Evaluation of the Adnexal Mass Non Neoplastic

Size: px

Start display at page:

Download "Evaluation of the Adnexal Mass Non Neoplastic"

Scot Owens
5 years ago
Views:

cta Radiológica Portuguesa, Vol.XXIII, nº 90, pág. 49-57, br.-jun.

1 cta Radiológica Portuguesa, Vol.XXIII, nº 90, pág , br.-jun., 2011 Evaluation of the dnexal Mass Non Neoplastic Jade Wong Professor of Radiology University of Maryland School of Medicine Visiting lecturer rmed Forces Institute of Pathology Outline Clinical and imaging characteristics of common non neoplastic ovarian and adnexal pathology Functional ovarian cysts Follicular Corpus luteal Usually asymptomatic Theca lutein ge of patient Essential information Symptoms such as fever, discharge, pain Menstrual status and time in cycle Pregnancy status Previous surgical and medical history, cancer Drugs: HRT, ovulation stimulation Functional ovarian cysts Very common incidental findings occurring during normal ovarian cycle Failure of ovulation or development of fluid in corpus luteum Most regress spontaneously (if <5 cm) or respond to hormonal suppression Ovary Functional cysts Endometrioma Hyperstimulation Exogenous: OHSS Gestational trophoblastic disease Torsion Polycystic ovary syndrome Serous inclusion cysts Follicular cyst Failure of mature follicle to rupture/ regress Usually 3-8 cm Unilocular simple cyst Well defined thin smooth wall RP 49

Follicular cyst C Symptomatic functional cysts Internal hemorrhage Rupture Into

rupture with free fluid F D Simple cyst in older patients Hemorrhagic

1% Few large ones are serous cystadenomas Doubtful if they ever become

cysts Imaging spectrum depends on age Rapid change Corpus luteum/cyst Normal CL

Hyperechoic in acute phase Fluid - debris level Thin wispy linear fibrin

concave solid area No flow on Doppler Mildly thickened wall Diffuse low level

endometriosis Corpus luteum cyst Thick vascular wall slightly echogenic Follow

ectopic Follicular cysts <3 cm: none >3-<5 cm: none but mention in report <5-<7

2 Follicular cyst C Symptomatic functional cysts Internal hemorrhage Rupture Into peritoneal cavity with bleeding, peritoneal signs and hypotension Simple rupture with free fluid F D Simple cyst in older patients Hemorrhagic functional cysts Risk of malignancy < 0.1% Few large ones are serous cystadenomas Doubtful if they ever become cystadenocarcinomas Follow up cute pain or asymptomatic More common in luteal cysts Imaging spectrum depends on age Rapid change Corpus luteum/cyst Normal CL <3 cm Unilocular Internal echoes from bleeding Hemorrhagic functional cysts Hyperechoic in acute phase Fluid - debris level Thin wispy linear fibrin strands reticular, fish net, cob web or lacy Retracting hyperechoic clot : concave solid area No flow on Doppler Mildly thickened wall Diffuse low level echoes with acoustic enhancement ground glass Usually a feature of endometriosis Corpus luteum cyst Thick vascular wall slightly echogenic Follow up: Premenopausal incidental cysts Crenulated Low resistance flow Mistaken for ectopic Follicular cysts <3 cm: none >3-<5 cm: none but mention in report <5-<7 cm: 1 yr FU > 7cm : MR or surgery Hemorrhagic cysts < 3 cm: none >3-<5 cm: none but mention >5 cm: 6-12 wk FU SRU consensus guidelines: Radiology 2010; 256: RP

Hemorrhagic cyst MR OHSS High on T1 Usually high on T2

Endometrial glands outside endometrial cavity Pelvic

menstruation/surgical implantation Metaplasia of

lutein cysts Gestational trophoblastic disease

hyperstimulation syndrome Secondary to infertility

Endometrium responds to cycle with cyclic bleeding

dhesions Laparoscopic staging with merican fertility

Hyperstimulation cysts ilateral enlarged ovaries

associated with ascites, pleural effusion, hemorrhage,

3 Hemorrhagic cyst MR OHSS High on T1 Usually high on T2 U Cyst rupture with intra peritoneal hemorrhage * * * Endometrial glands outside endometrial cavity Pelvic peritoneum, ovary, tube, anywhere Theories Retrograde menstruation/surgical implantation Metaplasia of mesothelium Induction: Combination of above Theca lutein cysts Gestational trophoblastic disease ssociated with high levels of HCG Ovarian hyperstimulation syndrome Secondary to infertility drugs bdominal pain, distension, nausea, vomiting Endometrium responds to cycle with cyclic bleeding Incites fibrosis and smooth muscle proliferation dhesions Laparoscopic staging with merican fertility Society classification (minimal to severe) Hyperstimulation cysts ilateral enlarged ovaries Multiple large cysts May bleed, rupture or torse OHSS associated with ascites, pleural effusion, hemorrhage, DIC Symptoms Dysmenorrhea Dyspareunia Pelvic pain Cyclic pain with menses May be asymptomatic ssociated with infertility (25%) RP 51

Peritoneal implants Ovaries Uterine ligaments Serosal

Urinary tract Endometrioma Imaging may be limited for

ovaries Deeply infiltrating > 5 mm below peritoneum

lesion Ground glass homogeneous low level echoes

septations Mural reflectors Endometrioma: mural

hemorrhagic cysts, dermoids and some ovarian cancers

wall/calcification Fluid fluid level nechoic fluid

and specific (90-96%) Thick walled cystic lesion

4 Peritoneal implants Ovaries Uterine ligaments Serosal surfaces Cul de sac obliteration Fallopian tubes owel Urinary tract Endometrioma Imaging may be limited for evaluation of small implants and adhesions Kissing ovaries Deeply infiltrating > 5 mm below peritoneum Retrocervical, uterosacral, rectovaginal septum, bladder, ureter, vagina, etc.. Endometrioma Chocolate cyst Thick walled cystic lesion Ground glass homogeneous low level echoes (highly suggestive) Unilocular/multilocular with septations Mural reflectors Endometrioma: mural reflectors Endometrioma Ground glass also seen in hemorrhagic cysts, dermoids and some ovarian cancers Less typical signs: Small solid areas along the wall/calcification Fluid fluid level nechoic fluid Heterogenity Tubular - MR Highly accurate, sensitive and specific (90-96%) Thick walled cystic lesion Hyperintense on T1-w (not fat) Hypointense on T2-w with shading high concentrations of intracellular methemoglobin and other protein or iron products 52 RP

Endometrioma T1-w fat sat T1w Hydrosalpinx

lesions Low signal fibrosis dhesions and

Low signal hemosiderin or fibrous ring MR

Clinical history Sequential imaging with

T2-w Single Ovarian (adnexal) torsion 3%

premenopausal 20% pregnant 80% associated

infiltrating endometriosis Low T2 signal

Enhancement with contrast nterior, middle

5 Endometrioma T1-w fat sat T1w Hydrosalpinx T2-w MR -other Multiple T1 hyperintense lesions Low signal fibrosis dhesions and enhancement of peritoneum Hematosalpinx Low signal hemosiderin or fibrous ring MR for inaccessible sites or for evaluation of response to medical treatment Endometrioma or hemorrhagic cyst? Clinical history Sequential imaging with US MR Less bright on T1-w No shading on T2-w Single Ovarian (adnexal) torsion 3% of gynecologic emergencies Usually premenopausal 20% pregnant 80% associated ovarian or paraovarian mass cute pain, nausea, vomiting Previous self limiting episodes Post menopausal torsion Deeply infiltrating endometriosis Low T2 signal mass like lesion Punctate high T1 signal Enhancement with contrast nterior, middle or posterior compartments of pelvis Consider malignancy as cause of torsion Delayed diagnosis 22% ovarian carcinoma 11% fibroma 8% mature teratoma 8% paraovarian cyst 8% cystadenoma 4% simple ovarian cyst Eitan R, et al. The risk of mal ignan cy i n post-m enop au sal wom en presentin g with ad nexal torsi on. Gyn ecologic Onc ology 106 (20 07) RP 53

dnexal torsion Ovarian torsion cute pain, nausea, vomiting Previous self limiting

normal a Left enlarged with no flow b Ultrasound Non specific gray scale, depends on

Torsed teratoma Twisted pedicle Ovarian torsion-enlarged ovary Doppler of torsion

enlarged Rescan early Dual ovarian arterial supply Incomplete and intermittent torsion 4

High resistance arterial flow Loss of venous flow Twisted vascular pedicle Corkscrew

6 dnexal torsion Ovarian torsion cute pain, nausea, vomiting Previous self limiting episodes Early diagnosis key Ultrasound first line Suggestive findings on CT Right normal a Left enlarged with no flow b Ultrasound Non specific gray scale, depends on cause Most suggestive: ipsilateral enlarged hypoechoic ovary (+/- peripheral follicles) Mass e.g teratoma, functional cyst Hemorrhagic infarction ssociated thickened fallopian tube Torsed teratoma Twisted pedicle Ovarian torsion-enlarged ovary Doppler of torsion Careful technique Compare to other side High index of suspicion if symptomatic ovary enlarged Rescan early Dual ovarian arterial supply Incomplete and intermittent torsion 4 cm Ovarian torsion Doppler is extremely useful bsence of arterial and venous flow late High resistance arterial flow Loss of venous flow Twisted vascular pedicle Corkscrew vessels UT can be relatively normal dnexal torsion: CT/MR Deviation of uterus to affected side Obliteration of fat planes Enlarged displaced ovary eak sign with congested vessels Lack of enhancement 54 RP

Torsion of cystadenoma PCOS * * Polycystic ovary

hirsutism, obesity, amenorrhea, and enlarged

(acne/alopecia) Post menopausal cysts Serous

trapping of surface epithelium in ovarian cortex

cm, inconsequential Majority resolve Thin walled

or surgery Polycystic ovary syndrome Serous

disturbances : obesity, insulin resistance,

4 clinical phenotypes Oligimenorrhea from

7 Torsion of cystadenoma PCOS * * Polycystic ovary syndrome 6-8% of women Stein Leventhal Syndrome hirsutism, obesity, amenorrhea, and enlarged bilateral polycystic ovaries Diverse symptoms and signs including infertility, menstrual irregularity, hirsutism, androgen excess (acne/alopecia) Post menopausal cysts Serous inclusion Secondary to remote ovulation with trapping of surface epithelium in ovarian cortex 21% of asymptomatic women have simple cysts < 1 cm, inconsequential Majority resolve Thin walled unilocular cysts 1-7 cm yearly follow up > 7 cm MR or surgery Polycystic ovary syndrome Serous inclusion cysts Commonly associated metabolic disturbances : obesity, insulin resistance, dyslipidemia, hypertension. 4 clinical phenotypes Oligimenorrhea from anovulation Polycystic ovary syndrome imaging dnexa Tubal Hydrosalpinx Pelvic inflammatory disease Paraovarian cyst Peritoneal inclusion cyst RP 55

Location Tubal near to but separate from ovary

Pathognomonic Mural nodules: beads on a string Pelvic

fluid Thick walled tube Cog wheel Internal echoes/debris

fluid filled structure Folding mimics multilocular

tube carcinoma larger and more solid components)

overlap with neoplasm but history and clinical findings

inflammatory disease Imaging for: Complications Failure

US first line CT or MR for difficult / severe cases

ovarian veins Post partum or post surgery/pelvic

8 Location Tubal near to but separate from ovary Configuration Tubular Waist sign Incomplete septa Retort Pathognomonic Mural nodules: beads on a string Pelvic inflammatory disease Normal US Indistinct uterus Complex fluid Thick walled tube Cog wheel Internal echoes/debris Tuboovarian complex TO Hydrosalpinx Pyosalpinx Tubular fluid filled structure Folding mimics multilocular lesion Sequela of PID, endometriosis, surgery (Fallopian tube carcinoma larger and more solid components) Fallopian tube Pelvic inflammatory disease TO may overlap with neoplasm but history and clinical findings essential More inflammatory stranding Pelvic inflammatory disease Imaging for: Complications Failure to respond to first line treatment lternative diagnosis US first line CT or MR for difficult / severe cases Ovarian vein thrombophlebitis Septic thrombosis in ovarian veins Post partum or post surgery/pelvic inflammatory disease Pain, fever and leucocytosis May be occult Treated with antibiotics and anticoagulants 56 RP

Post partum thrombophlebitis Paraovarian/paratubal cyst 10-20% of adnexal masses rise in broad ligament from

Ovarian vein thrombophlebitis Distended ovarian vein Thrombus Perivenous inflammatory changes Edematous adnexa

peritoneal fluid within adhesions Pelvic surgery/endometriosis/pid Pre or post menopausal Treatment Surgical

ppendiceal mucocele Lymphadenopathy Uterine anomaly Peritoneal inclusion cyst Septated cystic peritoneal lesion

ovoid or spherical Look for normal ovary suspended by adhesions spider in a web +/-Flow in septations Summary

9 Post partum thrombophlebitis Paraovarian/paratubal cyst 10-20% of adnexal masses rise in broad ligament from mesothelial and paramesonephric remnants ny age (3rd-4th decades most common) Simple unilocular adnexal cyst a c Ovarian vein thrombophlebitis Distended ovarian vein Thrombus Perivenous inflammatory changes Edematous adnexa Paraovarian cystadenoma Uncommon Small solid nodule or septum Peritoneal inclusion cyst (pseudocysts) Loculated peritoneal fluid within adhesions Pelvic surgery/endometriosis/pid Pre or post menopausal Treatment Surgical (30-50% recurrence) OCP +/- TV US guided aspiration Other pelvic masses Varices Tarlov cyst Neurogenic tumors ppendiceal mucocele Lymphadenopathy Uterine anomaly Peritoneal inclusion cyst Septated cystic peritoneal lesion surrounding normal ovary Mistaken for a cystic ovarian neoplasm but passive conforming to cavity Occasionally ovoid or spherical Look for normal ovary suspended by adhesions spider in a web +/-Flow in septations Summary Characteristic sonographic features allow diagnosis of most benign adnexal masses Dictates management MR useful for indeterminate adnexal mass RP 57

Category Term Definition Comments 1 Major Categories 1a

Working Lexicon Categories, Terms & Definitions Category Term Definition Comments 1 Major Categories 1a Physiologic Category (consistent with normal ovarian physiology) Follicle Simple 3 cm in premenopausal