USG PELVIC MASSES

1. ULTRASONOGRAPHIC
EVALUATION OF PELVIC
MASSES
Dr Abhijit R Singh
Resident Radiology
SMBT MED COLLEGE

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.
DR. ABS 2

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.
DR. ABS 3

4. 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
DR. ABS 4

5. 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.
DR. ABS 5

6. DD between benign and malignant
DR. ABS 6

7. 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).
DR. ABS 7

8. Simple ultrasound rules: 2012
DR. ABS
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 8

9. 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).
DR. ABS 9

10. 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).
DR. ABS 10

11. 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)DR. ABS 11

12. SONOGRAPHIC DIFFERENTIAL DIAGNOSIS OF PELVIC MASSES
Cystic
1. Completely cystic
Physiologic ovarian cysts
DR. ABS
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
12

13. Simple ovarian cyst.
Transvaginal color flow
Doppler image
demonstrates a large simple
ovarian
cyst.
DR. ABS
13

14. Postmenopausal cysts.
Transvaginal grayscale images of both ovaries demonstrate
simple cysts bilaterally in a postmenopausal woman.
DR. ABS 14

15. 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
DR. ABS 15

16. Para-ovarian 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. DR. ABS 16

17. 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
(arroW) DR. ABS 17

18. (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.
DR. ABS
18

19. (E) Transverse sonogram of complex predominantly
cystic right-adnexal mass with calcific focus (arrow)
arising from tooth within this dermoid cyst.
DR. ABS 19

20. (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.
DR. ABS 20

21. 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).DR. ABS 21

22. 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 DR. ABS 22

23. A) Predominantly
solid, complex mass
containing a layer of
echogenic material
(arrow) arising from
sebum within this
dermoid cyst.
Complex predominantly solid masses.
DR. ABS
(B) Transvaginal
sonogram of granulosa
cell tumor.
23

24. C) Transvaginal sonogram of dermoid cyst with layer
of echogenic sebum.
DR. ABS 24

25. 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).
DR. ABS 25

26. D) Transvaginal sonogram of hemorrhagic
ovarian cyst containing irregular solid area
corresponding to displaced hemorrhagic
ovarian tissue surrounding area of hemorrhageDR. ABS 26

27. (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.
DR. ABS 27

28. (G) Transvaginal sonogram of dermoid cyst
showing typical echogenic hairball (arrows).
DR. ABS 28

29. 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.
DR. ABS 29

30. 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.)
DR. ABS 30

31. 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.)
DR. ABS 31

32. 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.)
DR. ABS 32

33. 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 DR. ABS 33

34. 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.)
DR. ABS 34

35. 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.
DR. ABS 35

36. 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
DR. ABS 36

37. Surgically confirmed mucinous cystadenoma.
(A, B) Grayscale images in two different patients
demonstrate multiloculated cystic lesion with septations.
DR. ABS 37

38. Pseudomyxoma peritoneii.
Transabdominal grayscale image of the pelvis in a known
case of mucinous cystadenocarcinoma demonstrates
presence of loculated ascites. (UB, urinary bladder.)
DR. ABS 38

39. Dysgerminoma.
Grayscale (A) and color flow Doppler (B) images of the
right ovary demonstrate a solid mass with increased
vascularity.
DR. ABS 39

40. 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.)
DR. ABS 40

41. 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.)
DR. ABS 41

42. Subserosal fibroid.
Transvaginal grayscale US image of the pelvis
demonstrates a large solid adnexal lesion (Fib) arising
from the uterus (arrow). (UT, uterus.)
DR. ABS 42

43. 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.
 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
DR. ABS 43

44. Thank
you
DR. ABS 44