A Practical Approach to Adnexal Masses
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1 A Practical Approach to Adnexal Masses Darcy J. Wolfman, MD Section Chief of Genitourinary Imaging American Institute for Radiologic Pathology Clinical Associate Johns Hopkins Community Radiology Division Washington, DC, USA
2 Nothing to disclose
3 A Practical Approach to Adnexal Masses Clinical History Location Adnexal Lesions Diagnosis Follow Up
4 Adnexal Mass Clinical History
5 Positive pregnancy test Clinical History
6 Clinical History Positive pregnancy test Ectopic Pregnancy
7 Clinical History Positive pregnancy test Ectopic * Pregnancy
8 Clinical History Signs and Symptoms of Pelvic Inflammatory Disease
9 Clinical History Signs and Symptoms of Pelvic Inflammatory Disease Tubo-ovarian Abscess
10 Adnexal Mass Clinical History Ovary Extraovarian
11 Ovarian tissue extending around lesion Ovarian Location
12 Ovarian tissue extending around lesion Ovarian Location
13 Ovarian Location Ovarian tissue extending around lesion No separate ipsilateral ovary
14 Extraovarian Location Ipsilateral ovary separate from lesion
15 Extraovarian Location Ipsilateral ovary separate from lesion *
16 Common Extraovarian Lesions Para-ovarian cyst Also paratubal cyst
17 Common Extraovarian Lesions Para-ovarian cyst Hydrosalpinx Tubular
18 Common Extraovarian Lesions Para-ovarian cyst Hydrosalpinx Peritoneal inclusion cyst Uterine fibroid
19 Adnexal Mass Clinical History Ovary Extraovarian Simple Cyst
20 Ultrasound Criteria for a Simple Cyst Anechoic Imperceptible wall Increased through transmission Well defined back wall No color flow
21 Ultrasound Criteria for a Simple Cyst Anechoic Imperceptible wall Increased through transmission Well defined back wall No color flow *
22 Ultrasound Criteria for a Simple Cyst Anechoic Imperceptible wall Increased through transmission Well defined back wall No color flow
23 Ultrasound Criteria for a Simple Cyst
24 Simple Cyst
25 Simple Cyst * *
26 What size matters? Malignancy in a simple cyst by ultrasound criteria 0.7% Pre-menopausal 1.6% Post-menopausal Ekerhovd E, Wienerroith H, Staudach A, et al. Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis. Am J Obstet Gynecol. 2001; 184:48-54.
27 What size matters? Malignancy in a simple cyst by ultrasound criteria 0.7% Pre-menopausal 1.6% Post-menopausal All malignancies were over 7.5 cm Ekerhovd E, Wienerroith H, Staudach A, et al. Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis. Am J Obstet Gynecol. 2001; 184:48-54.
28 Follow up Pre-menopausal Simple Cyst Less than 5 cm No follow up Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Images at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 256(3):
29 Follow up Pre-menopausal Simple Cyst Less than 5 cm No follow up 5 to 7cm Could be functional cyst Follow up yearly Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Images at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 256(3):
30 Follow up Pre-menopausal Simple Cyst Less than 5 cm No follow up 5 to 7cm Could be functional cyst Follow up yearly Over 7 cm Further imaging or Surgical consultation Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Images at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 256(3):
31 Follow up Post-menopausal Simple Cyst Over 1 cm to 7 cm Follow up yearly Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Images at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 256(3):
32 Follow up Post-menopausal Simple Cyst Over 1 cm to 7 cm Follow up yearly Over 7 cm Further imaging or Surgical consultation Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Images at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 256(3):
33 Adnexal Mass Clinical History Ovary Extraovarian Simple Cyst Benign Lesions
34 Benign Lesions Hemorrhagic Cyst Mature Cystic Teratoma Endometrioma
35 Hemorrhagic Cyst Functional Cysts that develop internal hemorrhage
36 Hemorrhagic Cyst Functional Cysts that develop internal hemorrhage *
37 Ultrasound Appearance of Hemorrhagic Cyst Lace-like internal echoes Retracting clot Complicated cyst without internal flow No color flow
38 Hemorrhagic Cyst Lace-like internal echoes Often do not extend all the way across the cyst Very thin
39 Hemorrhagic Cyst Lace-like internal echoes Often do not extend all the way across the cyst Very thin *
40 Hemorrhagic Cyst Lace-like internal echoes
41 Hemorrhagic Cyst Lace-like internal echoes * *
42 Hemorrhagic Cyst Retracting clot Echogenicity with a concave margin
43 Hemorrhagic Cyst Retracting clot Echogenicity with a concave margin
44 Hemorrhagic Cyst Complicated cyst without internal flow
45 Hemorrhagic Cyst Complicated cyst without internal flow * *
46 Hemorrhagic Cyst Complicated cyst without internal flow
47 Hemorrhagic Cyst Complicated cyst without internal flow * *
48 Hemorrhagic Cyst Follow Up Pre-menopausal 5 cm or less No follow up Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Images at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 256(3):
49 Hemorrhagic Cyst Follow Up Pre-menopausal 5 cm or less No follow up Over 5 cm Follow up in 6-12 weeks to document resolution Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Images at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 256(3):
50 Hemorrhagic Cyst Follow Up Pre-menopausal 5 cm or less No follow up Over 5 cm Follow up in 6-12 weeks to document resolution Post-menopausal Follow up in 6-12 weeks to document resolution Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Images at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 256(3):
51 Hemorrhagic Cyst Follow Up 6 week follow up Ultrasound
52 Benign Lesions Hemorrhagic Cyst Endometrioma Mature Cystic Teratoma
53 Mature Cystic Teratoma Also called Dermoid Cyst
54 Mature Cystic Teratoma Also called Dermoid Cyst Most common ovarian neoplasm Over 98% benign
55 Mature Cystic Teratoma Also called Dermoid Cyst Most common ovarian neoplasm Over 98% benign Derive from ovarian germ cells Contain multiple germ call layers
56 Mature Cystic Teratoma Derive from ovarian germ cells Contains multiple germ call layers: Ectoderm 100% Skin, skin appendages, nervous system Hair follicle
57 Mature Cystic Teratoma Derive from ovarian germ cells Contains multiple germ call layers: Ectoderm 100% Mesoderm 90% Bones, muscles, connective tissue, blood vessels * *
58 Mature Cystic Teratoma Derive from ovarian germ cells Contains multiple germ call layers: Ectoderm 100% Mesoderm 90% Endoderm 70% Epithelium of respiratory system, urinary system and digestive tract *
59 Ultrasound Appearance of Mature Cystic Teratoma Shadowing echogenicity Focal or diffuse increased echogenicity Hyperechoic lines and dots No color flow
60 Mature Cystic Teratoma Shadowing echogenicity Tip of the iceberg
61 Mature Cystic Teratoma Focal or diffuse increased echogenicity Dermoid Plug, Rokitansky Protuberance/Nodule, Echogenic nodule
62 Mature Cystic Teratoma Focal or diffuse increased echogenicity Dermoid Plug, Rokitansky Protuberance/Nodule, Echogenic nodule
63 Mature Cystic Teratoma Focal or diffuse increased echogenicity
64 Mature Cystic Teratoma Focal or diffuse increased echogenicity
65 Mature Cystic Teratoma Focal or diffuse increased echogenicity
66 Mature Cystic Teratoma Focal or diffuse increased echogenicity
67 Mature Cystic Teratoma Hyperechoic lines and dots Dermoid mesh Not to be confused with lace like internal echoes
68 Mature Cystic Teratoma Mature cystic teratoma Hemorrhagic cyst
69 Mature Cystic Teratoma Hyperechoic lines and dots
70 Mature Cystic Teratoma Hyperechoic lines and dots
71 Mature Cystic Teratoma Follow Up Appearance on ultrasound can overlap with endometrioma Institution/Referring Physician Dependent CT or MR Fat is diagnostic Surgery
72 Mature Cystic Teratoma Follow Up Mature cystic teratoma Endometrioma
73 Mature Cystic Teratoma CT Contains any fat density Approximately -50 to -100 HU
74 Mature Cystic Teratoma CT Contains any fat density Approximately -50 to -100 HU
75 Mature Cystic Teratoma
76 Mature Cystic Teratoma
77 Mature Cystic Teratoma
78 Mature Cystic Teratoma
79 Mature Cystic Teratoma Follow Up
80 Mature Cystic Teratoma Follow Up
81 Mature Cystic Teratoma MR T1 Contains any fat density High T1 signal Low T1 fat sat signal High T2 signal T1 Fat Sat
82 Mature Cystic Teratoma MR T1 Contains any fat density High T1 signal Low T1 fat sat signal High T2 signal T1 Fat Sat
83 Mature Cystic Teratoma Follow Up T1 T1 Fat Sat
84 Mature Cystic Teratoma Follow Up T1 T1 Fat Sat
85 Mature Cystic Teratoma Complications Torsion Most common during pregnancy
86 Mature Cystic Teratoma Complications Torsion Rupture and chemical peritonitis Less than 1%
87 Mature Cystic Teratoma Complications Torsion Rupture and chemical peritonitis Adhesions
88 Mature Cystic Teratoma Complications Torsion Rupture and chemical peritonitis Adhesions Infection
89 Mature Cystic Teratoma Complications Torsion Rupture and chemical peritonitis Adhesions Infection Malignant degeneration
90 Mature Cystic Teratoma Malignant degeneration 2%
91 Mature Cystic Teratoma Malignant degeneration 2% Differentiated tissues within the mature cystic teratoma give rise to carcinoma or sarcoma
92 Mature Cystic Teratoma Malignant degeneration 2% Differentiated tissues within the mature cystic teratoma give rise to carcinoma or sarcoma Most common is squamous cell carcinoma arising from squamous lining of cyst
93 Mature Cystic Teratoma Malignant degeneration 2% Differentiated tissues within the mature cystic teratoma give rise to carcinoma or sarcoma Most common is squamous cell carcinoma arising from squamous lining of cyst Occurs in 60s or 70s
94 Mature Cystic Teratoma Malignant degeneration 2% Differentiated tissues within the mature cystic teratoma give rise to carcinoma or sarcoma Most common is squamous cell carcinoma arising from squamous lining of cyst Occurs in 60s or 70s??
95 Mature Cystic Teratoma
96 Mature Cystic Teratoma??
97 Mature Cystic Teratoma Squamous Cell Carcinoma Mature Cystic Teratoma Small Bowel
98 Benign Lesions Hemorrhagic Cyst Endometrioma Mature Cystic Teratoma
99 Endometrial glands and stroma outside the uterus Endometriosis
100 Endometrial glands and stroma outside the uterus Endometriosis
101 Endometrial glands and stroma outside the uterus Location Ovaries (80%) Uterosacral ligaments Pouch of Douglas Uterine Serosal Surface Fallopian Tube Rectosigmoid Colon Endometriosis
102 Ultrasound Appearance of Ovarian Endometrioma Diffuse, homogeneous low to medium level internal echoes Fluid-fluid or fluid/debris levels Echogenic wall foci No color flow
103 Ultrasound Appearance of Ovarian Endometrioma Diffuse, homogeneous low to medium level internal echoes Fluid-fluid or fluid/debris levels Echogenic wall foci No color flow *
104 Endometrioma Diffuse, homogeneous low to medium level internal echoes
105 Endometrioma Diffuse, homogeneous low to medium level internal echoes * *
106 Endometrioma Diffuse, homogeneous low to medium level internal echoes
107 Endometrioma Diffuse, homogeneous low to medium level internal echoes * *
108 Endometrioma Echogenic wall foci
109 Endometrioma Echogenic wall foci
110 Endometrioma Echogenic wall foci
111 Endometrioma Fluid-fluid level
112 Endometrioma Fluid-fluid level
113 Endometrioma Follow up Appearance on ultrasound can overlap with mature cystic teratoma Institution/Referring Physician Dependent MR Surgery
114 MR Appearance of Ovarian Endometrioma T2 shading High T1 signal lightblub bright T1 fat sat signal No enhancement T2 T1 Fat Sat
115 MR Appearance of Ovarian Endometrioma T2 shading High T1 signal lightbulb bright T1 fat sat signal No enhancement T2 T1 Fat Sat
116 Endometrioma Follow Up T1 Fat Sat T2
117 Endometrioma Follow Up T1 Fat Sat T2
118 Endometrioma Follow Up T2 T1 Fat Sat
119 Endometrioma Follow Up T2 T1 Fat Sat
120 Benign Lesions Hemorrhagic Cyst Mature Cystic Teratoma Endometrioma
121 Adnexal Mass Clinical History Ovary Extraovarian Simple Cyst Benign Lesions Possible Neoplasm
122 Possible Neoplasm Lesion does not meet criteria for Simple Cyst Hemorrhagic Cyst Mature cystic teratoma Endometrioma
123 Possible Neoplasm Lesion does not meet criteria for Simple Cyst Hemorrhagic Cyst Mature cystic teratoma Endometrioma Surgical consultation
124 Predicting Benign v Malignant Ovarian Neoplasm Grey scale and Color Doppler Ultrasound together are most predictive Kinkel K, Hricak H, Lu Y, et al. US characterization of ovarian masses: a meta-analysis. Radiology. 2000;217:
125 Predicting Benign v Malignant Ovarian Neoplasm Grey scale and Color Doppler Ultrasound together are most predictive Do not add predictive value Resistive Index Menopausal Status * Kinkel K, Hricak H, Lu Y, et al. US characterization of ovarian masses: a meta-analysis. Radiology. 2000;217:
126 Possible Neoplasm Complex cyst with color flow
127 Possible Neoplasm Complex cyst with color flow *
128 Possible Neoplasm Complex cyst with color flow Solid Mass
129 Possible Neoplasm Complex cyst with color flow Solid Mass * *
130 Complex Cyst with Color Flow
131 Complex Cyst with Color Flow
132 Complex Cyst with Color Flow
133 Complex Cyst with Color Flow
134 Solid Mass
135 Solid Mass
136 Adnexal Mass Clinical History
137 Conclusion-Clinical History Positive Pregnancy Test Ectopic Pregnancy Signs and symptoms of pelvic inflammatory disease Tubo-ovarian abscess
138 Adnexal Mass Clinical History Ovary Extraovarian
139 Conclusion-Location Ovarian Ovarian tissue surrounding the lesion Extraovarian Separate ipsilateral ovary
140 Adnexal Mass Clinical History Ovary Extraovarian Simple Cyst Benign Lesions Possible Neoplasm
141 Conclusion Simple Cyst Pre-Menopausal Less then 5 cm No follow up 5-7 cm Yearly Follow up Over 7 cm Further imaging or surgical consultation Post-Menopausal Over 1 cm to 7cm Yearly Follow up Over 7 cm Further imaging or surgical consultation
142 Benign Lesions Hemorrhagic Cyst Endometrioma Mature Cystic Teratoma
143 Conclusion Benign Lesions No color flow Hemorrhagic Cyst Pre menopausal 5 cm or less No follow up Over 5 cm Follow up in 6-12 weeks Post menopausal Follow up 6-12 weeks Mature cystic teratoma CT or MR Surgical consultation Endometrioma MR Surgical consultation
144 Conclusion Possible Neoplasm Does not meet criteria for Simple cyst Hemorrhagic Cyst Mature cystic teratoma Endometrioma Complex cyst with color flow Solid Mass Surgical consultation
145 Thank you!
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