms Fever Lower abdominal pain Palpable mass Risk Factors Pregnancy Oral contraceptives Pelvic infection Malignancy Recent surgery Sonographic Appearance May demonstrate an inflammatory mass lateral to the uterus and anterior to the psoas muscle Tubular/serpinginous hypoechoic structure in the adnexa adjacent to the ovarian artery If the ovarian vein is identifiable, the absence of Doppler flow can be a diagnostic feature Thrombus usually affects the most cephalic portion of the right ovarian vein and can be demonstrated as echogenic thrombus at the junction of the right ovarian vein with the IVC, sometimes extending into the IVC

Ovarian hyperstimulation syndrome

When hyperstimulation is accompanied by fluid shifts Mild Associated with lower abdominal discomfort but no significant weight gain Enlarged ovaries <5cm in diameter Moderate Weight gain 5-10pounds Enlarged ovaries 5-12cm Patient may have nausea and vomiting Severe Weight gain >10pounds Severe abdominal pain and distention Ovaried greatly enlarged >12cm Ovaries contain numerous large, thin-walled cysts, which may replace most of the ovary The associated ascites and pleural effusions may lead to depletion of intravascular fluids and electrolytes, resulting in hemoconcentration with hypotension, oliguria, and electrolyte imbalance

Fibroma

fewer thecal cells and abundant fibrous tissue - Benign - Unilateral - Occur most often in perimenopausal and postmenopausal women - Asymptomatic - Ascites is present in up to 50% of patients with fibromas >5cm in diameter - Meigs syndrome (associated ascites and pleural effusion) occurs in some cases - Fibromas also occur in approx. 17% of patients with basal cell nevus (Gorlin) syndrome o Bilateral o Calcified o Occur in younger women around 30yrs Sonographic Appearance Hypoechoic mass with marked posterior attenuation Main differential diagnosis is a pedunculated uterine fibroid Can have a varied sonographic appearance

Mature cystic teratoma

Are composed of three well-differentiated derivatives of the three germ layers - Ectoderm - Mesoderm - Endoderm Because ectodermal elements generally predominate, cystic teratomas are virtually always benign Contain developmentally mature skin complete with hair follicles and sweat glands, clumps of hair, pockets of sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue Typically seen in young women around 30yrs, and are the most common ovarian neoplasm in patients <20yrs Symptoms Uncomplicated dermoid tend to be asymptomatic and are often discovered incidentally Predispose ovarian torsion and then may present with acute pelvic pain Sonographic Appearance Cystic adnexal mass with some mural components Most lesions are unilocular Diffusely or partially echogenic mass with posterior attenuation owing to sebaceous material and hair within the cyst cavity - Echogenic interface at the edge of mass that obscures deep structures: tip of the iceberg sign Mural hyperechoic Rokitansky nodule - dermoid plug Echogenic, shadowing calcific or dental components Presence of fat-fluid levels Multiple thin, echogenic bands caused by hair in the cyst cavity: the dot dash pattern No internal vascularity on colour Doppler Intracystic floating balls sign

IOTA not classifiable

Because of poor visualisation

Hyperactive luteinalis

Caused by abnormal response to circulating hCG in the absence of ovulation induction therapy Usually occurs in the third trimester Symptoms Asymptomatic Maternal virilization 25% Incident increases in women with PCOS Sonographic Appearance Bilaterally enlarged ovaries with multiple cysts

Paraovarian cyst

Congenital remnants that arise from the wolffian or Mullerian duct in the mesovarium Account for 10-20% of adnexal masses Commonly seen in 3rd and 4th decades Key to making a diagnosis is to apply transducer pressure and separate these two contiguous structures Sonographic Appearance Thin walled, unilocular cysts Can hemorrhage No cyclic changes <8cm

Clear cell tumour

Considered to be of Mullerian duct origin and a variant of endometrioid carcinoma Almost always malignant and constitutes 5%-10% of primary ovarian carcinomas Occurs frequently in the 5th to 7th decades Is bilateral in 20% of patients Associated pelvic endometriosis is present in 50%-70% of clear cell carcinomas, and approx. one third arise within the lining of endometriomas Sonographic Appearance Usually presents as a nonspecific, complex, predominantly cystic mass

Follicular cyst

Develop when a mature follicle fails to ovulate or to involute Functional cyst Should resolve in 8-12 weeks Symptoms Asymptomatic Usually found incidentally Acute abdominal pain caused by internal hemorrhage, rupture, or leakage Sonographic Appearance Simple cyst >3cm

Pelvic congestion syndrome

Dilatation of pelvic veins and reduced venous return causing dull chronic pain that is exacerbated by prolonged standing and relieved by lying down and elevating the legs Sonographic Appearance Ovarian vein diameter >10mm with reflux Uterine vein engorgement Congestion of ovarian plexuses - tortuous and dilated pelvic venous plexuses in the adnexa with individual varices measuring >5mm Filling of the pelvic veins across the midline Spectral Doppler evaluation of ovarian veins may demonstrate reversed caudal flow

Pelvic adhesions

Endometriosis is commonly accompanied by the presence of pelvic adhesions Can be difficult to evaluate sonographically, however, sliding tests may be used Movement of normally mobile uterus and ovaries by pressure can show adherence of these structures to the adjacent broad ligament, pouch of Douglas, bladder, rectum, or peritoneum Deep infiltrating endometriosis is the most severe form of the disease

IOTA solid

Exhibits high echogenicity suggesting the presence of tissue Presence of flow

Hydrosalpinx

Fluid-filled dilatation of the fallopian tube If the fluid is infected with pus, then it is a pyosalpinx. If bloody, then it is a haematosalpinx Symptoms Asymptomatic Pelvic pain Infertility Causes Endometriosis Ovulation induction Pelvic inflammatory disease Post-hysterectomy Tubal ligation Tubal malignancy Sonographic Appearance Elongated tubular mass with indentations of its opposing walls - waist sign Incomplete septation, likely due to the infolding of the tube on itself Thick wall with 'cogwheel' appearance is common in acute inflammation Small mural nodules similar to beads on string suggest chronic dilatation

Theca luetin cyst

Functional ovarian cyst Originate due to excessive amounts of circulating gonadotrophins - bhCG Increases risk of ovarian torsion Associations Gestational trophoblastic disease Multifetal pregnancy PCOS Diabetes Ovulation induction Sonographic Appearance Bilateral enlarged, multicystic ovaries Large cysts 2-3cm Large amount of solid component

Granulosa cell tumour

Has low malignant potential 95% of the adult type occur in postmenopausal women Most common estrogenically active ovarian tumor, and clinical signs of estrogen production can occur, including development of endometrial carcinoma Juvenile type occurs in patients <30yrs Sonographic Appearance Variable appearance ranging from small solid masses to tumors with variable degrees of hemorrhage or fibrotic changes, to multilocular cystic lesions

Pelvic inflammatory disease

Inflammation of the endometrium, fallopian tubes, pelvic peritoneum, and adjacent structures Primary infection is a STI most often gonorrhea and chlamydia Infection generally ascends from vagina or cervix > endometrium > fallopian tubes > contiguous structures The disease is manifested by tubo-ovarian complexes, peritonitis, and abscess formation and is usually bilateral Long term sequalae include pelvic pain, infertility, and increased risk of ectopic pregnancy Symptoms Pain Fever Cervical motion tenderness Vaginal discharge Sonographic Appearance Often only demonstrates ascitic fluid in the peritoneal cavity or nonspecific thickening and increased vascularity of the endometrium In most severe cases, adnexal masses with a heterogenous echo-pattern may be seen Sonographic signs of tubal inflammation include - Thickened/dilated fallopian tubes - Incomplete septa in the tube - Increased vascularity around the tube on colour Doppler - The fat around the tube may be echogenic and there may be a small amount of reactive free fluid in the pelvis - Echogenic fluid in the tube (pyosalpinx) - Cogwheel sign - Beads on a string sign

Struma Ovarii

Is a teratoma composed entirely or predominantly of thyroid tissue Occurs in 3% of teratomas Colour flow is detected centrally in solid tissue Although associated hormonal effects are rare, the pelvis should be assessed in a hyperthyroid patient when there is no evidence of a thyroid lesions in the neck

Dysgerminoma

Malignant germ cell tumor Accounts for 5% of ovarian malignancies Composed of undifferentiated germ cells and are morphologically identical to the male testicular seminoma Occurs predominantly in women <30yrs Have good survival rate - 5yr survival rate of 75%-90% Sonographic Appearance Solid masses that are predominantly echogenic but may contain small anechoic areas caused by hemorrhage or necrosis Demonstrated prominent arterial flow within the fibrovascular septa of multilobulated, solid, echogenic mass

Endometriosis

Most common benign gynecologic disorder Presence of functioning endometrial tissue outside the uterus Can present in different adnexal forms - Endometriomas - Peritoneal plaques - Adhesions Common areas involved - Ovary - Fallopian tube - Broad ligament - Posterior cul-de-sac Symptoms Pelvic pain Dysmenorrhea Dyspareunia Dyschezia Urinary symptoms Infertility

Endometrioma

Most common manifestation of endometriosis Symptoms Chronic discomfort associated with menses Sonographic Appearance Diffuse homogenous low level internal echoes Well defined Unilocular or multilocular Predominantly cystic mass containing diffuse, homogenous, low level internal echoes - ground glass sign Colour Doppler shows minimal or no vascularity Occasionally, a fluid-fluid level may be seen Can have small calcification Postmenopausal Sonographic Appearance Multilocular mass More anechoic fluid or comprised of more heterogenous echogenicity Endometriomas show little change in size and echo pattern over time

Polycystic ovarian syndrome

Multifaceted endocrinologic disorder of ovarian dysfunction that includes abnormal estrogen and/or androgen production resulting in chronic anovulation and hyperandrogenism Diagnosis requires two of the following three criteria 1. Ovulatory dysfunction - oligo and/or anovulation 2. Clinical and/or biochemical signs of hyperandrogenism 3. Polycystic ovarian morphology on ultrasound Symptoms Oligomenorrhea or amenorrhea Hirsutism Obesity Infertility Higher than usual rate of early pregnancy loss Acne Lab Results Elevated serum luteinizing hormone (LH) Insulin resistance Sonographic Appearance Bilaterally enlarged ovaries >10mL >20 small follicles 2-9mm per ovary Ovaries are rounded with follicles located peripherally - string of pearls Increased stromal echogenicity These criteria are not considered valid if the patient is taking oral contraceptive or has a dominant follicle greater than 10mm

Corpus lutein cyst

Occurs when a corpus luteum fails to regress following the release of an ovum When associated with pregnancy, it is the most common pelvic mass encountered within the 1st trimester Functional cyst Should resolve in 8-12 weeks Symptoms Pain Sonographic Appearance Diffusely thick wall Peripheral vascularity 2-10cm Possible crenulated contour Can have complicating internal hemorrhage; fine internal lace-like echo pattern seen Ring of fire around cyst with no internal flow

Ovarian blood supply

Ovarian artery and uterine artery Right ovarian vein drains directly into IVC. Left ovarian vein drains into left renal vein then IVC

Waldeyer fossa

Ovarian fossa

Hyperstimulated ovaries

Pregnancy associated Normal response to elevated circulating levels of hCG Most common in women undergoing ovulation induction Sonographic Appearance Enlarged ovaries with multiple cysts Some cysts may be hemorrhagic Enlarged ovaries can undergo torsion Spontaneously regress during the pregnancy