Sonographic Evaluation of Pelvic

Masses

Aboubakr Elnashar

Benha university Hospital, Egypt

Aboubakr Elnashar

Sonography provides clinically important

parameters for the pelvic mass.

1. Confirmation of the presence or absence of a

pelvic mass.

2. Delineation of the size, internal consistency,

and contour of the mass.

3. Establishment of the origin and anatomic

relationship of the mass to other pelvic

structures.

4. A survey to establish the presence or absence

of abnormalities associated with malignant

disease, such as ascites or metastatic lesions.

5. Guidance for aspiration or biopsy of selected

pelvic masses.

Aboubakr Elnashar

TRANSVAGINAL SONOGRAPHY OF PELVIC

MASSES

important role in the evaluation of the uterus and

adnexa.

{its limited field of view and unusual image

orientation} it is best used as an adjunct to TAS.

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TVS is indicated:

1. Determination of the presence or absence, and

evaluation of, relatively small (<5 to 10 cm)

2. Determination of the origin of a mass (uterine,

ovarian, or tubal) and whether or not it has

torsed.

3. Detailed evaluation of its internal consistency

with particular emphasis on the presence or

absence of polypoid excrescences, septations,

or internal consistencies (blood, pus, serous fluid).

4. Guiding transvaginal aspiration of certain

masses.

5. Evaluation of endometrial or myometrial

disorders related to pelvic masses.

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DD between benign and malignant

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Morphologic scoring by TVS.

Each of four parameters as assessed, including inner

wall structure, wall thickness (mm), septa (mm), and

echogenicity. Malignancies tended to have high scores

(over 9).

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Simple ultrasound rules: 2012 5 ultrasonic features to predict a malignant tumour

(M features):

irregular solid tumour (M1),

ascites (M2),

at least four papillary structures (M3),

irregular multilocular solid tumour with a largest

diameter of at least 100 mm (M4), and

very high colour content on colour Doppler

examination (M5).

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5 ultrasonic features to predict a benign tumour (B

features):

unilocular cyst (B1),

presence of solid components for which the largest

solid component is <7 mm in largest diameter (B2),

acoustic shadows (B3)

smooth multilocular tumour (B4), and

no detectable blood flow on Doppler examination

(B5).

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If one or more M features were present in the

absence of a B feature, we classified the mass as

malignant (rule 1).

If one or more B features were present in the

absence of an M feature, we classified the mass as

benign (rule 2).

If both M features and B features were present, or if

none of the features was present, the simple rules

were inconclusive (rule 3).

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Sonographic signs of

malignancy. (A) Longitudinal

transabdominal sonography

showing irregular bulge

(arrow) in superior aspect of

ovarian tumor, indicating

capsular disruption by tumor.

(B) Gross specimen showing

tumor extruding through

capsule in malignant ovarian

cystadenocarcinoma. (C)

Irregular solid mass (arrow)

arising from peritoneum,

representing metastases from

ovarian carcinoma. (D) Bloody

ascites associated with recurrent

ovarian carcinoma appearing as

echogenic particulate material

(*). (E) Echogenic liver

metastasis from ovarian

carcinoma obstructing

intrahepatic portion of inferior

vena cava. Aboubakr Elnashar

SONOGRAPHIC DIFFERENTIAL DIAGNOSIS OF PELVIC MASSES

Cystic

1. Completely cystic

Physiologic ovarian cysts

Cystadenomas

Hydrosalpinx

Endometrioma

Paraovarian cyst

Hydatid cyst of Morgagni

2. Multiple

Endometriomas

Multiple follicular cysts

3. Septated

Cystadenoma (carcinoma)

Mucinous

Serous

Papillary

Complex

1. Predominantly

cystic

Cystadenomas

Tubo-ovarian

abscess

Ectopic

pregnancy

Cystic teratoma

2. Predominantly

solid

Cystadenoma

(carcinoma)

Germ cell tumor

Solid

1. Uterine

Leiomyoma

(sarcoma)

Endometrial

carcinoma,

sarcoma

Extrauterine

2. ovarian tumor Aboubakr Elnashar

Simple ovarian cyst.

Transvaginal color flow

Doppler image

demonstrates a large simple

ovarian

cyst.

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Postmenopausal cysts.

Transvaginal grayscale images of both ovaries demonstrate

simple cysts bilaterally in a postmenopausal woman.

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Corpus luteum cyst.

(A) Transvaginal grayscale image of the left ovary demonstrates a cyst with

debris within, suggestive of hemorrhage in a corpus luteum cyst.

(B) Corresponding

color flow Doppler image demonstrates peripheral vascularity—called the

‘‘ring of fire

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Parovarian cyst.

Transvaginal grayscale image demonstrates a left

parovarian cyst with a corresponding four-dimensional US

reformatted image that demonstrates better delineation and

extent of the cyst. Aboubakr Elnashar

Theca lutein cysts.

Transvaginal grayscale image of the pelvis demonstrates multiple

simple bilateral ovarian cysts in this patient with a hydatidiform

mole. A pocket of free fluid is present between the two ovaries (arrow).

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(A) Transverse sonogram showing cystic mass containing multiple thin internal

septations, representing mucinous cystadenoma.

(B) Transverse transabdominal sonogram showing septated mass with

echogenic material (*) in upper loculated area. The echogenic material was

mucin within this mucinous cystadenoma.

(C) Malignancy was suspected due to thickened septation (arrow) within this

mucinous cystadenocarcinoma.

(D)Papillary projections (arrow) were found within this malignant teratoma.

Septated cystic masses.

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(E) Transverse sonogram of complex predominantly

cystic right-adnexal mass with calcific focus (arrow)

arising from tooth within this dermoid cyst.

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(F) Transvaginal sonogram of a pelvic mass in a woman with

a renal transplant. This was found to represent a luteal cyst

with fluid surrounding adhesion.

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Peritoneal inclusion cyst.

Transvaginal grayscale image of the right adnexa

demonstrates a spider- web pattern with presence of

loculated fluid and an eccentric right ovary (OV). Aboubakr Elnashar

Sagittal (G) and axial (H) transvaginal sonogram showing a multiloculated

septated cystic mass with focal wall thickening. This represented a

mucinous cystadenoma with one locule containing thick mucinous

material.

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A) Predominantly solid,

complex mass containing a

layer of echogenic material

(arrow) arising from sebum

within this dermoid cyst.

(B) Transvaginal sonogram

of granulosa cell tumor.

Complex predominantly solid masses.

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C) Transvaginal sonogram of dermoid cyst with layer

of echogenic sebum.

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Bilateral mature cystic teratoma.

Transverse grayscale image demonstrates bilateral mature

cystic teratomas (arrows). This image also shows the ‘‘tip

of the iceberg’’ sign. Incidentally seen is a fibroid

(arrowhead) in the anterior wall of the uterus (UT).

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D) Transvaginal sonogram of hemorrhagic

ovarian cyst containing irregular solid area

corresponding to displaced hemorrhagic

ovarian tissue surrounding area of hemorrhage Aboubakr Elnashar

(E) Longitudinal transabdominal sonogram (TAS) of ovarian

cystadenocarcinoma containing irregular solid areas.

(F) Magnified transverse TAS of cul-de-sac hemorrhage (arrow) resulting from ruptured ectopic pregnancy.

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(G) Transvaginal sonogram of dermoid cyst

showing typical echogenic hairball (arrows).

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Hemorrhagic ovarian cyst.

(A)Transvaginal grayscale image of the right ovary

demonstrates a typical‘‘fishnet’’ appearance.

(B)Grayscale and color flow Doppler image of the

right ovarian cyst with a retracting blood

clot adherent to the cyst wall and absent vascularity. Aboubakr Elnashar

Endometrioma.

(A) Transvaginal grayscale image demonstrates a

left ovarian cyst with low-level echoes.

(B) Transabdominal grayscale image of the pelvis

with bilateral endometriomas demonstrates the

‘‘kissing ovaries’’ sign. (UT, uterus.)

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Hydrosalpinx.

Transvaginal grayscale (A) and color flow Doppler

(B) images of the left adnexa demonstrate serpiginous,

tubular, anechoic, and avascular structures in the left adnexa.

(LO, left ovary.)

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Pelvic inflammatory disease.

(A) Transvaginal grayscale image demonstrates debris

within the dilated fallopian tube.

(B) Transabdominal grayscale image in patient with fever

and confirmed PID reveals pelvic abscess (arrows). (UT,

uterus.)

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Polycystic ovarian disease.

(A) Power Doppler image of bilateral ovaries demonstrates multiple follicles.

(B) Corresponding four-dimensional images demonstrate ovarian volume

calculation in polycystic ovaries. Aboubakr Elnashar

Ectopic pregnancy.

(A) Transvaginal grayscale image demonstrates an extraovarian mass with an

embryonic pole (within calipers) and a tubal ring sign (arrows). (B) Grayscale and color

flow Doppler image demonstrates a nonovarian adnexal mass with tubal ring sign and

peripheral vascularity (ring of fire). (OV, ovary.) Aboubakr Elnashar

Ovarian remnant syndrome.

Transvaginal color flow Doppler image of right adnexa in a

patient with

history of oophorectomy demonstrates an ovarian cystic

structure with surrounding ovarian tissue secondary to

hormone stimulation.

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Surgically confirmed serous cystadenoma.

Transvaginal grayscale and corresponding three-

dimensional US image of the right ovary demonstrate a

complex cystic mass with a mural nodule that shows

vascularity on the three-dimensional image

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Surgically confirmed mucinous cystadenoma.

(A, B) Grayscale images in two different patients

demonstrate multiloculated cystic lesion with septations.

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Pseudomyxoma peritoneii.

Transabdominal grayscale image of the pelvis in a known

case of mucinous cystadenocarcinoma demonstrates

presence of loculated ascites. (UB, urinary bladder.)

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Dysgerminoma.

Grayscale (A) and color flow Doppler (B) images of the

right ovary demonstrate a solid mass with increased

vascularity.

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Krukenberg tumors.

Grayscale US image of the pelvis demonstrates bilateral solid

ovarian tumors in a known case of stomach cancer. (LO, left

ovary; RO, right ovary.) Aboubakr Elnashar

Nongynecologic pelvic masses.

(A) Lymphocele. Grayscale image of the pelvis

demonstrates a complex septated fluid collection.

(B) Postpartum collection. Grayscale image of the pelvis

demonstrates a complex collection (coll) in the cul-de-sac,

consistent with hemorrhage. (LO, left ovary; RO, right

ovary; UT, uterus.) Aboubakr Elnashar

Subserosal fibroid.

Transvaginal grayscale US image of the pelvis

demonstrates a large solid adnexal lesion (Fib) arising

from the uterus (arrow). (UT, uterus.)

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Conclusions The majority of adnexal masses in women in

the reproductive years are follicle cysts of the

ovary.

The most common benign neoplastic tumors

of the ovary are serous cystadenoma and

benign cysts.

The most common benign cystic neoplasms of

the ovary in the 20- to 44-year-old group are

benign cystic teratoma, serous cystadenoma,

and mucinous cystadenoma.

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Most benign cystic teratomas are 10 cm or less

in diameter, but about one sixth are larger.

Serous cystadenocarcinoma is the most

common malignant tumor in all age groups,

from 20 to 75 years old.

Dysgerminoma and teratoma are the most

common solid adnexal tumors in young

women.

Aboubakr Elnashar

Thank you

Aboubakr Elnashar