Adnexal Pathology Ovarian Neoplasms Flashcards by abbie anderson

____ cysts are the most common ovarian physiologic ovarian cysts

functional (benign)

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what type of cysts are these?

Follicular Cysts
Corpus Luteum Cysts
Hemorrhagic Cysts

what other type of cysts are there?

functional (benign)

parovarian

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explain follicular development

This is text for the following diagram starting with the
early primary follicle-left upper corner on diagram &
going clockwise
Following menses 4-5 primary follicles begin to
grow. Follicle growth produces low levels of
estrogen and minute amounts of progesterone.
High amounts of estrogen is produced by the
maturing follicles thus increasing blood estrogen
levels. High estrogen levels inhibit FSHRF thus
inhibiting secretion of FSH.
The Graafian follicle is the mature dominant follicle.
Normally, only one follicle dominates and the others
decrease. The Graafian follicle produces estrogen
and increases the endometrial lining to prepare for
implantation. It also secretes a small amount of
progesterone and the ovum undergoes meiosis. The
LH surge causes ovulation. The blue area is the
degenerating follicle

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what are these?

describe them sonographically

Functional Cysts - Follicular Cysts (f)

US Findings
– Usually multiple
– Thin-walled
– Unilocular
– Anechoic
(Green oval outlines theovary)

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where do follicles grow? what is the f? what phase of growth is this?

Early Follicular Phase

Note all the follicles growing around the
outside / periphery of the ovary. The left
image with the ‘F’ has one that seems to
becoming dominant

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what phase is this? what’s happening?

Late Follicular Phase
Dominant Follicle (note the small
calipers) will become the Graafian follicle

This follicle is getting the ovum inside ready to be
fertilized

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what is the us criteria of a simple cyst?

aka benign functional cyst

Anechoic
Smooth, thin walls
Posterior enhancement (yellow lines)
The ovarian outline is green

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what functional cyst has teh following clinical findings?

– Asymptomatic
– Pressure symptoms if the cyst becomes too large

Ruptured Dominant Follicle

– No longer meets simple cyst US criteria. Note the inside of the follicle does not have the classic ‘simple cyst’ appearance. The walls have collapsed (arrows) and so it is no longer a simple follicle

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___________ are functional preparing for pregnancy note
the wall thickness is thicker but not as
thick as with pregnancy
Corpus luteum during a pregnancy can
measure up to 5 cm and is associated
with maintaining the1st 10 weeks of
pregnancy
– These are generally resolved by 16 weeks
GA

Functional Cysts
Corpus Luteum Cysts

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what is this? describe it.

Functional Cysts
Corpus Luteum Cysts

US Findings
– Sonolucent to hypoechoic compared to ovary
– Smooth-walled
– Posterior enhancement
– Free fluid in cul-de-sac if ruptured

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_____cysts occur in the initial 2-3
weeks of the cycle

________ cysts occur in the final 1-2
weeks of the cycle

Graafian follicle

Corpus luteal

Majority of functional cysts will undergo
spontaneous regression, a 6-week US
follow-up (F/U) is warranted to make sure
a suspicious cystic lesion is not
pathologic

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What clinical findings are associated with the Benign Adnexal Cysts Hemorrhagic Cysts (Ovarian cysts are
commonly complicated by hemorrhage)

Clinical Findings
Pelvic pain, tenderness, may delay menstruation
Mimics ectopic pregnancy
Pain can be severe especially if cyst
– Ruptures
– Or there is torsion of the ovary with the cyst

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what is the ddx of hemorrhagic cyst (benign adnexal cyst)

US Findings:
Complex mass, depending on age of
hemorrhage (any simple cyst that hemorrhages
may appear as a complex mass)
Posterior enhancement
Differential diagnosis

– PID
– Ectopic pregnancy
– Cystic teratoma or dermoid
– Use patient symptoms to help the order of your differential list.

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what is this?

Acute
– Usually hyperechoic
– May mimic a solid mass
(top images – note follicles
in ovary enhancing too)
– Will have posterior
enhancement (yellow area

Hemorrhagic Cyst

Vary on amount and age
of hemorrhage

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what is this?

what do you need to be aware of?

Hemorrhagic Cyst
US Example of ‘Ring of Fire’
No vascular flow within the cyst
F/U US to distinguish between an endometrioma
& a corpus luteum with hemorrhage

If the corpus luteum is examined shortly
after ovulation, a ring of vessels will be
seen called a ‘ring of fire’ which disappears
after the corpus luteum hemorrhage has
been there for a while
A hemorrhagic cyst may be surrounded by
increased vascularity, but not have flow
within the cyst
Ectopic pregnancy can have ‘ring of fire’ too
which is why it is a differential diagnosis

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___ Accounts for approx. 10% of adnexal masses

Cyst involving the broad ligament
May have arisen from embryonic ducts
» Mesonephric/Wolffian
» Mesothelial
» Paramesonephric
» Hydatid of Morgagni

Paraovarian Cysts

(Benign Adnexal Cysts)

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what is this?

what abou tits us findings?

Note its’ location it is separate from ovary
Typically asymptomatic
On US may be unilocular or multilocular *
terms you’ll need to know
– May resemble serous cystadenomas

Thin walled without ovarian tissue around cyst
– Cyst size does NOT change with menstrual cycle
– May be difficult to distinguish from ovarian cysts

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what are teh most common clinical findings of a benign adnexal cysts?

Ovarian cysts are usually asymptomatic
They often are an incidental finding during
ultrasounds performed for other reason
Lower abdominal pain is the most common symptom
reported
Pain can be sharp, intermittent, sudden in onset, and
severe
A sudden onset of abdominal pain may suggest cyst
rupture but more serious etiologies must be
considered, including adnexal torsion, perforated
viscus, or ectopic pregnancy

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It is abnormal to find a cyst in a
postmenopausal woman who is
NOT on hormone replacement therapy

Finding a palpable mass or cyst in
these women should prompt a
thorough search for the type of
ovarian neoplasm

Adnexal Cysts
Postmenopausal women

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what types of tissue do the ovaries contain?

Epithelial-Stromal cells Covers the ovary
Germ cells Produce the ova that are formed on
the inside of the ovary
Sex-Cord Stromal cells. These produce most of the estrogen & progesterone

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what are the 3 main types of ovarian tumors

Epithelial-Stromal tumors start from the cells that cover the outer surface of the ovary. Most ovarian cancers start in this epithelial covering
Germ Cell tumors start from the cells
that produce the ova
Sex-Cord Stromal tumors start from connective tissue cells that hold the ovary together and produce the female
hormones estrogen and progesterone

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what are the 3 sub-groups for the epithelial ovarian tumors?

Benign epithelial tumors
Tumors of low malignant potential
Epithelial ovarian cancers

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______ tumors are

Most common ovarian tumor type at 65-75%

what are the common varieties, less common?

epithelial-stromal tumors

Common Varieties
Serous Cystadenoma - Serous Cystadenocarcinoma
Mucinous Cystadenoma - Mucinous Cystadenocarcinoma

Less Common Varieties
Brenner Tumor / Transitional Cell Tumor
Endometrioid Carcinoma
Clear Cell Carcinoma

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Serous Cystadenoma is the

__________ benign ovarian tumor
______are unilateral
Typical patient is _____years old

2nd most common (following dermoid)

70%

20-50

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\_\_\_\_ is Usually unilocular Thin-walled, fluid filled (serous fluid) May grow up to 20 cm May contain low-level echoes due to debris May have small mural nodules typically less than mucinous cystadenoma Anechoic Posterior enhancement Some may be multilocular Septations are typically thin Amount of septations varies

Serous Cystadenoma

what are typical findings w/ mucinous cystadenoma?

Typical patient is 20-50 years old, (13 – 45 years per Hagen-Ansert) Benign cyst with sticky, gelatinous mucin contents Multilocular daughter cells 10% malignant (usually after menopause)

mucinous cystadenoma us findings: how large can the become?

Usually unilateral More septations than serouscystadenoma Fluid filled mucin seen within mass May see fluid-fluid levels of fluid-debris separated by septa within mass Can become extremely large 15-30 cm

what is a brenner tumor aka what is it? is it benign or malignant?

Transitional Cell Tumor Relatively uncommon neoplasm Usually appears post-menopause Usually unilateral Well-encapsulated solid lesion can be either.

\_\_\_\_ is the 2nd Most common ovarian tumor type at 15-20% varieties incl: Teratoma – Benign » Mature AKA Dermoid – Malignant » Immature -- Dysgerminoma (Malignant)

Germ Cell Tumors

\_\_\_\_\_ is Associated with increased Alpha-fetoprotein (AFP) Human chorionic gonadotropin (hCG) Typically unilateral

germ cell tumors

what is a benign mature teratoma aka is it a common ovarian neoplasm? is it uni or bi -lateral?

dermoid Most common ovarian neoplasm Can be bilateral in approximately 15% Typical patient is of childbearing age Size variable Can cause pain if hemorrhage cause undergoes torsion

what do dermoid masses contain? what is it? what do they contain?

Benign Mature Teratoma. Mass contains variety of: Ectoderm, Mesoderm, Endoderm A bizarre tumor in the ovary that typically contains a variety of tissues including hair, teeth, bone, fat, thyroid, etc.

describe a dermoid on us? what can it be confused with?

Range of appearances depends on the amount and type of contents within the mass – This photo shows the tumor turned inside out bowel. Example: This US Shows a highly echogenic intraovarian mass with no normal ovarian tissue

what is this?

Benign Mature Teratoma AKA Dermoid Range of Appearances – Highly echogenic areas – Uniform echoes Example: The small, highly echogenic, (hyperechoic to the ovary) mass in an otherwise normal ovary

what is this? 17 year-old female with h/o left adnexal pain for 8 months (Selected trans-abdominal and trans-vaginal ultrasound images demonstrate a complex cystic/solid mass with the solid component predominating A dermoid cyst was suggested in the differential diagnosis. Surgical excision and subsequent histology confirmed the diagnosis of mature cystic teratoma/dermoid cyst with ectodermal, mesodermal and endodermal derivatives On gross examination, sebaceous material admixed with hair was seen. This may account for the "frond like" pattern seen on the transvaginal images. It is interesting to note the increased information about the internal architecture/anatomy of the mass when comparing the trans-abdominal images above with the trans-vaginal images)

dermoid. below is known as "tip of the iceberg sign" Example: Transverse TA image showing the uterus (U). In the right adnexal region there is a highly echogenic and attenuating mass (arrows). This is the classic ‘tip of the iceberg’ sign where the ‘top of the mass’ is seen but the mass attenuates the sound beam hiding the rest of the mass (think about the Titanic ship – the sailor saw the ‘tip of the iceberg’ but under the water the iceberg was huge and couldn’t be seen and cut a hole in the ship sinking it)

what has Elevated AFP is ½ of patients Typically occurs in 10 to 20 year old females Rapid growth rate Rare, yet \_\_\_\_\_\_\_\_\_\_\_\_ Solid malignant tumor with areas of necrosis & hemorrhage seen as multiple small cysts on US

Malignant Immature Teratoma Rare yet They are the most common malignant germ cell ovarian carcinoma Malignant solid tumor mostly occur in females under 30 years of age

what is this?

dysgerminoma - solid mass, may or may not have cystic areas w/i due to hemorrhage and/or necrosis Example: Transverse TA US in young woman shows a large, solid pelvic mass (M) adjacent to the uterus (U) Note: The most common explanation for a solid adnexa mass is a pedunculated uterine fibroid so it is important to find the organ or origin for the mass Differential most common to least common, then add clinical findings and rearrange list.

These types of tumors tend to be functioning and, by producing estrogens or androgens, may have dramatic clinical presentations Vaginal bleeding in postmenopausal women & pre-puberty girls (breast development in young girls) If male hormones are produced then facial & body hair may occur Typically solid adnexal masses

Sex Cord-Stromal Tumors

what type of sex-cird stromal tumors are there? what is the incidence

Incidence is 5-10% per Rumack Granulosa Cell Tumor (Low Grade cancer) Thecoma AKA Theca (Benign) Sertoli-Leydig Cell Tumors (Low Grade cancer) - Arrhenoblastomas, Androblastomas Fibroma (Benign tumor that DOESN’T function)

what type of tumor is a feminizing neoplasm composed of the granulosa cells of the Graafian follicle It is the most common of the _____ tumors of the ovaries Estrogen is produced by these functioning tumor Age determines clinical signs

granulosa cell tumor hormonal

If the patient is: Pre-menarche -- Causes pseudo precocious puberty Of reproductive age -- Metrorrhagia Post-menopausal -- Abnormal uterine bleeding they may have...

Granulosa Cell Tumor

what Benign solid functioning ovarian, rarely malignant Typically occurs in older women with the mean age at 59 FYI 84% occur after menopause 60% have abnormal bleeding 20% have endometrial carcinoma

Thecoma / Theca Cell

what tumor is AKA Arrhenoblastomas and Androblasomas

Sertoli-Leydig Cell Tumors

describe a sertoli-leydig cell tumor (AKA Arrhenoblastomas, Androblasomas) and its clinical findings us findings

Solid, uncommon group of tumors Hormonally active – producing / secreting androgens (mainly testosterone) causing virilization Clinical Findings Associated with amenorrhea & infertility May become malignant US Findings Unilateral Solid tumor with cystic components Well encapsulated Size can vary

what Benign, non-functioning solid lesion 90% are unilateral is Associated with Meigs’ syndrome?

fibroma

what are the 4 characteristics meigs' syndrome? what type of tumor is it associated with?

Has 4 Characteristics Ovarian mass (solid) Ascites Pleural effusion Resolves following surgery fibroma

what is this? describe it.

US Findings Solid ovarian mass Hypoechoic Little to no throughtransmission Similar to leiomyoma however it is NOT connected to the uterus

what blood test is available to test for women at high risk of ovarian cancer?

“For women at high risk of ovarian cancer or who have symptoms of ovarian cancer, transvaginal sonography & CA-125 blood test, in addition to the pelvic exam may be able to detect the disease.” quote American Cancer Society

2010 Estimates from American Cancer Society “New cases \_\_\_\_ Deaths per year \_\_\_\_ 5 year relative survival rate for localized stage: 93% 5 year relative survival rate for all stages combined: 46% 10 year relative survival rate for ovarian cancer patients is 38%”

21,880 13,850 “This is a cancer that mainly develops in older women. Around two-thirds of women are 55 or older. It is slightly more common in white women than African-American women.” quote American Cancer Society

\_\_\_\_\_\_ carcinoma – resembles low-grade transitional cell carcinoma of urinary bladder. Newly described but patients typically present with advanced disease and have a poor prognosis.

Transitional cell (Brenner)

ovarian carcinoma

\_\_\_\_ is the Most common malignant tumor of the ovary Majority of ovarian cancers are serous cystadenocarcinomas (85 to 90% per cancer.org) Occurs mostly from age 40 – 60 years, 50 - 70 years per HA and is Rare under age 35

Serous Cystadenocarcinoma

what are these US Findings associated with? Predominately cystic with variable thick walls with solid components inside Usually multilocular 25 - 30% bilateral at time of diagnosis Ascites if metastases has occurred

Serous Cystadenocarcinoma

describe these doppler findings associated with Serous Cystadenocarcinoma

Doppler Findings Extensive nodularity with vascularity confirms the morphologic suspicion of a malignant mass There is high diastolic flow, low RI

what is this? how can you tell?

Mucinous Cystadenocarcinoma US Findings Large cystic multiloculated Solid masses hemorrhage and necrosis are commonly present The image demonstrates septal nodularity (arrows) which raises the suspicion of malignancy

This 48-year-old female (G4 P2 Ab2) who presented with an enlarging abdominal girth over the last six months as her only complaint At her annual exam, a pelvic mass was discovered what is it?

Mucinous Cystadenocarcinoma At surgery a 22 pound mass was removed The histological diagnosis was low grade mucinous cystadenocarcinoma

what are the 4 stages of ovarian carcinoma?

Stage I. Growth limited to ovaries Stage II. Extension of neoplasm into the pelvis Stage III Disease extension to abdominal cavity Stage IV. Distant metastatic disease

what is the incidence of metastatic tumors? where do primary ones occur?

5-10% Uterus Stomach Colon Breast Lymphoma

\_\_\_\_ is teh Metastatic spread from carcinoma of the G.I. tract commonly spreads to the ovary

Krukenberg’s Tumor

what is this? describe it.

Krukenberg’s Tumor US Findings Bilateral ovarian masses Can be completely solid or solid with ‘moth-eaten’ cystic pattern Associated ascites

Adnexal Pathology Ovarian Neoplasms Flashcards

(60 cards)