Ultrasonography of Common

Ovarian Cystic Lesions

B.Zandi

Perofessor of Radiology

• Normal ovaries ▫ premenopausal ▫ Post-menopausal

• Functional cysts ▫ Follicular cyst ▫ Corpus luteum cyst ▫ Hemorrhagic ovarian cyst

• Other Benign cystic and Cyst-like lesions ▫ Endometrioma ▫ Polycystic ovary syndrome ▫ Ovarian hyperstimulation syndrome - Theca lutein cysts ▫ PID with tubo-ovarian abscess

• Benign Cystic Ovarian Neoplasms ▫ Mature Cystic Teratoma ▫ Cystadenoma and Cystadenofibroma

• Malignant Cystic Ovarian Neoplasms ▫ Serous Cystadeno-Carcinoma ▫ Mucinous Cystadeno-Carcinoma ▫ Endometrioid Ovarian Carcinoma ▫ Cystic Metastases to the Ovaries

Normal ovaries

• premenopausal • The normal ovary : • 2 Million primary Oocytes at birth, • 10 mature each menstrual cycle • 1 Dominant Follicle /size of 18-20 mm by mid-cycle, • The others become Atretic and Fibrous. • After Ovulation, it collapses, and the Granulosa Cells

proliferate and swell to form the Corpus Luteum . • Over the course of 14 days the Corpus Luteum degenerates, to

Corpus Albicans.

• Graafian follicles :

• Normal ovary in Pre-Menopausal women contains :

• Several Anechoic, Simple Cysts (Graafian Follicles )

• Post-menopausal • The Ovaries are Smaller • Gradually Stop forming Graafian follicles. • However, that Follicular Cysts may persist several years

after menopause.

Functional cysts

• The Most Common Cystic Ovarian Lesions • Functional cysts are : Graafian follicles or Corpora Lutea that Have Grown Too

Large or Have Bled, but are otherwise benign. • Pre-Monoposal , Common • Post-Menopause , may be seen. • Even in Late menopause, may be seen in up to 20% of women.

• Follicular cyst • ≥ 3 cm, (usually 3-8 cm) • On US: as a Simple Unilocular, Anechoic Cysts / Thin,

Smooth Wall • No Enhancing Nodules /or other Solid Components, • No Enhancing Septations, • No Ascites (more than physiologic ) • Resolve Spontaneously on follow-up.

• Corpus luteum cyst • Corpus Luteum may Seal and Fill with Fluid or Blood, forming a

Corpus Luteum Cyst • US :A Small Complex Cyst with Wall Vascularity on power Doppler • the ‘Ring of Fire‘: The Characteristic Circular Doppler appearance • Good Through-transmission /no Internal Vascularity, • NOTE : Birth Control Pills prevent ovulation / NO Corpus Luteum Fertility Drugs (Ovulation Induction) / Increase Chance of

Developing Corpus Luteum Cysts.

• Another case • Typical 'Ring of Fire' on US • Pathologic examination ; Collapsed Bloody Cyst • DDx : EP

• Clinically : the Classic Presentation : Acute Pelvic Pain sometimes an Incidental Finding/ in an

Asymptomatic Woman • Sonographic Appearances Depends on : the Stage and Duration of the Cyst Formation. It can take any of the following appearances

Hemorrhagic Ovarian Cysts : Bleeding in a Graafian Follicle / or Follicular Cyst ,

• 1) Fishnet Weave or Fine Reticular Pattern • is the Commonest Presentation of these Cysts • Multiple Fine Strands of Fibrin giving a Net-like

Appearance • The Septa are Thin and/ Typically Non Vascular

• 2) Retracting Clot appearance • Clot formation and Subsequent Retraction in a

Hemorrhagic Ovarian Cyst • a Triangular, inhomogenous Clot in a part of the cyst

with Serous Fluid occupying the remainder of the cyst.

• 3) Fluid Debris Level

• is formed by Sediment or / Fine Particulate Elements within the HOC.

• 4) Rupture of HOC • An Unusual Appearance may be caused by rupture of the HOC

resulting in blood within the pelvis • As Echogenic Fluid surrounding the cyst and uterus DDx : It can mimic an EP

• Hemorrhagic Ovarian Cyst

• US : a Unilocular /Thin-walled Cyst /with Fibrin-strands or/ Low-level Echoes and /Good Through Transmission

• Doppler : No Internal Vascularity

• Diagnosis ? • A 23 y-o woman : • Severe Acute Pelvic Pain/+ β-hCG • A, Rt Adnexal Mass with an irregular thick rind (arrows) • B, Echogenic Fluid (arrows) adjacent to the Lesion

• This was mistaken for a Ruptured EP

• but was a Ruptured HOC at laparoscopy

• The patient had a concurrent very early Intrauterine Pregnancy

• 5) HOC resembling a Solid Ovarian Neoplasm • Echogenic Material within the cyst, • usually happens at Sub-acute Period with Early Stage of Clot Formation • Follow-up US will show Dramatic Changes within the HOC usually in 4 to 6

weeks • Color Doppler will show Lack of Flow within the Hemorrhagic Cyst

• Ovulation induction

• Hemorrhagic cyst

• Diffferential Diagnosis of HOC : • Most of the Causes of Acute Pelvic Pain can mimic

the Symptoms and Signs of HOC Acute Appendicitis and EP PID , and Mesenteric Adenitis. • Of these, EP is the most important condition : • Serum beta HCG and • Careful examination of the adnexal structures : On probe pressure, the ovary moves away from the

adnexal/ tubal mass in EP ) • The “Ring of Fire” sign can be seen in EP and in HC

Other benign cystic and cyst-like lesions

• Endometrioma or Cystic Endometriosis • In 75% of patients Ovaries are involved • US Appearance can be Variable • Classic appearance ( 95% ) : as a Homogeneous, Hypoechoic Cyst

with Diffuse Low Level Echoes • Rarely ; Anechoic, Mimicking a Functional Ovarian Cyst • can be Multilocular / have Thin or even Thick Septations

• Mural Echogenic Foci , (1/3 of patients ) Cholesterol Deposits or/ Small Blood Clots or Debris • DDx from True Wall Nodules (At Doppler no Vascularity ). • In the presence of these foci, the diagnosis is Very Likely.

• A Cystic Lesion with a Hyperechoic Structure. • a wide range of DDx including : Ovarian Cystic Neoplasm with Solid Component Mature Cystic Teratoma with Hyperechoic Rokitansky Nodule Hemorrhagic Cyst with Clot Endometrioma with clot or debris.

Continue with the CT and MR.

• The next case • Unilocular, mildly Hypoechoic Ovarian Lesion with Through Transmission. • No Internal or Wall Vascularity on Doppler • DDx : either a HC or an Endometrioma.

Continue with the MR images • Hypointensity due to the presence of Deoxyhaemoglobin and

Methaemoglobin (shading sign), • Which is Very Suggestive of Endometrioma

• 6 months later a follow-up MRI • Bright on T1 and T1 Fat-Sat (indicating of Blood ) • T2 Shading (Hemorrhagic lesion ) • T1+C No Enhancement • Fluid-fluid Level (Re-Bleening in a Cystic Lesion ) • Duration : 6 Month • Bilateral Endometrioma Much More Likely than HC

T1

T1 +C

T2

T1 Fatsat T1

T1 +C

• (a) fat-satT1 Hyperintense signal

• (b) fat-satT2 : Shading and a T2 Dark Spot in the left adnexal lesion

• a 33-y-o woman Bilateral Pathologically Proved Endometriomas

• Endometrioma

• Completely Anechoic

• Avascular

• Ovarian Hyperstimulation Syndrome - Theca lutein cysts • Is usually Bilateral • Causes : • Hormonal Overstimulation by HCG, Throphoblastic Pregnancy,

Hormone Therapy, Pregnancy (rarely) • Imaging : Bilateral Ovarian Enlargement with Multiloculated Cyst

• theca lutein cysts: a young pregnant woman • US : • Bilateral Multiple cysts • An Invasive Uterine Mass, • Consistent with Invasive Molar Pregnancy.

Benign cystic ovarian neoplasms

Mature Cystic Teratoma • Characteristic US findings are: Hypoechoic mass with Hyperechoic

Nodule (Rokitansky nodule or Dermoid Plug) Usually Unilocular (90%) Calcifications / Ossification (30-60%) May contain Hyperechoic lines caused by Floating

Hair May contain a Fat-Fluid Level (fat floating on

aqueous fluid ) The presence of Fat is Diagnostic

• Mature (Benign) Cystic Teratoma

• A Cystic Mass, with a Hyperechoic Solid Mural Nodule, (Rokitansky Nodule or Dermoid plug )

• another case : • the ‘Tip-of-the-Iceberg‘ Sign: Acoustic Shadow from

the Hyperechoic Part • This may be Misinterpreted as Bowel Gas

(overlooked )

• Cystadenoma and Cystadenofibroma • Are Common Benign Ovarian Tumors (Serous or

Mucinous ) • Serous Cystadenomas : • Mostly Unilocular / Anechoic, (like a simple cyst) • Mucinous cystadenomas : • Mostly Multilocular with Thin Septa • The locules may contain Complex Fluid, due to

Proteinaceous Debris or Hemorrhage, or Both The Finding of Papillary Projections should raise the

Suspicion of Malignancy

Serous Cystadenomas • Left Ovarian Cyst /Anechoic , No Septations , No Ascites • However, a Nodule on the posterior wall /No Flow on Doppler DDx : Follicular Cyst with some debris /a Cystic Neoplasm

Can not be Excluded Work-up with MRI is recommended

• The next case • A Multiloculated Cystic Mass. • looks like a Cystic Ovarian Neoplasm , • but No Ovary could be identified. • Continue with the CT ›››.

• CT of the same patient • Multi-loculated Cystic Mass , Connected to the left ovarian

vein (arrow) • Thick Septations and Irregular Wall Thickening • DDx : a Benign or Malignant Ovarian Lesion • Pathology : Cystadenofibroma.

Malignant Cystic Ovarian Neoplasms

Remember : • The Role of Imaging is not : To Determine the Histological Nature of a Lesion, • but to : Possibly Distinguish Benign from Malignant Lesions

and , Guide Decisions on further Management • The Examples given Serve as a : Demonstration of Suspicious Imaging Features,

• Findings Indicating Possible Neoplasm:

• Large size While Benign lesions can be very large, the Likelihood of Malignancy Increases with Size.

• Thickened Vascularized Septations

• Thick Septa Indicates a Possible Neoplasm.

• Thickness > 3mm and Well-vascularized - while Non-Specific – Both Increase the Likelihood of Malignancy.

• Vascularized solid components Vascularized Nodularities, Papillary Projections, or Frank Solid Masses all Increase the Likelihood of a Neoplastic Nature.

• Vascularized thick, irregular wall

• Lesions with Thin Walls are More Often Benign

• Lesions with Thick, Irregular Walls are More Often Malignant

• However, there is some Overlap, making wall thickness a less useful criterion.

For example a Corpus Luteum cyst may also have a Thickened, Vascularized wall.

• Secondary findings associated with malignant lesions: Ascites ( Large quantities ), Lymphadenopathy and Peritoneal Deposits are Strongly Increase Likelihood of Malignancy.

• Serous Cystadenocarcinoma • US : • Left Ovary , a Complex Solid-Cystic mass • Right Adnex , a Very Large Complex Solid-Cystic Mass CT ›››

L,Ov R,Ov

• A Complex Solid-Cystic Mass with Thick, Enhancing Septations in the Rt Ov.

• These findings are Very Suspicious for a Malignant Cystic Neoplams.

• also Bilateral Lymphadenopathy (arrows). • Pathology : Serous Cystadenocarcinoma. • The Most Common type of Ovarian Cancer.

• Mucinous Cystadenocarcinoma • US : a Very Large Multi-loculated Cystic Lesion • Both Anechoic and Uniform Low-level Echoes (Proteineous / Hemorrhage /

Mucin ) • Thin and Avascular Septations • No Solid Components/No Ascites / No vascularity; in favor of Benign lesion However , the Zize / the Multi-loculated Aspect, are Suspicious for a Cystic

Neoplasm and Warant further evaluation • CT+C : Similar Findings • Pathology : Mucinous Cystadenocarcinoma of Low Malignant Potential.

Endometrioid Ovarian Carcinoma • US : Bilateral Enlarged Ovaries with Solid and Cystic Components The Complex Solid-Cystic Lesions + being Bilateral, are Suspicious

for a Cystic Neoplasm and Warrant Further Evaluation • CT : the Same Findings • The purpose of the CT = Staging (Left image; Peritoneal Implant )

• Pathology : Endometrioid Ovarian Carcinoma.

CT (or of MRI) is not to determine the Histologic Type For Epithelial tumors Staging is More Important

• Ovarian Metastase from Colon and Gastric ca

Cystic Metastases to the Ovaries Metastases to the ovary are Mostly Solid - but Cystic Metastases do occur.

• Cystic Metastases to the Ovaries • CT : Complex Cystic Masses in both ovaries • Colorectal Cancer (blue arrow) • Cystic Implants on the Peritoneal Reflection (red

arrow)

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