Ultrasound of the Female Pelvis Ultrasound Evaluation of the Adnexa- Ovary and Fallopian Tube Parts A & B 2-3 week lecture Holdorf Ultrasound of the Female Pelvis

Contents Physiologic Cysts Follicular Cysts Corpus Luteum Cysts Corpus Luteum of Pregnancy Theca Lutein Cysts Hemorrhagic Cysts Ovarian Torsion Polycystic Ovarian Syndrome (PCOD)

Surface Epithelial Stromal Tumors Serous Tumors Mucinous Tumors Endometrioid Tumors Clear cell tumor Transition cell (Brenner) Tumor Germ Cell Tumor Dysgerminoma Yolk Sac (Endodermal Tumor)

Sex Cord-Stromal Tumors Fibromas MEIG’S syndrome Thecoma Granulosa Sertoli-Leydig) (Androblastoma) Tumor Metastatic Tumors (to the ovary) Krukenberg Tumor Ovarian Cancer Screening

CA125 Adnexal Pathology Pelvic Inflammatory Disease (PID) Hydrosalpinx Endometriosis

Physiologic Cysts Ovarian cysts can be visualized sonographically in women of all ages. The presence of a simple (unilocular, anechoic, thin-walled) cystic mass related to either ovary measuring less than 3 cm is considered within normal limits. Sonographic and clinical follow-up however, is recommended when the dimensions of a cyst exceed 3cm. approximately 60% of ovarian cysts resolve spontaneously.

Several types of benign cysts exist: Functional cysts Follicular cysts Corpus luteum cysts Corpus luteum cyst of pregnancy Theca lutein cysts

Functional cysts Generic hormonally active cysts that usually result from the stimulation of released pituitary gonadotropins. They are the most common cause of ovarian enlargement in young women. Functional cysts range in size from 0.5 mm to 3cm, and are further categorized as the following;

Follicular cysts Corpus luteum cysts Corpus luteum cysts of pregnancy Theca lutein cysts

Follicular cysts Occur when a dominant follicle fails to extrude the ovum or fails to regress following ovulation. Serous fluid distends the lumen of the follicle creating cysts. Most follicular cysts are unilocular and measure 3 to 8cm. The maximum measurement of a normal dominant follicle is 3cm. Sonographic findings Anechoic Thin-walled Unilocular

Follicular Cyst

Corpus Luteum Cysts Occur when the dominant follicle extrudes the ovum. In the absence of a pregnancy, the corpus luteum cyst may continue to grow or hemorrhage into the lumen. They rarely exceed 4cm in diameter, may contain internal echoes, and cause symptoms that simulate an ectopic pregnancy. Sonographic findings Thick, hyperechoic Usually echogenic content Possible solid in appearance

Corpus Luteum Cyst

Corpus luteum cyst of pregnancy Is persistent in the corpus luteum in the presence of hCG. They can become enlarged, even grater than 6cm, and usually regress spontaneously by 14 weeks of gestation.

Corpus Luteum of Pregnancy

Theca Lutein cysts Are frequently multi-locular, and are the largest of the functional cysts. They result from overstimulation by the high levels of hCG associated with Trophoblastic disease or hCG administration during infertility treatment. The ovaries are bilaterally enlarged and the cysts may persist for days or weeks.

Theca Lutein Cyst

Hemorrhagic cyst Occasionally, an ovarian cyst may hemorrhage into the lumen, because of its large size, spontaneous rupture, or even torsion, Hemorrhage is most common in corpus luteum cysts. Clinically, patients present with a sudden onset of pelvic pain.

Sonographic findings Typical cystic appearance Acute cyst=hyperechoic, mimicking a solid mass, by with posterior acoustic enhancement Subacute hemorrhagic cyst=complex appearance, with internal echoes, strands, rarely a fluid-fluid level

Hemorrhagic Ovarian Cyst

OVARIAN TORSION Torsion of the ovary is caused by partial or complete rotation of the ovarian pedicle on its axis. Lymphatic and venous drainage is compromised, causing congestion and edema of the ovary, eventually leading to loss of artery perfusion and resultant infarction. Right sided torsion can clinically mimic acute appendicitis.

Risk factors for torsion include: Preexisting ovarian cyst or mass Children and young females with mobile adnexa (ovary is usually normal) Pregnancy

Sonographic findings Enlarged ovary, commonly with multiple cortical follicles Absent color and spectral Doppler flow (but this is varied depending on the degree of torsion Possible arterial Doppler flow but absent venous flow Possible adnexal mass

Ultrasound of ovarian torsion

POLYCYSTIC OVARIAN SYNDROME (PCOS)/Disease OR Stein-Leventhal Syndrome. Is an endocrinology disorder associated with chronic anovulation. It is most commonly found in adolescent girls and young women (teens to twenties). Diagnosis of PCOS is actually a clinical diagnosis, and not necessarily a sonographic diagnosis.

Clinical signs Obesity Oligomenorrhea or amenorrhea Hirsutism Infertility

Sonographic findings Bilateral multiple cysts of varying size throughout the subcapsular and stromal ovarian tissue Enlarged ovaries with tiny follicles in the subcapsular periphery Endovaginal Sonography may reveal multiple cysts present ranging from 2mm to 10mm ALWAYS bilateral

Cartoon of PCOS/Disease

Ultrasound of PCOS

Surface Epithelial Stromal Tumors Tumors arising form the surface epithelium that covers the ovary and the underlying ovarian stroma account for 65-75% of all ovarian neoplasms, and 89-90% of all ovarian malignancies. The tumor types are divided into five categories, based on epithelial differentiation:

Serous Mucinous Endometrioid Clear Cell Transitional Cell (Brenner)

Proliferative changes of these tumors are further divided into three categories: Benign Atypically proliferating (borderline, or low potential for malignancy) Malignant 10 to 15% of serious and mucinous tumors are borderline malignant. Although they have cytologic features of malignancy, they do not invade the stroma and have a good prognosis.

SEROUS TUMORS Common, accounting for 25-30% of al ovarian neoplasms. 50-70% of serous tumors are benign, but serous cystadenocarcinomas account for 40- 50% of all malignant ovarian neoplasms. Benign Serous tumors are bilateral 12-20% of the time, and occur most commonly in women 40-50 years of age. Malignant serous tumors are bilateral 50% of the time, and occur most commonly in per-and post menopausal women.

Cystadenofibromas A type of serous tumor with a solid component, more likely to mimic a malignant lesion. Tumor size varies, but typically serous are smaller than mucinous tumors. Sonographic findings of benign serous tumors Sharply marginated Anechoic Large, but usually unilocular Possibly internal thin-walled septations

Sonographic findings of malignant serous tumors Multi-locular Multiple papillary projections and septations Occasionally echogenic material within Possibly multiple echogenic foci Ascites

Benign serous tumor: Serous Cystadenoma: A: Unilocular Serous cystadenoma B: Multi-locular Cystadenoma

MUCINOUS TUMORS Benign mucinous tumors comprise 20-25% of all benign ovarian neoplasms, are more common in women 30-50 years of age, and very rarely are bilateral.

Malignant mucinous tumors account for only 5- 10% of all malignant primary ovarian neoplasms, occur most commonly in women 40-70 years of age. 15-20% are bilateral. Penetration of the tumor capsule or rupture may spread mucin-secreting cells into the peritoneal cavity, filling it with gelatinous material known as Pseudomyxoma Peritonei. It occurs with either benign or malignant mucinous tumors, and may have a sonographic appearance similar to ascites, possibly with multiple septations.

Sonographic findings of benign mucinous tumors Multi-loculated with thicker and more numerous septations Fine, gravity-dependent echoes Up to 50cm in diameter

Sonographic findings of malignant mucinous tumors Multi-loculated cystic lesions measuring 15-30cm in diameter Contain echogenic material and papillary projections

Benign Mucinous Tumor

Mucinous Cystadenoma

Malignant Mucinous Tumor: Mucinous Cystadenoma of low malignant potential

ENDOMETRIOID TUMORS 80% of ovarian Endometrioid tumors are malignant, but have a better prognosis than either serous or mucinous carcinomas. Endometrioid tumors account for 20-25% of all ovarian carcinomas. Histologically, Endometrioid tumors are identical to endometrial adenocarcinoma, and 30% of patients with this tumor have associated endometrial adenocarcinoma.

Sonographic findings Cystic mass with papillary projections In some cases, there may be a predominantly solid mass, possibly with areas of hemorrhage or necrosis  

Endometrioid Tumor

CLEAR CELL TUMOR Nearly always malignant, clear cell tumors constitute 5-10% of all malignant ovarian epithelial-stromal tumors. Most typically, they occur in women 50-70 years of age. Clear cell tumors are bilateral up to 20% of the time, and range in size up to 30cm. Sonographic findings Nonspecific Complex, but predominantly cystic in appearance

Confirmed Clear Cell Tumor

Transition cell (Brenner) tumor Only 1-2% of all primary ovarian tumors are Brenner tumors, and they are almost always benign. Occurring in women from 40-80 years of age, the mean age is 50 years. 6-7% are bilateral, and most are smaller than 2cm in diameter (few will exceed 10cm)  

Sonographic findings Hypoechoic solid mass Calcifications may be present Usually cystic areas are seen May mimic an ovarian fibromas

Brenner Tumor

GERM CELL TUMORS Are derived from the primitive germ cells of the embryonic gonad, and account for approximately 20% of all ovarian neoplasms. In adults, the vast majority of germ cell tumors are benign, 95% being the cystic Teratomas. In children and adolescents, more than 60% of ovarian neoplasms are of germ cell origin, and one- third of them are malignant. Three germ cell tumors are important to sonographers: Cystic teratoma Dysgerminoma Yolk sac (endodermal sinus) tumor

CYSTIC TERATOMA Most common benign germ cell tumor of the ovary, accounting for 15-25% of ovarian neoplasms Usually occurs in women of active reproductive years Also know as dermoid cyst, the tumors are composed of derivatives of all three germ layers (endoderm, mesoderm, ectoderm) In its purest form it is always benign

In approximately 2% of cases, malignant transformation can occur Up to 15% of tumors are bilateral Usually an incidental finding, but symptoms may include abdominal pain, abdominal mass or swelling, and abnormal bleeding Most common complication is ovarian torsion, less commonly rupture

Sonographic findings A wide range of sonographic appearances exist “DERMOID PLUG” – predominantly cystic mass with an echogenic mural nodule, which typically casts an acoustic shadow Tip of the iceberg sign – highly echogenic mass that shadows and obscures the posterior wall of the lesion Dermoid mesh-multiple echogenic linear interfaces floating within a cystic mass (hair fibers) Fat/fluid or hair-fluid level parent in an adnexal mass Calcifications present within an adnexal mass A complex, cystic adnexal mass

Predominantly Solid Dermoid

Dermoid Plug

Dermoid “Tip of the Iceberg”

DYSGERMINOMA A malignant germ cell tumor, comprising 3-5% of ovarian malignancies, Dysgerminoma occurs primarily in women under 30 years of age and are bilateral in 15% of cases. Highly radiosensitive, the 5-year survival rate is up to 90% Sonographic findings Muli-loculated, solid, echogenic ovarian mass

A known Dysgerminoma

YOLK SAC (ENDODERMAL SINUS) TUMOR The second most common malignant ovarian germ cell neoplasm after Dysgerminoma, the yolk sac tumor occurs in 20-30 year old women. Tumors are almost always unilateral, ranging in size from 3cm to 30cm in diameter. They are highly malignant, and metastasize via the lymphatic system and direct invasion of surrounding structures. Patients have increased levels of serum alpha-fetoprotein (AFP) Sonographic findings Similar in appearance to Dysgerminoma  

SEX CORD-STROMAL TUMORS Approximately 8% of all ovarian tumors are sex chord-stromal tumors, which arise from the sex cords of the embryonic gonad, or from ovarian stroma. One-half of these tumors are fibromas while most of the others are granulose cell tumors. Neoplasms of low-grade malignancy. Also included in this category are the Thecoma and Sertoli-Leydig cell (Androblastoma) tumors.

Fibroma Accounting for 4% of all ovarian neoplasms. Fibromas are benign. They occur at all ages, but most frequently during middle age. Fibromas range in size from microscopic to very large; ascites is associated with 10-15% of fibromas over 10cm in diameter.

MEIG’S SNYDROME Refers to ascites and pleural effusion associated with fibrous ovarian tumor (most commonly the fibromas), which disappears after excision of the tumor.

Sonographic findings Hypoechoic with posterior acoustic attenuation, a similar sonographic appearance to uterine leiomyomas Rarely with focal or diffuse calcifications Rarely bilateral Associated with ascites 10-15% of the time when the tumor is over 10cm Similar to Brenner tumor or Pedunculated uterine fibroid

Meig’s Syndrome: PE

Chest and abdominal CT, showing pleural effusion (white arrow) and ovarian teratoma (black arrow)

THECOMA Accounting for 1% of all ovarian tumors, thecomas occur most commonly in post- menopausal women who present with clinical sings of estrogen or androgen activity. 97% of cases are unilateral, and are rarely malignant. Varying in size, thecomas range form small to fairly large (5-10cm) in diameter

Sonographic findings Hypoechoic with posterior acoustic attenuation-similar to fibromas Possibly an abnormally thick endometrium secondary to hormonal stimulation

GRANULOSA 95% of granulose cell tumors are of the adult type, most often occurring in postmenopausal women of 50-55 years of age. These tumors commonly produce estrogen. Juvenile granulose cell tumors result in precocious puberty.

Sonographic findings Small tumors are predominantly solid, similar to uterine fibroids Large tumors are multi-loculated and cystic, similar to cystadenomas

SERTOLI-LEYDIG (ANDROBLASTOMA) TUMOR A rare tumor, accounting for less than 0.5% of ovarian neoplasms, 75% of these tumors occur in women under 30 years of age, and are almost all unilateral. Up to 20% are malignant. Approximately half of patients will present with symptoms of masculinization, or occasionally there is associated estrogen production. Most tumors are between 5 to 15cm in diameter

Sonographic Findings Appearance is similar to that of granulose cell tumors

METASTATIC TUMORS (to the ovary) It is estimated that approximately 5-10% of ovarian neoplasms are metastatic in nature. These neoplasms are usually bilateral sold masses. The most common primary sites of ovarian metastases are tumors of the breast and gastrointestinal tract.

Tumors spread to the ovary by several routes: Direct invasion Occurs usually from carcinomas of the uterus and fallopian tubes and occasionally from colonic and retroperitoneal malignancies. Peritoneal fluid. Carries malignant cells from anywhere within the abdominoplevic cavity Blood vessels and lymphatics Bring malignant cells from more distant sites.

KRUKENBERG TUMOR This specific type of metastatic ovarian cancer most commonly arises from a gastric carcinoma, but also from carcinomas of the large intestine, appendix and breast. It is characterized by the presence of mucin- filled signet-ring cells, and cannot be distinguished sonographically or by MRI from Primary carcinoma

Sonographic findings of metastatic ovarian carcinoma Bilaterally enlarged, solid ovarian masses Possible necrotic changes resulting in a complex, predominantly cystic appearance similar to cystadenocarcinoma Possible ascites

Krukenberg Ovarian Tumor

OVARIAN CANCER SCREENING Ovarian cancer is the fourth leading cause of cancer death and the fifth most frequent cancer in women. Ovarian cancer causes more deaths in American women than all other forms of primary gynecologic cancers. Because of its silence during its early stages, 60-70% of women have stage III or IV at the time of diagnosis. The overall five-year survival rate is 20-30%, but early detection in stage I increases the five-year survival rate to 80%. Protocols have recently been developed to screen for ovarian cancer and involve several components:

Risk assessment Average age = 50-59 years History of unsuccessful pregnancies, or nulliparity Family history criteria: ‘5% risk with one affected first-degree relative 7% risk with two or more affected-first degree relative Women who have used oral contraceptives are at REDUCED risk for ovarian cancer.  

CA125 A biological tumor marker that is elevated in the blood of most (80%) women with epithelial ovarian cancer, CA 125 has been found to detect less than 50% of stage 1 disease, and is insensitive to mucinous and germ cell tumors. Elevation is suggestive of the presence of carcinoma, but serum levels may also be elevated in women with other malignancies as well as benign GYN pathology, such as endometriosis and fibroids. Use of CA 125 with Sonography for screening has been more encouraging than use of CA 125 alone.

Sonography The presence of an ovarian mass in a post- menopausal woman with an elevated CA 125 is highly suggestive for carcinoma. However, Sonography cannot accurately distinguish benign form malignant masses; well-defined, anechoic lesions are more likely to be benign, whereas lesions with thick irregular septations, irregular walls, and solid components favor malignancy. Scoring systems based on sonographic characteristics have been proposed. One system, using two dimensional real-time Sonography alone, claims results of 97% sensitivity and 77% specificity.

ADNEXAL PATHOLOGY Pelvic inflammatory disease PID PID is a generic term refereeing to inflammation of pelvic and adnexal structures. The cause is most frequently sexually transmitted diseases, which ascend through the cervix and endometrial cavity into the pelvis. Common causative organisms include Chlamydia, gonorrhea, and E. coli, to name a few. Less commonly, infection can occur from Appendicular, diverticular, or postsurgical abscesses, or even post-abortion complications.

The inflammation may be localized or it may diffusely involve all pelvic organs. PID predisposes women to infertility, tubal scarring, and ectopic pregnancy.  

Hydrosalpinx HYDORSLAPINX is defined as the collection of fluid within a scarred or obstructed fallopian tube. The most frequent cause is the replacement of pus (pyosalpinx) by serous fluid in cases of documented PID. PID occurs in stages: Stage I early PID or endometritis Stage II salpingitis with or without pyosalpinx Stage III Severe PID with tubo-ovarian abscess (TOA) or pelvic peritonitis CHROINC long standing, Subacute condition which follows acute PID

Clinical signs A broad spectrum of non-specific complaints which include: Fever Leukocytosis Lower abdominal pain Pelvic tenderness, usually bilateral and diffuse Constant dull pain worsened by sexual activity (dyspareunia) Vaginal discharge - pus Vaginal bleeding

Hydrosalpinx

Tubo-Ovarian Abscess

ENDOMETRIOSIS Endometriosis is defined as the presence of functional endometrial tissue outside the endometrium and myometrium. Implants may occur anywhere within the pelvis, but most commonly occur in: Ovaries Fallopian tubes Uterine ligaments Posterior cul-de-sac Pelvic peritoneum

Implants may be small and sonographically undetectable, or large and palpable. Endometriosis is a benign proliferative disease that may cause extreme pain, or conversely be asymptomatic. Endometriosis is more common in Caucasians, women of reproductive age, and women of higher socioeconomic status who postpone having children until later in life. There are two forms of endometriosis: diffuse (scattered minute implants), or localized (endometrioma) which is a discrete mass sometimes called a chocolate cyst.

Clinical signs Chronic pain Infertility 4 Ds of endometriosis Dysmenorrhea-painful menses Dyspareunia-painful intercourse Dysuria-difficult urination Dyschezia-difficult defecation

Sonographic findings Well defined, unilocular or multi-locular cystic mass, often diffusely homogenous with low- level echoes Occasionally echo patterns may be solid, cystic, or complex Obliteration of pelvic tissue planes Diffuse form is rarely detected sonographically  

Cartoon of Endometriosis

Ultrasound of Endometriosis