ovaries/tubes pathology

benign ovarian cysts:

• functional cysts

• follicular cysts

• corpus luteum cysts

• theca lutein cysts

functional cyst

• most common cause of ovarian enlargement in young women

• usually results from stimulation of released pituitary gonadotropins

• generic hormonally active cyst

follicular cyst

• caused by the overstimulation of a follicle that fails to rupture

• serous fluid distends the lumen of the follicle, creating a cyst

• most are unilocular and measure 3-8 cm

corpus luteum cyst

• occurs following ovulation of the dominant follicle

• rarely exceeds 4 cm in diameter

sonographic appearance of a corpus luteum cyst:

• thick hyperechoic irregular walls

• usually presence of internal echoes

• possible solid appearance

theca lutein cyst

• largest of the functional cysts

• results from overstimulation by high levels of hCG

• associated with gestational trophoblastic disease or hC administration during infertility treatment

• multilocular and bilateral

polycystic ovarian syndrome (PCOS)

• AKA Stein-Leventhal syndrome

• endocrinologic disorder

• associated with chronic anovulation

• usually diagnosed in young women

clinical symptoms of PCOS:

• infertility

• obesity

• amenorrhea

• hirsutism

sonographic appearance of PCOS:

• bilateral multiple cysts of varying sizes

• cysts peripheral in location

• normal or enlarged ovaries

• “string of pearls”

ovarian torsion

• caused by partial or complete rotation of the ovarian pedicle on its axis

• lymphatic and venous drainage is compromised, causing congestion and edema, eventually leading to loss of arterial perfusion and resultant infarction

right-sided ovarian torsion can clinically mimic what?

acute appendicitis

risk factors for ovarian torsion:

• pre-existing ovarian cyst or mass

• children and young females

• pregnancy

sonographic appearance of ovarian torsion:

• enlarged ovary, often with multiple follicles

• absent color and spectral doppler flow (varied depending on degree of torsion)

• possible adnexal mass

• possible arterial flow but absent venous flow

epithelial tumors

arise from the surface of the epithelium that covers the ovary

5 categories of epithelial tumors:

• serous

• mucinous

• endometroid

• clear cell

• transitional cell (Brenner)

proliferative changes of epithelial tumors are divided into these 3 categories:

• benign

• atypically proliferating (borderline)

• malignant

serous tumors

• common

• occur most commonly in pre- and postmenopausal women

sonographic appearance of a benign serous tumor

• bilateral 20% of the time

• sharply marginated

• anechoic

• large

• possibly internal thin-walled septations

sonographic appearance of a malignant serous tumor

• bilateral 50% of the time

• multilocular

• multiple thick septations

• occasional echogenic material within

• ascites

mucinous tumor

• most are benign

• penetration of the tumor capsule or rupture may spread mucin-secreting cells into the peritoneal cavity, filling it with material known as pseudomyxoma peritonei

pseudomyxoma peritonei

may occur with either benign or malignant mucinous tumors

sonographic appearance of pseudomyxoma peritonei:

may look similar to ascites, possibly with multiple septations

sonographic appearance of a benign mucinous tumor:

• multiloculated

• thicker and more numerous septations

• gravity-dependent echoes

• up to 50 cm in diameter

sonographic appearance of a malignant mucinous tumor:

• multiloculated cystic lesions

• contain echogenic material and papillary projections

• can measure 15-30 cm in diameter

endometroid tumors

• most are malignant

• have a better prognosis than either serous or mucinous carcinomas

sonographic appearance of endometroid tumors:

• mixed cystic and solid mass

• echogenic material within

• both ovaries are markedly enlarged

• may be predominantly solid with areas of hemorrhage and necrosis

clear cell tumors

• nearly always malignant

• considered a histologic variant of endometroid and serous carcinomas

sonographic appearance of clear cell tumors:

• non-specific

• complex predominantly solid mass

• echogenic material within

transitional cell (Brenner) tumors

• AKA ovarian fibroepithelioma

• almost always benign

• smaller than 2 cm in diameter

sonographic appearance of a transitional cell (Brenner) tumor:

• hypoechoic solid mass

• may have small cystic spaces

• calcifications may be present

germ cell tumors

• derived from the primitive germ cells of the embryonic gonad

• most are benign and called cystic teratomas

germ cell tumor types:

• benign cystic teratoma (BCT)

• dysgerminoma

• endodermal sinus tumor

benign cystic teratoma (BCT)

• AKA dermoid cyst

• most common germ cell tumor of the ovary

• common complication is ovarian torsion

sonographic appearance of a benign cystic teratoma:

• depends on composition and arrangement of contents

• predominantly cystic

• complex

• diffusely echogenic

• “tip of the iceberg” - highly echoegnic mass with shadowing

• “dermoid plug” - predominantly cystic with an echogenic mural nodules

dysgerminoma

• malignant germ cell tumor

• originating from the primordial germ cells of the ovary

sonographic appearance of a dysgerminoma:

• multiloculated solid mass

• variable in size

endometrial sinus (yolk sac) tumor

• second most common germ cell malignancy

• highly malignant and metastatic tumors

• pt will have increased levels of serum. AFP

sonographic appearance of a endometrial sinus (yolk sac) tumor:

• almost always unilateral

• predominantly solid mass with areas of necrosis

sex cord stromal tumors

• arise from ovarian stroma

• neoplasms of low-grade malignancy

types of sex cord stromal tumors:

• fibroma

• thecoma

• granulosa cell tumor

• sertoli-leydig tumors

fibroma

• benign

• Meig’s syndrome is the association of ascites and pleural effusion with a fibrous ovarian tumor, which disappears after excision of the tumor

sonographic appearance of a fibroma:

• usually unilateral

• homogenous hypoechoic mass with posterior acoustic shadowing

• rarely focal or diffuse calcifications

• associated with ascites

thecoma

• estrogen producing tumors

• rarely malignant

• most commonly occurs in postmenopausal women who present with clinical signs of estrogen activity

sonographic appearance of a thecoma:

• solid hypoechoic mass with posterior acoustic shadowing

• similar to fibroma

• possibly an abnormally thick endometrium secondary to hormonal stimulation

granulosa cell tumor

• most often occurring in postmenopausal women

• commonly produce estrogen

sonographic appearance of a granulosa cell tumor:

• small tumors the are predominantly solid

• large tumors are multiloculated and cystic

• possibly an abnormally thick endometrium secondary to hormonal stimulation

• central vascular flow is present

Sertoli-Leydig tumor

• AKA arrhenoblastoma or androblastoma

• rare

• androgen producing

androgens

• a group of hormones that play a role in male traits and reproductive activity

• present in both males and females

• principle androgen is testosterone

sonographic appearance of a Sertoli-Leydig tumor:

• usually unilateral

• solid echogenic mass

• similar appearance to granulosa cell tumors

metastatic tumors

• usually bilateral solid ovarian masses

• most common sites of ovarian metastasis are tumors of the breast and GI tract

Krukenberg tumor

• arises from the GI tract from a gastric carcinoma

• more common on the right ovary if unilateral

sonographic appearance of a Krukenberg tumor:

• usually bilateral

• bilateral solid hyperechoic or complex predominantly solid masses

• possible ascites

ovarian cancer screening:

• avg age: 50-59 yrs old

• hx of unsuccessful pregnancies or nulliparity

• family hx

during an ovarian cancer screening, in any pt with a suspicious ovarian mass, the following should be evaluated:

• peritoneum for ascites

• lymph nodes

• liver

• pleural space

CA 125

• biological tumor marker

• elevated in the blood of most women with ovarian cancer

• insensitive to mucinous and germ cell tumors

• may also be seen in pts with other malignancies as well as benign gyn pathology like endometriosis and fibroids

pelvic inflammatory disease (PID)

general term referring to inflammation of pelvic and adnexal structures

PID can be caused by:

• ascending infection spreading from cervix through endometrial cavity to the fallopian tubes and adnexa and may be localized or diffuse

• STIs/STDs

PID predisposes pt to:

• infertility

• tubal scarring

• ectopic pregnancy

hydrosalpinx

a collection of fluid within obstructed fallopian tube

pyosalpinx

a collection of pus within obstructed fallopian tube

stage 1 PID:

• early PID

• endometritis

stage 2 PID:

acute salpingitis (pyosalpinx)

stage 3 PID:

• severe PID

• broad ligament and ovarian involvement

• may results in TOA and peritonitis

chronic PID:

• long standing condition

• adhesions may cause pelvic organs to merge centrally, leading to the “indefinite uterus sign”

clinical symptoms of PID:

• fever

• leukocytosis

• lower abdominal pain

• purulent vaginal discharge

• pelvic tenderness -bilateral and diffuse

• constant dull pain worsened by sexual activity

sonographic appearance of stage 1 PID:

• thickening and irregularity of the endometrium

• fluid, debris or gas within endometrial cavity

• diffuse hypoechoic uterus

• indistinct orders of pelvic structures

• fluid in posterior cul-de-sac (may be complex)

sonographic appearance of stage 2 PID:

• pyosalpinx

• tubular adnexal cystic masses

• thickened tubal wall

• unilateral or bilateral

sonographic appearance of stage 3 PID:

• tubal-ovarian abscess (TOA)

• unilateral or bilateral with hyperemic flow on doppler

• indistinct walls surrounding the mass

sonographic appearance of chronic PID:

• hydrosalpinx

• thin-waled dilated tube with anechoic fluid

• uterus and ovaries central in pelvis

• difficulties in visualizing borders