Ultrasound of Adnexal Masses - HD

Introduction

I am Rusty Brown.
I'm professor of radiology at Mayo Clinic in Rochester,
Minnesota, and we're gonna be talking about ultrasound
of adnexal masses.
We're gonna review ovarian masses primarily.
First, we'll talk about the normal ovary
and several things that really should not be considered
or reported as a mass.
We'll talk about common benign masses, neoplasms,
and particularly the most important indicators of malignancy.
We'll review some extra ovarian masses,
and a lot of the recommendations
and criteria that we'll talk about are based on the SRU consensus conference,
on adnexal cyst and other masses.
And the recommendations will be
for asymptomatic patients.

The Normal Ovary

First of all, let's review the normal ovary.
The ovary is unique in that it has small cyst,
which are really follicles as part of its normal structure.
We know these follicles get up to, on average, about two
to two and a half, almost centimeters at ovulation.
From the consensus conference,
we considered a follicle is up
to three centimeters in maximum diameter
to be normal in premenopausal women,
and we just consider that a dominant follicle.
You do not wanna report those as cyst.
The corpus lium is another normal structure that we see
after ovulation.
The typical appearance is in this one
where you have a cystic lesion with kind
of a thick c granulated wall.
Some internal echoes, if you put on color of power doppler,
it's often a vascular rim.
That's quite typical. These are usually less than two
to three centimeters in maximum diameter.
And this is just a typical appearance of a corpus lium
that we expect to see after ovulation.
And we don't wanna report these as abnormal
or masses that need follow up. Occasionally,
you may not be sure about one,
but most cases they have a characteristic enough appearance,
that you can be confident.

Terminology: Avoiding the Word "Cyst"

I'd just like to mention the word cyst.
I think it's problematic when we use the word cyst in the ovary since we do have these follicles
that are normal and they appear basically as a simple cyst,
that we would describe as cyst in any other organ.
The problem with the ovary is it can be misinterpreted
by our clinical colleagues, can be misinterpreted
by patients,
who now often can see the reports in many institutions.
So I would encourage you to try not to use the word cyst
for any structure in an ovary that you think is normal.
So these dominant follicles
of just call 'em a dominant follicle, it's the corpus lium.
I prefer not to use the word even corpus lium cyst.
Just call it a corpus lium.
Even multiple follicles
or physiologic cysts, I think can be misunderstood.
Normal's a great word.
I would encourage you just to use normal
or i'll often when it's a cyst, a dominant follicle
that is that getting close to three centimeters.
Just say normal ovary with a dominant follicle measuring X
or normal ovary with a corpus lium.
And just try not to use that word cyst
because it can be so misunderstood.

The Normal Postmenopausal Ovary

What about the normal postmenopausal ovary?
Often there's small and homogeneous like this.
It makes it even harder sometimes to be confident that
what you're looking at is truly the ovary.
But you can see small cyst,
and these probably are not follicles in the postmenopausal
ovaries, so I would call them cyst.
In this patient population, we know that about 20%
of postmenopausal women have small, simple
that is less than about a centimeter.
And these are considered of no clinical importance.
That was a recommendation from the SRU consensus
conference also.
So if you have this simple cyst in a postmenopausal patient
that's less than a centimeter, you could ignore it.
Or if you want to describe it,
you could just say it's a considerate of no clinical importance in a postmenopausal patient.

So in general, the things that are normal
and that we really don't want to call attention to
and that do not need follow up
are in the premenopausal patient.
A follicle less than three centimeters, a corpus lium.
Again, I would encourage you not to call the cyst
and in the postmenopausal patient a simple cyst of a centimeter or less in maximum diameter.

Tiny Echogenic Foci in the Normal Ovary

I wanna mention a couple of other things that you may see in the normal ovary.
So they're not misinterpreted.
These tiny echogenic foci are common.
They're typically one to three millimeters.
A few of them are pointed out here by the arrows.
Sometimes they have no distal artifact.
Occasionally there's a short comet tail artifact.
They do not typically have acoustic shadowing.
These are common
as best we know they're clinically insignificant.
Different studies have found different causes from calcification
to hemosiderin to tiny cyst,
where we're seeing speculative reflectors from the back
walls of these tiny cysts, regardless of the cause.
As best we know at this point,
they're generally insignificant.
I'll admit occasionally they're very extensive in the ovary.
There's just a few in this ovary.
If they're unusually extensive, I might follow them.
But even then, I doubt that they're clinically significant.
Aside from these tiny, more common one
to three millimeter echogenic foci,
you'll occasionally see a larger calcification
in the ovary like this.

Larger Calcifications in the Ovary

These are larger,
they're usually five millimeters or more.
They do have acoustic shadowing as in this case.
So this is different than the more common tiny
echogenic foci.
What do they mean? A study from many years ago found
that one patient developed a mucin cystadenoma,
and one patient later developed a dermoid that was not clear
that it was actually coming from this area of calcification.
A later study looked at these calcifications
of five millimeters or larger
and found really no clinical significance.
None of the patients developed tumors during follow up.
One patient had path correlation
and it showed calcification in the corpus albican.
So I think in general, when you see these
isolated course calcifications with no associated mass,
they're generally a little to no significance.
Probably don't need follow up,
but if you are gonna follow them, there's really no role
for early follow up.
I'd wait at least a year perhaps to follow these.
I think it's important not to report these as masses just
as isolated calcification.
And again, generally in my experience, there are little
to no clinical significance if there's no associated mass.
So that is important to make sure it's not part of a mass.
Dermoid. Sometimes people will consider these.
We know that dermoids can get calcification
or ossification,
but it's unusual for the dermoid just to be a focus
of calcification by itself without any other component of a mass.

Approach to Characterizing Adnexal Masses

So what's our approach to characterizing adnexal masses?
Several different attacks have been tried.
Subjective assessment is I think what many of us use.
And it's been shown to work well when done
by an experienced examiner.
There are different mathematical models.
There's a risk of malignancy index.
There's an aex mathematical model.
Several different ones have been proposed using a combination
of ultrasound features, sometimes clinical
or laboratory features.
In addition, the international ovarian tumor Analysis,
our out group has also done a lot of work in this area.
And they have a simple rules approach that identifies specific sonographic features that predict malignancy,
specific ones that predict malignancy.
And then if they meet those criteria,
you can constantly predict benign or malignant.
I think many of us still use the subjective approach.
We know what those features are,
and we'll review those that indicate benign
or malignant cause.
And we pretty much at this point,
I rely on subjective assessment.

Common Benign Ovarian Masses: The Big Four

First, I'd like to review the common benign ovarian masses.
I kind of call these the big four
because this is kind of the bread
and butter of ovarian ultrasound.
They account for the majority of masses
that will be seen in most clinical practices,
and they have a typical appearance in the majority of cases
that strongly suggest the correct diagnosis.
So it's really important that you know the typical appearance of these four masses.
And they're the simple cysts, the hemorrhagic cysts,
the endometrioma, and the dermoid.
Also term mature cystic teratoma.

Simple Cyst

So first review, the simple cyst need the same criteria
as a simple cyst in any other organ.
It's anti coic, basically no perceptible wall.
There's no solid component at all.
And there's typically distal acoustic enhancements.
So here we have an an coic mass, no real wall.
This is a ovarian tissue around it.
An acoustic enhancement,
typical simple adnexal cyst in this case
coming from the ovary.
Now, many years ago, used to think
that we didn't get simple cyst in postmenopausal patient.
I mentioned before in premenopausal patient,
if it's over three centimeters, then I would refer to it
as a simple cyst.
In postmenopausal patients, we're generally going
to follow them if they're over about a centimeter.
We have learned that somewhere around three to 18%
of postmenopausal women will have
simple cyst in their ovaries.
If we follow those simple cysts, what happens to them?
The these numbers you'll see here don't add up quite
to a hundred percent 'cause they're from different studies.
But in general, near half will disappear
and most do so within one to two years.
Another almost half tend to persist unchanged.
And then a small percent probably in the neighborhood of 10%
or less will increase in size.
Interestingly, the ones that end up being removed
surgically, and those obviously are gonna be
the larger ones.
In most cases, the majority,
about 85% are serous cystadenomas,
which are benign neoplasm.

So what about the follow up
for simple cyst from the SRU Consensus conference?
Yearly follow up was recommended
when it was over five centimeters,
but less than seven in premenopausal patient
in over one centimeter,
but less than seven in the postmenopausal patient.
There are some centers that might up this number from one
to perhaps two or three centimeters
before following them yearly.
That's not unreasonable either.
Should consider
that when the cyst is over seven centimeters, regardless
of menopausal status, that
you should think about doing MRI
or consider surgical evaluation.
The reason for that is a study
that found when they're over about seven to 7.5 centimeters,
that small solid nodules along the wall can be
missed sonographic.
So I think as the cyst gets larger,
it becomes more difficult to be confident
that there's no small solid component.
And as we'll talk about shortly,
the solid component is the most important sonographic
feature to predict malignancy.

So what about the risk
of malignancy in ocular or simple cyst?
First, it's important to realize
that simple cysts are not necessarily the
same as unilocular.
We just talked about the definition of a simple cyst.
However, the definition of ocular in many studies
and including the IOTA definition of a ocular cyst
allows for solid protrusions
of less than three millimeters from the wall.
That's considered an irregular wall and not a nodular
or papilla in their scheme,
but still qualifies as a UN cyst.
Could also have internal echoes and be a UN cyst.
So while they're sometimes the same,
that is all simple cysts will be un not all unilateral
cyst or simple cysts.
It's important to be aware of that distinction.
Since the Society of Radiologists
and Ultrasound Consensus Conference,
there has been a study from the IOTA group
that described four or 326 simple cysts,
and they actually did pull out the simple cysts,
not just the ocular cysts that were malignant.
They ranged in size from 4.5 to 4.8 to even 14.
And those did have small papilla at pathology
that were missed on ultrasound.
One lesion at 5.8 centimeters had no papilla identified at
path and was still malignant.
So it did find a very small percent, about 1%
of simple cysts that were malignant.
I think does this cause us to
change our recommendation from the SRU Consensus Conference
of seven millimeters?
I'm sorry, seven centimeters,
that you should consider further evaluation?
I think not. There's still good evidence that the majority
of cysts that are simple, that are less than 10 sonometers,
that malignancy is very unlikely.
So I don't think we need to change that seven soter,
threshold.
But I think the studies do emphasize the importance
of high scan quality
and looking carefully
for these small nodules along the wall.
So certainly should be true for any cyst
that you think is a simple cyst on ultrasound.
Look carefully along the wall for any solid component,
and particularly as it gets larger,
make sure you look at the entire wall
and that takes a little more time.
You have to be a little more careful.
But there is the potential that as you get larger,
it's easier to overlook small nodules
that would change your characterization
of that adnexal mass.
So just be careful. Make sure you really think it's a simple
cyst per ovarian.
Simple cyst are common in the SRU recommendations,
they were treated the same as ovarian.
One could perhaps argue that per ovarian cyst
or even less concern that ovarian cyst.
Part of the difficulty is some of the original studies
actually lump them together
and immediately, occasionally, it's hard
to tell whether a simple cyst in the ad nexus coming from
the ovary or is outside the ovary.
You could perhaps make an argument that a three and a half centimeter simple per ovarian cyst in a
postmenopausal woman maybe doesn't need the same follow up
as an ovarian cyst.
That's perhaps debatable,
but they were treated the same in the SRU recommendations.

Now, what about persistent simple ovarian cyst?
And this is a great question comes up a lot.
So you follow these two, three years, they're stable.
Can you stop following or can you change the frequency?
And I don't think we know the answer to that.
It probably is related to some degree on cyst size.
You know, I'd be more concerned about stop
to stop following a six centimeter cyst than I would a
two centimeter cyst.
How long? Is it just a couple of years? Is it five years?
Does the patient have other risk factors?
Some of this is patient preference two,
whether they want to keep following it.
So I don't know that we know enough to say
stop completely following it.
I think unless it's the larger ones
that perhaps if they've been stable for two to three years,
you might decrease the frequency of follow up.
I don't think that's unreasonable,
but I don't think we know enough at this point to say not
to follow them anymore after any period of time.

So the other question is
how much measured size change is real.
I'm not aware of a lot of data on the reproducibility
ovarian system measurement.
I do think it's important if you think a cyst has changed in
size, not just to look at pure numbers,
but look at those images, see how it was measured, see
how it was measured on the prior study.
See if you think you're measuring it in similar planes
before concluding whether it's changed or not.
And slight differences I think are often technical
and probably not a real change.
But before you say it's really changed,
I would look carefully at the images
and how the cyst was measured on both studies.

So that's the simple cyst.
The other one of the big four common benign cysts is the
hemorrhagic ovarian cyst.

Hemorrhagic Ovarian Cyst

This is typically due to hemorrhage.
And a corpus lium
or a follicular cyst majority will resolve within eight weeks, sometimes sooner.
There's anecdotal cases of them taking longer to resolve,
but in the vast majority of patients,
they will resolve within about eight weeks.
The typical ultrasound features is this reticular pattern
of internal echoes.
They're very fine linear echoes.
Notice that they're not true septations.
I would encourage you not to cause to call these septations.
The difference is with these particular pattern,
they're short, linear to curve linear echoes,
they don't go all the way across the cyst wall
and they're not as thick as true septations.
This has also been called Lacey spider web pattern.
And it's thought to be due to fibrin strands due
to the hemorrhage and clot.
So when you see this typical appearance
of a hemorrhagic cyst, you can be confident
that's what you're looking at.
Another feature is sometimes in hemorrhagic cyst,
you get a solid component.
If it has concave margins
as in this one rather than bulging out, it's concave in
and you don't get flow in that area.
With color doppler, that's also suggestive
of a hemorrhagic ovarian cyst.

What about follow-up of typical hemorrhagic ovarian cyst?
Again, most resolved within two months.
From the SRU consensus conference, we felt
that in an asymptomatic patient,
if it's less than five centimeters, you probably don't need
to follow those on a routine basis.
If it's over five centimeters, we suggested follow up,
we would usually await six to 12 weeks.
Ideally would re-image the patient days three to 10
of the menstrual cycle where you're less likely
to get hemorrhage into another cyst or corpus lium.
Although admittedly, it's sometimes hard
to plan the follow up at
that point of the menstrual cycle.

What about early postmenopausal patients?
Early post menopause refers
to the first five years since the final menstrual period.
There is evidence that women in this timeframe can occasionally ovulate.
I haven't seen it very often that is
to see hemorrhagic cyst in this time period,
though admittedly, you have perimenopausal patients
where sometimes you're not sure which group
they really fall in.
But if it's in the perimenopause
to early postmenopausal period,
I would follow those hemorrhagic cyst of any size at six to 12 weeks.
Once you get five years past the final menstrual period
and to the so-called late postmenopausal phase,
you really shouldn't have a hemorrhagic cyst anymore.
And I don't think I've really encountered this,
but I wouldn't be willing to accept it
as a hemorrhagic cyst, even
with a typical appearance if they were over five years since
the final menstrual period.
And I would probably do further imaging with MRI
or consider a surgical evaluation.

One pitfall with hemorrhagic cyst you wanna be aware of is
that acute to subacute clot can fool you
for a solid component.
Here's a big a mass in the ovary.
It actually looks solid in the sense
that it's got internal echoes,
but with color doppler,
we're not seeing any flow inside of it.
This should always be a tip off to you
and a premenopausal patient
that you may be looking at clot rather than true solid
tissue of a neoplasm.
So always think about this in a younger patient,
a premenopausal patient before I call a solid ovarian mass.
And the lack of flow would at least suggest, doesn't prove
that it's not a neoplasm,
but I would give this patient an interval follow up ultrasound in six to 12 weeks
to see if it resolves.
Hopefully it does, and you have your answer.
Obviously, if it's still there
and looks the same in six to 12 weeks, it hemorrhagic cyst becomes very unlikely.

Endometrioma

Another common benign mass is the endometrioma.
These classically have these homogeneous low
to medium level internal echoes, sometimes referred to
as a ground glass appearance without a solid component.
When you see this appearance, it's very typical
of an endometrioma.
You may have these small echogenic foci in the wall.
We talked about these earlier,
and a normal ovary is generally being insignificant.
I'm still not certain whether they're truly in the wall
or they just happen to be in the ovarian parenchyma next
to the endometrioma.
They have been described as a feature of endometrioma,
but they are not a requirement
to diagnose endometrioma.
So just be aware. You may see them,
but it's not a requirement.
The main thing you're looking for
with endometriomas is this homogeneous
low media level echoes ground glass
appearance in some terminologies.
Many are unilocular, but you can't have septations.
Here's one with two LOEs, both homogeneous internal echoes.
Here's one that can fool you for solid mass.
And I think in my experience this happens
with the more chronic endometriomas.
They're pretty homogeneous.
There's actually three lesions here
and they can look like a solid mass.
And I think these are just the
ones that have been around longer.
You get a little higher degree of internal echoes
and it can fool you for a solid mass.
So I consider that when there's no internal flow detected
in such a lesion.

What about follow up at any age?
Generally recommend a follow up in six to 12 weeks.
This is really more important if you're considering surgical
removal because there is some overlap in the appearance
of endometriomas and hemorrhagic cysts.
So particularly if a patient is planning
to have surgical removal of end endometrioma,
I think at least one follow-up ultrasound beforehand in the
six to 12 week range is helpful just for the infrequent occurrence of a hemorrhagic cyst
that might simulate an endometrioma
and would resolve in that timeframe.
If it's not surgically removed, we consider yearly follow up
to look for enlargement
or develop of any solid component
that would be more concerning.

There is a problem area with endometriomas
occasionally, and it happens probably in about five to 20%.
You see a small nodule along the wall of what
otherwise has homogeneous internal echoes.
So what do you do then?
As we'll talk about further in a few minutes,
these solid nodules are generally concerning for neoplasm
and a malignant neoplasm.
But we know they happen in a small percentage
of endometriomas.
This is a difficult area to sort out this little hyper,
slightly hyper coic nodule could be due to clot,
in which case with color power adopter, you would not expect
to see flow, but sometimes it's due to focal areas
of endometrial tissue.
And you could see flow in these by color
or power doppler ultrasound, if you did an mr,
sometimes they will enhance too if it's due
to focal endometrial tissue.
So these unfortunately occur in minority of endometriomas.
They're problematic.
We know that probably most
of these are still benign endometriomas.
But these are difficult ones to know how to manage
and may end up requiring surgical removal to be certain
that you're not dealing with a neoplasm instead,
even though, again, the majority of these in my experience,
are still gonna turn out to be endometriomas.
I think the ones I've seen have typically been small solid
components like this minimally hyper coic compared
to the adjacent ovarian parenchyma or cyst wall.

We know that a small percentage, 1%
or less of endometriomas can become malignant.
They typically evolve into an endometrioid
or clear cell carcinoma.
Here's such an example.
This one has the homogeneous echoes,
but the solid component in this malignancy is much larger,
more irregular than
what we just saw in the benign endometriomas.
So you start seeing this larger solid component, this,
I don't have the image available here,
but did have flow by color power doppler.
Then you become concerned that you're dealing
with an endometrioma that has become malignant
or occasionally there's other malignant neoplasms
that can simulate this when they have the solid component.
The majority of malignancies in endometriomas are larger
masses over about nine centimeters,
and the patients tend to be a little older age.
So certainly you should suspect malignancy if you see rapid
cyst growth or development of a solid component
that was not present previously.

Dermoid (Mature Cystic Teratoma)

So the last of the common the big four is we referred
to common benign masses is the dermoid
or mature cystic teratoma.
It's been reported as the most common ovarian neoplasm.
It is a benign lesion can occur in pre
or postmenopausal patients bilateral,
and 10 to 15% the torsion or rupture.
Risk is small.
Torsion hass been reported three
to 16% rupture, one to 4%.
I think these numbers are probably lower nowadays.
I don't think we see even that percentage of patients
with a dermoid who have torsion or rupture,
but it is a small risk.
The ultrasound features that are typical are focal
or diffuse hyper coic component, the hyper coic lines
and dots, which has been to termed the dermoid mesh.
You get areas of acoustic shadowing
you don't typically expect flow by doppler ultrasound.
And here's some examples of those.
Here's a hyper coic component,
may be faint acoustic shadowing.
This had more pronounced acoustic shadowing.
Here's the dermoid mesh.
Here we see these little short linear echoes
that actually are probably the hair fibers in a more liquid
component of the dermoid.
It's thought that when the hair fibers are in the more sebum
or fatty part, that you get a lot of interfaces
as in this part that may cause a more uniformly
hyper coic appearance.
Many dermoids will have more than one feature.
If you'll notice in this one
with the dermoid mesh over at the side,
there's actually a hyper coic component also,
which would make you even more confident
that this is a dermoid.
So these three are the most typical appearances you're gonna
see for a dermoid.
This last appearance has been described
as floating fat balls or globules.
If you'll notice, this is a transabdominal scan.
These little spherical areas are non-dependent.
That is, they're floating.
It's been reported as a pathognomonic appearance of dermoids.
However, it's not very common.
Tends to occur in larger masses
and you won't see this very often,
but it probably is highly predictive when you do see it.

If dermoids are not removed surgically.
The SRU consensus recommendations were
for yearly follow up to look for growth.
Admittedly, dermoids, if they grow, tend to do
so very slowly.
An average growth rate of only about one
to two millimeter per year has been reported.
And that's I think even tough
to pick up whether our measurement
accuracy is even that good.
But the main point is that dermoids, if they grow, tend
to do so very slowly
and you would of course look for a change in more
ology on follow up too.

Another appearance I just wanna mention
for dermoids is the fluid fluid level.
It's less common than the other appearances other than
perhaps the floating globules,
which is pretty rare.
This appearance is less common than the hyper coic nodule
or the dermoid mesh, but you may occasionally encounter it.
Important thing about the fluid
fluid level in dermoids is what's been described
as typical is that the non-dependent component as in this,
if it's the hyper coic component.
So if the non-dependent fluid is hyper coic compared
to the dependent fluid, that's what's
predictive of a dermoid.
Unfortunately, many dermoids that have a fluid fluid level,
it's often the opposite.
The non-dependent fluid can be less echogenic.
And in those cases hemorrhagic cys can do that too.
So it becomes less useful.
The fluid fluid level, again, is uncommon.
It's most helpful if the non-dependent area
of fluid is the more echogenic fluid has in this example.

What about dermoids and malignancy?
A small percentage of dermoids can also transform
to malignancy is typically a squamous cell carcinoma.
Not surprisingly, it tends
to be larger masses older patient.
So what are the features
that lets you predict a malignant dermoid?
It's actually not very clear.
These branching structures
that if they're iso coic rather than hyper coic compared
to the wall, have been reported as a feature
to consider for malignancy.
Obviously if you saw invasion into adjacent organs,
that would be concerning.
Another feature that may be helpful is color powered doppler ultrasound.
If you use it on the majority of dermoids,
you typically don't see flow centrally
that is in the hyper coic component or the dermoid mesh.
You may see it peripherally in the wall. That's okay.
But if you began to see flow in the hyper coic central
components out, that would be more concerning.
That's been reported uncommon and benign dermoids.
So we would look for that if you saw flow centrally.
It's not clear how predictive of malignancy that is,
but I think it would be more concerning for malignancy.
Again, peripheral flow only is okay for dermoids.

So those are the common four common benign masses
that it's really important
to know their sonographic features.
We'll move on to ovarian neoplasms.
And now at least other neoplasms beside the dermoid.

Ovarian Neoplasms

These are generally separated into four basic groups.
The epithelial neoplasms, that's the most common.
And that's the group that when we talk about ovarian cancer,
that most arise from,
then we've got the germ cell neoplasms.
We've already talked about the dermoid.
That's the most common one in that group.
We've got the sex cord stromal neoplasms,
and then the metastatic neoplasms.

Epithelial Neoplasms

So for the epithelial group, most are gonna be serous
or mucinous or endometrioid cystadenomas
or cys adenocarcinomas, at least the serous
and mucinous can have a benign version.
The cystadenoma. Then we've got the clear cell carcinoma
and the briner tumor is in this epithelial group.
It's a less common tumor.
Most of these epithelial neoplasms
have a complex cystic appearance.
That is, they have both cystic and solid components.
There's also the borderline
or low malignant potential group, which is malignant,
but has less stromal invasion.
They may metastasize still,
but they tend, these patients have a better prognosis than
the frankly malignant tumors.
Current thinking is that there's probably two types
of epithelial ovarian cancer that may actually arise
outside the ovary.
Type one, it's thought
to have a more indot course earlier stage at diagnosis
and perhaps arises from precursor lesions such
as endometriosis.
The type two is the more aggressive form,
more advanced stage, typically at diagnosis.
And maybe the reason
that screening has been difficult in some of the studies
that these have a very short lead time, develop rapidly
and become advanced very quickly.
And these actually may develop in the fallopian tube rather
than the ovary itself.

So what are the ultrasound features
that make us most concern for these malignant neoplasms,
particularly that epithelial group?
It's a solid nodule that has blood flow
by doppler ultrasound as in this patient
who has a cystic mass.
There's a septation, there's a li or solid component
and there is blood flow within it.
Just to mention one thing about blood flow,
if you see a length of a vessel as in this example, I think
that's adequate for saying
that there's flow in that solid tissue.
If you only see a a dot or two of color that is a pixel
or two of color, it's important I think
that you put on spectral doppler
to make sure you see an arterial venous waveform.
If it's just a couple of dots
of color without seeing a distinct vessel,
that could be noise.
And since it's important
to know whether there's blood flow detected in
that solid area, just be careful when you don't see a
distinct vessel and put on
that spectral doppler if it's only a few pixels of flow.
And see if you get a typical arterial venous waveform.

So again, the solid nodule with blood flow is the feature
with that's most concerning,
has the highest likelihood for malignancy.
Focal wall thickening, at least more than three millimeters,
is considered similar to this as a solid component.
The other thing that's concerning is thick septations
or irregular septations.
Here we have a cystic mass with a few septations
that are a little over three millimeters.
They're slightly irregular here.
And this was also a malignant epithelial neoplasm ovarian cancer.
So these type lesions are pretty easy to characterize.
We know they're very likely to be malignant.
You really don't need to do any other imaging
and most of these patients to characterize the mass.
You may need to do other imaging such as CT for staging.
But generally if it's got a solid component
or thick sept stick, irregular septations with blood flow,
that's concerning enough for malignancy alone.

Germ Cell Neoplasms

What about the germ cell neoplasm group?
We already talked about the dermoid
or mature cystic teratoma.
There are some rare subtypes such as the stru OV ai
or thyroid tissue predominates.
Those actually don't always have the typical dermoid
look on ultrasound and may end up having a
non-specific appearance.
Disc germin, yolk sac
or endodermal sinus tumors are also in this group
as our embryonal cell and choal carcinoma.
Those are less frequent.
The only other one we're gonna mention today is the disc germin.
It's an uncommon malignant tumor,
though generally a good prognosis.
If you see a lobulated solid mass,
pretty well-defined borders, it can have plenty of flow
by doppler and a younger patient
less than about 30 years old.
That's a typical appearance of disc germin.
So I would consider that as a likely diagnosis.
If you encounter such a large solid mass in a younger patient,
obviously the patient would probably still need
histologic proof.
But it consider this germin
as the most likely diagnosis in that instance.

Sex Cord Stromal Neoplasms

The sex cord stromal group also has several subtypes.
These are the four most common.
We'll talk about fibromas and the comas granulosis cell.
We're really not gonna go into
however, granulosis cell is the one
that can secrete estrogen different tumors
and can secrete hormones.
But the classic one
that secretes estrogen is the granulosis cell tumor.
And these, some patients also have endometrial abnormalities including endometrial
cancer because of the high estrogen levels.
In my experience, most
of those are solid though the literature would say
that they can be both cystic
and solid, particularly when larger.
I'll just mention all the, so the Serato late cell tumor,
many of these small ones or many are small solid masses.
They can secrete androgens.
This is the typical one that can cause visualization
by secreting androgens in about a third of the cases.
And these can be difficult to identify
because they're small, solid lesions.
The main ones, the more common ones we're gonna talk
about in this group are the fibromas and the the comas.
They often coexist. The appearance is probably similar.

So the for the fibromas, these are benign neoplasms.
They're most common in middle age 40 to 50
to 60-year-old patients.
They're typically solid, generally completely solid.
They can be heterogeneous as in this case and be solid.
They can be more homogeneous and solid.
And also a typical appearance is marked
attenuation of sound.
You can actually overlook the mass
because you might think it's shadowing from bowel gas.
But this occurs in a minority of fibromas.
But it is pretty predictive when you see it.
It's different from acoustic shadowing from say
calcification or dermoid.
'cause if you'll notice here this acoustic shadowing,
where is it coming from?
Well, with calcification
or a dermoid, you expect
to see a hyper coic area from which the acoustic shadowing
originates here.
It basically just looks like if you will,
a black hole just all
of a sudden there's acoustic shadowing.
There's no hyper coic lead point.
And that's a tip off that you may be dealing with one
of these fibromas that has marked attenuation of sound.
And again, the Theas can look similar.
They often coexist histologically in the same mass.

So this brings up another topic that it's important
to know how to approach.
And that's when you have a solid adnexal mass
that is completely solid.
If it's completely solid in ovarian, in origin,
you're probably dealing with the neoplasm.
And in the appropriate age group,
I'd think about the ovarian fibroma
as the most likely cause.
Now some studies have suggested that solid masses increase the risk for malignancy.
Part of the difficulty there is that in most
of those studies, the definition of solid allowed for up
to a 20% cystic component.
So and certainly yes, some of those
with the more cystic component have a higher
chance of being malignant.
My experience, the completely solid mass that is
with no cystic component, particularly if you're dealing
with a patient who's 40 50 to sick, perhaps 60 years old,
majority of those are gonna be the about nine fibroma.
Admittedly, they'll still typically need surgical
evaluation to confirm that.
But I think the completely solid masses
are often benign.

So it's important to consider alternative diagnoses other
than just an ovarian origin.
When you're faced with a patient
who has a completely solid adnexal mass,
what else do we consider?
Well, pedunculated fibroids the main one,
fibroids are just so common.
And if they're pedunculated off the uterus protruding out into the ad nexa,
they can simulate an ovarian mass.
And this is particularly problematic if you cannot identify
the ovary on the side of the solid adexo mass.
The thing that can be helpful here is to look
for the vascular pedicle by Doppler ultrasound,
connecting the mass to the uterus.
Other things that I always like to consider
before I attribute a solid
and nal mass as an ovarian cause
is the subacute hemorrhagic
cysts that we talked about earlier.
It can simulate a solid mass.
So just be suspicious in these younger patients
where it looks solid and there's no flow detected in it.
Think about that chronic endometrioma
that might simulate a truly solid ovarian neoplasm
and MRI could be helpful in these patients.
And this is an instance where if you're really unsure
of the origin of the solid edex mass,
that is particularly when you cannot find the ovary on
that side by ultrasound, that MRI is often helpful.

So here's a case, a solid adnexal mass,
and this is an example of using a color doppler to see
that connecting vessel between the uterus and the mass.
Confirming that you're looking at the pedicle
of pedunculated fibroid is if you think about most
pedunculated fibroids, do we see the pedicle
with gray scale ultrasound?
Typically not. You may occasionally if you look,
look hard and get a little bit lucky,
you may find it in gray scale, but I think that color
or power doppler addition is what really helps you find the,
the pedicle in a pedunculated fibroid
and be confident of the diagnosis.
If you don't see the connecting pedicle
might still be a fibroid.
Maybe you just didn't find it,
but you certainly would have to proceed then to either MRI or consider surgical evaluation.
If you cannot confirm
that it's a pedunculated fibroid by ultrasound.

Metastatic Neoplasms

The last general group of neoplasms
to the ovaries is the metastatic group.
What are the most common primaries
to metastasize to the ovary?
Will breast and GI tract are probably the
biggest ones with breast cancer.
It's typically the patients with more advanced disease.
Colon and stomach are also high up the list as primary sites that metastasize to the ovary.
As we'll talk about in just a moment, many
of these are thought to be solid masses.
There's some evidence that mets from colon cancer are more
likely to be cystic than other primary tumors.
And then of course, you know,
many primary tumors have been described.
Breast, GI tract, the most common
lymphoma endometrial cancer have also been described.
Can we really distinguished a primary from a
metastatic neoplasm?
Not clear how good we are at that.
A traditional teaching for many years is that solid
and bilateral favors metastatic?
It was certainly true in this patient
who had a predominantly solid mass in the
right ovary and the left.
This was metastatic from gastric carcinoma.
So in my experience, they often are solid in bilateral,
but we know from the literature that's not always true.
And in some cases it will be difficult
to know whether you're dealing with a primary
or a metastatic lesion.
Trying to find the primary cause may be helpful
in those instances.

Masses Outside the Ovary (Extra-Ovarian Masses)

So now we're gonna move on to masses outside the ovary.
'cause it's important when you see a mass in the adexo
to not assume it's coming from the ovary.
Admittedly, most will come from the ovary,
but if it's extra ovarian we're gonna be thinking
about different causes.
So always try to determine whether the mass you're looking at is truly coming
from the ovary or not.
Here's an example of a cyst.
You can see a rim of ovary around it.
Perhaps some would call this a claw sign
where you got this little rim
or claw of ovarian tissue going around the edge.
And so if we see that ovarian tissue around it,
you could be confident it's coming from the ovary
and in the premenopausal patient,
those small follicles in the
ovarian parenchyma can help you.
If it's not ovarian, sometimes it's obvious
as in this case here we've got an ovary with a follicle,
a few of those insignificant echogenic foci.
Here's this peril ovarian cyst sitting off to the side.
So sometimes it's easy, it's obvious
that the lesion you're looking at
is separate from the ovary.
If it's not obviously coming from the ovary, it is important
to try to tell its origin.
You can use gentle transducer pressure
with a transvaginal transducer
or your non scanning hand on the patient's abdomen
and see if you can separate the lesion from the ovary.
That can be helpful in some patients.
If you don't find the ovary at all,
then sometimes it is more difficult.
I do think it's important
to not only look transvaginally,
but to look transabdominally even without a full bladder,
to at least look briefly
because sometimes the ovary is
superiorly positioned in the pelvis
and you may only see it on transabdominal scanning.

So when we're faced with an extra ovarian mass,
what are the things we consider?
Well, I've kind of put 'em into mostly cystic, mostly solid.
And the more common
and the less common, we're only gonna talk about
the more common ones.

Mostly Cystic Extra-Ovarian Masses

So for the mostly cystic extra ovarian mass,
the more common lesions of the per ovarian cyst,
hydrocele pinks and the peritoneal occlusion cysts,
the peril variant or per tubal,
I'll use the term synonymously 'cause we can't always tell the difference,
but it's mainly you're seeing a simple cyst in the adnexa
that's separate from the ovary.
These are usually simple cysts meet the same definition
of a simple cyst we talked about earlier.
And in this case where it's just sitting right next
to the ovary, it's an easy diagnosis to make.
These are pretty common small ones we may overlook
because of bowel gas,
but these are generally of little to no significance.

What about the hydro alpines?
When do we suggest that diagnosis?
Well, obviously a tubular shape
as in this case an incomplete septation,
the waist sign in these small nodules also called beads on a
string have been described.
So just to go back to this one,
here's our tubular shape.
This incomplete septation.
It's not a true septation in most instances.
It's really just the wall of the distended fallopian tube
as it folds back on itself
simulates an incomplete septation.
It was originally reported as pathognomonic.
It's since been found not to be.
You can occasionally see these in other etiologies,
but in fact if it's tubular shaped
and has an incomplete septation,
I think those frequently are hydroceles.
Another feature that's been described as perhaps one
of the best signs is the so-called waist sign.
And this refers to this indentation along opposite sides.
It's like a waist, it's kind
of indent the cystic structure on opposite sides.
And that's the waist sign
and that's a very useful feature
for identifying hydro cell pinks also.
So that tubular shaped cystic mass
with the waist sign, look for that.

The other thing to be aware of
with the hydro cell pinks is these small mural nodules.
It's been called beads on a string.
You know, here's a cystic mass, a little nodules there.
We'll see it here on the video clip on the same patient.
This tubular shaped mass.
You see these little nodules along the wall here.
If you did not recognize that this lesion was
outside the ovary and you had these small nodules,
you might confuse it for an ovarian neoplasm.
But we know that hydro cell pinches can have
these small nodules.
They are thought to be due
to the thickened endo cell penal folds that become inflamed in the hydro cell pinks.
So if you see these small nodular small nodules and what
otherwise looks like a hydro cell pinks, that's okay.
You don't have to be concerned about malignancy.
Fallopian tube neoplasm is admittedly uncommon.
It can have solid components though in my experience they're
typically larger solid components,
not these tiny nodules along the wall.

Peritoneal inclusion cyst also been referred to
as peritoneal pseudocyst.
It's thought that you need two things
to have one a functioning ovary in adhesions.
The most common risk factors for adhesions are surgery,
endometriosis, and pelvic inflammatory disease.
So the ultrasound features,
there's typically a septated cystic mass
and you look for it extending around the ovary
or the ovary suspended within it.
They also frequently conform to the shape
of adjacent structures.
So here's a cystic mass, kind
of a thick irregular septation on transabdominal scanning.
But when we look transvaginally,
you can actually see the ovary inside the cystic mass.
And this was a peritoneal inclusion cyst in a patient
with endometriosis.
So always consider that
option when I've got a septated cystic mass.
They have risk factors for adhesions look
and try to find that ovary somewhere within it
and that can help you make the diagnosis.

Mostly Solid Extra-Ovarian Masses

Now mostly solid extra brain masses.
We've already talked about this pedunculated fibroid.
It's by far the most common entity that you'll deal with.
Occasionally fibroids
as we know can have cystic degeneration.
You know, this one's solid,
but here's one with cystic degeneration.
This, if you didn't know the origin would be very difficult
to distinguish from ovarian carcinoma
'cause it middle east's got cystic components,
irregular solid components, whether fibroid,
ovarian neoplasm, it could have flow.
This was a pedunculated fibroid with cystic degeneration
that simulated ovarian carcinoma.
So just be aware of that
and again, try to look for
that vascular pedicle that we looked at earlier.
Admittedly, if it has cystic degeneration,
that may be a little more problematic
and make a confident diagnosis if you're not able
to find the ipsilateral ovary.

Cysts with Indeterminate Features

Now we're gonna shift to cysts
that have indeterminate features.
We talked about the benign features.
We've talked about the malignant features.
Occasionally there's cysts that are more problematic.
And there's four general groups.
Two of them are less concerning, two
of 'em are a little bit more concerning.
The one that's less concerning is what I like
to call the almost simple cyst.
And that is it has one thin septation
or it has a little calcification along
the wall with nothing else.
These we recommend following similar
to simple cyst in the ovary.
Occasionally you get these cysts that have some features
that might look like a little bit like one
of these benign ones that we talked about.
For instance, you know, it's a little hyper coic here,
but gee, am I really confident that's a dermoid
or here's one, it's a little heterogeneous
and I'm thinking it has that reticular pattern
of a hemorrhagic cyst, but it's not quite classic.
So you know, these have features that make me think perhaps a dermoid make me think, perhaps a hemorrhagic cyst,
but I'm not confident enough to be sure.
And these are the ones that would probably follow up
with ultrasound in six to 12 weeks,
particularly in the premenopausal patient.
If it persists unchanged in six to 12 weeks,
then a hemorrhagic cyst is very unlikely
and it would do further evaluation at that time.

The features that are a little more concerning
and indeterminate are the multiple septations
and the solid nodule that is a non-hyper coic,
solid nodule without flow.
Then we think about neoplasm more.
They'll usually benign neoplasms such as a cys a no fibroma.
So here's an in patient with multiple septations.
There's different degrees of echogenicity in the various
septations that actually is typical of a mucin cystadenoma.
And another patient with a small solid nodule along the
wall without detectable flow in a patient
with a cys adeno fibroma.
So these are features that are indeterminate,
but again, probably are gonna be benign,
but we're certainly can't be confident we're gonna have
to do further evaluation or consider surgical evaluation.

Alright, and these recommendations were summarized in the report of the adnexal cyst co consist conference
that was published in radiology with Dr
Debbie Levine as the lead author.
So those are available and we keep those up in our reading
room and refer to them frequently.

Miscellaneous Lesions

Tubo-Ovarian Abscess

A couple of miscellaneous lesions.
This dimension in closing the tub ovarian abscess
and adnexal mass is unique to pregnancy.
The tub ovarian abscess
or TOA as it's often called,
can really have a variety of appearances.
There's typically nothing suggestive enough
based on the ultrasound appearance alone.
They have cystic and solid components, internal echoes.
They can simulate a neoplasm,
they can simulate a hemorrhagic cyst.
One feature that may help you graphically is if you see a
tubular cystic component
that would make you consider fallopian tube
that is a hydro cell pinks or pile cell pinks,
because it's got internal echoes that could suggest
that you're dealing with a tub ovarian abscess.
Otherwise, the appearance again is quite variable
and it's really the clinical setting of pelvic inflammatory disease that helps point
to the correct diagnosis.
So again, other than perhaps seeing a hydro cell hydro pinks
or PEOs pinks component, I think it's difficult
to competently diagnose a tub ovarian abscess
by ultrasound alone.
You really need clinical information.

Adnexal Masses Unique to Pregnancy

I wanna mention a few adnexal masses unique to pregnancy.
In closing, they're thecal luan cyst,
de centralizing endometrioma and the Loma pregnancy.
Do you think ilu in cyst are typically bilateral,
septated masses, multiple thin septations?
It can simulate a multiloculated neoplasm.
These basically occur
with high serum beta H CG levels.
I think it's the bilateral nature
and appearance of these when it occurs with a known association.
And the most common associations are gestational
trophoblastic disease.
Certainly the most common one we think about
ovarian hyperstimulation.
And patients have undergone in vitro fertilization or other types
of assisted reproductive techniques have
a similar appearance.
And then occasionally patients with multiple pregnancy
or hydro drops can also get these.
That's sometimes referred to as hyperact lutein analysis.
It's invariably used term,
but sometimes used when patients have these thi lutian cyst
in the absence of trophoblastic disease.
In the absence of ovulation induction,

decentralized endometrioma is uncommon,
but certainly important to consider as it can simulate.
Malignancy is typically cystic with a solid component.
We have the patient with an endometrioma
that has the ectopic endometrial tissue in it,
and when they're pregnant, the endometrial tissue can grow
and appears similar to the solid component of a neoplasm.
Here's a patient, it has
that homogeneous echoes like many endometriomas do,
but this has got a kinda lobulated irregular solid
component, has some blood flow in it.
So we would have to be concerned about
malignancy in a patient like this.
But she's pregnant and she has known endometriosis
and this actually was a de digitalized endometrioma
that was path proven ended up being removed.
But can you make a confident diagnosis so
that the patient can avoid surgery?
It can be challenging.
Doppler imaging probably isn't reliable
as the de visualized endometrioma can have
flow in the solid areas.
It doesn't necessarily mean it's malignant.
I think the reasons to suspect this diagnosis are if the
patient has known endometriosis,
particularly a known endometrioma,
no other features of malignancy.
And if on follow up, you know, it doesn't change
or it actually they'll occasionally decrease in size,
that's also suggestive.
But admittedly this just requires a high index
of suspicion and can be confident to make can be difficult to make a confident diagnosis in these patients, but you should at least consider it,
particularly when the patient has known endometriosis.

Can MRI help?
Perhaps it may show other features typical
of an endometrioma.
There's been some suggestion that the sim signal intensity
of the solid parts similar to endometrium that's supportive,
we're probably not gonna give gadolinium during pregnancy.
So the MRI can give you some at least supportive evidence,
but again, it's gonna be difficult
to make a confident diagnosis.
Lastly, the luteal pregnancy is a very rare lesion.
There's really no specific ultrasound appearance,
though it's typically solid.
The tip off here is maternal ization, that if you have TM
elevated androgens, that's a typical of loma of pregnancy.
So it's really not so much the imaging appearance,
but the associated clinical finding
and maternal visualization that suggests Loma of pregnancy.

Summary

So just to sum up, I think that the key points are
that it's important to understand what's normal
and not to consider it a cyst or mass.
And that gets back to what we call a follicle
or corpus lium.
Please don't call it a cyst.
When you're faced with an adnexal mass,
don't assume it's ovarian.
Really try to determine whether it's arising from the ovary
or is extra variant in origin.
'cause that will certainly change your
differential diagnosis.
It's important to know the common ultrasound appearances
of these benign lesions.
The four I mentioned, the simple cyst, the hemorrhagic cyst,
the endometrioma and the dermoid,
because those are the most common lesions you're likely
to encounter, and they frequently have one
of those typical appearances.
And then lastly, the cystic mass that has a solid component
with flow is the most predictive feature for malignancy.
Thank you.