Ovaries and Physiologic Cysts

Ovaries

• Paired and almond-shaped organs
• Internal iliac arteries lie posterior to the ovaries and it's a good landmark
• The homogeneous echotexture consists of an echogenic medulla and multiple anechoic follicles around the cortex
• Ovarian appearance varies with age and menstrual cycle
• Standard ovarian size is 3.5 x 2.0 x 1.5 cm
• Standard ovarian volume is 3.2 - 5.1 cm
• Ovarian volume calculation formula: 0.523 x length x width x height

Physiologic Cysts

• Functional cysts include:
  • Follicular cysts
  • Corpus luteum cysts
  • Hemorrhagic cysts
  • Theca lutein cysts

Functional Ovarian Cysts

• Function of ovary is to produce the dominant follicle
• A dominant follicle measures 3 mm to 24 mm
• Corpus Luteum can be 1 to 10 cm
• Physiologic ovarian enlargement
• Cysts less than 3 cm are considered Within Normal Limits (WNL) if simple, anechoic, and thin-walled
• Cysts greater than 5 cm need follow up
• Hormonal therapy suppresses cysts
• Surgery is considered for cysts > 6 cm persisting for 8 weeks

Follicular Cyst

• Follicular cysts occur due to the non-rupture of a dominant follicle
• Follicular cysts occur due to the failure of an immature follicle to undergo atresia
• They range from 2-20cm
• They are an incidental finding, usually unilateral and asymptomatic
• On ultrasound, they appear anechoic, unilocular, and thin-walled

Corpus Luteum Cyst

• Corpus Luteum Cysts occur following ovulation
• Corpus Luteum Cyst secrete PROGESTERONE
• No treatment is required
• Usually less than 4 cm and Unilateral
• They are prone to hemorrhage and rupture
• If pregnancy occurs, it secretes progesterone for up to 16 weeks
• On ultrasound, the can appear as simple or complex, thick walled.

Hemorrhagic Cyst

• This is bleeding into a cyst during the follicular or, more commonly, the corpus luteal stage
• Sonographic appearance varies as clot develops
  • Acute: Hyperechoic, mimicking a solid mass but has acoustic enhancement
  • Subacute: Internal echoes become more complex and echogenic
• This is unilateral and can cause sudden onset of pelvic pain

Theca Lutein Cyst

• These are the largest of the functional cysts, ranging from 3-20 cm
• This results from high levels of hCG
• Often found with Molar pregnancy which is about -30% of the time
• Can be caused by infertility treatment (Clomid/Pergonal)
• usually Bilateral, multi-loculated cystic masses

Ovarian Hyperstimulation Syndrome (OHS)

• This is often a Complication of ovulation induction
• Ovaries are swollen and painful
• This is an Iatrogenic cause, usually due to fertility treatments
• Cases are typically Bilateral
• Severe cases can be associated with ascites, pleural effusion and large painful cysts

Polycystic Ovarian Syndrome (PCOS)

• AKA Stein-Leventhal Syndrome
• Endocrine disorder (imbalance of LH, FSH and testosterone)
• Chronic anovulation and the clinical signs include
  • Infertility
  • Obesity
  • Oligomenorrhea
  • Hirsutism (dark hair on face or chest of woman)
  • Have more male characteristics; deeper voice, smaller breasts, more muscle mass
• Younger women in their teens to 20's will often have this
• It's Diagnosis based on clinical signs and blood tests
• The sonographic appearance includes
  • They appear two to five times normal size
  • Increased number of follicles (peripheral cyst)
  • More than 19 follicular cysts
  • Always bilateral
  • Ovarian volume > 10cm3

Par(a)ovarian Cyst

• 10% of adnexal simple cysts are Paraovarian
• These arise from the broad ligament, NOT the ovary
• Located separate from the ovary, within the broad ligament
• Wolffian duct remnants

Ovarian Torsion

• This is Caused by partial or complete rotation of the ovary on its axis
• This Restricts blood flow
• Clinical symptoms inlcude acute and severe unilateral pain
• Right side pain can mimic appendicitis
• Sonographic Appearance:
  • Enlarged ovary
  • Absent or dampened arterial flow on color or pulsed doppler; always compare to other side (should be the same)
• Usually occurs in childhood and adolescence, during pregnancy, or in a patient with a history of a large ovarian cyst
• Accounts for 3% of GYN emergency surgeries
• Ovarian death occurs quickly

Benign Ovarian Tumors

• 80% of all Ovarian masses are Benign

Cystic Teratoma

• Also known as Dermoid Cyst
• Most Common Germ cell Tumor
• Found in Women of childbearing age
• Composed of hair, teeth, bones, & fat
• Complex mass may have:
  • Calcifications
  • Fat/fluid levels
  • Diffusely echogenic with shadows
  • "Tip of the iceberg” appearance
  • Dermoid plug
  • May mimic bowel
  • high Risk for torsion

Epithelial Tumors

• Most Common Types
  • Mucinous Cystadenoma
  • Serous Cystadenoma
• Less Common Type
  • Brenner Tumor

Mucinous Cystadenoma

• Most common benign cystic tumor of ovary
• Tumor lined with mucinous elements of the endo cervix
• 25% of benign ovarian neoplasms
• Occurs in patients ages 30 - 50 years
• 85% are benign
• Large 15 to 50 cm (weighing up to 100 lbs)
• Unilateral
• Ultrasound shows numerous, thick-walled septations, multiloculated cysts
• Clinical symptoms: Pressure, pain, increased abdominal girth

Serous Cystadenoma

• Second most common benign tumor of ovary
• Unilateral
• Smaller than mucinous
• Multiloculated cysts with thin septations
• Clinical: Pressure and bloating
• Sonographic Appearance:
  • Anechoic
  • Large, usually unilocular
  • Thin wall septations

Brenner Tumor

• (Epithelial/Transitional Cells)
• Found in Women 40–80 yrs; avg 50's
• Unilateral
• Incidental finding
• It is Rare
• Ultrasound Appearance:
  • Small, hypoechoic, solid mass, may have small cystic spaces, may have calcifications

Stromal Tumors

• Sex cord of ovarian stroma
• These include Fibroma, Thecoma and Sertoli-Leydig tumor
• Fibroma
  • Unilateral
  • Postmenopausal women
  • Microscopic to melon size
  • Homogeneous, hypoechoic mass with posterior attenuation, shadowing
  • Larger tumors are prone to torsion (pressure and pain)
  • When tumor is over 5 cm, it can be associated with Meigs' Syndrome (Ascites and Pleural Effusion)

Thecoma

• Unilateral
• Estrogen Producing
• Rare
• Postmenopausal women
• Ultrasound:
  • Solid hypoechoic mass with posterior shadow
  • Possible thick endometrium due to estrogen secretion

Steroli-Leydig Tumor

• AKA Arrhenoblastoma/Androblastoma
• Very rare
• Unilateral
• Usually in Women <30 years
• Androgen (testosterone) producing
• Masculinization symptoms 50%
• 5-15cm in size
• 20% may become malignant
• Ultrasound Findings
  • Solid, echogenic mass

Ovarian Malignancy

• 8th leading cause of cancer death in women worldwide
• 5-year survival rate is 30-50%
• 15,000 women die annually in US
• 207,000 women die globally
• 80% are women > 60

Ovarian Cancer: Lab Tests

• CA 125
  • A biological tumor marker that is elevated in the blood of most women with ovarian cancer
  • 80% ovarian cancers result in high levels
  • Non-specific to ovarian cancer
  • Insensitive to mucinous and germ cell tumor
  • In any patient with a suspicious ovarian mass, always consider additional testing for ascites and mets in peritoneum, lymph nodes, liver, pleural space

Risk Factors For Ovarian Cancer

• Age (women over 50)
• Nulliparity
• Early menses or late menopause
• Family history of ovarian or breast cancer
• BRCA 1 or 2 gene

Ovarian Cancer Clinical Signs and Symptoms

• Known as silent killer
• Vague complaints (early on)
• Abdominal pain/swelling, Frequent urination
• Increasing abdominal girth & vaginal bleeding
• Poor prognosis due to late diagnosis
  • 65% of patients have stage III or IV at time of diagnosis

Treatment

• Early detection has an 80% five-year survival rate
• Late detection has 5% five-year survival rate
• Multifaceted treatment methods include surgery, chemotherapy, radiation

Sonographic Screening

• It's useful to use Endovaginal imaging with CA125 tool
• Check the ovarian
• Size/Volume, Echogenicity, Symmetry
• Arterial flow resistance: most ALL cancer has low resistant flow patterns
• Best to screen Days 3-7 of menstrual cycle due to changes in ovarian arteries' waveforms

Cancer Staging

• Stage I, Limited to ovary
• Stage II, Limited to pelvis (uterus, fallopian tubes)
• Stage III, Limited to abdomen (colon, retroperitoneal)
• Stage IV, Spread beyond abdomen (liver)

Epithelial Cell Tumor

• Arise from surface that covers ovary
• 80 – 90 % of ovarian malignancies

Serous Cystadenocarcinoma

• It accounts for about 80% of ovarian cancers
• Most common malignant tumor
• Found Bilaterally 50% of the time
• Peri- and postmenopausal women
• Sonographic appearance:
  • Multilocular
  • Multiple papillary projections/septations
  • Calcification, Ascites
  • Smaller than Mucinous

Mucinous Cystadenocarcinoma

• Rare 5-10% of tumors
• Occurs in women ages 40-70 years
• Can become very large and is likely to rupture
• Can cause Pseudomyxoma peritonei
  • Tumor capsule ruptures spreading cells into peritoneal cavity filling it with gelatinous material (cancer cells)
  • Appears as complex ascites, fluid with septations
• Sonographic appearance:
  • Multiloculated cystic lesions measuring 15-30 cm
  • Contain echogenic material
  • Similar to Serous
  • Ascites with possible septations

Germ Cell Neoplasms

• Derived from germ cells of the embryonic gonads

Immature Teratoma

• Very rare and rapidly growing
• Occurs in the first two decades of life (girls ages 10-20 years)
• Unilateral and creates Elevated AFP (Alpha Fetoprotein)
• Sonographic appearance:
  • Looks the Same as mature teratoma (dermoid cyst)

Dysgerminoma

• A malignant germ cell tumor originating from germ cells of ovary
• Occurs in women under 30 and it
• Highly malignant
• Appears Unilateral
• Sonographic appearance:
  • Multilobulated hyperechoic solid mass with areas of hemorrhage and necrosis
  • Usually unilateral

Endodermal Sinus (Yolk Sac) Tumor

• 2nd most common germ cell malignancy
• Occurs in young adults (20-30 years)
• Unilateral and variable in size
• Highly malignant
• Metastasizes to surrounding organs
• Increased AFP & LDH
• Mostly solid mass with necrosis

Sex Cord Tumor

• Stromal Tumor arise from connective tissue

Granulosa Cell Tumor

• Most common hormone-active estrogenic tumor
• Mimics Graafian Follicle
• Occurs in the range of Ages 50-55, more common after menopause
• Commonly produce estrogen which causes bleeding
• Possible thickened endometrium due to estrogen influence
• Unilateral
• May lead to Meigs' syndrome
• Sonographic appearance:
  • Small tumors which are Predominantly solid and Similar to adenoma or fibroids
  • Large tumors are Multiloculated/cystic and Similar to cystadenomas
  • Can have Thickened endometrium

Metastases to Ovary

• Arise from Breast, GI, Uterus and Lymph
• Krukenberg Tumor indicates the metastasis is from the Primary GI tract and is
  • Typically Bilateral
• Sonographic findings:
  • Bilateral solid hypoechoic or complex solid masses
  • Possible ascites

Key points to remember

• The more sonographically complex the tumor, the more likely it is malignant
• Malignancies rely heavily on BLOOD flow to sustain their spread
• Solid adnexal masses have many differential diagnoses including pedunculated fibroid, dermoid, fibroma, thecoma, granulosa cell tumor, Brenner tumor, or metastasis, get a BIOPSY to verify
• Tubo-ovarian abscess, ovarian torsion, hemorrhagic cysts, and ectopic pregnancy may appear as solid adnexal masses. How can you tell?
• Always use DOPPLER on any SOLID APPEARING MASS!!!! COLOR, POWER, & PULSED DOPPLER