DMS 200- Unit 3

Normal sonographic appearance of the ovaries

Homogenous, cyst like structures around the periphery; echogenic foci is normal typically 1-2 mm

Volume

___________ is the most consistent way to size ovaries, shape varies from patient to patient

3 cc

Premenarche volume is typically __ ____

9.8 cc

Menstruating volume is typically ___ ____ or less. 10 cc + is concerning.

6.8 cc

Menopausal volume is typically __ ____

Twice

If one ovary is _______ the volume of the other, it’s imperative to double check. If true, an abnormality should be suspected.

LH & FSH

Hormones that help with growth and maturation follicles

Progesterone

Hormone produced by corpus luteum, sustains and supports early pregnancy until the placenta takes over

Days 1-10

Best time to scan in the cycle

Moderate to high resistive

Normal wave form of the ovary

> .4

Normal RI for the ovaries

> 1

Normal PI for the ovaries

Suspicion for malignancy

Low resistive waveform, intratumoral vascularity

RI

If there’s a question of a waveform for where the patient is at in their cycle or a concern for something else, get an ___

Types of Functional Cysts

Follicular cysts, corpus luteum cysts, theca lutein cysts, hemorrhagic cysts

Ovarian

Most cysts are of _________ origin

Surgical consult

Cyst greater than 6 cm for a sustained 8 weeks

Follicular ovarian cyst

• A mature follicle fails to ovulate or involute, post ovulation, < 2 - 20 cm

• Unilateral

• Typically asymptomatic

• Spontaneously regress

Corpus luteum cysts

• Failure of absorption or excessive bleeding into corpus luteum, > 4 - 10cm

• Can last into first 4 days of period

• Prone to hemorrhage, simple to complex in appearance

Low

Corpus Luteal flow may have ____ resistive waveform

First

Corpus luteum cysts are the most common adnexal mass in the ______ trimester, will monitor through the whole pregnancy and even afterwards if it doesn’t regress.

Hemorrhagic cysts

• Internal hemorrhage occurring in follicular or corpus Luteal cyst

• Can appear starkly different due to age of blood

• Acute will be closer to hypoechoic, as time goes on it will become more complex

Theca Lutein cysts

• Largest functional cyst, from overstimulation of HCG

• Bilateral, multilocular

• Can be from molar pregnancy, multiples, or treatment for fertility

• May have nausea and vomiting, ascites including pleural effusion has happened

Mild Theca Lutein cysts

Pelvic discomfort

Moderate Theca Lutein cysts

Ovaries still less than 5 cm in diameter, more pelvic discomfort, no major weight gain

Severe Theca Lutein cysts

Abd distention, greater than 10 cm in diameter, severe pain

PCOS

• Endocrine disorder associated with chronic anovulation, imbalance between LH and FSH due to abnormal estrogen and androgen production

• LH levels increased in pts, FSH levels decreased- androgens NOT being changed into estrogen hormones

Stein-Leventhal syndrome qualifications

1. Infertility

2. Oligomenorrhea

3. Hirsutism

4. Obesity

Sonographic appearance of PCOS

Must be coupled with sx; at least 12 follicles, all cysts have to be 2 - 10 mm in size (< 1cm)

Peritoneal Inclusion cysts

• Adhesions trap peritoneal fluid around the ovary, mesothelial cell lining

• Large adnexal masses

• Multiloculated, septated in appearance around the ovary

Paraovarian cysts

• Cystic structures arising from broad ligaments or adnexal structures

• Possible by demonstrating normal ovary next to the cyst, has to prove they’re not connected

• Will not regress due to not being influenced by hormones

Benign cysts in Fetuses & Adolescents

• Maternal hormone stimulation (hormones from mom)

• Simple cysts from 1 - 7mm

• Followed closely as the child grows, regresses

• Occasionally produces precocious puberty

Simple cysts in postmenopausal women

• Usually simple cyst causing enlarged ovary

• Should not be present in postmenopausal women, cause for investigation

• < 5cm is likely benign, RI > .4 likely benign

• CA 125 for screening

Ovarian Torsion

• Rotation of the ovarian pedicle on its axis occluding the blood supply

• Can be partial or complete

•  Risk for rupture, hemorrhage, infection, peritonitis

• Sx are severe lower abd pain, nausea, vomiting, fever

Sonographic appearance of ovarian torsion

Enlarged edematous ovary >4cm , “solid” adnexal mass, absent blood flow is emergent

Ovarian carcinoma

• Considered a silent killer

• Leading cause of death in gyn- 25%

• Risk is increased with age

• Highest incidence is > 50 y.o. (50% > 63 y.o.)

Ovarian CA Stage I

CA in situ, limited to ovary

Ovarian CA Stage II

CA limited to the pelvis

Ovarian CA Stage III

CA limited to the abd

Ovarian CA Stage IV

CA spread beyond the abd

Lymphnodes

CA primarily spreads via _____________, once it reaches them it can travel to other parts of the body

Liver

The ________ is the more, if not most common organ to have Mets.

Ovarian Mass Scoring System

0,1,2,3

3

Ovarian mass scoring of __ is greatest increased risk for malignancy

Ovarian Mass Score 0

• Smooth or small irregularities in the wall, less than 3 mm

• Shadowing present behind

• No septa or less than 3mm

• May be anechoic or low levels witin

Ovarian Mass Score 1

• No shadowing of mass

• Thick septations of greater than 3 mm, may see blood flow in the septation

Ovarian Mass Score 2

• Solid wall structure in mass

Ovarian Mass Score 3

• Papillary projections from wall of mass

• Mixed or high echogenicity of internal contents

Malignancy risk factors in a mass

Solid elements, septations, blood flow in solid elements, abnormal CA 125, older age, ascites, liver Mets, low RI

Ovarian CA Treatment

Surgery or chemotherapy

CA 125 False Positive Reasons

• Endometriosis

• PID

• Fibroids

• Pregnancy

• Other CA’s

5 cm

Post meno cysts greater than __ ___ should be removed

Ovaries

If there are post meno cysts present, the sono should look beyond the _________ to the pelvic area, abd, liver, and look for ascites

Vague Sx of Ovarian Masses

• Pelvic fullness

• Lower abd pain

• Pelvic pressure

Malignancy sx

• Progressive weakness

• Weight loss

• Loss of appetite

• Cachexia

Cachexia

A wasting syndrome

Ascites

Ovarian CA is associated with massive __________.

Differentials for Ovarian Mass

• Pelvic kidney

• Omental cyts

• Hydroureters

• Colonic masses/impaction

• Diverticular abscesses

• Retroperitoneal masses

Benign, malignant

Adenoma means _______, Adenocarcinoma means ____________

Mucinous cystadenoma

• 13-45 y.o.

• Mucinous elements of endocervix and bowel, benign

• Typically unilateral, large

• Multiloculated cyst like appearance

Mucinous cystadenocarcinoma

• 40-70 y.o

• Malignant, higher incidence of rupture

• Large, thick irregular walls with papillary projections

• Ascites with possible bright echoes within

Pseudomyxoma peritonei

• Occurs when a mucinous cystadenocarcinoma ruptures

• Spread of ruptured contents, with loculated/ debris filled ascites that fills much of the abd

Serous cystadenoma

• 2nd most common benign ovarian tumor

• In post meno women

• Smaller in size, unilateral

• Multiloculated, papillary projections, septations

Serous cystadenocarcinoma

• More than 50% are bilateral

• 60-80% of ALL ovarian carcinomas

• Lymphnode spread

• Irregular borders, may have calcs, mulitloculated, internal papillary projections, ascites

Endometroid tumors

• Nearly always malignant

• 50% bilateral

• Tissue similar to the endometrium

Brenner Tumor

• RARE, majority are benign

• 40-70 y.o.

• Dense fibrous stroma, solid tumor

• Small, hypoechoic, solid, may have calcs

Clear Cell Adenocarcinoma

• Malignant, can become large in size

• Associated with endometriosis

• Clear cytoplasm

• Predominately cystic in appearance, non specific complex

Teratoma

• Germ cell tumor, adolescent age group

• Mature, benign

• Ectodermal tissue in origin

• 75% unilateral

• Usually small, cystic to complex depending on contents