Week 7 - Ovarian Pathology Pt. 1 2024 PDF

PATHOLOGY OF THE OVARIES DMS 202 OB/GYN Sonography I Prof. Robert - Fall 2024 Chapter 44 Copyright © 2018 Elsevier Inc. All rights reserved. Ovarian Pathology Normal Ovaries Review Functional Ovarian Cysts Syndromes and Torsion Anato...

PATHOLOGY OF THE OVARIES DMS 202 OB/GYN Sonography I Prof. Robert - Fall 2024 Chapter 44 Copyright © 2018 Elsevier Inc. All rights reserved. Ovarian Pathology Normal Ovaries Review Functional Ovarian Cysts Syndromes and Torsion Anatomy Follicular cysts Ovarian Hyperstimulation Syndrome Corpus luteum cysts Sonographic findings Polycystic Ovarian Syndrome Hemorrhagic cysts Function Theca-lutein cysts Paraovarian cysts Cystic vs solid masses Ovarian Torsion Doppler findings Copyright © 2012, 2006, 2001, 1995, 1989, 1983, 1978 by Mosby, an 2 imprint of Elsevier Inc. Anatomy of the Ovaries Paired, almond-shaped structures situated one on each side of uterus close to lateral pelvic wall Variable in position; influenced by uterine location and ligament attachments In anteflexed midline uterus, ovaries usually identified laterally or posterolaterally Copyright © 2018 Elsevier Inc. All rights reserved. 3 Ovarian Functions Ovary functions: 1. Mature oocytes until ovulation Under influence of LH and FSH from pituitary gland 2. Ovary synthesizes androgens and converts them to estrogens Androgen- male hormones, estrogen -female hormones 3. Produces progesterone After ovulation by corpus luteum to sustain early pregnancy Until placenta produces progesterone by 10-12 weeks gestation Copyright © 2018 Elsevier Inc. All rights reserved. 4 Location of the Ovaries Uterus lies right or left of midline Ipsilateral ovary often lies superior to uterine fundus. Uterus retroverted Ovaries tend to be lateral and superior, near uterine fundus. Uterus enlarged Ovaries tend to be displaced more superiorly and laterally After hysterectomy Ovaries tend to be located more medially and directly superior to vaginal cuff. Can be located high in pelvis or in cul-de-sac Superiorly or extremely laterally placed ovaries may not be visualized by TVS because they are out of FOV Copyright © 2018 Elsevier Inc. All rights reserved. 5 Normal Sonographic Appearance Homogeneous echotexture May exhibit central, more echogenic medulla Small anechoic or cystic follicles may be seen peripherally in cortex. Appearance varies with age and menstrual cycle. Ellipsoid in shape Craniocaudal axes paralleling internal iliac vessels, which lie posterior and serve as reference point Copyright © 2018 Elsevier Inc. All rights reserved. 6 Normal Sonographic Appearance Copyright © 2018 Elsevier Inc. All rights reserved. 7 Normal Sonographic Appearance Copyright © 2018 Elsevier Inc. All rights reserved. 8 Normal Sonographic Appearance Copyright © 2018 Elsevier Inc. All rights reserved. 9 Normal Sonographic Appearance Copyright © 2018 Elsevier Inc. All rights reserved. 10 Normal Sonographic Appearance Three phases recognized sonographically during each menstrual cycle during reproductive years Early proliferative phase: Stimulation by both FSH and LH Many follicles develop and increase in size Until about day 8-9 of cycle https://radiologykey.com/ultrasound-evaluation-of-the-ovaries/ One follicle becomes dominant, reaching up to 2-2.5 cm at ovulation Copyright © 2018 Elsevier Inc. All rights reserved. 11 Normal Sonographic Appearance Cumulus oophorus: Normal sonographic finding Occasionally detected Eccentrically located, cyst like, 1 mm internal mural protrusion. Indicates mature follicle and imminent ovulation Other follicles degenerate Follicular cyst develops if fluid in nondominant follicles not reabsorbed Copyright © 2018 Elsevier Inc. All rights reserved. 12 Normal Sonographic Appearance Ovulation: Dominant follicle usually disappears immediately after rupture at ovulation. Occasionally follicle decreases in size and develops a wall that appears crenulated (scalloped). Occurrence of fluid in cul-de-sac commonly seen after ovulation and peaks in early luteal phase Copyright © 2018 Elsevier Inc. All rights reserved. 13 Normal Sonographic Appearance Luteal phase: After ovulation, mature corpus luteum develops May be identified sonographically as a small hypoechoic or isoechoic structure peripherally within ovary. May appear irregular with echogenic crenulated walls and contain low-level echoes. May include typical “ring” color Doppler pattern around wall of isoechoic corpus luteum. In absence of fertilization: Corpus luteum undergoes involutional changes on postovulatory days 8 or 9 (days 22-23 of menstrual cycle) Disappears shortly before or with onset of menstruation Copyright © 2018 Elsevier Inc. All rights reserved. 14 Normal Sonographic Appearance Multiple small, punctate, echogenic foci commonly seen in normal ovary Foci reported to be common finding with TVS Generally very small (1 to 2 mm) and located in periphery Foci are nonshadowing and can be multiple https://radiologykey.com/ultrasound-evaluation-of-the-ovaries/ Copyright © 2018 Elsevier Inc. All rights reserved. 15 Normal Sonographic Appearance Postmenopausal: Ovary atrophies Follicles disappear with increasing age Sonographically: Difficult to visualize sonographically Smaller size and lack of discrete follicles Stationary loop of bowel may mimic small shrunken ovary Look for peristalsis in bowel. http://learningradiology.com/lectures/facultylectures/Introduction%20to%20Pelvic%20US- MH/Introduction%20to%20Pelvic%20US-MH/Introduction%20to%20Pelvic%20US-MH.html Copyright © 2018 Elsevier Inc. All rights reserved. 16 Ovarian Volume Adult menstruating female, normal ovary: Vol up to 22 ml, Mean ovarian volume of 9.8 +/- 5.8 ml. Postmenopausal patient: Vol > 8.0 ml definitely considered abnormal for Vol > 2x of opposite side also be considered abnormal- regardless of actual size. S/p hysterectomy: Ovaries can be difficult to visualize with ultrasound. Use of both transabdominal and transvaginal approaches increases chance of visualization. S/p = status post Copyright © 2018 Elsevier Inc. All rights reserved. 17 Simple Cystic Masses Majority of ovarian masses are simple cysts, most of which are benign Possible causes: Corpus luteum Abnormal unruptured follicle Can persist and reach 1-10 cm Sonographic criteria for simple cyst: Thin, smooth wall Anechoic contents Acoustic enhancement Copyright © 2018 Elsevier Inc. All rights reserved. 18 Simple Cystic Masses Interventions: If cyst >6 cm persists more than 8 weeks, surgical intervention may be considered. Ultrasound-guided needle aspiration has become another option for reducing recurrent simple ovarian cysts in carefully selected cases. Postmenopausal ovaries: Small anechoic cysts may be seen Can disappear or change in size over time Serial sonographic studies monitor size and document changes Surgery generally recommended for: Postmenopausal cysts >5 cm Postmenopausal cysts containing internal septations and/or solid nodules Copyright © 2018 Elsevier Inc. All rights reserved. 19 Complex Masses Any simple cyst that hemorrhages as it involutes may appear as complex mass. In patients of reproductive age, classic differential considerations of complex adnexal mass are ectopic pregnancy, endometriosis, and pelvic inflammatory disease (PID). Dermoids and other benign tumors can appear in a similar fashion. Copyright © 2018 Elsevier Inc. All rights reserved. 20 Solid Tumors Mixed solid to cystic ovarian masses typical of all epithelial ovarian tumors Most common are serous types: Cystadenoma Cystadenocarcinoma During fertile years, only 1:15 malignant Increases to 1:3 after age 40 Copyright © 2018 Elsevier Inc. All rights reserved. 21 Solid Tumors The more sonographically complex the tumor, the more likely it is to be malignant, especially if associated with ascites Ovary with volume twice that of opposite side generally considered abnormal When solid mass found, always identify possible connection with uterus to differentiate ovarian lesion from pedunculated fibroid Color Doppler helpful by using color to identify vascular pedicle between uterus and mass (pendunculated) Copyright © 2018 Elsevier Inc. All rights reserved. 22 Doppler of the Ovary Patients with normal menstrual cycles best scanned in first 10 days of cycle This avoids confusion with normal changes in intraovarian blood flow because high diastolic flow occurs in luteal phase. Copyright © 2018 Elsevier Inc. All rights reserved. 23 Doppler of the Ovary PI and RI values may vary considerably in fertile patient during menstrual cycle. In first 7 days, flow to ovaries has the greatest resistance with the lowest diastolic flow, and indices are at their highest. Later in each cycle, diastolic flow increases, particularly to dominant ovary, and may lower indices sufficiently to falsely suggest malignant process. Copyright © 2018 Elsevier Inc. All rights reserved. 24 Doppler of the Ovary Color Doppler Helpful in differentiating potential cyst from adjacent vascular structures Localize flow to further determine flow velocity with pulsed Doppler; can be obtained on all ovarian masses Pulsed Doppler Used to demonstrate arterial and venous flow within ovarian tissue Intramural flow to determine resistive index or pulsatility index Prominent flow to ovary during hyperstimulation phase of infertility treatment. Copyright © 2018 Elsevier Inc. All rights reserved. 25 Doppler of the Ovary What is the value of RI in distinguishing between benign and malignant adnexal masses? Signs that may be worrisome for malignancy: Intratumoral vessels Low-resistance flow Absence of normal diastolic notch in Doppler waveform Abnormal waveforms can be seen in inflammatory masses, metabolically active masses (including ectopic pregnancy), and corpus luteum cysts. Copyright © 2018 Elsevier Inc. All rights reserved. 26 Doppler of the Ovary Pulsatility index (PI) Peak-systolic velocity minus end-diastolic velocity divided by mean velocity. Resistive index (RI) Peak-systolic velocity minus end-diastolic velocity divided by peak-systolic velocity. RI is not a sensitive indicator of malignancy. No clear/hard rule of PI and RI indices Different studies have different cut-off values However: Increased diastolic flow suggests neovascularity and the likelihood of a malignancy. Complete absence or minimal diastolic flow (very elevated RI and PI values) usually benign Copyright © 2018 Elsevier Inc. All rights reserved. 27 Doppler of the Ovary General cut-off value for PI is 1.0 and RI is 0.4 Malignancy considered more likely below these values Benign disease more likely above these values. Inflammatory masses, active endocrine tumors, and trophoblastic disease (ectopic pregnancies) may give low indices, mimicking cancer. Copyright © 2018 Elsevier Inc. All rights reserved. 28 Ovarian Pathology Normal Ovaries Review Functional Ovarian Cysts Syndromes and Torsion Anatomy Follicular cysts Ovarian Hyperstimulation Syndrome Corpus luteum cysts Sonographic findings Polycystic Ovarian Syndrome Hemorrhagic cysts Function Theca-lutein cysts Paraovarian cysts Cystic vs solid masses Ovarian Torsion Doppler findings Copyright © 2012, 2006, 2001, 1995, 1989, 1983, 1978 by Mosby, an 29 imprint of Elsevier Inc. Functional Ovarian Cysts Description: Functional cysts result from normal function of ovary Dominant follicle does not succeed in ovulating Remains active though immature Most common cause of ovarian enlargement in young women Usually unilateral, may grow up to 8 cm Usually disappear spontaneously by resorption or rupture Treatment: Hormonal therapy sometimes administered to suppress cyst Most cysts measure 4 cm in diameter Torsion typically involves not only ovary but also fallopian tube 10% increased incidence of torsion occurring in contralateral adnexa after torsion occurs Usually occurs in children and younger females with mobile adnexa, preexisting ovarian cyst or mass, or pregnancy. Copyright © 2018 Elsevier Inc. All rights reserved. 55 Ovarian Torsion Treatment: Surgical emergency Acute abdominal condition Requires prompt diagnosis and surgical intervention Gross pathology specimen of torsed right ovary and large paraovarian cyst. https://radiopaedia.org/cases/ovarian-torsion-66?lang=us Copyright © 2018 Elsevier Inc. All rights reserved. 56 Ovarian Torsion Clinical: Acute severe unilateral pain Intermittent pain may precede acute pain by weeks Fever, nausea, vomiting possible Palpable mass felt in more than 50% of patients Right ovary is three times more likely to torse than the left. Symptoms mimicked by many other pelvic or lower abdominal processes Torsion part of differential diagnostic list https://radiopaedia.org/cases/13050/studies/13109?lang=us&source_of=htt ps%3A%2F%2Fradiopaedia.org%2Farticles%2Fovarian-torsion%3Flang%3Dus Copyright © 2018 Elsevier Inc. All rights reserved. 57 Ovarian Torsion Sonographic findings: Enlarged ovary, with or without peripheral follicles Heterogeneous due to edema, hemorrhage, and/or necrosis Usually associated with mass Mass may not be appreciated if mixed in with the necrosis and hemorrhage of the torsed mass Absent blood flow on Doppler examination Free fluid in cul-de-sac https://radiopaedia.org/cases/30458/studies/31128 Copyright © 2018 Elsevier Inc. All rights reserved. 58 Ovarian Torsion – “Whirlpool Sign” Copyright © 2018 Elsevier Inc. All rights reserved. 59