Ultrasound of the Female Pelvis - PowerPoint Presentation

Slide1

Ultrasound of the Female Pelvis

Ultrasound Evaluation of the Adnexa- Ovary and Fallopian Tube

Parts A & B

2-3 week lecture

HoldorfSlide2

Contents

Physiologic Cysts

Follicular Cysts

Corpus Luteum Cysts

Corpus Luteum of Pregnancy

Theca Lutein Cysts

Hemorrhagic Cysts

Ovarian Torsion

Polycystic Ovarian Syndrome (PCOD)Slide3

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)Slide4

Sex Cord-Stromal Tumors

Fibromas

MEIG’S syndrome

Thecoma

Granulosa

Sertoli-Leydig) (Androblastoma) Tumor

Metastatic Tumors (to the ovary)

Krukenberg Tumor

Ovarian Cancer ScreeningSlide5

CA125

Adnexal Pathology

Pelvic Inflammatory Disease (PID)

Hydrosalpinx

EndometriosisSlide6

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. Slide7

Several types of benign cysts exist:

Functional cysts

Follicular cysts

Corpus luteum cysts

Corpus luteum cyst of pregnancy

Theca lutein cystsSlide8

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;Slide9

Follicular cystsCorpus luteum cysts

Corpus luteum cysts of pregnancy

Theca lutein cystsSlide10

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

UnilocularSlide11

Follicular CystSlide12

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 appearanceSlide13

Corpus Luteum CystSlide14

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.Slide15

Corpus Luteum of PregnancySlide16

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.Slide17

Theca Lutein CystSlide18

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.Slide19

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 levelSlide20

Hemorrhagic Ovarian CystSlide21

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. Slide22

Risk factors for torsion include:

Preexisting ovarian cyst or mass

Children and young females with mobile adnexa (ovary is usually normal)

PregnancySlide23

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 massSlide24

Ultrasound of ovarian torsionSlide25

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.Slide26

Clinical signs

Obesity

Oligomenorrhea or amenorrhea

Hirsutism

InfertilitySlide27

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 Slide28

Cartoon of PCOS/DiseaseSlide29

Ultrasound of PCOSSlide30
Slide31

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:Slide32

SerousMucinous

Endometrioid

Clear Cell

Transitional Cell (Brenner)Slide33

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.Slide34

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.Slide35

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 septationsSlide36

Sonographic findings of malignant serous tumors

Multi-locular

Multiple papillary projections and septations

Occasionally echogenic material within

Possibly multiple echogenic foci

AscitesSlide37

Benign serous tumor: Serous Cystadenoma: A: Unilocular Serous cystadenoma B: Multi-locular CystadenomaSlide38

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.Slide39

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.Slide40

Sonographic findings of benign mucinous tumors

Multi-loculated with thicker and more numerous septations

Fine, gravity-dependent echoes

Up to 50cm in diameterSlide41

Sonographic findings of malignant mucinous tumors

Multi-loculated cystic lesions measuring 15-30cm in diameter

Contain echogenic material and papillary projectionsSlide42

Benign Mucinous TumorSlide43

Mucinous CystadenomaSlide44

Malignant Mucinous Tumor: Mucinous Cystadenoma of low malignant potentialSlide45
Slide46

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.Slide47

Sonographic findings

Cystic mass with papillary projections

In some cases, there may be a predominantly solid mass, possibly with areas of hemorrhage or necrosis

 Slide48

Endometrioid TumorSlide49

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 appearanceSlide50

Confirmed Clear Cell TumorSlide51

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)

 Slide52

Sonographic findings

Hypoechoic solid mass

Calcifications may be present

Usually cystic areas are seen

May mimic an ovarian fibromasSlide53

Brenner TumorSlide54

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) tumorSlide55

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 benignSlide56

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 ruptureSlide57

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 massSlide58

Predominantly Solid DermoidSlide59

Dermoid PlugSlide60

Dermoid “Tip of the Iceberg”Slide61

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 massSlide62

A known DysgerminomaSlide63

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

 Slide64

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.Slide65
Slide66

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.Slide67

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.Slide68

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 fibroidSlide69

Meig’s Syndrome: PESlide70

Chest and abdominal CT, showing pleural effusion (white arrow) and ovarian teratoma (black arrow)Slide71
Slide72

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 diameterSlide73

Sonographic findings

Hypoechoic with posterior acoustic attenuation-similar to fibromas

Possibly an abnormally thick endometrium secondary to hormonal stimulationSlide74

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.Slide75

Sonographic findings

Small tumors are predominantly solid, similar to uterine fibroids

Large tumors are multi-loculated and cystic, similar to cystadenomasSlide76

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 diameterSlide77

Sonographic Findings

Appearance is similar to that of granulose cell tumorsSlide78

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.Slide79

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.Slide80

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 carcinomaSlide81

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 ascitesSlide82

Krukenberg Ovarian TumorSlide83

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:Slide84

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.

 Slide85

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.Slide86

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.Slide87

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. Slide88

The inflammation may be localized or it may diffusely involve all pelvic organs.

PID predisposes women to infertility, tubal scarring, and ectopic pregnancy.

 Slide89

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 PIDSlide90

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 bleedingSlide91

HydrosalpinxSlide92

Tubo-Ovarian AbscessSlide93

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 peritoneumSlide94

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.Slide95

Clinical signs

Chronic pain

Infertility

4 Ds of endometriosis

Dysmenorrhea-painful menses

Dyspareunia-painful intercourse

Dysuria-difficult urination

Dyschezia-difficult defecationSlide96

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

 Slide97

Cartoon of EndometriosisSlide98

Ultrasound of EndometriosisSlide99