ASYMPTOMATIC ADNEXAL MASSES

ULTRASOUND EVALUATION

Osama M Warda MDOsama M Warda MDOsama M Warda MDOsama M Warda MD Professor of Obstetrics and Gynecology

Mansoura University--EGYPT

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INTRODUCTION

� Various disease processes can present as a clinical problem when a patient comes to a physician’s office for a routine gynecologic examination & an asymptomatic palpable adnexal mass is felt.

� The differential diagnosis include

1. Functional ovarian cysts (vast majority)

2. Endometriosis

3. Dermoids

4. Ovarian tumors (B9 > malig.)

5. Tubo-ovarian abscess

6. Subserous fibroids

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IMPORTANT CLINICAL PARAMETERS FOR DIAGNOSIS

� Patient’s age;

-Pre-menopausal

-Post-menopausal

� Apparent size of the mass on palpation;

? 5-6 cm, less or more

� Consistency (feel) of the mass;

? cystic, soft, solid

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GENERAL PLAN OF MANAGEMENT

1---- FollowFollowFollowFollow----up clinical exam for up clinical exam for up clinical exam for up clinical exam for 1111----2 2 2 2 menstrual menstrual menstrual menstrual cycles in:cycles in:cycles in:cycles in:

� Premenopausal patient

� Mass is < 6cm

� Mass feels cystic or soft

A- if mass disappeared well and good

B- if persisted or increased in size;

-TVS evaluation (CT or MRI rarely needed)

- Other non radiologic investigation (eg CA125) may be needed according to imaging results

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GENERAL PLAN OF MANAGEMENT

2222---- A palpable A palpable A palpable A palpable adnexaladnexaladnexaladnexal mass in a mass in a mass in a mass in a postmenopausalpostmenopausalpostmenopausalpostmenopausal woman:woman:woman:woman:

should be investigated immediately (no role for follow-up)

with TVS . Adding color Doppler increases the sensitivity

and positive predictive value in characterizing the

adnexal mass over the conventional grey scale.

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SIMPLE CYST

-It is the most common finding

- simple cyst is characterized by:

1. anechoic

2. smooth margins

3. unilocular

4. good sound transmission to the adjacent soft tissue

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SIMPLE CYST- THE OUTCOME

Simple cysts <6cm in premenopausal or <5 cm in postmenopausal women when found are followed up with ultrasound imaging after 1-2 months.

COCs may be used to help resolve the cyst and prevent development of other functional ovarian cysts as they decrease FSH level.

Most simple cysts disappear within that period. Spontaneous regression is less likely with cysts > 6cm.

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HEMORRHAGIC CYST

Bleeding in a cyst complicates the diagnosis. Variable characteristics can be seen

because of clot formation, lysis, and retraction. The cyst may have:

1. Appearance of a solid component

2. Mural nodularity

3. Septations

4. Focal wall thickening

5. Fluid debris levels

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HEMORRHAGIC CYST

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HEMORRHAGIC CYST

Thin, fibrous strands, clot retraction with convex

borders, fluid levels & homogeneous low echoes

throughout the mass with good transmission

suggest hemorrhage in this cystic mass.

Most hemorrhagic cysts will resolve spontaneously

over time but surgical excision may be necessary.

Ruptured cysts are associated with free fluid in

cul-de-sac, or even intra-peritoneal fluid.

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THECA LUTEIN CYSTS

Are functional cysts & usually associated with;

1- some form of GTD 2- Ovarian hyper-stimulation with ovulation drugs 3-

with spontaneous pregnancy especially mutifetal pregnancy.

The exact etiology is unknown but the are associated with high levels of HCG

Elevated pituitary FSH or increased HCG sensitivity may be involved

Are usually bilateral and multilocular

They may remain for several weeks after the removal of the offending cause

and usually asymptomatic

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POLYCYSTIC OVARIES

it is a complex clinical, laboratory, and ultrasound picture

ON ULTRASOUNDON ULTRASOUNDON ULTRASOUNDON ULTRASOUND:

There is a bilateral increased number of small (<There is a bilateral increased number of small (<There is a bilateral increased number of small (<There is a bilateral increased number of small (<8888mm) follicle cysts usually as many mm) follicle cysts usually as many mm) follicle cysts usually as many mm) follicle cysts usually as many

as as as as 10 10 10 10 in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)

Mature follicles (Mature follicles (Mature follicles (Mature follicles (15151515----30303030mm) can be found in up to mm) can be found in up to mm) can be found in up to mm) can be found in up to 15151515% of cases.% of cases.% of cases.% of cases.

Follicles > Follicles > Follicles > Follicles > 30303030mm can be seenmm can be seenmm can be seenmm can be seen

Increased ovarian Increased ovarian Increased ovarian Increased ovarian echogenicityechogenicityechogenicityechogenicity (=dense (=dense (=dense (=dense stromastromastromastroma))))

A combination of follicular and ovarian volume is the most sensitive objective A combination of follicular and ovarian volume is the most sensitive objective A combination of follicular and ovarian volume is the most sensitive objective A combination of follicular and ovarian volume is the most sensitive objective

parameter in diagnosis. The upper limit of normal ovarian volume is parameter in diagnosis. The upper limit of normal ovarian volume is parameter in diagnosis. The upper limit of normal ovarian volume is parameter in diagnosis. The upper limit of normal ovarian volume is 15151515CmCmCmCm3333

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OVARIAN ENDOMETRIOSIS

- Women between 25-35 years with dysmenorrhea

- Complex and primarily cystic masses due to repeated bleeding episodes during

menses.

The focal blood collection may be anechoic or complex, with multiple EVENLY

distributed echoes, clot nodules, or debris levels

There is usually good through sound transmission

The wall is usually thickened or irregular

Septa are unusual

In severe cases, multiple collections can be seen

Treatment is essentially SURGICAL

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PARAOVARIAN CYST

They arise in the broad ligament derivatives of They arise in the broad ligament derivatives of They arise in the broad ligament derivatives of They arise in the broad ligament derivatives of mesothelialmesothelialmesothelialmesothelial or or or or periperiperiperi----mesothelialmesothelialmesothelialmesothelial structures.structures.structures.structures.

They comprise They comprise They comprise They comprise 10101010% of % of % of % of adnexaladnexaladnexaladnexal cystic masses & mostly seen in cystic masses & mostly seen in cystic masses & mostly seen in cystic masses & mostly seen in the middlethe middlethe middlethe middle----age women.age women.age women.age women.

Although the are mostly simple cysts, they may be complicated Although the are mostly simple cysts, they may be complicated Although the are mostly simple cysts, they may be complicated Although the are mostly simple cysts, they may be complicated be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.

To be diagnosed as To be diagnosed as To be diagnosed as To be diagnosed as paraparaparapara----ovarian,aovarian,aovarian,aovarian,a tissue plane between the tissue plane between the tissue plane between the tissue plane between the cyst & the normal ovary must exist.cyst & the normal ovary must exist.cyst & the normal ovary must exist.cyst & the normal ovary must exist.

The usual treatment is EXCISION as it does not respond to The usual treatment is EXCISION as it does not respond to The usual treatment is EXCISION as it does not respond to The usual treatment is EXCISION as it does not respond to hormones. hormones. hormones. hormones.

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HYDROSALPINX

TheyTheyTheyThey are oblong ( or retortare oblong ( or retortare oblong ( or retortare oblong ( or retort---- shape) cystic structures shape) cystic structures shape) cystic structures shape) cystic structures

near the normally appearing ovary which is usually near the normally appearing ovary which is usually near the normally appearing ovary which is usually near the normally appearing ovary which is usually

separated by the cyst wallseparated by the cyst wallseparated by the cyst wallseparated by the cyst wall

Antibiotic/antiAntibiotic/antiAntibiotic/antiAntibiotic/anti----inflammatory treatment usually tried inflammatory treatment usually tried inflammatory treatment usually tried inflammatory treatment usually tried

with limited. with limited. with limited. with limited.

In infertility treatment excision or disconnection is In infertility treatment excision or disconnection is In infertility treatment excision or disconnection is In infertility treatment excision or disconnection is

recommended recommended recommended recommended

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TUBO-OVARIAN ABSCESS

The US appearanceThe US appearanceThe US appearanceThe US appearance varies according to their appearance at the varies according to their appearance at the varies according to their appearance at the varies according to their appearance at the

time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.

The mass may be purely cystic, have thick septa, have multiple The mass may be purely cystic, have thick septa, have multiple The mass may be purely cystic, have thick septa, have multiple The mass may be purely cystic, have thick septa, have multiple

loculationloculationloculationloculation, and contain complex debris., and contain complex debris., and contain complex debris., and contain complex debris.

A more serious diagnosis such as benign or malignant A more serious diagnosis such as benign or malignant A more serious diagnosis such as benign or malignant A more serious diagnosis such as benign or malignant

neoplasm must be considered because both conditions are quite neoplasm must be considered because both conditions are quite neoplasm must be considered because both conditions are quite neoplasm must be considered because both conditions are quite

similar on ultrasound.similar on ultrasound.similar on ultrasound.similar on ultrasound.

TuboTuboTuboTubo----ovarian abscesses are usually removed surgically ( ovarian abscesses are usually removed surgically ( ovarian abscesses are usually removed surgically ( ovarian abscesses are usually removed surgically ( although although although although

asymptomaticasymptomaticasymptomaticasymptomatic) as masses do not change over time.) as masses do not change over time.) as masses do not change over time.) as masses do not change over time.

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OVARIAN NEOPLASM

� Ovarian neoplasm; 80% benign, 10-15% malignant, and 5% are metastases.

� Age range for benign t is 20-45y, for malignant is 40-65y.

� Ovarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solid

� Ultrasound criteria suggesting malignancy include:

� Bilateral tumors Bilateral tumors Bilateral tumors Bilateral tumors

� Heterogeneous Heterogeneous Heterogeneous Heterogeneous echogeneityechogeneityechogeneityechogeneity

� Presence of intraPresence of intraPresence of intraPresence of intra----cystic septa, multiple cystic septa, multiple cystic septa, multiple cystic septa, multiple loculesloculesloculeslocules

� Presence of papillae (intraPresence of papillae (intraPresence of papillae (intraPresence of papillae (intra----cystic, or extracystic, or extracystic, or extracystic, or extra----cystic)cystic)cystic)cystic)

� Presence of intraPresence of intraPresence of intraPresence of intra----cystic solid partscystic solid partscystic solid partscystic solid parts

� Presence of ascitesPresence of ascitesPresence of ascitesPresence of ascites

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OVARIAN NEOPLASM- CYSTADENOMAS

Serous Serous Serous Serous cystadenomacystadenomacystadenomacystadenoma

MucinousMucinousMucinousMucinous CystadenomaCystadenomaCystadenomaCystadenoma Papillary serous Papillary serous Papillary serous Papillary serous cystadenomacystadenomacystadenomacystadenoma

Serous Serous Serous Serous cystadenocarcinomacystadenocarcinomacystadenocarcinomacystadenocarcinoma

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OVARIAN NEOPLASM- SOLID TUMORS

Granulosa cell t Immature solid teratoma

Brenner

Germ cell t

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OVARIAN NEOPLASM- DERMOID CYST

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SUBSEROUS MYOMA

UUUUsually appears sually appears sually appears sually appears ecogenicecogenicecogenicecogenic, similar to the , similar to the , similar to the , similar to the

uterine walluterine walluterine walluterine wall

Sometimes it appears with variable size Sometimes it appears with variable size Sometimes it appears with variable size Sometimes it appears with variable size

hyperecchogenichyperecchogenichyperecchogenichyperecchogenic areas due to calcificationareas due to calcificationareas due to calcificationareas due to calcification

Sometimes it may appear with mixed Sometimes it may appear with mixed Sometimes it may appear with mixed Sometimes it may appear with mixed

echogenicityechogenicityechogenicityechogenicity (complex mass) due to cystic (complex mass) due to cystic (complex mass) due to cystic (complex mass) due to cystic

degenerationdegenerationdegenerationdegeneration

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THANK YOU THANK YOU THANK YOU THANK YOU

شكرا و السالم عليكم

و رحمة اهللا وبركاته

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