Sonographic Evaluation of Pelvic Masses


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Sonographic Evaluation of Pelvic Masses

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Sonographic Evaluation of Pelvic Masses

  1. 1. Sonographic Evaluation of Pelvic Masses Aboubakr Elnashar Benha university Hospital, Egypt Aboubakr Elnashar
  2. 2. Sonography provides clinically important parameters for the pelvic mass. 1. Confirmation of the presence or absence of a pelvic mass. 2. Delineation of the size, internal consistency, and contour of the mass. 3. Establishment of the origin and anatomic relationship of the mass to other pelvic structures. 4. A survey to establish the presence or absence of abnormalities associated with malignant disease, such as ascites or metastatic lesions. 5. Guidance for aspiration or biopsy of selected pelvic masses. Aboubakr Elnashar
  3. 3. TRANSVAGINAL SONOGRAPHY OF PELVIC MASSES important role in the evaluation of the uterus and adnexa. {its limited field of view and unusual image orientation} it is best used as an adjunct to TAS. Aboubakr Elnashar
  4. 4. TVS is indicated: 1. Determination of the presence or absence, and evaluation of, relatively small (<5 to 10 cm) 2. Determination of the origin of a mass (uterine, ovarian, or tubal) and whether or not it has torsed. 3. Detailed evaluation of its internal consistency with particular emphasis on the presence or absence of polypoid excrescences, septations, or internal consistencies (blood, pus, serous fluid). 4. Guiding transvaginal aspiration of certain masses. 5. Evaluation of endometrial or myometrial disorders related to pelvic masses. Aboubakr Elnashar
  5. 5. DD between benign and malignant Aboubakr Elnashar
  6. 6. Morphologic scoring by TVS. Each of four parameters as assessed, including inner wall structure, wall thickness (mm), septa (mm), and echogenicity. Malignancies tended to have high scores (over 9). Aboubakr Elnashar
  7. 7. Simple ultrasound rules: 2012 5 ultrasonic features to predict a malignant tumour (M features): irregular solid tumour (M1), ascites (M2), at least four papillary structures (M3), irregular multilocular solid tumour with a largest diameter of at least 100 mm (M4), and very high colour content on colour Doppler examination (M5). Aboubakr Elnashar
  8. 8. 5 ultrasonic features to predict a benign tumour (B features): unilocular cyst (B1), presence of solid components for which the largest solid component is <7 mm in largest diameter (B2), acoustic shadows (B3) smooth multilocular tumour (B4), and no detectable blood flow on Doppler examination (B5). Aboubakr Elnashar
  9. 9. If one or more M features were present in the absence of a B feature, we classified the mass as malignant (rule 1). If one or more B features were present in the absence of an M feature, we classified the mass as benign (rule 2). If both M features and B features were present, or if none of the features was present, the simple rules were inconclusive (rule 3). Aboubakr Elnashar
  10. 10. Sonographic signs of malignancy. (A) Longitudinal transabdominal sonography showing irregular bulge (arrow) in superior aspect of ovarian tumor, indicating capsular disruption by tumor. (B) Gross specimen showing tumor extruding through capsule in malignant ovarian cystadenocarcinoma. (C) Irregular solid mass (arrow) arising from peritoneum, representing metastases from ovarian carcinoma. (D) Bloody ascites associated with recurrent ovarian carcinoma appearing as echogenic particulate material (*). (E) Echogenic liver metastasis from ovarian carcinoma obstructing intrahepatic portion of inferior vena cava. Aboubakr Elnashar
  11. 11. SONOGRAPHIC DIFFERENTIAL DIAGNOSIS OF PELVIC MASSES Cystic 1. Completely cystic Physiologic ovarian cysts Cystadenomas Hydrosalpinx Endometrioma Paraovarian cyst Hydatid cyst of Morgagni 2. Multiple Endometriomas Multiple follicular cysts 3. Septated Cystadenoma (carcinoma) Mucinous Serous Papillary Complex 1. Predominantly cystic Cystadenomas Tubo-ovarian abscess Ectopic pregnancy Cystic teratoma 2. Predominantly solid Cystadenoma (carcinoma) Germ cell tumor Solid 1. Uterine Leiomyoma (sarcoma) Endometrial carcinoma, sarcoma Extrauterine 2. ovarian tumor Aboubakr Elnashar
  12. 12. Simple ovarian cyst. Transvaginal color flow Doppler image demonstrates a large simple ovarian cyst. Aboubakr Elnashar
  13. 13. Postmenopausal cysts. Transvaginal grayscale images of both ovaries demonstrate simple cysts bilaterally in a postmenopausal woman. Aboubakr Elnashar
  14. 14. Corpus luteum cyst. (A) Transvaginal grayscale image of the left ovary demonstrates a cyst with debris within, suggestive of hemorrhage in a corpus luteum cyst. (B) Corresponding color flow Doppler image demonstrates peripheral vascularity—called the ‘‘ring of fire Aboubakr Elnashar
  15. 15. Parovarian cyst. Transvaginal grayscale image demonstrates a left parovarian cyst with a corresponding four-dimensional US reformatted image that demonstrates better delineation and extent of the cyst. Aboubakr Elnashar
  16. 16. Theca lutein cysts. Transvaginal grayscale image of the pelvis demonstrates multiple simple bilateral ovarian cysts in this patient with a hydatidiform mole. A pocket of free fluid is present between the two ovaries (arro Aboubakr Elnashar
  17. 17. (A) Transverse sonogram showing cystic mass containing multiple thin internal septations, representing mucinous cystadenoma. (B) Transverse transabdominal sonogram showing septated mass with echogenic material (*) in upper loculated area. The echogenic material was mucin within this mucinous cystadenoma. (C) Malignancy was suspected due to thickened septation (arrow) within this mucinous cystadenocarcinoma. (D)Papillary projections (arrow) were found within this malignant teratoma. Septated cystic masses. Aboubakr Elnashar
  18. 18. (E) Transverse sonogram of complex predominantly cystic right-adnexal mass with calcific focus (arrow) arising from tooth within this dermoid cyst. Aboubakr Elnashar
  19. 19. (F) Transvaginal sonogram of a pelvic mass in a woman with a renal transplant. This was found to represent a luteal cyst with fluid surrounding adhesion. Aboubakr Elnashar
  20. 20. Peritoneal inclusion cyst. Transvaginal grayscale image of the right adnexa demonstrates a spider- web pattern with presence of loculated fluid and an eccentric right ovary (OV). Aboubakr Elnashar
  21. 21. Sagittal (G) and axial (H) transvaginal sonogram showing a multiloculated septated cystic mass with focal wall thickening. This represented a mucinous cystadenoma with one locule containing thick mucinous material. Aboubakr Elnashar
  22. 22. A) Predominantly solid, complex mass containing a layer of echogenic material (arrow) arising from sebum within this dermoid cyst. (B) Transvaginal sonogram of granulosa cell tumor. Complex predominantly solid masses. Aboubakr Elnashar
  23. 23. C) Transvaginal sonogram of dermoid cyst with layer of echogenic sebum. Aboubakr Elnashar
  24. 24. Bilateral mature cystic teratoma. Transverse grayscale image demonstrates bilateral mature cystic teratomas (arrows). This image also shows the ‘‘tip of the iceberg’’ sign. Incidentally seen is a fibroid (arrowhead) in the anterior wall of the uterus (UT). Aboubakr Elnashar
  25. 25. D) Transvaginal sonogram of hemorrhagic ovarian cyst containing irregular solid area corresponding to displaced hemorrhagic ovarian tissue surrounding area of hemorrhageAboubakr Elnashar
  26. 26. (E) Longitudinal transabdominal sonogram (TAS) of ovarian cystadenocarcinoma containing irregular solid areas. (F) Magnified transverse TAS of cul-de-sac hemorrhage (arrow) resulting from ruptured ectopic pregnancy. Aboubakr Elnashar
  27. 27. (G) Transvaginal sonogram of dermoid cyst showing typical echogenic hairball (arrows). Aboubakr Elnashar
  28. 28. Hemorrhagic ovarian cyst. (A)Transvaginal grayscale image of the right ovary demonstrates a typical‘‘fishnet’’ appearance. (B)Grayscale and color flow Doppler image of the right ovarian cyst with a retracting blood clot adherent to the cyst wall and absent vascularity. Aboubakr Elnashar
  29. 29. Endometrioma. (A) Transvaginal grayscale image demonstrates a left ovarian cyst with low-level echoes. (B) Transabdominal grayscale image of the pelvis with bilateral endometriomas demonstrates the ‘‘kissing ovaries’’ sign. (UT, uterus.) Aboubakr Elnashar
  30. 30. Hydrosalpinx. Transvaginal grayscale (A) and color flow Doppler (B) images of the left adnexa demonstrate serpiginous, tubular, anechoic, and avascular structures in the left adnexa. (LO, left ovary.) Aboubakr Elnashar
  31. 31. Pelvic inflammatory disease. (A) Transvaginal grayscale image demonstrates debris within the dilated fallopian tube. (B) Transabdominal grayscale image in patient with fever and confirmed PID reveals pelvic abscess (arrows). (UT, uterus.) Aboubakr Elnashar
  32. 32. Polycystic ovarian disease. (A) Power Doppler image of bilateral ovaries demonstrates multiple follicles. (B) Corresponding four-dimensional images demonstrate ovarian volume calculation in polycystic ovaries. Aboubakr Elnashar
  33. 33. Ectopic pregnancy. (A) Transvaginal grayscale image demonstrates an extraovarian mass with an embryonic pole (within calipers) and a tubal ring sign (arrows). (B) Grayscale and color flow Doppler image demonstrates a nonovarian adnexal mass with tubal ring sign and peripheral vascularity (ring of fire). (OV, ovary.) Aboubakr Elnashar
  34. 34. Ovarian remnant syndrome. Transvaginal color flow Doppler image of right adnexa in a patient with history of oophorectomy demonstrates an ovarian cystic structure with surrounding ovarian tissue secondary to hormone stimulation. Aboubakr Elnashar
  35. 35. Surgically confirmed serous cystadenoma. Transvaginal grayscale and corresponding three- dimensional US image of the right ovary demonstrate a complex cystic mass with a mural nodule that shows vascularity on the three-dimensional image Aboubakr Elnashar
  36. 36. Surgically confirmed mucinous cystadenoma. (A, B) Grayscale images in two different patients demonstrate multiloculated cystic lesion with septations. Aboubakr Elnashar
  37. 37. Pseudomyxoma peritoneii. Transabdominal grayscale image of the pelvis in a known case of mucinous cystadenocarcinoma demonstrates presence of loculated ascites. (UB, urinary bladder.) Aboubakr Elnashar
  38. 38. Dysgerminoma. Grayscale (A) and color flow Doppler (B) images of the right ovary demonstrate a solid mass with increased vascularity. Aboubakr Elnashar
  39. 39. Krukenberg tumors. Grayscale US image of the pelvis demonstrates bilateral solid ovarian tumors in a known case of stomach cancer. (LO, left ovary; RO, right ovary.) Aboubakr Elnashar
  40. 40. Nongynecologic pelvic masses. (A) Lymphocele. Grayscale image of the pelvis demonstrates a complex septated fluid collection. (B) Postpartum collection. Grayscale image of the pelvis demonstrates a complex collection (coll) in the cul-de-sac, consistent with hemorrhage. (LO, left ovary; RO, right ovary; UT, uterus.) Aboubakr Elnashar
  41. 41. Subserosal fibroid. Transvaginal grayscale US image of the pelvis demonstrates a large solid adnexal lesion (Fib) arising from the uterus (arrow). (UT, uterus.) Aboubakr Elnashar
  42. 42. Conclusions The majority of adnexal masses in women in the reproductive years are follicle cysts of the ovary.  The most common benign neoplastic tumors of the ovary are serous cystadenoma and benign cysts.  The most common benign cystic neoplasms of the ovary in the 20- to 44-year-old group are benign cystic teratoma, serous cystadenoma, and mucinous cystadenoma. Aboubakr Elnashar
  43. 43. Most benign cystic teratomas are 10 cm or less in diameter, but about one sixth are larger.  Serous cystadenocarcinoma is the most common malignant tumor in all age groups, from 20 to 75 years old.  Dysgerminoma and teratoma are the most common solid adnexal tumors in young women. Aboubakr Elnashar
  44. 44. Thank you Aboubakr Elnashar