Sonographic Evaluation of Pelvic

Masses

Aboubakr Elnashar

Benha university Hospital, Egypt

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Contents1.Parametrs of pelvic US

2.Transvaginal sonography of pelvic masses

3.Sonographic differential diagnosis

1.RuLes

2.Benign or malignant

3.Type

Summary

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1. Parameters of pelvic US .1. Confirmation

presence or absence

2. Determination of 1. Size

2. consistency

3. contour .

4. Origin

5. anatomic relationship

3. Determine

abnormalities associated with malignant

disease: ascites or metastatic lesions.

4. Guidance for 1. Aspiration

2. biopsy

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TVS and TA

TVS:

used as an adjunct to TAS.

evaluation of the uterus and adnexa.

tumor composition

location

its limited field of view and unusual image

orientation}

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Color Doppler sonography (CDS)

helpful in distinguishing

benign from malignant ovarian masses

evaluation of adnexal torsion

an adjunct to morphologic assessment of

ovarian lesions.

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2. DD between benign and malignant

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Morphologic scoring by TVS.

Each of four parameters as assessed

Malignancies tended to have high scores (over 9).

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Simple ultrasound rules: 2012

5 ultrasonic features to predict a malignant tumour

(M features):

Irregular solid tumour (M1),

Ascites (M2),

At least four papillary structures (M3),

Irregular multilocular solid tumour with a largest

diameter of at least 100 mm (M4)

Very high colour content on colour Doppler

examination (M5).

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5 ultrasonic features to predict a benign tumour (B

features):

Unilocular cyst (B1),

Presence of solid components for which the largest

solid component is <7 mm in largest diameter (B2)

Acoustic shadows (B3)

Smooth multilocular tumour (B4)

No detectable blood flow on Doppler examination

(B5).

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3. Type of mass

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Purely cystic:

more likely to be benign

Complex cyst :

more likely to be malignant.

Purely solid:

more likely to be benign.

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ovaryuterus

Unilocular, thin-walled, anechoic

I. CYSTIC

Simple Cystic

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Unilocular

Thin-walled

Anechoic

Follicular cyst ABOUBAKR ELNASHAR

Simple cysts

Corpus luteal or follicular cyst

Haemorrhagic cysts

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Massively enlarged ovariesThin-walled septationAscites may be present

OHSS

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Hydrosalpinx

Tubular-shaped

structure

Anechoic content

Incomplete septum

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Low-level echo cysts1. Endometrioma 95%2. Hemorrhagic cyst 50%3. Teratoma 18%4. Malignant Neoplasm 12%(Patel et al, 1999.)

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Anechoic with lacelike internal echoes within cyst

Hemorrhagic C.

Corpus Luteum

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Low-level echo cysts + Characteristic Features Endometrioma

Hyperechoic wall foci (in 35%)

Hemorrhagic cyst :Lacelike internal echoes (in 40%)

TeratomaRegional bright echoes ( in 97% )

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Diffuse ‘ground glass’ pattern

{old blood}Endometrioma

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smooth-walled ovarian cyst. Same patient after 5 w.

complete regression of the

physiologic cyst.

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Completely cystic ovarian

masses in peri-menopausal

woman.

most small cystic ovarian

masses in pre- and

perimenopausal women are

physiologic

Completely cystic ovarian

masses in post menopausal

woman.

most postmenopausal cysts

are inclusion cysts.

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Septated cystic masses. Mucinous cystadenoma.

cystic mass containing

multiple thin internal

septations

Mucinous cystadenoma.

septated mass with

echogenic material (*) in

upper loculated area.

The echogenic material was

mucin

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Mucinous cystadenocarcinoma

Malignancy was suspected

due to thickened septation

(arrow)

Malignant teratoma.

Papillary projections (arrow)

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1-Dermoid Cyst

The commonest 36%

2-Endometriotic cyst 5%

3-Malignant Cyst 1-3%

II. COMPLEX CYST

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Dermoid

Complex mass solid and

cystic (fat, bone)

Fill in Pattern

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Echogenic mural nodule in cystic mass.

Papillary serous Cystadenoma

Few small papillae

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Mucinous Cystadenocarcinoma

Solid areas Many papillary. P

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COMPLEX

Dermoid cyst.

Transverse sonogram of

complex predominantly cystic

with calcific focus (arrow)

arising from tooth

luteal cyst

with fluid surrounding

adhesion.

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Mucinous cystadenoma

Sagittal and axial transvaginal sonogram:

multiloculated septated cystic mass with focal wall

thickening. This represented a with 1 locule containing thick

mucinous material

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Dermoid cyst

layer of echogenic sebum

(*).

Hemorrhagic ovarian cyst

irregular solid area

corresponding to

displaced hemorrhagic

ovarian tissue surrounding

area of hemorrhage.ABOUBAKR ELNASHAR

Ovarian cystadenocarcinoma

irregular solid areas. Magnified transverse TAS of

cul-de-sac hemorrhage

(arrow) resulting from

ruptured ectopic pregnancy.

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Dermoid cyst

typical echogenic hairball

(arrows).

Dermoid cyst.

TV-CDS showing vessels

within the solid part

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Torsed right ovary.

(TAS)

solid mass (arrow) in cul-

de-sac

Transverse TAS of same

patient as in showing that left

ovary (straight arrow) is normal

in size and adjacent to torsed

right ovary (curved arrow).

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Interligamentous fibroid (*)

appearing as solid pelvic

mass.

Transabdominal sonogram of

predominantly solid undifferentiated

ovarian neoplasm (arrow) containing a few

cystic areas.

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Cystadenofibroma

TAS

solid pelvic mass

with calcifications (arrow) in

elderly patient.

Longitudinal TAS of pelvic

kidney (arrow). Pelvocalyceal

system accounts for central

echogenicity.

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Transverse TAS showing

solid left-adnexal mass

(between +’s), which

represented hemorrhagic

corpus luteum cyst.

Longitudinal TAS of solid

teratoma with calcified areas.

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Magnified TAS of solid mass (between +’s) representing

hemorrhagic corpus luteum cyst.

Sagittal and transverse

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TAS: 5 × 7 cm solid mass

associated with ascites.

This was ovarian cancer.

TVS

large solid tumor representing

a dysgerminoma

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Adnexal (ovarian) torsion

TVS: enlarged right ovary (between

+’s) with mildly echogenic area

resulting from internal hemorrhage

Cul-de-sac fluid adjacent to left side

of uterus in same patient

Two days later, the ovary (arrow) has

enlarged secondary to retorsion. On

TAS, enlarged size of ovary relative to

uterus can be better appreciated.ABOUBAKR ELNASHAR

SUMMARY

Although the sonographic features of a pelvic mass

may not allow a specific diagnosis, clinically useful

information can usually be obtained.

TVS is a useful adjunct to TAS because it adds specificity in determining intraversus extraovarianmasses and endometrial and myometrial disorders. TVS affords an accurate means for evaluation of the

ovaries and is particularly useful in obese,

postmenopausal women in whom the incidence of

ovarian carcinoma is especially high.

Although not always specific, sonographic assessment

of tumor morphology can lead to accurate diagnoses.

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Thank you

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