IMAGING OF ADNEXAL MASSES

By Harmit H & Tekle

June 17,2009
Anatomy
 Adnexa contain the ovaries, fallopian
tubes, broad ligament and ovarian &
uterine vessels.
 The fallopian tubes are not visible unless
enlarged ,it is 5-6cm long.
 The ovaries lie in lateral pelvic side wall
and, their size and appearance varies
with age and hormonal response.
♦In Neonate,1.5x 0.5x0.5cm,in childhood
volume less than 1ml and in adult
3.5x1.5x2 cm(4x3x2 cm average) usually
less than 10cm3and postmenopausal
ovary atrophies ,measuring less 2cm in
length.
♦Volume could be measured LXWXHX.52.
TA u/s
TV u/s postmenopausal &
menstruating
Preovulation, 10 days & with
cumulus
Imaging Modalities
 Ultrasound: the commonest method of
adnexal evaluation
■Trans vaginal(5-7MHz)
■Indication: uncertain TA u/s
♣better characterization
♣strong fam Hx of ovarian Ca
♣obese and
♣pt unable to fill bladder
■Trans abdominal(3.5-5MHz)
■Color Doppler: about vascularity
(neovascularty of tumor)
♦Appearance of ovary :echogenic central
stroma and homogenous echo texture &
small cystic follicles peripherally in the
cortex
Computed tomography
■Commonly used to evaluate the extent of
malignancy and detect persistent &
recurrent tumor or for CT guided biopsy
 Uniform soft tissue density punctuated
by small cystic regions be seen in
premenopous and in postmenopausal, it
may not be even seen
Spiral CT ovarian cysts
Magnetic Resonance Imaging

 Appearance of ovary on MRI, on T1W

homogenously low to intermediate signal
intensity and on T2W follicle be bright
than surrounding and normal fallopian
tube small size & not routinely imaged.
FS T2W ovarian cysts & rt
hemorrhagic corpus luteum cyst
T1W isointense & T2W follicles
 Hysterosalphingography: for fallopian tube
study
 Barium and IVU may be used to evaluate
adnexa indirectly and the effect of adnexal
masses to bowel or urinary system.
 Plain radiography: can detect calcification
and soft tissue density
 Positron emision tography
Plain radiography
Adnexal masses can be
classified as
 Cystic masses: benign or malignant
 Complex
 Solid masses
Benign cystic lesions of ovary
and Para ovarian structures
 Functional cysts:
-usually asymptomatic
-may occur at any age but are most
common during reproductive years
-most due to abnormal release of
anterior pituitary gonadotropin
-may occur due to OCP & GnRH
analogues
Follicular cysts

 Unilocular,3-8cm or may be large

 Failure of follicle to rupture or in volute
 Smooth thin walled
 Content serous or serosanguineous fluid
to clotted blood.
Corpus luteum cyst
 Failure of involution of corpus luteum after
ovulation, symptomatic
 Thick wall than follicular cyst
 5-10cm
 U/S: has thick hyperechoic occasionally
crenulated wall & usually has an echogenic
content
 May appear solid after complete collapse of
cyst
Corpus luteum cyst TV u/s
Theca lutein cyst
 Rarely large
 Due to over stimulation by high level of
circulating hcg
 Usually bilateral and multi locular
 Found in association with polycystic
ovarian ds, hydatidiform mole,
choriocarcinoma, chorionic gonadotropin
Congenital ovarian cyst
 Can reach large size
 Occasionally contain internal septetion or
debris
 Presumed to result from influence of
maternal hormones
Plain film & T1W ovarian cyst in
neonate
Polycystic ovaries
 Clinical triad of hirsutism, obesity and
oligomenorhea constitutes stein-levental
syndrome
 Enlarged ,spherical ovaries with multiple small
peripheral cysts
 More than 10 cysts of greater than 5mm in
ovary & the volume exceeds the expected 14ml
is considered typical
 Increase level of LH or ratio LH/FSH or direct
pathologic examination diagnostic .
PCOD TV u/s enlarged ovary
Hyper stimulated ovaries
 Increased HCG in serum
 Cystic enlargement of both ovaries
 Commonly seen in –trophoblastic ds and
exogenous administration.
 Tropoblastic ds: ↑HCG, large multi
septated ovaries & bilateral in 50%,
ovary may reach 10cm,ascitis and
electrolyte imbalance.
 ovarian size: mild-5cm,moderate 5-12cm
& sever >12cm.
TA u/s sagittal
Ovarian remnant syndrome
 If small amount of functioning ovarian
tissue left behind at Oophorectomy ,cyst
formation may occur producing
confusion in face of history of prior
surgical removal of both ovary
 Simple and hemorrhagic
Torsion

■Common in teen age and young

■Predisposing condition : ovarian mass (functional
cyst, dermoid & inflammatory)
■C/F: pain ,fever, nausea, vomiting & leukocytosis.
♦U/S: 4-10cm,texture from large solid to nearly
cystic ,free fluid in pelvis
♦Color flow Doppler helpful
 a cluster of dilated vessels in periphery of
tortsioned ovary
Ovarian torsion, TA u/s, & color
Doppler
Ovarian torsion TA u/s
Endometriotic cyst
♦In young
♦Result from cyclic hemorrhagic of
functioning endometrial tissue in to a
confined space
♦10-15cm well circumscribed mass
♦Complex with low level internal echoes or
may be septated.
Endometrioma TV u/s (fluid-fluid
level)
Para ovarian cyst

♦Simple smooth walled cyst may be

indistinguishable from functional cyst of
ovary
♦Hemorrhagic
♦Separate from ovary
♦3-5cm
Peritoneal inclusion cyst
♦Occur when there is adhesion
♦Common post op, trauma &
endometriosis.
♦Multi loculated
♦Fluid in b/n and ovary entrapped
Peritoneal inclusion cyst TA u/s
THANK YOU
Reference
●Ultrasound in obstetric and gynecology, 2nd
edition
●Diagnostic ultrasound 2nd edition
●Abdominal and general ultrasound,2nd edition
●Granger and Allison’s 4th edition
●Text Book of Radiology & Imaging David
Sutton 7th edition
●Taveras & Ferrucci, Radiology Diagnosis,
Imaging & Intervention