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This simple lecture was designed as a part of the content of the basic ultrasound workshop held periodically by the department of Obstetrics & gynecology - Faculty of medicine - Mansoura university- Egypt as a part of continuous medical education program.
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ASYMPTOMATIC ADNEXAL MASSES
ULTRASOUND EVALUATION
Osama M Warda MDOsama M Warda MDOsama M Warda MDOsama M Warda MD Professor of Obstetrics and Gynecology
Mansoura University--EGYPT
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INTRODUCTION
� Various disease processes can present as a clinical problem when a patient comes to a physician’s office for a routine gynecologic examination & an asymptomatic palpable adnexal mass is felt.
� The differential diagnosis include
1. Functional ovarian cysts (vast majority)
2. Endometriosis
3. Dermoids
4. Ovarian tumors (B9 > malig.)
5. Tubo-ovarian abscess
6. Subserous fibroids
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IMPORTANT CLINICAL PARAMETERS FOR DIAGNOSIS
� Patient’s age;
-Pre-menopausal
-Post-menopausal
� Apparent size of the mass on palpation;
? 5-6 cm, less or more
� Consistency (feel) of the mass;
? cystic, soft, solid
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GENERAL PLAN OF MANAGEMENT
1---- FollowFollowFollowFollow----up clinical exam for up clinical exam for up clinical exam for up clinical exam for 1111----2 2 2 2 menstrual menstrual menstrual menstrual cycles in:cycles in:cycles in:cycles in:
� Premenopausal patient
� Mass is < 6cm
� Mass feels cystic or soft
A- if mass disappeared well and good
B- if persisted or increased in size;
-TVS evaluation (CT or MRI rarely needed)
- Other non radiologic investigation (eg CA125) may be needed according to imaging results
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GENERAL PLAN OF MANAGEMENT
2222---- A palpable A palpable A palpable A palpable adnexaladnexaladnexaladnexal mass in a mass in a mass in a mass in a postmenopausalpostmenopausalpostmenopausalpostmenopausal woman:woman:woman:woman:
should be investigated immediately (no role for follow-up)
with TVS . Adding color Doppler increases the sensitivity
and positive predictive value in characterizing the
adnexal mass over the conventional grey scale.
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SIMPLE CYST
-It is the most common finding
- simple cyst is characterized by:
1. anechoic
2. smooth margins
3. unilocular
4. good sound transmission to the adjacent soft tissue
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SIMPLE CYST- THE OUTCOME
Simple cysts <6cm in premenopausal or <5 cm in postmenopausal women when found are followed up with ultrasound imaging after 1-2 months.
COCs may be used to help resolve the cyst and prevent development of other functional ovarian cysts as they decrease FSH level.
Most simple cysts disappear within that period. Spontaneous regression is less likely with cysts > 6cm.
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HEMORRHAGIC CYST
Bleeding in a cyst complicates the diagnosis. Variable characteristics can be seen
because of clot formation, lysis, and retraction. The cyst may have:
1. Appearance of a solid component
2. Mural nodularity
3. Septations
4. Focal wall thickening
5. Fluid debris levels
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HEMORRHAGIC CYST
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HEMORRHAGIC CYST
Thin, fibrous strands, clot retraction with convex
borders, fluid levels & homogeneous low echoes
throughout the mass with good transmission
suggest hemorrhage in this cystic mass.
Most hemorrhagic cysts will resolve spontaneously
over time but surgical excision may be necessary.
Ruptured cysts are associated with free fluid in
cul-de-sac, or even intra-peritoneal fluid.
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THECA LUTEIN CYSTS
Are functional cysts & usually associated with;
1- some form of GTD 2- Ovarian hyper-stimulation with ovulation drugs 3-
with spontaneous pregnancy especially mutifetal pregnancy.
The exact etiology is unknown but the are associated with high levels of HCG
Elevated pituitary FSH or increased HCG sensitivity may be involved
Are usually bilateral and multilocular
They may remain for several weeks after the removal of the offending cause
and usually asymptomatic
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POLYCYSTIC OVARIES
it is a complex clinical, laboratory, and ultrasound picture
ON ULTRASOUNDON ULTRASOUNDON ULTRASOUNDON ULTRASOUND:
There is a bilateral increased number of small (<There is a bilateral increased number of small (<There is a bilateral increased number of small (<There is a bilateral increased number of small (<8888mm) follicle cysts usually as many mm) follicle cysts usually as many mm) follicle cysts usually as many mm) follicle cysts usually as many
as as as as 10 10 10 10 in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)
Mature follicles (Mature follicles (Mature follicles (Mature follicles (15151515----30303030mm) can be found in up to mm) can be found in up to mm) can be found in up to mm) can be found in up to 15151515% of cases.% of cases.% of cases.% of cases.
Follicles > Follicles > Follicles > Follicles > 30303030mm can be seenmm can be seenmm can be seenmm can be seen
Increased ovarian Increased ovarian Increased ovarian Increased ovarian echogenicityechogenicityechogenicityechogenicity (=dense (=dense (=dense (=dense stromastromastromastroma))))
A combination of follicular and ovarian volume is the most sensitive objective A combination of follicular and ovarian volume is the most sensitive objective A combination of follicular and ovarian volume is the most sensitive objective A combination of follicular and ovarian volume is the most sensitive objective
parameter in diagnosis. The upper limit of normal ovarian volume is parameter in diagnosis. The upper limit of normal ovarian volume is parameter in diagnosis. The upper limit of normal ovarian volume is parameter in diagnosis. The upper limit of normal ovarian volume is 15151515CmCmCmCm3333
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OVARIAN ENDOMETRIOSIS
- Women between 25-35 years with dysmenorrhea
- Complex and primarily cystic masses due to repeated bleeding episodes during
menses.
The focal blood collection may be anechoic or complex, with multiple EVENLY
distributed echoes, clot nodules, or debris levels
There is usually good through sound transmission
The wall is usually thickened or irregular
Septa are unusual
In severe cases, multiple collections can be seen
Treatment is essentially SURGICAL
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PARAOVARIAN CYST
They arise in the broad ligament derivatives of They arise in the broad ligament derivatives of They arise in the broad ligament derivatives of They arise in the broad ligament derivatives of mesothelialmesothelialmesothelialmesothelial or or or or periperiperiperi----mesothelialmesothelialmesothelialmesothelial structures.structures.structures.structures.
They comprise They comprise They comprise They comprise 10101010% of % of % of % of adnexaladnexaladnexaladnexal cystic masses & mostly seen in cystic masses & mostly seen in cystic masses & mostly seen in cystic masses & mostly seen in the middlethe middlethe middlethe middle----age women.age women.age women.age women.
Although the are mostly simple cysts, they may be complicated Although the are mostly simple cysts, they may be complicated Although the are mostly simple cysts, they may be complicated Although the are mostly simple cysts, they may be complicated be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.
To be diagnosed as To be diagnosed as To be diagnosed as To be diagnosed as paraparaparapara----ovarian,aovarian,aovarian,aovarian,a tissue plane between the tissue plane between the tissue plane between the tissue plane between the cyst & the normal ovary must exist.cyst & the normal ovary must exist.cyst & the normal ovary must exist.cyst & the normal ovary must exist.
The usual treatment is EXCISION as it does not respond to The usual treatment is EXCISION as it does not respond to The usual treatment is EXCISION as it does not respond to The usual treatment is EXCISION as it does not respond to hormones. hormones. hormones. hormones.
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HYDROSALPINX
TheyTheyTheyThey are oblong ( or retortare oblong ( or retortare oblong ( or retortare oblong ( or retort---- shape) cystic structures shape) cystic structures shape) cystic structures shape) cystic structures
near the normally appearing ovary which is usually near the normally appearing ovary which is usually near the normally appearing ovary which is usually near the normally appearing ovary which is usually
separated by the cyst wallseparated by the cyst wallseparated by the cyst wallseparated by the cyst wall
Antibiotic/antiAntibiotic/antiAntibiotic/antiAntibiotic/anti----inflammatory treatment usually tried inflammatory treatment usually tried inflammatory treatment usually tried inflammatory treatment usually tried
with limited. with limited. with limited. with limited.
In infertility treatment excision or disconnection is In infertility treatment excision or disconnection is In infertility treatment excision or disconnection is In infertility treatment excision or disconnection is
recommended recommended recommended recommended
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TUBO-OVARIAN ABSCESS
The US appearanceThe US appearanceThe US appearanceThe US appearance varies according to their appearance at the varies according to their appearance at the varies according to their appearance at the varies according to their appearance at the
time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.
The mass may be purely cystic, have thick septa, have multiple The mass may be purely cystic, have thick septa, have multiple The mass may be purely cystic, have thick septa, have multiple The mass may be purely cystic, have thick septa, have multiple
loculationloculationloculationloculation, and contain complex debris., and contain complex debris., and contain complex debris., and contain complex debris.
A more serious diagnosis such as benign or malignant A more serious diagnosis such as benign or malignant A more serious diagnosis such as benign or malignant A more serious diagnosis such as benign or malignant
neoplasm must be considered because both conditions are quite neoplasm must be considered because both conditions are quite neoplasm must be considered because both conditions are quite neoplasm must be considered because both conditions are quite
similar on ultrasound.similar on ultrasound.similar on ultrasound.similar on ultrasound.
TuboTuboTuboTubo----ovarian abscesses are usually removed surgically ( ovarian abscesses are usually removed surgically ( ovarian abscesses are usually removed surgically ( ovarian abscesses are usually removed surgically ( although although although although
asymptomaticasymptomaticasymptomaticasymptomatic) as masses do not change over time.) as masses do not change over time.) as masses do not change over time.) as masses do not change over time.
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OVARIAN NEOPLASM
� Ovarian neoplasm; 80% benign, 10-15% malignant, and 5% are metastases.
� Age range for benign t is 20-45y, for malignant is 40-65y.
� Ovarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solid
� Ultrasound criteria suggesting malignancy include:
� Bilateral tumors Bilateral tumors Bilateral tumors Bilateral tumors
� Heterogeneous Heterogeneous Heterogeneous Heterogeneous echogeneityechogeneityechogeneityechogeneity
� Presence of intraPresence of intraPresence of intraPresence of intra----cystic septa, multiple cystic septa, multiple cystic septa, multiple cystic septa, multiple loculesloculesloculeslocules
� Presence of papillae (intraPresence of papillae (intraPresence of papillae (intraPresence of papillae (intra----cystic, or extracystic, or extracystic, or extracystic, or extra----cystic)cystic)cystic)cystic)
� Presence of intraPresence of intraPresence of intraPresence of intra----cystic solid partscystic solid partscystic solid partscystic solid parts
� Presence of ascitesPresence of ascitesPresence of ascitesPresence of ascites
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OVARIAN NEOPLASM- CYSTADENOMAS
Serous Serous Serous Serous cystadenomacystadenomacystadenomacystadenoma
MucinousMucinousMucinousMucinous CystadenomaCystadenomaCystadenomaCystadenoma Papillary serous Papillary serous Papillary serous Papillary serous cystadenomacystadenomacystadenomacystadenoma
Serous Serous Serous Serous cystadenocarcinomacystadenocarcinomacystadenocarcinomacystadenocarcinoma
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OVARIAN NEOPLASM- SOLID TUMORS
Granulosa cell t Immature solid teratoma
Brenner
Germ cell t
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OVARIAN NEOPLASM- DERMOID CYST
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SUBSEROUS MYOMA
UUUUsually appears sually appears sually appears sually appears ecogenicecogenicecogenicecogenic, similar to the , similar to the , similar to the , similar to the
uterine walluterine walluterine walluterine wall
Sometimes it appears with variable size Sometimes it appears with variable size Sometimes it appears with variable size Sometimes it appears with variable size
hyperecchogenichyperecchogenichyperecchogenichyperecchogenic areas due to calcificationareas due to calcificationareas due to calcificationareas due to calcification
Sometimes it may appear with mixed Sometimes it may appear with mixed Sometimes it may appear with mixed Sometimes it may appear with mixed
echogenicityechogenicityechogenicityechogenicity (complex mass) due to cystic (complex mass) due to cystic (complex mass) due to cystic (complex mass) due to cystic
degenerationdegenerationdegenerationdegeneration
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THANK YOU THANK YOU THANK YOU THANK YOU
شكرا و السالم عليكم
و رحمة اهللا وبركاته
WARDA 2014
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