Pathology of the Ovary

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Should the Graafian follicle fail to ovulate, it could continue to enlarge and result in a —

follicular cyst

Follicular cysts range in size from —; however, larger cysts have been documented.

3 to 8 cm

surgical intervention or drainage may be warranted because a large cyst increases the risk for —

ovarian torsion

The surgical removal of an ovarian cyst is referred to as —

ovarian cystectomy.

Normal sonographic appearance of the ovary. A. In this longitudinal endovaginal image of the pelvis, the ovary (between calipers) is noted adjacent to the iliac artery (IA) and iliac vein (IV). B. A normal ovary can be seen in this longitudinal transabdominal image of the pelvis between the urinary bladder (UBL) and prominent ureter (arrows).

Transverse image of the ovary on day 5 of the menstrual cycle revealing a high-impedance waveform.

Transverse image of the ovary during day 10 of the menstrual cycle revealing a low-impedance waveform pattern with more diastolic flow. (Color image provided online.)

Early follicular phase

• High impedance (resistance) with absent or low end-diastolic velocity

• RI = 1.0

Late follicular phase

• Low impedance (resistance) with increased end-diastolic flow

• RI = 0.5'

Early luteal phase

• Low impedance (resistance) with increased end-diastolic flow

• RI = 0.5

Late luteal phase

• High impedance (resistance) with absent or low end-diastolic velocity

• RI = 1.0

Simple ovarian cyst. Coronal image of the right ovary demonstrating a simple ovarian cyst (arrows), surrounded by normal ovarian tissue (arrowheads).

Hyperstimulation of the ovaries, or —, from fertility treatment will also result in the development of multiple, enlarged follicular cysts

ovarian hyperstimulation syndrome

A follicular cyst that contains blood is referred to as a —, and it most often appears complex or completely echogenic depending on the hemorrhagic component present and the stage of lysis

hemorrhagic cyst

The sonographic manifestation of a hemorrhagic cyst may be described as demonstrating a —

weblike or lacy appearance

clinical findings of follicular cysts

1. aysmptomatic

2. pain associated with hemorrhage and enlargement of cyst

— is a physiologic (functional) cyst that develops after ovulation has occurred.

The corpus luteum cyst

The corpus luteum is formed as a result of the — and is responsible for producing progesterone

rupture of the Graafian follicle

the corpus luteum will normally regress if— but may rarely be maintained and continue to enlarge

fertilization does not occur

When regression takes place, a small, echogenic structure may be noted within the ovary, representing the —

corpus albicans

Hemorrhagic ovarian cyst

sonographic findings of follicular cyst

1. Simple cyst–anechoic, thin walled, unilocular, round, posterior enhancement

2. Hemorrhagic cyst—variable appearances, including complex components or entirely echogenic, depending on the amount of blood and the stage of lysis; may have a weblike or lacy appearance as well

Corpus luteum cysts may reach sizes up to —, with resolution of the cyst taking place within 1 to 2 months in menstruating patients

8 cm

In the presence of a pregnancy, and thus the production of human chorionic gonadotropin (hCG) by the trophoblastic cells of the pregnancy, —

the corpus luteum is preserved

These cysts are considered the most common pelvic masses seen during a first-trimester sonographic examination

corpus luteum of pregnancy

corpus luteum of pregnancy may even reach sizes up to 10 cm, although most often they resolve by 16 weeks gestation and do not exceed —

3 cm

A complex or thick-walled corpus luteum cyst can resemble an —, so precaution to establish the presence of an intrauterine pregnancy should be taken in this regard, as well as careful consideration of the entire clinical picture

ectopic pregnancy

clinical findings of corpus luteum cysts and corpus luteum of pregnancy

1. asymptomatic

2. Pain associated with hemorrhage and enlargement of cyst

3. Corpus luteum of pregnancy accompanies a pregnancy

thin-walled unilocular cyst

a thick-walled cyst

a complex cyst with septations

structure that contains diffuse internal echoes

sonographic findings of corpus luteum cysts and corpus luteum of pregnancy

1. Simple cyst appearance

2. May have a thick wall, be completely echogenic, and may be difficult to differentiate from other solid and cystic adnexal masses

3. Hemorrhagic components may appear complex or have a weblike or lacy appearance depending on the amount of blood and stage of lysis

— are the largest and least common of the functional cysts

Theca lutein cysts

Theca lutein cysts are found in the presence of —, often exceeding 100,000 mIU per mL

elevated levels of hCG

— are common conditions associated with theca lutein cysts

gestational trophoblastic disease (molar pregnancy) and ovarian hyperstimulation syndrome

— would also have higher levels of hCG and therefore increase the likelihood of developing theca lutein cysts

multiple gestations

Theca lutein cysts are large cysts and are frequently —

bilateral and multiloculated, and may reach sizes up to 15 cm

Theca lutein cysts tend to regress after the —

high level of circulating hCG diminishes

Theca lutein cysts. Transabdominal image

clinical findings of theca lutein cysts

1. Markedly elevated levels of hCG (as seen in cases of gestational trophoblastic disease, ovarian hyperstimulation, and twin gestations)

2. Nausea and vomiting

3. Pelvic fullness

4. Pain associated with hemorrhage, rupture, and ovarian torsion

sonographic findings of paraovarian cysts

1. Simple cyst located adjacent, but not attached, to the ovary

2. If hemorrhagic, will appear complex

Parovarian cysts are small cysts located adjacent to the ovary, and most likely arise from the —

fallopian tubes or broad ligaments

paraovarian cysts can range in size from —

1.5 to 19 cm

sonographic findings of theca lutein cysts

1. Large, bilateral, multiloculated ovarian cystic masses

2. May contain hemorrhagic components

clinical findings of paraovarian cysts

1. asymptomatic

2. If cyst is large, patients may present with pelvic pain and increased lower abdominal girth

Paraovarian cyst. A. A simple appearing cyst (C) is noted adjacent to the ovary (arrows) and posterior to the urinary bladder (B) in this longitudinal image. B. The same patient in transverse.

The most common benign ovarian tumor is the —, also referred to as a dermoid cyst

ovarian cystic teratoma

Dermoids result from the —

retention of an unfertilized ovum that differentiates into the three germ cell layers.

these germ cell tumors are composed of —

ectoderm, mesoderm, and endoderm

As a result of the combination of these germ cells, a cystic teratoma may contain any number of tissues, including —

glandular thyroid components, bone, hair, sebum, fat, cartilage, and digestive elements

Dermoids are commonly found in the — but may also be found in postmenopausal patients

reproductive-aged group

— denotes the sonographic appearance of the mass when only the anterior element of the dermoid cyst is seen, while the greater part of the mass is obscured by shadowing

The “tip of the iceberg” sign

Often, dermoid tumors contain a —

“dermoid plug.”

The dermoid plug contains various tissues that will be a source of —

posterior shadowing

The “dermoid mesh” has been used to describe the visualization of —

hair within the mass.

clinical findings of a cystic teratoma

1. Often asymptomatic

2. If torsion or rupture occurs, the patient may present with acute pelvic pain

sonographic findings of a cystic teratoma

1. Complex, partially cystic mass in the ovary that includes one or more echogenic structures that may shadow

2. “Tip of the iceberg” sign–only the anterior element of the mass is seen, while the greater part of the mass is obscured by shadowing

3. Dermoid plug–produces posterior shadowing

4. Dermoid mesh–produced by hair and will appear as numerous linear interfaces within the cystic area of the mass

Cystic teratoma. A. A coronal image of the female pelvis demonstrating a complex ovarian mass (between large arrows) with several typical sonographic characteristics of a dermoid, including the dermoid plug (small arrows) and the posterior shadowing (between arrowheads) from the plug. B. In the sagittal plane, this dermoid (between arrows) reveals a solid (arrows) shadowing (between arrowheads) structure within its borders.

Cystic teratoma and the “tip of the iceberg” sign

— is a benign ovarian sex cord-stromal tumor

A thecoma

Thecomas are most often found in postmenopausal women and may be associated with —

Meigs syndrome

Meigs syndrome describes the condition of a having a —

benign ovarian tumor with ascites and pleural effusion

Thecomas are —; therefore, patients often complain of postmenopausal vaginal bleeding associated with the unconstrained estrogen stimulation upon the endometrium.

estrogen-producing tumors

thecomas are most often — and may appear similar to a pedunculated uterine leiomyoma

unilateral

clinical findings of a thecoma

1. May be asymptomatic

2. Postmenopausal vaginal bleeding or abnormal vaginal bleeding secondary to estrogen stimulation

3. Meigs syndrome (ascites and pleural effusion)

sonographic findings of a thecoma

1. Hypoechoic, solid mass with posterior attenuation

2. No posterior enhancement

3. If large, it may mimic a pedunculated leiomyoma

— is considered to be the most common estrogenic tumor

The granulosa cell tumor, also referred to as the granulose theca cell tumor,

the granulosa cell tumor is also a— like the thecoma

sex cordstromal tumor

the granulosa cell tumors typically occur — but they can also be found in younger patients

unilaterally and are more commonly seen in the postmenopausal female

Because of its estrogen-producing potential, a granulosa cell tumor will present clinically much like the —.

thecoma

As a result of consistent estrogen stimulation, postmenopausal patients with granulosa cell tumors have approximately a 10% to 15% chance of developing —

endometrial carcinoma

Granulosa cell tumors can reach sizes up to — and do have malignant potential.

40 cm

clinical findings of granulosa cell tumors

1. Adolescence–pseudoprecocious puberty

2. Reproductive-aged and postmenopausal women will have abnormal vaginal bleeding

sonographic findings of granulosa cell tumors

1. Solid, hypoechoic mass

2. Complex or partially cystic mass

In pediatric patients, the granulosa cell tumor is associated with —

pseudoprecocious puberty.

Granulosa cell tumor. Longitudinal image of a 3-year-old girl suffering from premature breast development demonstrating a granulosa cell tumor (between arrows) located posterior to the urinary bladder (B).

An ovarian fibroma is also considered a —

sex cord-stromal tumor

Unlike thecomas and granulosa cell tumors however, fibromas are —

not associated with estrogen production

Fibromas are most often found in —

middle-aged women

fibromas are benign ovarian masses that may be complicated by —

Meigs syndrome as well

Often, fibromas, like thecomas, may mimic —

pedunculated uterine leiomyoma

The ascites and pleural effusions associated with Meigs syndromes usually resolve after —

resection of the tumor

clinical findings of a fibroma

1. May be asymptomatic

2. Meigs syndrome (ascites and pleural effusion)

sonographic findings of a fibroma

1. Hypoechoic, solid mass with posterior attenuation

2. No posterior enhancement

3. If large, it may mimic a pedunculated leiomyoma

Ovarian fibroma. Sagittal image of the right ovary demonstrating a solid mass (arrows) with a homogeneous echotexture.

Brenner tumors, or —, are most often small, solid, hypoechoic unilateral tumors that may contain calcifications.

transitional cell tumors

brenner tumors are almost always benign, but they can —

undergo malignant degeneration

clinical findings of a brenner tumor

1. May be asymptomatic

2. Meigs syndrome (ascites and pleural effusion)

sonographic findings of a brenner tumor

1. Small, solid, hypoechoic mass

2. May contain calcifications

— is a benign, blood-containing tumor that is associated with endometriosis and forms from the implantation of ectopic endometrial tissue

An endometrioma

This ectopic endometrial tissue is —

functional

It is this hemorrhage that forms into focal areas of bloody tumors—-

endometriomas

Consequently, they have been nicknamed — because they appear as dark, thick bloody masses during gross examination

“chocolate cysts”

Endometriomas can be located anywhere outside the endometrial cavity, including on any other pelvic organ, such as the bladder and bowel, but are more commonly found on—

the ovary

Most often, these masses are multiple and seen more often in the —

reproductive years.

endometriomas can be found within the — and present as a palpable mass that may change shape throughout the menstrual cycle in relation to hormone alterations

cesarean section scar

clinical findings of endometriomas

1. Patient may be asymptomatic

2. pelvic pain

3. infertility

4. dysmenorrhea

5. menorrhagia

6. dyspareunia

7. painful bowel movements (dyschezia)

sonographic findings of endometriomas

1. Predominantly cystic mass with low-level internal echoes (may resemble a hemorrhagic cyst)

2. Anechoic or complex, mostly cystic mass with posterior enhancement and may have a fluid–fluid level