Khaled Sakhel, MD, FACOG

• Define ovarian masses.

• Understand the utility of 3-D ultrasound in gynecology.

Slide 1 ___________________________________

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The Adnexa
Kal Sakhel, MD ___________________________________
Associate Professor
Director, Minimally Invasive Gynecology and Robotic
Surgery
Director, student clerkships
OBGYN Department
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Eastern Virginia Medical School, Norfolk, VA

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Slide 2 ___________________________________
Scoring systems

• Lerner score ___________________________________

• Minaretzis et al.
• Tailor et al.
• Prompeler et al. ___________________________________
• Timmerman et al.
• Lu et al.
• Jokubkiene et al.
• Amor et al ___________________________________

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Slide 3 ___________________________________

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International Ovarian Tumor
Association
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Slide 4 International Ovarian Tumor ___________________________________
Association
 All cysts to be described as ___________________________________
 Unilocular cyst
 Unilocular-solid cyst
 Multilocular cyst ___________________________________
 Multilocular-solid cyst
 Solid cyst
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Timmerman 2000

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Slide 5 International Ovarian Tumor ___________________________________

Association
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 Unilocular-solid cyst (no septum but has

some measurable solid area)
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Timmerman 2000

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Slide 6 International Ovarian Tumor ___________________________________

Association
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 Multilocular-solid cyst (at least one ___________________________________

septum and some measurable solid area)
Timmerman 2000

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Slide 7 International Ovarian Tumor ___________________________________
Association
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 Solid cyst have >80% solid component

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Timmerman 2000

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Slide 8 International Ovarian Tumor ___________________________________

Association
 Fluid within the cyst described as
 Anechoic (black)
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 Low level echogenic (mucinous tumors or
amniotic fluid)
 Ground Glass appearance (endometrioma) ___________________________________
 Hemorrhagic (internal thread-like fibrin
strands, star shaped, cob-web or mixed jelly
like)
 Mixed echogenic (teratomas)
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Timmerman 2000

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Slide 9 International Ovarian Tumor ___________________________________

Association
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Timmerman 2000

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Slide 10 International Ovarian Tumor ___________________________________
Association
 Subjective assessment of vascular
flow within the septum, wall or solid
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component is scored as
 1 no flow
 2 Minimal ___________________________________
 3 Moderate
 4 Marked (Highly vascular)

 Score given once for entire tumor ___________________________________

Timmerman 2000

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Slide 11 Ultrasound Evaluation-

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Vascular Flow
 At some point growing tumors will ___________________________________
need to develop neovascularization
 Breast CA it seems to be at 1-2mm
diameter ___________________________________
 Ovarian ?

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Slide 12 ___________________________________

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Slide 13 Ultrasound Evaluation-
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Vascular Flow
 Fleisher PI>1.0 is normal ___________________________________
 Timor-Ilan RI>0.40 is normal
PSV12cm/sec is
normal ___________________________________

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Slide 14 ___________________________________

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Slide 15 ___________________________________
Simple Cysts

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Slide 16 ___________________________________
Simple Cysts

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 Thinsmooth wall
 Non-echogenic Fluid

 Acoustic enhancement
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Simple Cysts

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Peritoneal Inclusion Cysts

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Slide 19 ___________________________________
Peritoneal Inclusion Cysts

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Peritoneal Inclusion cysts

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Case

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Slide 22 ___________________________________
Hemorrhagic cyst

 Thin linear strands

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 Variable echogenicity

 Broad base and convex clot ___________________________________

 Jiggles and shifts with
movement
 No central color flow ___________________________________

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Slide 23 ___________________________________
Hemorrhagic cysts

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Hemorrhagic cysts

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Slide 25 ___________________________________
Hemorrhagic cysts

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Hemorrhagic cysts

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Hemorrhagic cysts

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Hemorrhagic cysts

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Hemorrhagic cysts

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Hemorrhagic cysts

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Slide 31 ___________________________________
Hemorrhagic cysts

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Hemorrhagic cysts

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Slide 37 ___________________________________
Corpus Luteum

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Corpus Luteum

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Slide 39 Corpus Luteum ___________________________________

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Slide 40 ___________________________________
Corpus Luteum

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Slide 41 ___________________________________
Corpus Luteum

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Slide 42 ___________________________________
Torsion
 Ovarian enlargement; > 4cm ___________________________________
 Loss of ovoid shape
 Tiny follicles around hypoechoic
mass or solid mass ___________________________________
 Doppler (is not decisive)
revealing low flow does not rule
out torsion ___________________________________

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Slide 43 ___________________________________
Ovarian Torsion

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Slide 44 ___________________________________
Ovarian Torsion

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Ovarian Torsion

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Slide 46 ___________________________________
Endometrioma

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 Thin walled
 Unilocular

 Homogeneous ___________________________________
 ground glass appearance
 No vascular signals
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Slide 47 ___________________________________

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Slide 51 ___________________________________
Polycystic Ovary

 Enlarged ovary ___________________________________

 Thickened and hyper-
echogenic stroma
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 Peripheral pearl-string
appearing cystic structures
 Multiple, small follicles ___________________________________

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Slide 52 ___________________________________
Polycystic Ovary

 Ovarian Volume >10cc ___________________________________

 Follicles > 11, size 2-9 mm

 May appear normal ___________________________________

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Slide 53 ___________________________________
Polycystic Ovary
 The syndrome will require the ___________________________________
presence of 2/3 of the
following
 PCO appearing ovaries on
ultrasound
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 Clinical/lab evidence of
hyperandrogenism
 Oligomenorrhea/amenorrhea ___________________________________
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group.
Fertil Steril. 2004

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Slide 54 ___________________________________
Polycystic Ovary

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Slide 55 ___________________________________
Polycystic Ovary

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Slide 56 ___________________________________
Benign Cystic Teratoma
 Contain all 3 germ layers although ___________________________________
ectoderm predominates
 5-25% of all ovarian neoplasms
 Vast majority are cystic, mature, benign
 Bilateral in 10-15% ___________________________________
 Contains a solid outgrowth
(Rokitansky’s nodule) which may
contain bone, teeth, fat, hair
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Talerman A. Germ cell tumors of the ovary.
Kurman RJ: Blaustein’s Pathology of the female
Genital tract

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Slide 57 ___________________________________
Benign Cystic Teratoma

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Slide 58 ___________________________________
Benign Cystic Teratoma

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Slide 59 ___________________________________
Benign Cystic Teratoma

 Complications include ___________________________________

 Torsion 16%
 Rupture 1-2%
 Infection 1%
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 Malignant degeneration 2%

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Talerman A. Germ cell tumors of the ovary.
Kurman RJ: Blaustein’s Pathology of the female
Genital tract

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Slide 60 ___________________________________
Benign Cystic Teratoma

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Slide 61 ___________________________________
Benign Cystic Teratoma

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Slide 62 ___________________________________
Benign Cystic Teratoma

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Benign Cystic Teratoma

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Slide 64 ___________________________________
Benign Cystic Teratoma

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Slide 65 ___________________________________
Benign Cystic Teratoma

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Slide 66 ___________________________________
Fibroma

 Hyperechoic ___________________________________
 Shadowing(Venetian Blinds)
 Ascites
and edema (Meig’s
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Syndrome)

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Slide 67 ___________________________________
Fibroma

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Slide 68 ___________________________________
Fibroma
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Slide 69 ___________________________________
OHSS

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Slide 70 ___________________________________
OHSS

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Case

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Slide 75 ___________________________________
Ovarian Cancer

 Mostly solid ___________________________________

 Complex

 Central blood flow

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 Low resistance vascular flow
 Papillary projections

 Ascites ___________________________________

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Slide 76 ___________________________________
Ovarian Cancer

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Slide 77 ___________________________________
Ovarian Cancer

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Ovarian Cancer
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Ovarian Cancer

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Ovarian Cancer
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Ovarian Cancer

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Ovarian Cancer

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CASE
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What is the ___________________________________

diagnosis?
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What is the ___________________________________

diagnosis?
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What is the ___________________________________

diagnosis?
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What is the ___________________________________

diagnosis?
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What is the ___________________________________

diagnosis?
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Case

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What is the ___________________________________

diagnosis?
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What is the ___________________________________

diagnosis?
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Slide 112 ___________________________________

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Case

 71 year old Caucasian woman with ___________________________________

urinary incontinence
 Buldge per vagina

 Hystory of TAH ___________________________________

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Slide 114 ___________________________________

Anything else in the history

you want to know about a ___________________________________
patient with pelvic mass
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Slide 115 ___________________________________

Status of ovaries ___________________________________

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 No clear history of BSO but was done ___________________________________

when she was in her 30s making BSO
unlikely
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Slide 117 ___________________________________

Bowel habits-Risk of
colon/bladder/cervical/endo ___________________________________
metrial caner
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Slide 118 ___________________________________

 Surgically absent cervix/uterus ___________________________________

 3-4 bowel movements per week and
sometimes has to strain a lot and
occasionally has to do transvaginal ___________________________________
splinting to push.
 No hematochezia

 No decrease appetite, early satiety.

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Slide 119 ___________________________________

Pelvic exam ___________________________________

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 Pelvic exam revealed a 10-12 cm ___________________________________

pelvic mass
 No abdominal tenderness

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Slide 121 ___________________________________

Ultrasound ___________________________________

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Slide 124 ___________________________________
Describe
 Mass is
 Cystic
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 Solid cystic
 Solid
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 Uniloculated
 Multiloculated

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Slide 125 ___________________________________

What do you want to
know more about ___________________________________
this mass
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Slide 126 ___________________________________

Color/Doppler scan

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Slide 127 ___________________________________
Color/Doppler scan

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Slide 128 ___________________________________

Color/Doppler scan

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Slide 129 ___________________________________

Describe the vascular flow

 1 no flow ___________________________________
 2 Minimal
 3 Moderate
 4 Marked (Highly vascular) ___________________________________

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Slide 130 ___________________________________
Ascitis
 None noted in the pelvis
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Slide 131 ___________________________________

Description
 Multiloculated Solid cystic mass with multiple
septations with marked low impedance vascular
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flow within the solid areas and the septations.
 Highly suspicious for a malignancy
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Slide 132 ___________________________________

Probable diagnosis

 A. Hemorrhagic corpus luteum ___________________________________

 B. Endometrioma
 C. Dermoid cyst
 D. cystadenoma ___________________________________
 E. cystadenocarcinoma

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Slide 133 What would you
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recommend?
 A. Follow up as clinically indicated
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 B. Follow up in 3 months
 C. Follow up in 6 months
 D. Surgical correlation recommended
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