1. 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

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

3. 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)

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

5. CA125
Adnexal Pathology
Pelvic Inflammatory Disease (PID)
Hydrosalpinx
Endometriosis

6. 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.

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

8. 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;

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

10. 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

11. Follicular Cyst

12. 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

13. Corpus Luteum Cyst

14. 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.

15. Corpus Luteum of Pregnancy

16. 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.

17. Theca Lutein Cyst

18. 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.

19. 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

20. Hemorrhagic Ovarian Cyst

21. 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.

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

23. 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

24. Ultrasound of ovarian torsion

25. 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.

26. Clinical signs
Obesity
Oligomenorrhea or amenorrhea
Hirsutism
Infertility

27. 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

28. Cartoon of PCOS/Disease

29. Ultrasound of PCOS

31. 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:

32. Serous
Mucinous
Endometrioid
Clear Cell
Transitional Cell (Brenner)

33. 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.

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

35. 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

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

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

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

39. Malignant mucinous tumors account for only 5- 10% of all malignant primary ovarian neoplasms,
occur most commonly in women years of age % 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.

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

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

42. Benign Mucinous Tumor

43. Mucinous Cystadenoma

44. Malignant Mucinous Tumor: Mucinous Cystadenoma of low malignant potential

46. 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.

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

48. Endometrioid Tumor

49. 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 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

50. Confirmed Clear Cell Tumor

51. 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 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)

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

53. Brenner Tumor

54. 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

55. 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

56. 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

57. 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

58. Predominantly Solid Dermoid

59. Dermoid Plug

60. Dermoid “Tip of the Iceberg”

61. 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

62. A known Dysgerminoma

63. YOLK SAC (ENDODERMAL SINUS) TUMOR
The second most common malignant ovarian germ cell neoplasm after Dysgerminoma, the yolk sac tumor occurs in 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

64. 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.

66. 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.

67. 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.

68. 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

69. Meig’s Syndrome: PE

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

72. 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

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

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

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

76. 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

77. Sonographic Findings
Appearance is similar to that of granulose cell tumors

78. 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.

79. 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.

80. 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

81. 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

82. Krukenberg Ovarian Tumor

83. 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:

84. 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.

85. 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.

86. 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.

87. 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.

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

89. 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

90. 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

91. Hydrosalpinx

92. Tubo-Ovarian Abscess

93. 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

94. 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.

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

96. 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

97. Cartoon of Endometriosis

98. Ultrasound of Endometriosis