Ultrasound Evaluation of the Adnexa (Ovary and Fallopian Tubes)

Ultrasound morphology for discrimination between benign and malignant extrauterine

pelvic masses

• Subjective evaluation of grayscale ultrasound image- PATTERN RECOGNITION

• Has been shown to be superior to all other ultrasound methods ( simple
classification systems, scoring systems, mathematical models for calculating the
risk of malignancy) for discriminating between benign and malignant masses

The role of Doppler Ultrasound for discrimination between benign and malignant masses

• Subjective evaluation of the color content of the tumor scan or measurement of

time-averaged maximum velocity are better than RI and PI
• Color content of the tumor scan probably reflects tumor vascularity better than
any other Doppler variable
• Over all impression of tumor vascularization ( number and size of vessels and
functional capacity)

The ovaries

• Ellipsoid
• Location may be variable especially in women who have been pregnant
• In the nulliparous female, they are situated in the ovarian fossa or Fossa of
Waldeyer
• Ovarian size varies depending on age, menstrual status, pregnancy status, body
habitus and phase of the menstrual cycle
• In menstruating subjects, the mean ovarian volume was 9.8 ml (2.5- 21.9 ml)
• For premenarchal girls, the mean was 3.0 ml (0.2-9.1 ml)
• For postmenopausal patients 5.8 ml (1.2-14.9 ml)
• By day 8 to 12, one or more dominant follicles can be recognized
• Up to 80% of patients have a second non dominant follicle that becomes almost as
large as the dominant follicle
• Non-dominant follicles may show limited further growth or even a decrease in
size.
• The dominant follicle grows by 2-3 mm per day to reach a pre ovulation diameter
of 23 mm (14-29 mm)
• The cumulus oophorus may occasionally be seen as an eccentrically located cyst-
like 1mm internal mural protrusion (predicts ovulation in 36 hours)
Ultrasound morphology for making a specific diagnosis in an extrauterine pelvic mass

• Some types of tumors can be diagnosed correctly using grayscale pattern

recognition
• Endometriomas, Mature cystic teratomas (dermoid cyst), hydro-,
pyo-, hemato-salpinx, peritoneal pseudocysts, parovarian cysts,
hemorrhagic corpus luteum cyst, myomas, abscesses, ovarian
fibromas, thecomas, and Brenner tumors

Sonographic Differential Diagnosis of Pelvic Masses

• CYSTIC ( Completely cystic, Multiple, septated)

• COMPLEX ( Predominantly cystic, Predominantly solid, Cystadenocarcinoma,
Germ cell tumors)
• SOLID ( Uterine or Extrauterine in origin)

Cystic Pelvic Masses

Completely Cystic
Physiologic ovarian cyst
Cystadenomas
Hydrosalpinx
Endometrioma
Paraovarian cyst
Hydatid cyst of Morgagni

Multiple
Endometrioma
Multiple Follicular cyst

Septated
Cystadenoma
Mucinous
Serous
Papillary

Complex Pelvic Masses

Predominantly Cystic
Cystadenomas
Tubo-ovarian abscess
Ectopic pregnancy
Cystic teratoma
Predominantly Solid
Cystadenocarcinoma
Germ Cell tumors
Solid Pelvic Masses
Uterine
Leiomyomas
Leiomyosarcoma
Extrauterine
Solid ovarian tumor

Physiologic Cysts
• Follicular cysts
• Corpus Luteum Cysts
• Theca Lutein Cysts
• Hyperreactio Luteinalis

Physiologic Cyst: Follicular Cyst

• Occur due to failure of a mature follicle to rupture
• Thin-walled, unilocular, with a smooth capsule and anechoic fluid
• 3-8 cm in diameter
• Usually asymptomatic and appear as incidental findings on TVS

Physiologic Cyst: Corpus Luteum

• Most frequent appearance is a cyst with echogenic crenulated walls containing
low level echoes
• Presence of fibrin strands within may give it a fine trabecular echoes and may
mimic neoplastic tumors with septations
• May grow slowly to reach 25-40 mm in diameter
• Generally single, but in 5% of cases it can be multiple and bilateral
• Ultrasound appearance may vary dramatically
• Typically contains spider web-like material
• With color/power doppler it is possible to observe their typical high-velocity, low-
impedance peripheral vascularization around the corpus luteum
• "Ring of fire"
• Usually have thick, hyperechoic, occasionally crenated walls and may contain
hemorrhagic areas
• A "fluid-fluid" level may be demonstrated between the fluid content and the more
dependent hemorrhagic clot
• Absence of color in the solid areas on color doppler indicating lack of vascularity
• Bizarre blood clots may be seen which can be confused with papillary projections
and solid components
 • Follow up ultrasound after 6-12 weeks some may take 4 months to regress

Physiologic Cyst: Theca Lutein Cyst

• These result from high levels of human chorionic gonadotrophins ( HCG)

• As in trophoblastic disease or from hyperstimulation in the treatment of infertility
• Multilocular often bilateral anechoic masses
Physiologic Cyst: Hyperreactio Luteinalis

• Results from multiple luteinized follicle cyst secondary to HCG stimulation

• Associated with GTN, fetal hydrops, multiple gestations and may be seen in
normal pregnancy
• Usually seen in the third trimester with bilateral ovarian enlargement

Ovarian Hyperstimulation Syndrome (OHSS)

• Incidence of 0.2-0.3%
• Usually seen after administration of follicle-stimulating hormone (FSH) or a
GnRH analogue or rarely Clomiphene Citrate
• Young lean women with PCO are at a higher risk
• Women with high serum estradiol (>16,000 pmol/L) or more than 35 follicles >10
ml are more susceptible
• Ovarian enlargement and fluid shifts, such as ascites and pleural effusion are more
rapid than HL
• Usually regress after 6 weeks
• Operative management is necessary only if there is rupture or torsion
• Ovaries are cystically enlarged and usually are > 5 cm in diameter with minimal
to moderate pelvic fluid

Polycystic Ovarian Syndrome (PCOS)

• Grossly the ovaries are two to five times bigger than normal but may be normal in
size occasionally
• Immature follicles are twice as numerous as normal ovaries
• A corpus luteum may be visualized in 30% of cases
• More sensitive to exogenous gonadotrophins
• 2003 Rotterdam Criteria for PCO
• 12 cysts measuring 2-9 mm in diameter and/or ovarian volume >10 cm3
• Retain their appearance throughout reproductive life
• Elevated LH levels

Multifollicular Ovaries
 • Seen in mid to late normal puberty with hyperprolactinemia, hypothalamic
anovulation, and weight related amenorrhea
• Differ from PCO having fewer cysts (6-10 per ovary) tend to be larger (10 mm)
• No stromal hypertrophy
• Normal levels of LH and reduced levels of FSH

Endometrioma

• Prevalence estimated to be up to 16%

• May be unilocular or multiple, may be bilateral in 1/2 - 1/3 of cases
• Thin-walled or thick-walled cyst with diffuse low level echoes
• Manifest typical ground glass appearance at gray scale imaging
• They may be confused with mature teratomas (dermoid cysts, abscesses, ovarian
adenofibromas, ovarian fibromas, benign ovarian cysts, mucinous and serous
cystadenomas, and hemorrhagic cysts
• The presence of punctate or linear bright echogenic foci on the wall of the cyst is
seen in 45% of endometriomas
• Some may show echoic internal projections that simulate solid areas or papillary
formations
• The presence of punctate or linear bright echogenic foci on the wall of the cyst is
seen in 45% of endometriomas
• Some may show echoic internal projections that simulate solid areas or papillary
formations
• Some may show echoic internal projections that simulate solid areas or papillary
formations
• Represent blood clots which are adherent to the wall of the cyst
• May be multilocular, but septations are thin and regular

Ovarian Neoplasms

• Surface epithelial tumors account for 60% of all ovarian neoplasms and 80-90%
of primary ovarian malignancies
• Germ Cell tumors are the second most common, comprising 20% of all ovarian
tumors, a third of which are malignant. Among adults, 95% are benign and
majority of these are dermoid cysts
• The third most common ovarian tumor are the sex cord-stromal tumors (8%) .
Around half are fibromas. Among this group are neoplasms of low grade
malignancy, including granulosa tumor and the Sertoli-Leydig cell tumor

Epithelial Ovarian Tumors

Serous Tumors
Serous Cystadenocarcinoma
Mucinous Tumors
Mucinous Adenocarcinoma
Endometrioid
Clear cell tumor
Brenner Tumor

Serous Tumors
• Common accounting for 25% of all benign ovarian neoplasms
• Malignant serous tumors account for 40-50% of all malignant ovarian tumors
• Bilateral in 12-20% of cases
• Benign serous tumors are usually anechoic and unilocular
• Occasionally, thin septations and fine papillary projections may be seen

Serous Cystadenocarcinoma

• Usually multilocular, with more distinct septations and papillary projections.

• Multiple echogenic foci may be seen
• Ascites is also more associated with malignant lesions

Mucinous Tumors

• Comprise 20-25% of all benign ovarian tumors and bilateral in 5% of cases

• Frequently encountered in the 3rd to 5th decade of life
• Multilocular due to presence of numerous thin septations
• Can reach large dimensions up to 15-30 cm
• Thick-walled, often septated, anechoic and may contain fine, gravity-dependent
echoes produced by its thick content
• Gentle tapping on the cyst wall may cause the debris to move
• Rare to find papillary projections in the benign tumor

Mucinous Cystadenocarcinoma

• Contain abundant septations and some papillary excresences

• Comprise 5-10% of malignant ovarian tumors
• Frequently in the 4th to 7th decades of life
• 15-20% are bilateral
• Solid areas, hemorrhage and necrosis are more common

Endometrioid Tumors

• Second most common malignant ovarian tumor accounting for 20-25%

• 80% of endometrioid tumors are malignant
• Bilateral in 28% of cases and occur more often in the 5th-6th decades of life
 • 70% arise from endometriosis and endometrioid ovarian tumors
• These tumors appear similar to serous tumors, with cystic anechoic mass and
papillary projections
• Occasionally it may be predominantly solid

Clear Cell Tumor

• Comprise 5-10% of all ovarian epithelial tumors, and the majority is malignant
• Seen in the 5th to 7th decade of life
• Bilateral in 15-20%
• 50-70% associated with endometriosis, may reach up to 30 cm
• Thick-walled unilocular cyst, often with fleshy nodules, focal necrosis and
hemorrhages.
Brenner Tumor

• Comprise 1-2% of all ovarian tumors and majority are benign

• Mean age at diagnosis is 50
• 6-7% are bilateral, usually 2-10 cm in diameter
• Well-circumscribed, firm tumors with cystic components and calcification
• Malignant tumors are bigger, 10-30 cm in diameter
• With large cystic areas, polypoid mural nodules, areas of hemorrhage and necrosis
• Associated with other ovarian epithelial tumors
• Small and solid, with areas of calcification, may mimic an ovarian fibroma

Germ Cell Tumors

Dermoid Cyst
Immature Teratoma
Dysgerminoma
Yolk Sac Tumor

Dermoid Cyst

• Mature cystic teratomas are the most common benign germ cell tumor and the
most common ovarian neoplasm
• Typically contain mature tissues of ectodermal (skin, brain), mesodermal (muscle,
fat) and endodermal (mucinous or ciliated epithelium) origin
• Affect younger age group (mean age 30)
• Most common ovarian masses in children
• Most are aymptomatic
• Slow growth rate : 1.8 mm each year
• Non-surgical management (< 6 cm)
 • Tumors are bilateral in 10%
• There is usually a raised protruberance projecting into the cyst cavity known as
ROKITANSKY nodule
• Ultrasound appearance is very varied because of the varied echotexture of the
tissues it contains
• Most mature cystic teratomas are easily recognized at grayscale imaging because
of their fat and hair content
• May also have a fluid-fluid level, so called "tip of the iceberg" sign
• Refers to the strong cone of shadow behind some dermoid cysts, permitting only
visualization of the portion closest to the probe

Different Characteristic Ultrasound features of Mature cystic teratomas

(1) Presence of a white ball (corresponding to hair and sebum) sometimes occupying the
entire cystic tumor
(2) Long echogenic white lines and prominent echogenic dotsin cyst fluid (corresponding
to hair floating freely in non-fatty fluid)
3) Shadowing which often makes it difficult or impossible to correctly measure the size
of the mature cystic teratoma
(4) The Rokitansky nodule or dermoid plug is hyperechogenic with shadowing due to
adipose tissue, hair and calcifications
(5)Intracystic non-dependent spheres of lipid material produces a dramatic appearance
(6)Small mature teratoma within the ovary which does not deform its shape

Immature Teratoma

• Rare malignant tumor

• Occurring most commonly in the first two decades of life
• Very large, predominantly solid but may contain cystic areas

Dysgerminoma

• Most common malignant germ cell tumor accounting for 1-2% of primary ovarian
tumors
• 3rd-4th decade of life
• Bilateral in 10-17%
• Large solid tumors, with a lobulated appearance

Yolk Sac Tumor

 • Second most common malignant germ cell tumor
• 2nd-3rd decades of life
• Usually unilateral, large, reaching up to 30 cm in diameter
• Mainly solid with some cystic spaces, similar to dysgerminoma

Sex Cord Stromal Tumors

Fibromas
Granulosa cell Tumor
Sertoli-Leydig Tumor

Fibromas

• Originate from the ovarian stroma and consists of fibroblasts and collagen
(fibroma) or a mixture of these and cells from the internal theca (fibro-thecoma)
• Fairly rare, 4% of all ovarian tumors
• 90% unilateral
• Encountered in the middle age
• Echopattern is indistinguishable from that of pedunculated myomas
• Solid, round or oval tumors with smooth outline and regular striped echogenicity
• Thecomas and thecofibromas have lobular contours and slightly irregular
echogenicity

Meig’s Syndrome

• Associated with 1% fibromas

• Consists of ascites and pleural effusion
• Appear to be solid, sometimes complex due to the presence of calcified areas
• Difficult to differentiate from a subserous myoma

Ovarian Fibromas vs Pedunculated uterine myomas

Ovarian Fibromas Pedunculated Myoma

Morphology Variable Ovoidal/Spherical
External profile Irregular Regular
Pseudocapsule Absent Present
Fluid areas Frequent Rare
Vascularization Central Peripheral
Vascular peduncle Absent Present
Flow resistance High Average

Granulosa Cell Tumor

• Rare tumors accounting only for 1-2% of all ovarian tumors

• Postmenopausal women
• Estrogen producing tumors so they are associated with abnormal uterine bleeding,
hyperplasia, 5% endometrial carcinoma
• Large, predominantly cystic with locules containing clotted blood and solid areas
• 10-12% complicated with rupture and hemoperitoneum
• Small tumors resemble uterine myomas, while large tumors are multiloculated

Sertoli-Leydig Cell Tumors

• Account for < 0.5% of all ovarian tumors

• 2nd-3rd decades
• Virilization associated with a third of cases
• Range from 5-15 cm
• Similar to granulosa cell tumors

Metastatic Tumors (Krukenberg)

• Account for 6-7% of cases

• Most common primary tumors are intestinal, gastric or breast cancers
• Bilateral in 2/3-3/4 of cases
• On ultrasound they appear as bilateral solid masses

Ovarian Masses in the Pregnant Patient

• The prevalence of adnexal masses is 1-2%

• Functional cysts are the most common
• Cystic adnexal masses less than 5 cm that are detected in the first 16 weeks are
usually functional and almost always resolve spontaneously

Ovarian Masses in the Pregnant Patient

Functional ovarian cysts (follicular, corpus luteum and theca lutein)

Benign mature cystic teratomas
 Serous cystadenomas
Parovarian cysts
Mucinous cystadenomas
Endometriomas
malignant tumors

Most common ultrasound characteristics of malignant ovarian masses

• Large dimensions
• Septations
• Solid papillary projections originating in the cyst wall
• Complex appearance, partly solid and partly cystic
• Bilaterality is frequent
• Scarce mobility, infiltration of the surrounding organs
• Solid hypoechoic implants in the pelvic peritoneum
• Omental cake

Ultrasound Characteristics of Pelvic Inflammatory Disease (Hydro-Pyo-Hematosalpinx)

Hydrosalpinx

• Fluid-filled sausage shaped cystic structure

• Presence of incomplete septa that are not seen to reach the opposite wall of the
cystic structure
• On transverse section of the fluid filled tube, mucosal folds are seen to protrude
into the lumen
• “cogwheel” sign
• When the tube is no longer acutely swollen
• “Beads-on-a-string” appearance

Pyosalpinx

• The acutely inflammed tube has a lumen filled with hyperechogenic material
(pus)

Tuboovarian Complex

• The tube and ovary are seen distinctly but are not separable with the transvaginal
probe

Tuboovarian abscess
 • There is loss of architectural definition between one or both of the adnexa with
the formation of a conglomerate
• Neither the ovary or tube can be separately recognized
• May be unilocular or a complex multicystic structure with thick walls or septae
filled with homogenous echogenic material
• Can be confused with endometriomas or malignancies

Paratubal and Paraovarian cysts

• Arise from the remnants of the Wolffian (mesonephric) duct and Mullerian
(paramesonephric) duct
• More common in the third and fourth decades
• Measuring 2-10 mm in diameter
• Ipsilateral ovary is distinct from the cyst visualized

Paraovarian cysts

• May be of mesothelial, mesonephric or paramesonephric in origin

• May be seen clearly separate from the ovary
• Sometimes difficult to distinguish an ovarian cyst from a par0varian cyst
• The cyst fluid may be anechoic, or echogenic
• Papillary projections and septa may be present
• Malignancy may develop (borderline tumors) in cysts larger than 5 cm with
papillary projections

Peritoneal Pseudocysts

• Fluid filled collections among adhesions occuring after an inflammatory process

in the peritoneal cavity or after an operation
• Cystic mass following the contours of the pelvis
• Deformed ovary suspended amongst the adhesions (centrally or peripherally)
• Cyst fluid may be anechoic or echoic
• May contain septa and papillary projections

Ultrasound in the diagnosis of adnexal torsion

Adnexal Torsion

• Fifth most common gynecologic surgical emergency

• Prevalence of 2.7%
• May involve twisting of the ovary, fallopian tube or both structures
• Torsion usually occurs in the adnexa containing a lesion (ovarian cyst or
hydrosalpinx)
• If a normal ovary is involved in the torsion, the ovary loses its oval shape and
becomes more round or globular
• Presence of several small round cysts up to 25 mm in diameter at the periphery of
the ovary
• UNILATERAL OVARIAN ENLARGEMENT with peripheral dilated cysts
• Torsion involving an ovarian cyst and hydrosalpinx would show swelling of the
wall, mucosal folds and septa
• If hemorrhagic infarction has occurred, echogenic fluid may be seen in cystic
spaces in the tumor