Pathology of the Ovaries Powerpoint first 1/2

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1

Wolffian Duct and mesonephros

Lumbar region

Where do the ovaries develop from?

What region do the ovaries begin in?

They gradually decend into the pelvic region as it enlarges to accommodate them.

2

1. cortex - outer part (tunica) : ovarian follicles, corpus lutea, and fibrous capsule - tunica albuginea

2. medulla - smaller inner part (stroma) : contains blood vessels, mainly veins and fibrous tissue

Ovaries consist of what 2 parts?

3

Ellipsoid in shape, with craniocaudad axes paralleling internal iliac vessels, which lie posterior and serve as a refrence point

Locations varies with uterine size, position and location

Anatomy of the uterus

Location?

4

Patients with normal menstrual cycles are best scanned in the first 10 days of cycle

This avoids confusion with normal changes in intraovarian blood flow because high diastolic flow occurs in the luteal phase

When is the best time to doppler the ovary?

Why?

5

Inflammatory masses, metabolically active masses (including ectopic pregnancy), and corpus luteum cysts

NO

Abnormal doppler waveforms can be seen in what?

Is RI a sensitive indicator for malignancy?

6

Benign

Masses showing complete absence or minimal diastolic flow (very elevated RI and PI values) are usually ____?

Diastolic notch in early diastole may also be a sign of ____ disease.

7

Intratumoral vessels, low-resistance flow, and absence of normal diastolic notch in doppler waveform

Inflammatory masses, active endocrine tumors, and trophoblastic disease (ectopic pregnancies)

Doppler signs that may be worrisome for malignancy:

What diseases may give low indicies, mimicking cancer?

8

Menopause

Postmenopausal

Normal Sonographic Appearance

Following ____, ovary atrohpies and follicles disappear with increasing age.

____ ovary difficult to visualize sonographically because of smaller size and lack of discrete follicles.

Stationary loop of bowel may mimic small shrunken ovary, look for peritstalsis in bowel.

9

Simple cysts

6

Majority of ovarian masses are ____, most of which are benign.

Criteria for ____ include thin, smooth wall, anechoic contents, and acoustic enhancement.

If cyst greater than ___ cm persists more than 8 weeks, surgical intervention may be recommended.

10

Postmenopausal

Small anechoic cysts may be seen in ____ ovaries.

Surgery is recommended for ____ cysts greater than 5 cm and for those containing internal septations and/or solid nodules.

11

Follicular cyst, corpus luteum cyst, benign cystic teratoma, paraovarian cyst, polycystic ovarian disease, hydrosalpinx, endometrioma (low level echoes), and hemorrhagic cyst

Common cystic or complex benign ovarian masses:

12

Functional ovarian cysts

____ result from normal function of the ovary.

____ are the most common cause of ovarian enlargement in young women.

include: follicular, corpus luteum, hemorrhagic, and theca-lutein cysts

13

Functional ovarian cysts

5

Hormone therapy is sometimes administered to suppress ____.

Most cysts measure less than ___ cm in diameter and regress during subsequent menstrual cycle.

Follow up in 6 weeks usually documents change in size.

14

Follicular cysts

____ occur when a dominant follicle does not ovulate, but remains active although its immature.

Usually unilateral, thin-wall, translucent, contains watery fluid, and may project about or within the surface of the ovary.

May grow 1-8 cm

15

Follicular Cysts

____ usually disappear spontaneously by re-absorption or rupture.

Present as asymptomatic to dull, adnexal pressure and pain, abnormal ovarian function, and torsion of the ovary resulting in severe pain.

Appear as a simple cyst.

16

Corpus Luteum Cysts

____ result from hemorrhage within persistently mature corpus luteum.

Are filled with blood and cystic fluid.

They may accompany intrauterine pregnancy (IUP)

17

Corpus Luteum Cysts

___ may grow 1-10 cm in size.

Present as irregular menstrual cycle, pain, mimic ectopic preganancy, rupture

"Cystic" type of lesion that may have internal echoes secondary to hemorrhage and increased color flow.

18

Hemorrhagic Cyst

____ may occur in follicular cysts, or more commonly in corpus luteum cysts

Patient may present with acute onset of pelvic pain

Usually hyperechoic, may mimic a solid mass; smooth posterior wall, enhancement, diffuse low-level echoes may be seen, becomes complex

19

Theca-Lutein Cysts

___ are large, bilateral, multiloculated cysts that are associated with high levels of hCG. They are seen in 30% of patients with gestational trophoblastic disease.

Present with nausea and vomiting

Multilocular cysts in both ovaries

20

Ovulation induction

Ovarian hyperstimulation sydrome is a complication of ___?

In mild form, presents with pelvic discomfort, but no significant weight gain

Ovaries are enlarged and measure less than 5 cm in diameter.

21

Severe hyperstimulation sydrome

With ___ the patient has severe pelvic pain, abdominal distention, enlarged ovaries measuring greater than 10 cm.

Associated with ascites, pleural effusions, numerous large, thin-walled cysts throughout the periphery of the ovary.

When treated, usually resolves within 2-3 weeks

22

Polycystic ovarian syndrome

____ includes Stein-Leventhal syndrome

Bilaterally enlarged, rounded, multiple peripheral cystic ovaries

Occurs in late teens through 20s

Patient may have endocrine imbalance

23

Polycystic ovarian syndrome

____ presents as amenorrhea, obesity, infertility and hirsutism.

Appears as multiple tiny cysts around the periphery of the ovary; known as "string of pearls"; ovary may be normal size or enlarged

Decreased FSH; increased LH and testosterone

24

Ovarian remnant sydrome

____ is described as a small amount of tissue left behind after an oopherectomy than can function and produce cysts and appears as a thin rim of ovarian tissue.

Unlikely to see

25

Peritoneal inclusion cyst

___ is formed when adhesions trap peritoneal fluid around ovaries, resulting in a large adnexal mass

Aka benign cystic mesothelioma that is lined with mesothelial cells

Presents with pelvic pain and/or a pelvic mass

Associated with postmenopausal women with a history of surgery

26

Multiloculated cystic mass

Peritonal inclusion cysts sonographic findings include a ____.

Must see intact ovary within or on the margin for diagnosis

It may hemorrhage

27

Paraovarian Cysts

____ are usually simple cysts located in the broad ligament that are remnants of the Wolffian duct.

Can bleed or torse

10% of all adnexal masses and are more common in the 3rd and 4th decades of life.

28

Paraovarian cysts

____ present asymptomatic

Simple cyst adjacent to ovary with thin, deformable walls that may contain nodular areas or septations. They vary in size and are not altered with hormones. They are difficult to distinguish from ovarian cysts.

29

Fluid collections in adhesions

____ are odd shaped, and throughout the abdomen.

Omental - higher abdomen

Urachal - midline anterior abdominal wall

30

Benign fetal and pediatric cysts

____ are a normal finding that result from maternal hormones.

Pediatrics - small follicles are normal

Can produce symptoms of precocious puberty

31

Endometriosis

___ is a common condition in which functioning endometrial tissue is present outside the uterus. It can be found almost anywhere in the pelvis including ovary, fallopian tube, broad ligament, external surface of uterus, scattered over peritoneum, cul-de-sac, and even bladder.

32

Endometriosis

____ tissue cyclicially bleeds and proliferates.

Is rarely diagnosed by ultrasound.

33

Diffuse and localized. In diffuse form, leads to disorganization of pelvic anatomy with appearance similar to PID or chronic ectopic pregnancy. Diffuse is more common and consists of endometrial plantings within peritoneum. Localized consists of a discrete mass called a endometrioma or "chocolate cyst" and are frequently found in multiple sites.

2 forms of endometriosis; describe each

34

Endometriosis

___ may appear as bilateral or unilateral ovarian cysts.

Patterns ranging from anechoic to solid. It depends on amount of blood and its organization.

35

Endometrioma

___ is a well-defined unilocular or multilocular predominantly cystic mass.

It contains diffuse homogeneous, low-level internal echoes.

36

Ovarian Torsion

___ is caused by partial or complete rotation of ovarian pedicle on its axis.

Produces enlarged edematous ovary usually greater than 4 cm in diameter

Accounts for 3% if gynecologic operative emergencies

Presents with the "whirlpool sign"

37

Ovarian Torsion

Classical ___ - multiple tiny follicles around a hypoechoic mass to completely solid adnexal mass.

Doppler examination usually reveals absent blood flow

Free fluid is often present in the pelvis

38

Ovarian Torsion

___ causes edema and eventual loss of arterial perfusion with subsequent artifact.

Typically involves not only the ovary but also the fallopian tube. Once ___ has occured, 10% increased incidence of occurrence in contralateral adnexa.

39

Ovarian Torsion

___ usually occurs in children and younger females with mobile adnexa, preexisting ovarian cyst or mass, or pregnancy.

It is usually associated with a mass.

RT ovary is 3 times more likely than the left.

40

Ovarian Torsion

___ presents with fever, nausea and vomiting, palpable mass is felt in more than 50% of patients and acute severe unilateral pain.

Hypoechoic enlarged heteogeneous ovary owing to edmena, hemorrhage and/or necrosis; with or without peripheral follicles, absent blood flow, free fluid in the cul-de-sac and is a surgical emergency.

41

Ovarian tumors

Cystadenoma and cystadenocarcinoma

Mixed solid cystic ovarian masses typical of all epithelial ____.

Most common are serous types? (2)

Only 1 in 15 are malignant in peak fertile years. Ratio becomes 1 in 3 after age 40.

42

Tumors

The more sonographically complex the ____, the more likely to be malignant, especially if associated with ascites. Epithelium of serous ___ are tubal in type, may be one or multiple cysts

1/4 are bilateral (most are unilateral); most occur in women over 40. Large and often fill pelvic cavity

43

Solid Tumors

Ovary with volume twice that of opposite side generally are considered abnormal

When ___ are found, indentification of connection uterus to differentiate ovarian lesion from pedunculated. Color is helpful to identify a vascular pedicle between the uterus and mass.

44

Only 3% of ovarian cysts less than 5 cm are malignant. Cysts greater than 5 cm are recommended for surgical removal.

Well defined anechoic lesions are more likely to be benign; lesions with irregular walls, thick irregular septations, mural nodules and solid echogenic elements favor malignancy.

What percentage of ovarian neoplasms are malignant?

What appearance of ovarian neoplasms suggests being benign or malignant?

45

Low resistance pattern

Doppler examination of ovarian neoplasms shows ____.

46

Extension beyond the ovary into the omentum or peritoneum; multilocular, thickly septated masses and masses with solid nodules; peritoneal carcinomatosis with malignant ascites and peritoneal implants; any change in ovarian echogenicity or volume of more than 20 ml; and enlarged echogenic ovaries

What characteristics of an ovarian neoplasm suggest its malignancy?

47

They become atrophic and often do not have follicles.

Hormone replacement therapy

What happens to ovaries in postmenopausal women?

Only women receiving ____ continue to have normal-sized ovaries.

48

Ovarian Carcinoma

___ is also known as the silent killer

Has a relative absence of symptoms in early stages. it is commonly not detected until advanced, having spread beyond capsule but still within pelvis (stage 2) or into abdomen (stage 3). Adnexal finding ranging from almost "normal" to slightly enlarged firm irregular ovaries to pelvic masses.