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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