Ovarian pathology: A practical approach to imaging diagnosis and management

Transcription

1 Ovarian pathology: A practical approach to imaging diagnosis and management Award: Certificate of Merit Poster No.: C-1865 Congress: ECR 2015 Type: Educational Exhibit Authors: A. Castan, A. Mir Torres, G. Riazuelo, I. Escartin, C. Ospina, C. Rodríguez, C. Sebastián, J. Gonzalez, J. J. Castillo; Zaragoza/ES Keywords: Neoplasia, Education and training, elearning, Education, Diagnostic procedure, Ultrasound, MR, CT, Genital / Reproductive system female DOI: /ecr2015/C-1865 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 112

2 Learning objectives 1. Describe the normal ovarian imaging. 2. Identify the most specific imaging features of ovarian lesions. 3. Propose an algorithmic approach for the differential diagnosis and management of adnexal mass. Background Ovarian lesions are a common finding among women. Clinical history helps us to make a correct diagnosis, but imaging findings play a fundamental role. Ultrasound (US) is the imaging modality of choice. Advantages and limitations of transabdominal and transvaginal sonographic approach are shown in the following graph (Figure. 1). Color Doppler and spectral Doppler sonography are an essential complement that provides additional information about the vascularity of ovarian lesions, improving their characterization. Page 2 of 112

3 Fig. 1 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain CT is used for staging malignant lesions and MRI is the complementary imaging tool in the characterization of ovarian lesions. We retrospectively reviewed the imaging findings of ovarian lesions from patients who have been attended at our hospital. Images for this section: Page 3 of 112

4 Fig. 1 Page 4 of 112

5 Findings and procedure details Normal ultrasound anatomy 1. Age-related changes Premenopausal patient: Ovaries have homogeneous echostructure with hyperechoic stroma and peripheral follicles in the cortex. Postmenopausal patient: Ovaries are atrophic and follicles disappear, being difficult to visualize them by ultrasound. 2. Dynamic changes during the menstrual cycle Morphologic changes During the proliferative phase of the menstrual cycle, several follicles begin to develop. By day 8-12, one dominant follicle matures and the rest begin to regress. On day 14 the follicle ruptures and the egg is extruded. After ovulation, corpus luteum is formed, and if fertilization does not occur, the corpus luteum degenerates into a corpus albicans. Page 5 of 112

6 Fig. 2: 1. Immature follicles 2. Dominant follicle 3. Cumulus oophorus inside the preovulatory follicle 4. Corpus luteum: cystic echostructure and festooned contour 5. Corpus luteum: solid echostructure 6. Corpus albicans References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Cyclic variation of ovarian arterial vascularization The ovarian artery blood shows high-resistance flow pattern indicative of an inactive state of the ovary. The flow resistance of the ovarian artery is maximum during the first 8 days of the cycle.ovarian artery has a low-resistance flow that reaches the lowest level during the early luteal phase. At this time, the intra-ovarian vascularization is easily detectable. In late luteal phase, ovarian arterial flow is medium-resistance and gradually increases in proliferative phase. Page 6 of 112

7 Fig. 3: A. Spectral Doppler ultrasound shows a normal ovarian artery with a highresistance flow pattern, low end-diastolic velocity and an early diastolic notch during proliferative phase. B. Ovarian artery with low-resistance flow during early luteal phase. C. Ovarian artery with medium-resistance flow during late luteal phase References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Ovarian pathology Classification of ovarian pathology is summarized in table 1. Page 7 of 112

8 Fig. 4 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Simplified histological classification of ovarian neoplasms is shown in table 2. Page 8 of 112

9 Fig. 5 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Imaging modalities do not allow a specific histological diagnosis and sometimes it is difficult to distinguish benign from malignant tumors. We review the different ovarian lesions with a practical approach to the radiologist by a didactic algorithm based on ultrasound findings, which will allow us to approach the most probable diagnosis. Four questions must be answered when we see an adnexal lesion on ultrasound examination. First: Is it an ovarian lesion? Second: Is it a cystic or a solid lesion? Third: Does it have a typical echographic pattern? Fourth: Does it have findings indicating malignancy? Page 9 of 112

10 Fig. 6 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Mimics of ovarian lesion There are anatomical structures and extraovarian lesions in pelvis that can mimic the appearance of ovarian masses (table 3 of figure 7). Page 10 of 112

11 Fig. 7 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Occasionally, the morphology and size of unilocular cystic cystadenoma can simulate a distended bladder. We must review medical history of the patient, ask for sensation of bladder filling, and determine the location of both structures separately. Page 11 of 112

12 Fig. 8 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain On static images, bowel and blood vessels can mimic a normal ovarian, we must interpret images during the real-time examination for easily differentiate them. When transducer pressure is applied, bowel will compress and we will see its peristalsis. Vessels (typically pelvic varices) will also compress and will demonstrate flow with Doppler sonography. Page 12 of 112

13 Fig. 9 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 13 of 112

14 Fig. 10 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Although the majority of adnexal pathology is originated in the ovary, there are also extraovarian adnexal lesions, for distinguish them we must see the dependence or not of ipsilateral ovarian tissue. In large masses or in postmenopausal patients with small ovaries without follicles will be very difficult to determine the origin. Page 14 of 112

15 Fig. 11 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 15 of 112

16 Fig. 12 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 16 of 112

17 Fig. 13 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 17 of 112

18 Fig. 14 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 18 of 112

19 Fig. 15 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 19 of 112

20 Fig. 16 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 20 of 112

21 Fig. 17 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 21 of 112

22 Fig. 18: 80-year-old woman under treatment with Sintrom and hypogastric pain. AC) Transabdominal US. Hematoma with thick septations and absent color Doppler flow, simulating low-grade ovarian carcinoma. D-E) CT performed 10 days later identify bilobed collection that is located in left anterolateral pelvic wall, compatible with encapsulated hematoma. B and D) Hematoma produces extrinsic compression over left wall of the bladder (V). D) Small left adnexal cyst with benign characteristics. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 22 of 112

23 Fig. 19: 50-year-old woman. A-B) Transabdominal US. C-D) Axial CT. Voluminous cystic mass with thin wall, absent color Doppler flow and presence of fluid-fluid level. Mass is located in the hypogastric with backward displacement of the uterus and ovaries (arrows). Surgeons viewed that large mass was localized in small bowel mesentery. Surgical pathology confirmed that it was a chylous mesenteric cyst. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain CYSTIC OR CYSTIC PREDOMINANCE OVARIAN LESIONS BENIGN CYSTIC LESIONS Benign cystic lesions are the most common forms of ovarian pathology; we describe six typical ultrasound patterns, which are known as the "Big 6"(table 4 of figure 7). Page 23 of 112

24 Fig. 7 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Follicular cyst Follicular cyst develops when the mature follicle does not release the ovule or does not involute. US features: rounded morphology, thin wall with posterior acoustic shadowing / enhancement and anechoic content. Most of them are asymtomatic. Solved in 8-12 weeks. Page 24 of 112

25 Fig. 20 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Corpus luteum cyst Corpus luteum cyst occurs when there isn t reabsorption of the corpus luteum after ovulation. US aspect: Variable appearance, from thick-walled cyst with festooned contours to a more collapsed cyst, giving it a relatively solid appearance. Color Doppler ultrasound demonstrates peripheral flow that has been called a "ring-of-fire", with a low-resistance waveform. Clinic: It can cause pain because they tend to bleed and rupture. Solved in 8-12 weeks. Page 25 of 112

26 Fig. 21 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Polycystic ovaries Diagnostic criteria for polycystic ovary syndrome: Clinical criterion: Oligo-ovulation and/ or anovulation Analytical criterion: Hyperandrogenism US criteria: >12 folliclesand measure 2-9 mm in diameter Page 26 of 112

27 Increased ovarian volume (> 10 cm3) Typical peripheral distribution of follicles and hyperechogenic stroma; but it s not considered diagnostic criterion, because this ovarian morphology is common, especially in adolescents without menstrual dysfunction Fig. 22 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Hemorrhagic cyst Hemorrhagic cyst is caused by internal bleeding in functional cyst (more common in corpus luteum cyst). US appearance is variable: Page 27 of 112

28 Acute phase: hyperechoic avascular cyst of heterogeneous or homogeneous echostructure Subacute phase: A reticular pattern of thin internal echoes due to fibrin strands and absence of detectable flow at Doppler US Phase of clot retraction: solid avascular mass with concave outer margin The presence of free fluid echogenic indicates leaking or rupture of cyst Clinic: Acute pelvic pain. Solved in 8 weeks. Fig. 23 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 28 of 112

29 Fig. 24 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 29 of 112

30 Fig. 25 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 30 of 112

31 Fig. 26 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Endometrioma Endometrioma corresponds to functional endometrial tissue located in the ovary. US features: Avascular, well defined, uni or multilocular cyst that contains diffuse, homogeneous and low- to medium-level internal echoes, which have a "ground-glass" appearance Additional features reported include echogenic foci in the wall and small solid areas along the wall. This may be confused with a solid neoplasm A small percentage of endometriomas have less typical US features such as anechoic fluid or a fluid-fluid level Page 31 of 112

32 Clinic: Pelvic pain during menstrual periods. No solved. Fig. 27 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 32 of 112

33 Fig. 28 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 33 of 112

34 Fig. 29 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Mature cystic teratoma (dermoid cyst) Mature cystic teratomas contain tissues derived from the three primary cell layers, with predominance of ectodermal components. US: variable appearance from anechoic to hyperechoic cysts. Most dermoids have a variety of typical sonographic features, which, in most cases, may be used to make an accurate diagnosis. Dermoid plug or Rokitansky nodule: a hyperechoic nodule +/- posterior sonic attenuation. This feature is believed to be caused by a mixture of hair and sebum Page 34 of 112

35 "Tip of the iceberg" sign: The hyperechoic area of the cyst causes posterior attenuation of sound, so the deeper part of the mass is not seen. Attenuation of sound is probably caused by hair and sebum. It mimics intestinal gas. "Dermoid mesh": Multiple thin, echogenic lines caused by floating hair in the cyst cavity. Presence of calcifications or dental (tooth) components Presence of fluid-fluid levels Risk of ovarian torsion; the rupture and malignant transformation are rare. Fig. 30 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 35 of 112

36 Fig. 31 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 36 of 112

37 Fig. 32 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 37 of 112

38 Fig. 33 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 38 of 112

39 Fig. 34: 51-year-old woman. Cystic lesion in right ovary is hyperintense on T2 with a fluid-fluid level and an unenhanced thin wall; findings compatible with hemorrhagic cyst. Heterogeneous cystic lesion in left ovary with high signal on T1, less intensity on T2 by "shading effect" and absence of enhancement, compatible with endometriotic cyst. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 39 of 112

40 Fig. 35: 20-year-old woman. Transabdominal US: hyperechogenic mass in Douglas space, with probable right adnexal origin. The lesion doesn t present flow on color Doppler US and for its echogenicity is suggestive of ovarian teratoma. MRI: On the T1-weighted image with saturation fat, there is suppression of the signal that confirms the fatty content and it is diagnostic of teratoma. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Other typical sonographic patterns: Page 40 of 112

41 Fig. 7 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Unilocularcystic cystadenoma Ovarian cystadenoma is a benign epithelial tumor. Variable size (4-20cm). US: Cystic lesion with avascular thin wall and presence of anechoic content (serous) or low-level echoes (mucin). Page 41 of 112

42 Fig. 36 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Ovarian hyperstimulation syndrome The ovarian hyperstimulation syndrome is a complication of ovarian stimulation treatment for in vitro fertilisation. Rarely, it may also occur as a spontaneous event in normal pregnancy and in gestational trophoblastic disease. US:Bilateral symmetric enlargement of ovaries (often > 12 cm in size) with multiple theca lutein cysts of varying sizes and thin wall, which they can replace most of the ovary. Ovarian torsion Torsion occurs in normal ovaries or associated with adnexal lesion. Page 42 of 112

43 US features: Enlarged ovarian Multiple cortical follicles Absence or decreaseflow on Doppler ultrasound compared to contralateral ovarian. Presence of flow does not eliminate the possibility of torsion Free liquid in Douglas space Fig. 37 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Tubo-ovarian abscess Tubo-ovarian abscess is a late complication of pelvic inflammatory disease. US: Multi-locular complex cyst with internal echoes, septations, and irregular thick walls. Page 43 of 112

44 Clinical features of infection is a key to distinguish of other pathologies with similar. appearances There may be echogenic liquid (pus) in Douglas space. Fig. 38 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 44 of 112

45 Fig. 39 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain INDETERMINATE CYSTIC LESIONS Occasionally, cystic lesions have some atypical sonographic features, in which case they should be classified as indeterminate lesions (table 4 of figure 7). Page 45 of 112

46 Fig. 7 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain In these cases the main differential diagnosis is considered between cystadenoma and cystadenocarcinoma. Page 46 of 112

47 Fig. 40 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Benign lesions, such as hemorrhagic cysts, endometriomas and teratomas, will be included in the differential diagnosis, because they can also have atypical features. For example a hemorrhagic cyst that contain retracting clot inside can mimic an ovarian tumor. Page 47 of 112

48 Fig. 41: 32-year-old woman US shows ovarian cystic lesion with indeterminate characteristics. Pathological diagnosis: Mature cystic teratoma References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain MALIGNANT CYSTIC LESIONS Sonographic criteria of malignancy Radiographic findings that orient malignancy are shown in table 4 of figure 7. Page 48 of 112

49 Fig. 7 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain The features suggesting malignancy on color and spectral Doppler ultrasound are: High-velocity arterial flow (peak systolic velocity > 15 cm / s) Low-resistance arterial flow (resistance index<0.4) Tortuous vessels, with multiple inter-vessel connections and dilatations with changing calibers. Presence of central vascularization in the complex or solid component Tumors of the epithelial cells Epithelial cells tumors account for 70% of all ovarian tumors and 90% of malignant ones. Imaging cannot differentiate histological types of epithelial neoplasms. Page 49 of 112

50 Ovarian serous cystadenocarcinoma Serous cystadenocarcinomas are the most common tumors. Typical Feature:Papillary projections arising from the walls and septations. Ovarian mucinous cystadenocarcinoma Typical characteristics: Tumor can be seen as a large cystic mass occupying the entire pelvis and abdomen Tumor contains low-level echoes due to mucinous content Borderline ovarian tumor Tumor has histological features of malignancy, but without evidence of stromal invasion, so they have a good prognosis. Endometrioid ovarian carcinoma Endometrioid carcinoma is the second most frequent malignant epithelial neoplasm. It has a similar appearance to other malignant epithelial tumors. Clear-cell ovarian carcinoma Clear cell tumors are arising from the embryonic mesonephros. US: complex predominantly cystic mass, without distinguishing characteristics of other epithelial tumors. Page 50 of 112

51 Fig. 42: Voluminous mass that is predominantly cystic, with thin septations (some calcified) and solid areas that present enhancement after contrast injection. Pathological diagnosis: ovarian mucinous cystadenocarcinoma References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 51 of 112

52 Fig. 43: Bilateral papillary serous cystadenocarcinoma. Tumor presents general features of advanced malignancy such as ascites, peritoneal implants some of them calcified, denominated "psammomatous bodies" (arrow) and metastatic lymph nodes. Pathological confirmation. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 52 of 112

53 Fig. 44: Ultrasound reveals left cystic adnexal mass with internal septations and vascularized solid component that presents a low-resistance flow pattern. Pthological diagnosis: Papillary seromucinous cystadenocarcinoma with foci of seromucinous borderline tumor. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain OVARIAN SOLID LESIONS Tumors of the epithelial cells Transitional cell tumor or Brenner tumor Solid tumor composed of fibrous stromal. Cysts areas are unusual and when they are present usually due to a coexisting cystadenoma. These tumors are very similar to ovarian thecomas and uterine leiomyomas. Page 53 of 112

54 Fig. 45 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Tumors of the germ cells Germ tumors account for 15-20% of all ovarian neoplasms and 95% corresponds to mature cystic teratoma (benign neoplasm already seen in the section on typical ovarian lesions). Immature ovarian teratoma, ovarian dysgerminoma and endodermal sinus tumor are the most common malignant neoplasm in girls and young women. Predominantly solid ovarian mass identified on a girl or young woman should consider the diagnosis of malignant germ cell tumor. Sex cord/stromal ovarian tumors Page 54 of 112

55 Sex cord/stromal ovarian tumors account for 8-10% of all ovarian tumors. Ovarian Fibroma / Ovarian Thecoma / Ovarian fibrothecoma Benign tumors of sex cord - stromal origin (theca cells and fibrous tissue). Thecomas are associated with estrogen production. US Features: Hypoechoic mass with marked acoustic shadowing (not present if cystic degeneration or edema of the tumor exist). Differential diagnosis: uterine leiomyoma and Brenner tumor. Fig. 46: Well-circumscribed solid mass in the left ovary with marked acoustic shadowing and low-flow on color Doppler US. Hypointensity on both T1 and T2 Page 55 of 112

56 weighted sequences with delayed weak enhancement. Pathological diagnosis: Ovarian fibrothecoma. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Granulosa cell tumor of ovary It is the most common estrogen-producing ovarian tumor. Variable appearance: Mass with predominant solid or cystic component. Fig. 47: 75-year-old woman with pelvic mass. US and CT show a voluminous solidcystic lesion. Pathological diagnosis:granulosa cells tumor. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 56 of 112

57 Ovarian Sertoli-Leydig cell tumor Rare tumor. Virilizing symptoms in 30% of the cases. Tumor has a solid aspect similar to granulose cell tumors. Ovarian metastasis Metastases represent 5-10% of all ovarian neoplasms. Breast and gastrointestinal tumors are the most common primary tumors to result in ovarian metastasis. Krukenberg tumor is referred to ovarian metastases that contain mucin-secreting "signet ring" cells and usually originate in gastric or colonic tumors. US features: Bilateral solid masses Presence of necrosis in metastasis can give a predominantly cystic aspect that simulates a primary cystadenocarcinoma Page 57 of 112

58 Fig. 48: Heterogeneous solid masses compatible with bilateral ovarian metastases from breast cancer. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 58 of 112

59 Fig. 49: Enlarged ovaries with vascularized solid masses that present low-resistance arterial flow. Findings are in relation with ovarian metastases of a patient with advanced gastric carcinoma. References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain MANAGEMENT OF OVARIAN LESIONS Management of ovarian lesions will depend on imaging findings and the presence of risk factors (postmenopausal women, elevated tumor markers, family or personal history of breast or ovarian cancer). Type of guideline for an ovarian lesion diagnosed by ultrasound: Nothing: lesion doesn t need periodic control or written report of ultrasound finding Ultrasound report: Lesion is indicated in the report, but it does t require monitoring Page 59 of 112

60 Ultrasound monitoring: Lesion requires periodic ultrasound control Evaluation by MRI Evaluation by CT Surgery Management of ovarian pathology is summarized in tables 5-6. Fig. 50 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Page 60 of 112

61 Fig. 51 References: Department of Radiology, University Hospital Miguel Servet; Zaragoza, Spain Images for this section: Page 61 of 112

62 Fig. 2: 1. Immature follicles 2. Dominant follicle 3. Cumulus oophorus inside the preovulatory follicle 4. Corpus luteum: cystic echostructure and festooned contour 5. Corpus luteum: solid echostructure 6. Corpus albicans Page 62 of 112

63 Fig. 3: A. Spectral Doppler ultrasound shows a normal ovarian artery with a highresistance flow pattern, low end-diastolic velocity and an early diastolic notch during proliferative phase. B. Ovarian artery with low-resistance flow during early luteal phase. C. Ovarian artery with medium-resistance flow during late luteal phase Page 63 of 112

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78 Fig. 18: 80-year-old woman under treatment with Sintrom and hypogastric pain. A-C) Transabdominal US. Hematoma with thick septations and absent color Doppler flow, simulating low-grade ovarian carcinoma. D-E) CT performed 10 days later identify bilobed collection that is located in left anterolateral pelvic wall, compatible with encapsulated hematoma. B and D) Hematoma produces extrinsic compression over left wall of the bladder (V). D) Small left adnexal cyst with benign characteristics. Page 78 of 112

79 Fig. 19: 50-year-old woman. A-B) Transabdominal US. C-D) Axial CT. Voluminous cystic mass with thin wall, absent color Doppler flow and presence of fluid-fluid level. Mass is located in the hypogastric with backward displacement of the uterus and ovaries (arrows). Surgeons viewed that large mass was localized in small bowel mesentery. Surgical pathology confirmed that it was a chylous mesenteric cyst. Page 79 of 112

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94 Fig. 34: 51-year-old woman. Cystic lesion in right ovary is hyperintense on T2 with a fluid-fluid level and an unenhanced thin wall; findings compatible with hemorrhagic cyst. Heterogeneous cystic lesion in left ovary with high signal on T1, less intensity on T2 by "shading effect" and absence of enhancement, compatible with endometriotic cyst. Page 94 of 112

95 Fig. 35: 20-year-old woman. Transabdominal US: hyperechogenic mass in Douglas space, with probable right adnexal origin. The lesion doesn t present flow on color Doppler US and for its echogenicity is suggestive of ovarian teratoma. MRI: On the T1weighted image with saturation fat, there is suppression of the signal that confirms the fatty content and it is diagnostic of teratoma. Page 95 of 112

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101 Fig. 41: 32-year-old woman US shows ovarian cystic lesion with indeterminate characteristics. Pathological diagnosis: Mature cystic teratoma Page 101 of 112

102 Fig. 42: Voluminous mass that is predominantly cystic, with thin septations (some calcified) and solid areas that present enhancement after contrast injection. Pathological diagnosis: ovarian mucinous cystadenocarcinoma Page 102 of 112

103 Fig. 43: Bilateral papillary serous cystadenocarcinoma. Tumor presents general features of advanced malignancy such as ascites, peritoneal implants some of them calcified, denominated "psammomatous bodies" (arrow) and metastatic lymph nodes. Pathological confirmation. Page 103 of 112

104 Fig. 44: Ultrasound reveals left cystic adnexal mass with internal septations and vascularized solid component that presents a low-resistance flow pattern. Pthological diagnosis: Papillary seromucinous cystadenocarcinoma with foci of seromucinous borderline tumor. Page 104 of 112

105 Fig. 45 Page 105 of 112

106 Fig. 46: Well-circumscribed solid mass in the left ovary with marked acoustic shadowing and low-flow on color Doppler US. Hypointensity on both T1 and T2 weighted sequences with delayed weak enhancement. Pathological diagnosis: Ovarian fibrothecoma. Page 106 of 112

107 Fig. 47: 75-year-old woman with pelvic mass. US and CT show a voluminous solid-cystic lesion. Pathological diagnosis:granulosa cells tumor. Page 107 of 112

108 Fig. 48: Heterogeneous solid masses compatible with bilateral ovarian metastases from breast cancer. Page 108 of 112

109 Fig. 49: Enlarged ovaries with vascularized solid masses that present low-resistance arterial flow. Findings are in relation with ovarian metastases of a patient with advanced gastric carcinoma. Page 109 of 112

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112 Conclusion Ovarian pathology is a common entity and its management will depend largely on a good interpretation of the imaging findings. Personal information References 1. Brown DL, Dudiak KM, Laing FC. Adnexal masses: US characterization and reporting. Radiology. 2010; 254(2): Levine D, Brown DL, Andreoti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010; 256 (3): Brown, DL. A practical approach to the ultrasound characterization of adenxal masses. Ultrasound Quarterly. 2007; 23: Laing FC, Allison, SJ. US of the ovary and adnexa: to worry or not to worry?. Radiographics. 2012; 32: Patel, MD. Practical approach to the adnexal mass. Radiol Clin North Am. 2006; 44: Page 112 of 112