Common Gynecological Anomalies – Part 2

Common Gynaecological Anomalies- Part 2

MDU,BMI,ECHO&ECG,DDR

ADNEXAL MASSES:

• Role of Ultrasound
• Dx of benign disease
• may result in less invasive or elective surgery
• may eliminate need for surgery altogether
• Dx of malignancy
• allows prompt referral to experienced gyn-oncologic surgeon
• Indeterminate US

consider MRI

NORMAL ANATOMY

• Oval
• Echogenic central stroma
• Small anechoic cysts

3 x 2 x 1 to 2 cm inpremenopausal women

NORMAL ANATOMY

Normal Ovaries

Us evaluation of adnexal masses

• Location
• Morphology
• pattern recognition for benign pathology
• Size
• Echotexture:cystic, complex (mixed cystic and solid), or solid.
• Vascularity

Associated findings

A.CYSTIC ADNEXIAL MASSES

Morphologic features suggestive of benignity

• Smooth walls
• No septations
• Thin septations that are avascular

1.Simple ovarian cysts

• Size
• Likely benign if:
• < 6 cm in premenopausal
• < 5 cm in postmenopausal
• > 3 cm get follow up to ensure regression or stability
• More common than originally thought
• Postmenopausal follicular cysts
• > 5 cm
• increased likelihood of malignancy
• less likely to resolve
• > 3 cm

get follow-up

Simple ovarian cysts: US Findings

• Anechoic
• Well defined
• Thin wall
• Posterior enhancement

Sharp Back wall

Simple ovarian cysts

Follicular cysts- Functional cysts

Anechoic cysts have a thin wall, are completely anechoic, and are enhanced through transmission.

• Regardless of their size, they are unlikely to be malignant
• In women of menstrual age, the most common anechoic cyst is the functional cyst

These usually are small < 2 cm in diameter; however, they may enlarge up to 10 cm.

Simple ovarian cysts

• They typically regress spontaneously.

At times, birth control pills are necessary to suppress their growth.

When an anechoic cyst is seen that is larger than 6 cm, the likelihood of neoplasm is high.

If there are no wall irregularities or septations, the cyst is most likely secondary to a benign neoplasm such as a cystadenoma

2.Paraovarian cyst

• 10% of all adnexal masses
• Adjacent to ovary
• Less likely to resolve
• If > 6 cm may lead to torsion
• Rarely malignant
• They arise from the broad ligament.

Their size does not change during the menstrual cycle.

PARAOVARIAN CYST

Clear plane between cyst and ovary

3.Complex cysts

• Seen in Malignant/Infected cysts/ Haemorrhagic cysts
• Features
• Thick walled
• Septated
• Echocomplex; Mixed echogenicity

Mural Nodularity

Complex Cyst

Note the Thick walls and Mural Nodularity

4.Endometriosis

• Ectopic location of endometrial tissue outside uterus.
• Location varies: peritoneal cavity, pelvic organs, ligaments extra pelvic.
• Functionalis layer, Repetitive cycles of hemorrhage
• Begins 2 – 7 days before menses but sever during Menses.
• Similar repeated period related pains.

Past uterine surgery may implant endometrial cells along incision.

Endometriosis- Endometrioma

• In most cases, sonography cannot demonstrate the tiny ectopicimplant
• Difficult to see by US especially if lesions small.

Cystic or complex lesions may be seen (endometriomas).

The localized form of the disease creates an endometrioma. This is seen as a cyst on transabdominal scanning Ultrasound shows a diffuse low-level echoes are seen: the “chocolate” cyst echoes due to blood

ENDOMETRIOMAS:

• US Findings

Homogeneous, low-level echoes

ENDOMETRIOMAS:

• US Findings

Low- lovel internal echoes

Endometriosis- Sonographic pitfall

• Masses may give septations and nodularity. DD cancer.
• MRI helps to confirm presence of blood.
• Laparatomy is gold standard.
• Rx may be surgical but Hormonal suppression may be done.

Oophrectomy and Hysterectomy for severe cases.

Clot/Debris

• :

ENDOETRIOMA

Mural Nodularity

Clear Cell Carcinoma

ENDOMETRIOMA:

Mural Nodules

ENDOMETRIOSIS

• Beware mural irregularities or nodules
• increased incidence of clear cell and endometroid Ca.
• May have vascular wall
• Adhesions
• If US features suggestive but non-specific
• confirm with MRI
• CAs rarely contain hemorrhage

laparoscopy

5.HEMORRHAGIC CYST

• Hemorrhagic cysts more often
• present with acute pain
• contain clot

solitary

HEMORRHAGIC CYSTS:

• US Findings
• Pattern of internal echoes variable but changes over time
• Ultimately resolves
• Thin, regular wall
• Increased through transmission

No internal vascularity

HEMORRHAGIC CYSTS:

• US Findings

Diffuse homogeneous, low level echoes

HEMORRHAGIC CYSTS:

• US Findings

HEMORRHAGIC CYSTS:

• US Findings

Dependent debris

HEMORRHAGIC CYSTS:

• US Findings

Echogenic clot

HEMORRHAGIC CYSTS:

Evolving Appearance

HEMORRHAGIC CYSTS:

• US Findings

No internal vascularity

HEMORRHAGIC CYSTS

• For questionable clot versus mural nodule
• check vascularity

roll patient

HEMORRHAGIC CYSTS

• (esp. if clinical presentation is atypical)

clot should change

6.Dermoid

Dermoids are the most common ovarian neoplasm.

Rare forms of dermoids include the specialized tumors of struma ovarii (with thyroid tissue) and carcinoid tumors. Malignant degeneration (into squamous cell carcinoma) of dermoids is rare. This typically occurs in older women.

Immature teratomas occur in young women 10 to 20 years of age.

7.CYSTIC TERATOMA

• Most common ovarian neoplasm
• Most common in the reproductive years
• Contains txs from all 3 germ cell layers
• Typically assx, found incidentally
• Complications: torsion, rupture

Malignant transformation < 2%

DERMOID CYSTS:

• US Findings
• Echogenic mass

Posterior sound attenuation

DERMOID CYSTS:

• US Findings
• Fat/fluid level

Floating debris (hairball)

DERMOID CYSTS:

• US Findings

Mural nodules, +/- Ca++

DERMOID CYSTS:

• US Findings

Echogenic linear speckles

CFI may be helpful

pedunculated leiomyoma

9.Polycystic ovary disease

Polycystic ovary disease, which includes Stein-Leventhal syndrome (infertility, hirsutism, and oligomenorrhea), is one of the most common endocrine disorders.

• The diagnosis is made on the basis of clinical, sonographic, and biochemical criteria.

Luteinizing hormone is elevated and follicle-stimulating hormone levels are low.

Sonographically, the ovaries are normal or enlarged with multiple small peripheral cysts, less than 8 mm in diameter

PCOD: US Findings

• Prominent ovarian stroma
• Numerous, peripheral, small cysts

“string of pearls”

PCOD: US Findings

+/- Enlarged ovaries, with multiple small cysts

Morphologic features suggestive of malignancy

• Papillary projections
• Solid tissue
• Mural nodularity
• Thick, vascular septations, > 3 mm
• Size
• Increased vascularity
• Blood flow
• Older age of patient
• Ascites

Metastases

Morphologic features suggestive of malignancy

Morphologic features suggestive of malignancy

Thick vascular septations

Morphologic features suggestive of malignancy

Increased Vascularity

Morphologic features suggestive of malignancy

Mural nodularity + Vascularity

B.SOLID ADNEXIAL MASSES

• Considered neoplastic
• Even just an enlarged ovary

Will include some benign lesions e.g Pedunculated Fibroid and Dermoids

Dysgerminoma

Kruckenberg Tumor

A malignancy to the ovary that metastasized from a primary site, commonly the GIT but also from breast

SOLID OVARIAN MASSES: Fibromas

• hypoechoic
• posterior showing
• ovary not separate

MRI helpful in select cases

FIBROMAS

Fibrothecoma

• Thecoma

Solid ovarian masses

Be careful to differentiate from:

• pedunculated leiomyomata
• hemorrhagic cysts
• dermoid
• MRI helpful in select cases

SOLID OVARIAN MASSES

Dermoid- Benign masses

Solid ovarian masses

MALIGNANT ASCITES