Asymptomatic palpable adnexal masses: ultrasound evaluation- warda

987
-1

Published on

This simple lecture was designed as a part of the content of the basic ultrasound workshop held periodically by the department of Obstetrics & gynecology - Faculty of medicine - Mansoura university- Egypt as a part of continuous medical education program.

Published in: Education, Health & Medicine
0 Comments
12 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
987
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
57
Comments
0
Likes
12
Embeds 0
No embeds

No notes for slide

Asymptomatic palpable adnexal masses: ultrasound evaluation- warda

  1. 1. 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 WARDA 2014
  2. 2. 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 WARDA 2014
  3. 3. 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 WARDA 2014
  4. 4. GENERAL PLAN OF MANAGEMENT 1---- FollowFollowFollowFollow----up clinical exam forup clinical exam forup clinical exam forup clinical exam for 1111----2222 menstrualmenstrualmenstrualmenstrual 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 WARDA 2014
  5. 5. GENERAL PLAN OF MANAGEMENT 2222---- A palpableA palpableA palpableA palpable adnexaladnexaladnexaladnexal mass in amass in amass in amass 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. WARDA 2014
  6. 6. 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 WARDA 2014
  7. 7. 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. WARDA 2014
  8. 8. 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 WARDA 2014
  9. 9. HEMORRHAGIC CYST WARDA 2014
  10. 10. 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. WARDA 2014
  11. 11. 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 WARDA 2014
  12. 12. 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 manymm) follicle cysts usually as manymm) follicle cysts usually as manymm) follicle cysts usually as many asasasas 10101010 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 tomm) can be found in up tomm) can be found in up tomm) 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 ovarianIncreased ovarianIncreased ovarianIncreased ovarian echogenicityechogenicityechogenicityechogenicity (=dense(=dense(=dense(=dense stromastromastromastroma)))) A combination of follicular and ovarian volume is the most sensitive objectiveA combination of follicular and ovarian volume is the most sensitive objectiveA combination of follicular and ovarian volume is the most sensitive objectiveA combination of follicular and ovarian volume is the most sensitive objective parameter in diagnosis. The upper limit of normal ovarian volume isparameter in diagnosis. The upper limit of normal ovarian volume isparameter in diagnosis. The upper limit of normal ovarian volume isparameter in diagnosis. The upper limit of normal ovarian volume is 15151515CmCmCmCm3333 WARDA 2014
  13. 13. 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 WARDA 2014
  14. 14. PARAOVARIAN CYST They arise in the broad ligament derivatives ofThey arise in the broad ligament derivatives ofThey arise in the broad ligament derivatives ofThey arise in the broad ligament derivatives of mesothelialmesothelialmesothelialmesothelial orororor periperiperiperi----mesothelialmesothelialmesothelialmesothelial structures.structures.structures.structures. They compriseThey compriseThey compriseThey comprise 10101010% of% of% of% of adnexaladnexaladnexaladnexal cystic masses & mostly seen incystic masses & mostly seen incystic masses & mostly seen incystic 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 complicatedAlthough the are mostly simple cysts, they may be complicatedAlthough the are mostly simple cysts, they may be complicatedAlthough 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 asTo be diagnosed asTo be diagnosed asTo be diagnosed as paraparaparapara----ovarian,aovarian,aovarian,aovarian,a tissue plane between thetissue plane between thetissue plane between thetissue 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 toThe usual treatment is EXCISION as it does not respond toThe usual treatment is EXCISION as it does not respond toThe usual treatment is EXCISION as it does not respond to hormones.hormones.hormones.hormones. WARDA 2014
  15. 15. HYDROSALPINX TheyTheyTheyThey are oblong ( or retortare oblong ( or retortare oblong ( or retortare oblong ( or retort---- shape) cystic structuresshape) cystic structuresshape) cystic structuresshape) cystic structures near the normally appearing ovary which is usuallynear the normally appearing ovary which is usuallynear the normally appearing ovary which is usuallynear 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 triedinflammatory treatment usually triedinflammatory treatment usually triedinflammatory treatment usually tried with limited.with limited.with limited.with limited. In infertility treatment excision or disconnection isIn infertility treatment excision or disconnection isIn infertility treatment excision or disconnection isIn infertility treatment excision or disconnection is recommendedrecommendedrecommendedrecommended WARDA 2014
  16. 16. TUBO-OVARIAN ABSCESS The US appearanceThe US appearanceThe US appearanceThe US appearance varies according to their appearance at thevaries according to their appearance at thevaries according to their appearance at thevaries 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 multipleThe mass may be purely cystic, have thick septa, have multipleThe mass may be purely cystic, have thick septa, have multipleThe 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 malignantA more serious diagnosis such as benign or malignantA more serious diagnosis such as benign or malignantA more serious diagnosis such as benign or malignant neoplasm must be considered because both conditions are quiteneoplasm must be considered because both conditions are quiteneoplasm must be considered because both conditions are quiteneoplasm 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 ( althoughalthoughalthoughalthough 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. WARDA 2014
  17. 17. 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 tumorsBilateral tumorsBilateral tumorsBilateral tumors HeterogeneousHeterogeneousHeterogeneousHeterogeneous echogeneityechogeneityechogeneityechogeneity Presence of intraPresence of intraPresence of intraPresence of intra----cystic septa, multiplecystic septa, multiplecystic septa, multiplecystic 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 WARDA 2014
  18. 18. OVARIAN NEOPLASM- CYSTADENOMAS SerousSerousSerousSerous cystadenomacystadenomacystadenomacystadenoma MucinousMucinousMucinousMucinous CystadenomaCystadenomaCystadenomaCystadenoma Papillary serousPapillary serousPapillary serousPapillary serous cystadenomacystadenomacystadenomacystadenoma SerousSerousSerousSerous cystadenocarcinomacystadenocarcinomacystadenocarcinomacystadenocarcinoma WARDA 2014
  19. 19. OVARIAN NEOPLASM- SOLID TUMORS Granulosa cell t Immature solid teratoma Brenner Germ cell t WARDA 2014
  20. 20. OVARIAN NEOPLASM- DERMOID CYST WARDA 2014
  21. 21. SUBSEROUS MYOMA UUUUsually appearssually appearssually appearssually appears ecogenicecogenicecogenicecogenic, similar to the, similar to the, similar to the, similar to the uterine walluterine walluterine walluterine wall Sometimes it appears with variable sizeSometimes it appears with variable sizeSometimes it appears with variable sizeSometimes it appears with variable size hyperecchogenichyperecchogenichyperecchogenichyperecchogenic areas due to calcificationareas due to calcificationareas due to calcificationareas due to calcification Sometimes it may appear with mixedSometimes it may appear with mixedSometimes it may appear with mixedSometimes 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 WARDA 2014
  22. 22. THANK YOUTHANK YOUTHANK YOUTHANK YOU ‫ا‬‫ﺮ‬‫ﺷﻜ‬ ‫ﻋﻠﻴﻜﻢ‬ ‫اﻟﺴﻼم‬ ‫و‬ ‫ﻛﺎﺗﻪ‬‫وﺑﺮ‬ ‫اﷲ‬ ‫رﺣﻤﺔ‬ ‫و‬ WARDA 2014

×