The document discusses sonographic evaluation of pelvic masses. Transvaginal sonography (TVS) is useful as an adjunct to transabdominal sonography (TAS) for evaluating the uterus, adnexa, and tumor composition and location. Although sonography may not allow a specific diagnosis, it can provide clinically useful information on size, consistency, contour, origin, and relationships to other structures. Sonographic assessment of tumor morphology and features like irregularity, papillary structures, and blood flow can help distinguish between benign and malignant masses. Masses may appear purely cystic, complex cystic, or purely solid, and sonography can identify characteristics that suggest certain pathologies.

1. Sonographic Evaluation
of Pelvic Masses
Prof. Aboubakr Elnashar
Benha university Hospital, EgyptABOUBAKR ELNASHAR

2. Contents
1.Parametrs of pelvic US
2.Transvaginal sonography of pelvic masses
3.Sonographic differential diagnosis
1.RuLes
2.Benign or malignant
3.Type
Summary
ABOUBAKR ELNASHAR

3. 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
ABOUBAKR ELNASHAR

4. 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}
ABOUBAKR ELNASHAR

5. Color Doppler sonography (CDS)
helpful in distinguishing
benign from malignant ovarian masses
evaluation of adnexal torsion
an adjunct to morphologic assessment of
ovarian lesions.
ABOUBAKR ELNASHAR

6. 2. DD between benign and malignant
ABOUBAKR ELNASHAR

7. Morphologic scoring by TVS.
Each of four parameters as assessed
Malignancies tended to have high scores (over 9).
ABOUBAKR ELNASHAR

8. 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).
ABOUBAKR ELNASHAR

9. 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).
ABOUBAKR ELNASHAR

10. 3. Type of mass
ABOUBAKR ELNASHAR

11.  Purely cystic:
more likely to be benign
 Complex cyst :
more likely to be malignant.
 Purely solid:
more likely to be benign.
ABOUBAKR ELNASHAR

12. ovary
uterus
Unilocular, thin-walled, anechoic
I. CYSTIC
Simple Cystic
ABOUBAKR ELNASHAR

13. Unilocular
Thin-walled
Anechoic
Follicular cyst ABOUBAKR ELNASHAR

14. Simple cysts
Corpus luteal or follicular cyst
Haemorrhagic cysts
ABOUBAKR ELNASHAR

15. Massively enlarged
ovaries
Thin-walled septation
Ascites may be present
OHSS
ABOUBAKR ELNASHAR

16. Hydrosalpinx
Tubular-shaped
structure
Anechoic content
Incomplete septum
ABOUBAKR ELNASHAR

17. Low-level echo cysts
1. Endometrioma 95%
2. Hemorrhagic cyst 50%
3. Teratoma 18%
4. Malignant Neoplasm 12%
(Patel et al, 1999.)
ABOUBAKR ELNASHAR

18. Anechoic with lacelike
internal echoes within cyst
Hemorrhagic C.
Corpus Luteum
ABOUBAKR ELNASHAR

19. Low-level echo cysts + Characteristic
Features
Endometrioma
Hyperechoic wall foci (in
35%)
Hemorrhagic cyst :
Lacelike internal echoes (in 40%)
Teratoma
Regional bright echoes ( in 97% )
ABOUBAKR ELNASHAR

20. Diffuse ‘ground glass’ pattern
{old blood}Endometrioma
ABOUBAKR ELNASHAR

21. smooth-walled ovarian cyst. Same patient after 5 w.
complete regression of the
physiologic cyst.
ABOUBAKR ELNASHAR

22. 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
ABOUBAKR ELNASHAR

23. Mucinous cystadenocarcinoma
Malignancy was suspected
due to thickened septation
(arrow)
Malignant teratoma.
Papillary projections (arrow)
ABOUBAKR ELNASHAR

24. 1-Dermoid Cyst
The commonest 36%
2-Endometriotic cyst 5%
3-Malignant Cyst 1-3%
II. COMPLEX CYST
ABOUBAKR ELNASHAR

25. Dermoid
Complex mass solid and
cystic (fat, bone)
Fill in Pattern
ABOUBAKR ELNASHAR

26. Echogenic mural nodule in cystic mass.
Papillary serous Cystadenoma
Few small papillae
ABOUBAKR ELNASHAR

27. Mucinous Cystadenocarcinoma
Solid areas Many papillary. P
ABOUBAKR ELNASHAR

28. COMPLEX
Dermoid cyst.
Transverse sonogram of
complex predominantly cystic
with calcific focus (arrow)
arising from tooth
luteal cyst
with fluid surrounding
adhesion.
ABOUBAKR ELNASHAR

29. 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
ABOUBAKR ELNASHAR

30. Dermoid cyst
layer of echogenic sebum
(*).
Hemorrhagic ovarian cyst
irregular solid area
corresponding to
displaced hemorrhagic
ovarian tissue surrounding
area of hemorrhage.ABOUBAKR ELNASHAR

31. Ovarian cystadenocarcinoma
irregular solid areas.
Magnified transverse TAS of
cul-de-sac hemorrhage
(arrow) resulting from
ruptured ectopic pregnancy.
ABOUBAKR ELNASHAR

32. Dermoid cyst
typical echogenic hairball
(arrows).
Dermoid cyst.
TV-CDS showing vessels
within the solid part
ABOUBAKR ELNASHAR

33. Transverse sonogram
showing enlarged right ovary
(between +’s) with echogenic
areas consistent with
hemorrhage due
to ovarian rupture.
Same patient showing
intraperitoneal fluid
representing blood from
ruptured ovary.
III. SOLID MASSES.
ABOUBAKR ELNASHAR

34. 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).
ABOUBAKR ELNASHAR

35. Interligamentous fibroid (*)
appearing as solid pelvic
mass.
Transabdominal sonogram of
predominantly solid undifferentiated
ovarian neoplasm (arrow) containing a few
cystic areas.
ABOUBAKR ELNASHAR

36. Cystadenofibroma
TAS
solid pelvic mass
with calcifications (arrow) in
elderly patient.
Longitudinal TAS of pelvic
kidney (arrow). Pelvocalyceal
system accounts for central
echogenicity.
ABOUBAKR ELNASHAR

37. Transverse TAS showing
solid left-adnexal mass
(between +’s), which
represented hemorrhagic
corpus luteum cyst.
Longitudinal TAS of solid
teratoma with calcified areas.
ABOUBAKR ELNASHAR

38. TAS: 5 × 7 cm solid mass
associated with ascites.
This was ovarian cancer.
TVS
large solid tumor representing
a dysgerminoma
ABOUBAKR ELNASHAR

39. 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

40. 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 extraovarian
masses 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.
ABOUBAKR ELNASHAR

41. Thank you
ABOUBAKR ELNASHAR