Sonographic Evaluation of Pelvic Masses

1. Sonographic Evaluation of Pelvic
Masses
Aboubakr Elnashar
Benha university Hospital, Egypt
Aboubakr Elnashar

2. Sonography provides clinically important
parameters for the pelvic mass.
1. Confirmation of the presence or absence of a
pelvic mass.
2. Delineation of the size, internal consistency,
and contour of the mass.
3. Establishment of the origin and anatomic
relationship of the mass to other pelvic
structures.
4. A survey to establish the presence or absence
of abnormalities associated with malignant
disease, such as ascites or metastatic lesions.
5. Guidance for aspiration or biopsy of selected
pelvic masses.
Aboubakr Elnashar

3. TRANSVAGINAL SONOGRAPHY OF PELVIC
MASSES
important role in the evaluation of the uterus and
adnexa.
{its limited field of view and unusual image
orientation} it is best used as an adjunct to TAS.
Aboubakr Elnashar

4. TVS is indicated:
1. Determination of the presence or absence, and
evaluation of, relatively small (<5 to 10 cm)
2. Determination of the origin of a mass (uterine,
ovarian, or tubal) and whether or not it has
torsed.
3. Detailed evaluation of its internal consistency
with particular emphasis on the presence or
absence of polypoid excrescences, septations,
or internal consistencies (blood, pus, serous fluid).
4. Guiding transvaginal aspiration of certain
masses.
5. Evaluation of endometrial or myometrial
disorders related to pelvic masses.
Aboubakr Elnashar

5. DD between benign and malignant
Aboubakr Elnashar

6. Morphologic scoring by TVS.
Each of four parameters as assessed, including inner
wall structure, wall thickness (mm), septa (mm), and
echogenicity. Malignancies tended to have high scores
(over 9).
Aboubakr Elnashar

7. 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), and
very high colour content on colour Doppler
examination (M5).
Aboubakr Elnashar

8. 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), and
no detectable blood flow on Doppler examination
(B5).
Aboubakr Elnashar

9. If one or more M features were present in the
absence of a B feature, we classified the mass as
malignant (rule 1).
If one or more B features were present in the
absence of an M feature, we classified the mass as
benign (rule 2).
If both M features and B features were present, or if
none of the features was present, the simple rules
were inconclusive (rule 3).
Aboubakr Elnashar

10. Sonographic signs of
malignancy. (A) Longitudinal
transabdominal sonography
showing irregular bulge
(arrow) in superior aspect of
ovarian tumor, indicating
capsular disruption by tumor.
(B) Gross specimen showing
tumor extruding through
capsule in malignant ovarian
cystadenocarcinoma. (C)
Irregular solid mass (arrow)
arising from peritoneum,
representing metastases from
ovarian carcinoma. (D) Bloody
ascites associated with recurrent
ovarian carcinoma appearing as
echogenic particulate material
(*). (E) Echogenic liver
metastasis from ovarian
carcinoma obstructing
intrahepatic portion of inferior
vena cava.
Aboubakr Elnashar

11. SONOGRAPHIC DIFFERENTIAL DIAGNOSIS OF PELVIC MASSES
Cystic
1. Completely cystic
Physiologic ovarian cysts
Cystadenomas
Hydrosalpinx
Endometrioma
Paraovarian cyst
Hydatid cyst of Morgagni
2. Multiple
Endometriomas
Multiple follicular cysts
3. Septated
Cystadenoma (carcinoma)
Mucinous
Serous
Papillary
Complex
1. Predominantly
cystic
Cystadenomas
Tubo-ovarian
abscess
Ectopic
pregnancy
Cystic teratoma
2. Predominantly
solid
Cystadenoma
(carcinoma)
Germ cell tumor
Solid
1. Uterine
Leiomyoma
(sarcoma)
Endometrial
carcinoma,
sarcoma
Extrauterine
2. ovarian tumor
Aboubakr Elnashar

12. Simple ovarian cyst.
Transvaginal color flow
Doppler image
demonstrates a large simple
ovarian
cyst.
Aboubakr Elnashar

13. Postmenopausal cysts.
Transvaginal grayscale images of both ovaries demonstrate
simple cysts bilaterally in a postmenopausal woman.
Aboubakr Elnashar

14. Corpus luteum cyst.
(A) Transvaginal grayscale image of the left ovary demonstrates a cyst with
debris within, suggestive of hemorrhage in a corpus luteum cyst.
(B) Corresponding
color flow Doppler image demonstrates peripheral vascularity—called the
‘‘ring of fire
Aboubakr Elnashar

15. Parovarian cyst.
Transvaginal grayscale image demonstrates a left
parovarian cyst with a corresponding four-dimensional US
reformatted image that demonstrates better delineation and
extent of the cyst.
Aboubakr Elnashar

16. Theca lutein cysts.
Transvaginal grayscale image of the pelvis demonstrates multiple
simple bilateral ovarian cysts in this patient with a hydatidiform
mole. A pocket of free fluid is present between the two ovaries (arro
Aboubakr Elnashar

17. (A) Transverse sonogram showing cystic mass containing multiple thin internal
septations, representing mucinous cystadenoma.
(B) Transverse transabdominal sonogram showing septated mass with
echogenic material (*) in upper loculated area. The echogenic material was
mucin within this mucinous cystadenoma.
(C) Malignancy was suspected due to thickened septation (arrow) within this
mucinous cystadenocarcinoma.
(D)Papillary projections (arrow) were found within this malignant teratoma.
Septated cystic masses.
Aboubakr Elnashar

18. (E) Transverse sonogram of complex predominantly
cystic right-adnexal mass with calcific focus (arrow)
arising from tooth within this dermoid cyst.
Aboubakr Elnashar

19. (F) Transvaginal sonogram of a pelvic mass in a woman with
a renal transplant. This was found to represent a luteal cyst
with fluid surrounding adhesion.
Aboubakr Elnashar

20. Peritoneal inclusion cyst.
Transvaginal grayscale image of the right adnexa
demonstrates a spider- web pattern with presence of
loculated fluid and an eccentric right ovary (OV).
Aboubakr Elnashar

21. Sagittal (G) and axial (H) transvaginal sonogram showing a multiloculated
septated cystic mass with focal wall thickening. This represented a
mucinous cystadenoma with one locule containing thick mucinous
material. Aboubakr Elnashar

22. A) Predominantly solid,
complex mass containing a
layer of echogenic material
(arrow) arising from sebum
within this dermoid cyst.
(B) Transvaginal sonogram
of granulosa cell tumor.
Complex predominantly solid masses.
Aboubakr Elnashar

23. C) Transvaginal sonogram of dermoid cyst with layer
of echogenic sebum.
Aboubakr Elnashar

24. Bilateral mature cystic teratoma.
Transverse grayscale image demonstrates bilateral mature
cystic teratomas (arrows). This image also shows the ‘‘tip
of the iceberg’’ sign. Incidentally seen is a fibroid
(arrowhead) in the anterior wall of the uterus (UT).
Aboubakr Elnashar

25. D) Transvaginal sonogram of hemorrhagic
ovarian cyst containing irregular solid area
corresponding to displaced hemorrhagic
ovarian tissue surrounding area of hemorrhageAboubakr Elnashar

26. (E) Longitudinal transabdominal sonogram (TAS) of ovarian
cystadenocarcinoma containing irregular solid areas.
(F) Magnified transverse TAS of cul-de-sac hemorrhage
(arrow) resulting from ruptured ectopic pregnancy.
Aboubakr Elnashar

27. (G) Transvaginal sonogram of dermoid cyst
showing typical echogenic hairball (arrows).
Aboubakr Elnashar

28. Hemorrhagic ovarian cyst.
(A)Transvaginal grayscale image of the right ovary
demonstrates a typical‘‘fishnet’’ appearance.
(B)Grayscale and color flow Doppler image of the
right ovarian cyst with a retracting blood
clot adherent to the cyst wall and absent vascularity.
Aboubakr Elnashar

29. Endometrioma.
(A) Transvaginal grayscale image demonstrates a
left ovarian cyst with low-level echoes.
(B) Transabdominal grayscale image of the pelvis
with bilateral endometriomas demonstrates the
‘‘kissing ovaries’’ sign. (UT, uterus.)
Aboubakr Elnashar

30. Hydrosalpinx.
Transvaginal grayscale (A) and color flow Doppler
(B) images of the left adnexa demonstrate serpiginous,
tubular, anechoic, and avascular structures in the left adnexa.
(LO, left ovary.)
Aboubakr Elnashar

31. Pelvic inflammatory disease.
(A) Transvaginal grayscale image demonstrates debris
within the dilated fallopian tube.
(B) Transabdominal grayscale image in patient with fever
and confirmed PID reveals pelvic abscess (arrows). (UT,
uterus.)
Aboubakr Elnashar

32. Polycystic ovarian disease.
(A) Power Doppler image of bilateral ovaries demonstrates multiple follicles.
(B) Corresponding four-dimensional images demonstrate ovarian volume
calculation in polycystic ovaries. Aboubakr Elnashar

33. Ectopic pregnancy.
(A) Transvaginal grayscale image demonstrates an extraovarian mass with an
embryonic pole (within calipers) and a tubal ring sign (arrows). (B) Grayscale and color
flow Doppler image demonstrates a nonovarian adnexal mass with tubal ring sign and
peripheral vascularity (ring of fire). (OV, ovary.)
Aboubakr Elnashar

34. Ovarian remnant syndrome.
Transvaginal color flow Doppler image of right adnexa in a
patient with
history of oophorectomy demonstrates an ovarian cystic
structure with surrounding ovarian tissue secondary to
hormone stimulation.
Aboubakr Elnashar

35. Surgically confirmed serous cystadenoma.
Transvaginal grayscale and corresponding three-
dimensional US image of the right ovary demonstrate a
complex cystic mass with a mural nodule that shows
vascularity on the three-dimensional image
Aboubakr Elnashar

36. Surgically confirmed mucinous cystadenoma.
(A, B) Grayscale images in two different patients
demonstrate multiloculated cystic lesion with septations.
Aboubakr Elnashar

37. Pseudomyxoma peritoneii.
Transabdominal grayscale image of the pelvis in a known
case of mucinous cystadenocarcinoma demonstrates
presence of loculated ascites. (UB, urinary bladder.)
Aboubakr Elnashar

38. Dysgerminoma.
Grayscale (A) and color flow Doppler (B) images of the
right ovary demonstrate a solid mass with increased
vascularity.
Aboubakr Elnashar

39. Krukenberg tumors.
Grayscale US image of the pelvis demonstrates bilateral solid
ovarian tumors in a known case of stomach cancer. (LO, left
ovary; RO, right ovary.)
Aboubakr Elnashar

40. Nongynecologic pelvic masses.
(A) Lymphocele. Grayscale image of the pelvis
demonstrates a complex septated fluid collection.
(B) Postpartum collection. Grayscale image of the pelvis
demonstrates a complex collection (coll) in the cul-de-sac,
consistent with hemorrhage. (LO, left ovary; RO, right
ovary; UT, uterus.) Aboubakr Elnashar

41. Subserosal fibroid.
Transvaginal grayscale US image of the pelvis
demonstrates a large solid adnexal lesion (Fib) arising
from the uterus (arrow). (UT, uterus.)
Aboubakr Elnashar

42. Conclusions
The majority of adnexal masses in women in
the reproductive years are follicle cysts of the
ovary.
 The most common benign neoplastic tumors
of the ovary are serous cystadenoma and
benign cysts.
 The most common benign cystic neoplasms of
the ovary in the 20- to 44-year-old group are
benign cystic teratoma, serous cystadenoma,
and mucinous cystadenoma.
Aboubakr Elnashar

43. Most benign cystic teratomas are 10 cm or less
in diameter, but about one sixth are larger.
 Serous cystadenocarcinoma is the most
common malignant tumor in all age groups,
from 20 to 75 years old.
 Dysgerminoma and teratoma are the most
common solid adnexal tumors in young
women.
Aboubakr Elnashar

44. Thank you
Aboubakr Elnashar