Sonographic Evaluation of the Ovary: To Worry or not to Worry? - SD

Introduction

My name is Stay Lang
and I'm currently working at
Georgetown University Hospital in the Department
of Radiology in Washington DC where I am part
of the abdominal imaging section and professor of radiology.

Today we will be talking about ultrasound of the ovary
to worry or not to worry.
Today we're gonna talk about the ovary.
I just wanna say a brief hello again.
And some of you may know that I recently moved
to Georgetown or to Washington DC beautiful city.
We see Thomas Jefferson,
and this is actually
where I work now in Georgetown University Hospital.
It's on the campus of a beautiful university.
This is part of the university, one of the buildings.
And Georgetown,
if you've not visited it is a very special place.
It's in our nation's capital.
A lot of people live in these beautiful big homes.
I'm lucky I could afford something a little more modest as we see here.
And I'm having a great time in Washington DC.

Before I was in Georgetown, I worked in Boston for 18 years
where I was up at Harvard.
And some of you may recognize this logo from Harvard.
Very formal, very fancy.
So I thought when I went to Georgetown, I should replace it
with an equally beautiful logo from Georgetown
University Hospital.
So I went searching
and the best I could come up with was Jack the Bulldog,
who is a very big favorite on the campus of this university.
So I urge you if you can come and visit us.

Ultrasound of the Ovary: To Worry or Not to Worry

So today we're gonna talk about ultrasound of the ovary,
whether or not we should worry,
of course we wanna feel secure as we're doing our imaging,
not feel that we are hanging on for dear life
by our fingertips.
And we'd like to be up here with our friends.
Fortunately, most women who we examine have normal ovaries.
And here we have the sort of index appearance to an ovary
with a beautiful ovoid shape, small peripheral follicles.
And this is what we would love to see in all patients.
But we know that not uncommonly things happen in the ovary.
And it's very important that we are able to recognize things
that happen to the ovary that are either worrisome
or as in the majority of patients, the great majority things
that are not worrisome.
And we're gonna stress this in the discussion
that we are gonna have in the next few minutes.

Of course, sometimes we see things in the ovary
that are clearly disturbing, as in this nice diagram
or schematic seen.
All of these come right the way from Dr.
Netter and his group, Frank Netter, to which I want
to give a big thank you.

Starting Scans and Patient History

So it's very important when we're starting to do our scans,
we typically begin our abdominal scans.
We begin with an abdominal scan
and then often go to a vaginal scan
to know the patient's history.
Now this woman came in clearly had a palpable mass on
more than a single occasion.
And I think it's very easy when you look at a scan like this
to say you don't see anything significant.
There's a little bit of fluid in the pelvis here,
which is not uncommonly seen
and it's not necessarily a problem.
But what is more difficult in this case is to realize that
that is not the bladder that is an ovarian cyst
that mimics the bladder.
As a matter of fact, there is the bladder in this patient.
It's not well distended.
So how do you find that you don't get yourself in trouble?
Because to miss a 10 centimeter ovarian cyst
for a sinologist would truly be in an
embarrassing situation.

The first thing I'd like to stress is
to know the history of the patient.
If somebody consistently feels a mass
and you are only seeing one ovary, you don't see an ovary on
that side, be concerned that perhaps you're dealing
with a mimicker for the bladder,
in which case this would be the ovarian cyst.
The second thing is, if I was doing a scan like this,
I'd say to the woman, now empty your bladder.
I'm going to do a vaginal scan.
But you quickly she'll tell you
that she just did empty her bladder and it's empty.
So there's a mismatch here.
You could get out of this problem
and solve it in several ways.
One is you could ask the woman to drink a lot of water
to try to fill up her bladder,
make sure this isn't the bladder.
You could also put a Foley catheter in.
But what I like to do is when I'm doing my vaginal scan,
every time I put the transducer in I can see the urethra.
And the urethra of course is a landmark
because it will connect to the bladder
and you'll quickly recognize this to be the bladder
and that to be separate from it.
And so there's nothing intrusive to the patient
in terms of discomfort like a Foley catheter
or discomforting like filling her bladder
to get it very distended.
So I urge you to remember this case, be aware of mimics,
there are many others that you can see
as we see here being pointed to by the various arrows.
And what these are in the,
these particular cases we're dealing with bowel vessels
and even fibroids that can mimic the ovary.

Obviating Mimics

So how do you obviate the problems here?
One is a real time scan is certainly a good way to
bail yourself at 'cause bowel should perol.
So if you compress it with the probe, you'll see
that bowel will compress
and maybe you'll start peristalsis vessels.
You could either put color flow on as we see here,
but typically these are small veins that have flow in them.
And if you were to just turn up your gain setting,
you will see the slow flow.
The echoes move slowly within these veins.
And also of course you can compress them
with the probe similar to
how you do a DVT study, compressing the veins.
So the main thing is to recognize that these are not,
this isn't the ovary
and sometimes these veins can mimic follicles.
So be aware of this and solve the situation.
Go elsewhere, look for the vessel, look for the ovary.

Now this case is probably the most problematic
because I think it really does look like an ovary,
but you can see I'm taking the probe
and I'm blotting by the uterus.
And this structure sticks with the uterus,
therefore it's part of the uterus and
therefore it would be a subserosal fibroid.
So once you recognize this, take your picture
and then move elsewhere to find the ovary.

Finding Ovaries with Large Pelvic Masses

Now I begin all my scans, transabdominally
as I showed you in the initial case with that pseudo ovary,
pseudo bladder due to the ovary.
Here's another example, big mass in the pelvis, which
would most likely be a fibroid, which is what it is.
But the question is, at this point, can I find an ovary?
And many people give up very quickly saying I'll never find
an ovary with such a big mass, as in this case
with a big fibroid.
And I would like to urge you not to have this attitude
because when there's a big mass in the pelvis,
the ovary typically goes in one of two places.
One is it's moved superior to the side,
so lateral and superficial.
So that's up out and superficial.
Or if it's not there, it may be located deep in the pelvis.
So what I would do at this point is change my transducer
to one that could see better superficially
and I'd go looking for the ovary.
So in this case we changed to a curved probe,
a higher megahertz that's being six, the other being four
harmonics is on to get rid of the noise, you can compress
with this probe.
And sure enough we see two normal appearing ovaries.
And at this point the study is probably finished
because you're not gonna see this uterus better
with a vaginal scan.
Had I not seen the ovaries,
however, I would've proceeded to do a vaginal scan
to see if I could find the ovaries deep in the cul-de-sac.
But the main thing,
or in the pelvis, the main thing I would like
to stress is don't give up
and say I can't find the ovaries in a patient
who has a large pelvic mass
because you will be rewarded if you know where
and how to find them.

Approach to Ovarian Cysts: The Big Six

Now what I'd like to focus a large part of this lecture on
is an approach to women who have cysts in their ovary
because most things that happen to the ovary are cystic.
And I would like to suggest that if you have one
of these six conditions, which I will call the big six,
they're all common benign
and recognizable, you are gonna be able to see
at least 90 to 95% of the conditions that affect the ovaries
and you'll know what to do with them.
And this is obviously important
because in these situ, in this situation, all
of these conditions are benign.

1. Physiologic Cysts

So we've already mentioned that what happens
to the ovary is it develops cysts far and away.
The most common cysts
that develop are the physiologic cysts associated
with the normal menstrual cycle.
Or sometimes the cycle goes becomes a bit confused
and you no longer have a normal cycle.
And this is because of the associated hormones, typically
estrogen and progesterone that cause the cycle
to become abnormal.
And you develop what we call functioning ovarian cysts.
So far and away these are the most common.

Now again, thanks to Dr. Netter's beautiful diagram.
We can see what happens to an ovary in a cycle immediately
after menses there are no dominant follicles,
but by the time day 14 rolls around, we develop a follicle
that is typically larger than the others and has the egg
or cumulus within it.
After ovulation, we then develop the corpus lutetium.

Whenever I do a gynecologic scan,
I always ask the patient two questions, one,
when was your last period?
And two, are you on hormones?
Because I want to tie what I see on the ultrasound exam to
what her responses are relative to
where she is in her cycle.
And I know that follicles
become their largest just prior to ovulation.
They can become as large as 30 millimeters
and they're associated with estrogen production.
And here we have case number one on day 14
showing a follicle with a little cumulus.

So how do I report this?
Well this is a normal finding for this woman.
We'll talk about in a minute
an a recently published consensus as to
how we should address this situation.

Now, right after ovulation you develop the corpus lium
and I put the word cyst here in quotations
because as we can see, that cyst quickly involutes
to become more or less solid looking,
but we need to recognize them.
They also can be up to about 30 millimeters
and are associated with progesterone production.
And here we have case number two of a corpus lium
immediately after ovulation or shortly thereafter.
Notice the thick irregular granulated wall.
If I was to put color on this, there would be flow within
that wall with a low resistance pattern.
As the follicle matures,
it involutes becomes more solid looking.
And if you were to put duplex on,
you would see the color is only in the periphery
with a low resistance flow that in every way can mimic a
neoplastic flow pattern.
But be careful because of the history
and the appearance on the gray scale are consistent
with a corpus lium.
This is a normal finding in a woman who is ovulating.

2. Functioning Ovarian Cysts

Now sometimes the cycle doesn't continue.
Normally you may fail to ovulate, you may fail
to involute a corpus lium
or you may hemorrhage into it, in which case you may end up
with what we call a functioning ovarian cyst.
And the word functioning implies there is an excessive
amount of hormone in the neighborhood, progesterone
or estrogen for the corpus lium
and the follicle respectively.

So starting with a follicle, a functioning follicle is one
that is greater than the three centimeters
that I talked about before.
And you may, it would be in a patient who often may fail
to ovulate and you're left with this large follicle cyst
or functioning follicle.
The corpus lium may hemorrhage, it may even the ovary
or the cyst may actually rupture
and you can get even a large hemoperitoneum in association
with these functioning corpus luteal cysts.

So here we have a functioning follicle.
It measures roughly three by five centimeters.
It's simple and given time, usually a few months.
This should involute.
Here we have one of the appearances
for a hemorrhagic corpus lium.
This is associated with increased progesterone
and also given a few months this will involute
the third kind of functioning cyst seen here
where we see multiple large
peripheral cystic structures or follicles.
And these are seen in certain conditions
where there is a million of increased HCG on board
and these are follicles then that are stimulated
and all follicles live in the periphery,
pretty much of the ovary.
So that's what these are
and they're stimulated by the HCG to get large in a patient
who has uni.

The history here either been given HCG in an effort
to become pregnant, perhaps overshot the mark
and had the development of a multi fetal pregnancy,
in which case each placenta will in itself
elaborate HCG.
So again, an excessive amount of HCG on board
to stimulate the ovary or a patient who has one form
or another of gestational trophoblastic disease such
as a classic mole
or even down the range of these conditions
to choriocarcinoma people who have too much HCG on board,
I'm sure you know, can be prone
to have fluid collections in the way of ascites,
pleural effusions or even pericardial effusions.
These patients are treated depending upon the etiology
for their thecal lutian cysts.
And in many cases, particularly the top two,
it's watchful waiting.

Consensus Conference on Ovarian Cysts

So in late 2009, a group
of many people
with great experience in ultrasound
and interest in ultrasound convened with the Society
of Radiologists and ultrasound meeting for a two day
consensus conference addressed to what we should do
with ovarian cysts.
This was in late 2009 in Chicago.
And Debbie Levine, who's currently one of the editors
of radiology, wrote the paper
that has now been published in at least three
places that I know of.
One is ultrasound quarterly, another is radiology.
And the third one I believe is in the
gynecologic literature.
Basically we're trying to disseminate this information,
as I said, from experts in radiology, ologists,
gynecologists, pathologists, so many and
and statisticians.
So many people who are interested in the business of what
to do with many of these cysts.

So what they addressed
and said with respect to pre-menopausal cysts,
what do you do about them in terms of follow up?
Their suggestion is if it's a simple looking cyst,
three centimeters
or less, probably don't even need to report it
and certainly don't need to get a follow up
because these are normal physiologic cyst seen
with the normal menstrual cycle.

Now what's confusing is if you see a cyst in other organs
like the liver or the kidney, that's not normal.
But I wanna emphasize the point made by many
of us at that conference.
Cysts are normal in the ovary
and so if it's normal, don't mention it,
but make sure you know the patient's history with respect to
one, when was your last period?
And two, are you on hormones?
And knowing where you are on the cycle
and assuming the history is she's not on hormones,
you should be able to figure out if you're dealing with a
physiologic follicle, if it's between three
and five centimeters,
it's probably gonna be a functioning follicle,
in which case you know it should disappear in a
period of a few months.
The people who are addressing this meeting agreed
that we should put this in the report,
but no need to follow it since they should go away.
It's only those large cysts somewhere between five
and seven centimeters.
That should undergo a yearly follow up.
And we'll talk more about this again
as we continue in this lecture,
but seven centimeters appears to be the recent
newly announced cutoff
for when we should start to intervene.
Perhaps because of the threat of torsion when things get
that large, a hemorrhagic cyst should be treated in the same
way as a physiologic follicle in
that the small ones we can ignore in terms of follow up,
perhaps report the larger ones,
but they too should disappear within
a period of a few months.
The larger ones probably a good idea
to get a short interval follow up
because sometimes these hemorrhagic cys can
mimic endometriomas.
There's a crossover in their appearance
and just to make sure that they do go away then.
So it would be a good idea then to,
to follow these if they stayed, entertain the thought
of an endometrioma.

3. Non-Neoplastic Cysts: Postmenopausal, Polycystic, Hemorrhagic, Endometriomas

Now what about the large group of patients
who have non neoplastic cysts?
And certainly we'll talk about neoplasms.
What we wanna talk about
with non neoplastic cysts are these three postmenopausal
polycystic ovaries
and go into more detail with respect
to hemorrhagic processes that could include endometriomas
and hemorrhagic cysts.

So let's start with postmenopausal women
who have cysts in their ovary.
The first thing I would like to do is put color on
and make sure there we are dealing
with a cyst in the ovary.
The other fluid collection was just a vessel point.
One is that postmenopausal ovaries,
whether you're on hormones
or not, should not be terribly vascular.
So note whether they are or not,
and hopefully they won't be.

Now many articles have been published about postmenopausal
cysts and the first one was again Debbie Levine.
She was either a medical school student
or a radiology resident at this point in time
who noted a large number of postmenopausal cysts
and commented that cancer did not develop in any case.
And this has been subsequently shown in other literature
that has been published.
And these cysts have been measured as five centimeters
or less in diameter.
The article that Dr. Levine wrote noted a 17% incident,
subsequent articles, a lower incidence possibly
because of the size of these cysts.
If you measure every teeny little fluid collection,
you will have a higher incidence.
But most of these are about, I'd say about half
of these are gonna resolve within the next year or two.

Should you follow up these cysts.
The consensus statements suggest
because they're so common
to see small cys in post-menopausal women
that if they're a centimeter
or less probably should not follow them up
and consider even not reporting them as again,
you start mentioning the word cyst,
these people will come back to you
and since these are benign, non-threatening condition,
don't need to follow them up between one
and all the way up to seven centimeters.
The consensus statement said definitely to report this
and then consider doing a yearly follow up.
Many of these cysts are gonna stay stable in size
or grow very, very slowly, which is the why the thoughts were
that they don't need to be reported.
But once you get to be maybe seven centimeters because of the threat
of possible torsion at
that point might wanna consider removing these cysts
and seven centimeters and above.
Again, the idea would be to either remove them.
I'm not sure how MRI would add to the ultrasound in terms
of saying what this is,
but most of us, I think were in the mindset to consider doing surgery
at that point.

Polycystic Ovaries

Well what about number four on our list of common treatable,
common benign conditions that are seen in the ovary.
If you see a large number of small peripheral,
these would be the location of follicles.
As we see in the picture here people have described these
as looking like a string of pearls
around a woman's neck.
This is consistent with a polycystic ovary.

Now a consensus statement came out a few years ago
with these numbers more than 12 peripheral follicles,
none of which is greater than 10 millimeters
and the ovary is slightly enlarged usually round.
I find all these numbers a bit confusing to remember.
So I would like to suggest an easy way
to remember a polycystic ovary is using that rule of 10.
If you have 10 follicles,
you're probably gonna have 12 and more.
Because there are many at the periphery, none
of which have a diameter of greater than 10 millimeters
and the ovary is somewhat enlarged having a volume
of greater than 10 cubic centimeters to
diagnose a polycystic ovary.
The consensus statement said it only needed
to affect a single ovary.

Now in my report I don't report these as
polycystic ovarian syndrome.
That is a clinical entity with a amenorrhea herm
and often obesity
and abnormal endocrine function increased androgen and lh.
So my job is to define what the ovary looks like
and I would call this a polycystic ovary
and let the clinician figure out if this is part
of the spectrum of polycystic ovarian syndrome.
These ovaries are often scanned by us
because patients are manipulated
'cause they're anovulatory in an effort to get pregnant.
And these ovaries are very sensitive
to hormonal manipulation.
These are the people who not uncommonly develop ovarian
hyperstimulation, which we've shown you an example of
with the thecal lutian cyst.

Interestingly, even though these women are amenorrheic,
they have a very vascular stroma, particularly in the center
of the ovary with a low resistance pattern.
And I find this rather intriguing
because when women are typically anovulatory
and the most common reason for
that would be a case like this,
multiple small follicles throughout the ovary in an
avascular ovary, the most common appearance
or reason women will have an ovary like this is a woman
on oral contraception.
Contraception.
And I don't know why these women are
so vascular in their ovaries,
but when I see what looks like a polycystic ovary,
I always turn on my flow
and see if it's a hypervascular ovary
and more than likely, if it is,
it will be a polycystic ovary.

Endometriomas

Now moving into another entity, which is very common
and classic is the woman who has a
homogeneously echogenic mass in the ovary.
Sometimes hard to see if the genicity of it is similar
to the background of the ovary.
And you can see some small follicles here peripherally
turning on this case.
You can see actually there's a fluid debris level.
Not always gonna have that,
but not uncommonly
with a dependent debris level notice the fluid debris looks
vertically and that is not
because the woman is in an unusual position, it's just
because whenever we look at a vaginal scan
as we see in this case the front
of the probe is always put on the top of the screen.
So this actually is the patient's feet, her head
anterior and posterior.
So it's an anterior posterior fluid debris level.

If you were to put color on in this entity,
which is a classic for endometrioma, you can see
a little bit of movement with the doppler.
But when we put doppler on, notice
how we've increased the flow greatly in that endometrioma.
And this is to remind me to tell you of course
that doppler has increased energy
and that's why we're striking these echoes more forcibly
causing them to have this kind of motion.
And I urge you when you see such a thing
to be reminded if you're doing pregnancy related scanning,
particularly in the first trimester,
I am definitely not a fan of using doppler at that point
because of delivery higher air energy
to a developing embryo.
So I would urge you to not use doppler
unless you have a very good reason to do so.
And honestly, I for many years I have not found
that good reason in my early pregnancy studies.

But let's get back to endometriomas.
Most women who have endometriosis know their diagnosis.
And what is the most common ultrasound appearance in a woman
who comes in saying, I know I have endometriosis.
Most commonly it's a normal ultrasound study
because they will not have a focal endometrioma.
So don't be surprised to see a normal study
when a woman develops an endometrioma,
it typically occurs within the ovary
and we've just shown you what they look like.
They're masses that have filled
with low level homogeneous echoes.

What did the consensus statement say about endometriomas?
It was said that initially we should do a follow up in about
anywhere between six and 12 weeks.
And why would that be? Because we wanna make sure
that really is an endometrioma,
in which case it will not change appreciably
or it won't go away.
And there is, as we said, a crossover between endometriomas
and hemorrhagic cysts, which should go away,
hence the short term follow up.
But then the consensus people also suggested we do a yearly
follow up just to keep our eye on these things.
They should not go away
and they may grow a little bit slowly,
but if there's an appreciable change in the size
probably should be removed
because there is unfortunately an association in women
with chronic endometriomas to subsequently or change the appearance
and become malignant in the way
of developing an endometrioid carcinoma.
So that's why we wanna keep our eye on women
with endometriomas.

Now most endometriomas look the same,
but occasionally we have an one of them
that looks different from the rest of the gang.
So here's an example of a slightly atypical endometrium,
much coarser echoes.
And here's one that frankly looks very, very atypical
with mural nodules, thickening of the wall, septations
and even flow in the septations.
When I see something like this,
even if a woman has a history of endometriosis,
I'm gonna be concerned in this case to the point
that if I get concerned then the clinician will get
concerned along with the patient
and it will be removed surgically.
And this was proven to be an endometrioma.
So I'm showing you a spectrum.
Fortunately this is a an unusual situation
here we have a typical endometrioma in this woman
and subsequently follow up showed it looks very different,
looks more like a hemorrhagic cyst that's evolving.
But in this case this went back
and forth over time, subsequently being surgically proven
to just be an endometrioma.
And what I think happens here is these women cyclically will
bleed into the endometrioma
and the blood products may evolve as a hemorrhagic cyst
but only to hang around for the long term,
become low level homogeneous echoes as we see here.

Occasionally you may see something like this
in the wall of the bladder.
Now I'm not saying this is not,
you can't tell this from a bladder neoplasm,
but a woman who has a history of endometriosis
and particularly if she has cyclic hematuria,
you might wanna think about the possibility
that this is an endometrial implant in the wall
of the bladder as we see here through a cystoscope.

This is an interesting lady who does have endometriosis
and I'll show you her endometrium in a minute,
but complained about pain near her umbilicus.
And of course if somebody's complaining about pain,
it's my job I believe
to go see if I can help find out what's going on.
So we saw this mass near her umbilicus
and we saw it again a while later
that it was even getting bigger now sort of bi lobed.
And she had endometriosis
and endometriomas in her uterus, I'm sorry,
in her pelvis, in her ovaries.
And we can see a homogeneous very typical
appearing endometriomas.

So what is causing this mass up by her umbilicus?
When we looked at this patient with a real time clip,
you can see this is in the abdominal wall right next
to her umbilicus.
So what this represents is an endometrial implant in the
scar thanks to a laparoscopy that was done.
And I've seen certainly endometriomas in this location,
I've seen them in C-section and other scars
and endometriosis can have a way
of implanting far away from the ovary
and often will be cyclically painful
as there's hemorrhage into these
unusually located endometriomas.

Hemorrhagic Cysts

Now if you look at this next case, there are very,
there's a very hyper genic area occupying the majority
of the ovary that is avascular.
It doesn't have the typical appearance
of the low level homogeneous echos of the
endometrioma, but it's avascular.
And this woman in all likelihood is acutely symptomatic at
this point because she has hemorrhaged into a cyst IE
into a corpus lutetium.
And these can be very, very painful.
And this is what the acute hemorrhage should look like.
These are going to go away with time a period of months
and we shouldn't worry about them.

So mentioned ovarian cancer does a lot of things
but it rarely hemorrhages.
So if you see what looks like something
that could be hemorrhage, if you elect to follow it
and not everybody does today according
to our consensus statement, it should resolve.
But if you were to follow it,
these hemorrhagic cysts evolve often in
a predictable manner.
One way they evolve is to develop a retraction of clot
as we see in these two examples.

Now you might say to yourself,
why is this not a mural nodule with a tumor?
Well for one thing it is avascular
and tumors are typically vascularized.
So can we do anything else?
Another case avascular probably a hemorrhagic cyst
with a clot in evolution.

Now I know that if I have a clot it is going
to be relatively soft.
And what I like to do at this point is take the transducer
and push against it to see if it's soft,
if I can get it to jiggle.
And this is one of my favorite clips
where I show this clot moves and jiggles
and tumor doesn't behave like this.
If I have a tumor and you look at a clip you can see this
as much firmer doesn't move.
And of course this woman also has ascites.
If I was to show you what color looks like in a minute,
this is a mural nodule because it is firm and
but if I showed you what it looked like with color,
it is going to be vascularized in contrast to a cystic
structure with a hemorrhage in it that is evolving.

So neural nodules should be separable from hemorrhagic
ovarian cyst in evolution.
But don't get fooled, keep your eyes open
and if there's any question of course get
that short term follow up.

Now another thing that hemorrhagic clock can do
as it's evolving is it conform these
reticulated appearing masses.
And I think eclipse says it better than me
where these lines are avascular.
And the point I wanna emphasize is your terminology,
this S word
or septation I think should be avoided if possible
because clinicians see something
or read something in their report
that says the word septation.
There is a knee jerk that they would suggest that
that represents a tumor because tumors are often septated.
So I would urge you not to use that word if possible.
There are many other adjectives
and descriptive terms you can use such
as it's a reticulated process, it is sponge-like.
Perhaps consider the word cobweb in appearance.
But if you go to use the word septation say there are fine,
you might wanna say they're fine linear echoes as opposed
to septation to avoid the word septation in your report,
which could be confusing to a clinician.

4. Ovarian Torsion

So now we've talked about the varying
and common non-plastic cystic conditions.
I'd like to talk about two others
before we turn our attention to neoplasm.
What about ovarian torsion?
Well as the name implies, it's a twisting
of an ovarian pedicle and often there are tumors
or cystic structures within that ovary
to predispose to the twist.
Similar to testicular torsion, these occur in young women
and some of these women may have loose ligaments
that predispose them to twist.

Now there are many ultrasound features
that have been published,
but I would like to emphasize the two
that I think are very important
and go hand in hand is in an enlarged ovary in an
unusual location.
I would like to suggest that I have never seen a normal size
and appearing ovary that is actively TA
because that doesn't seem to occur.
Also, you might consider looking for the twisted pedicle
that's involved with the torsion
and consider what the blood flow looks like.
We will address these.

So when I'm dealing with a patient
who I'm considering the possibility of torsion,
let's look at a couple of examples.
These are both transabdominal scans.
Notice each have a mass in the midline
located very unusually anterior to the uterus.
That is not the location
where an OV an ovary should be located.
I'm not saying it never can be,
but this is distinctly unusual.
And in a woman who has pain over this enlarged ovary,
clearly both have masses located in this location.
I would be very concerned about a torsion.
And indeed in these this two situations these were tossed
ovaries located anterior to the uterus,
but you can also tors and end up deep in the pelvis
and a location posterior to the uterus
and if not in the contralateral ad nexa
as we see in this patient whose
left ovary on a vaginal scan is going
behind the uterus into the right adnexa notice a leading
edge where the cyst
and this case both ovaries are located to the same side
of the uterus.
They're both on the right side with respect
to the uterus, very unusual.
And this case also had a leading edge
and these ovaries were tender,
unusually located deep in the pelvis and
therefore very compatible with a torsion.

Now the pedicle that leads
or feeds its blood supply to the ovary,
there are two sources of blood flow to the ovary.
Unlike a man who only has a single testicular artery,
there's the ovarian artery here
and a branch of the uterine artery here.
So the ovary having a dual blood supply,
you can imagine you could force one of these blood supplies
and maintain flow to the ovary from the opposite
ovarian vessel that's feeding the ovary.
So it's important to recognize that point.
Number one, the dual blood supply point number two,
these normal pedicles that feed the ovary are straight.
We see that nicely in this case
because we have fluid around the the pedicle.
So typically a pedicle in either side should be straight.
When you have a torsion as the name implies,
you'll twist the pedicle
and this has been termed the whirlpool sign.
So either of these could twist with a torsion
and what they look like through a laparoscope is a twist
or as we affectionately like to note
a whirlpool based on the ultrasound appearance.

So look for the twist pedicle.
And here we have a case
where on the gray scale clip you can see it looks like a
whirlpool, a twist.
And there's leading edge to the ovary here that's twisted.
If I just do a steady state not moving the probe on my
clip, you can see there is blood flow in here
and it looks like a whirlpool or twist.
Very important to look for that
and if you see it you can make the diagnosis of a torsion.
Don't think the CT added a whole lot.

Now here's a challenge case.
This lady comes in
with an enlarged ovary located deep in the
cul-de-sac and it was tender.
And by the way, you often will get a history
of when women will tors,
they will give you a history just like a man does
that they have had intermittent torsion
and subsequently when they come into the er
the pain becomes overwhelming.
And so intermittent pain is not uncommon
because I think many of these people have a lax ligament
that allows their ovary to intermittently twist
when they come in with a severe pain.
By the way, they're often vomiting
and that seems to go hand in hand with torsion
that's been published as one of the clinical appearances
that people have when they tors.

So what's interesting to me about this case is notice there
is both arterial and venous blood flow.
Now it's been said that when women tors the ovaries swells
and you cut off the venous blood supply.
So in this case you can see arterial and venous blood flow.
So what did we do in this situation?
Well I couldn't ignore her history of intermittent pain
and now it's much worse.
Her ovary was tender
and when I looked in her pelvis I knew this was
deep in the cul-de-sac.
I was worried. So I got on the phone
and I called the clinician
and I said I think this woman has
to her ovary even though there's good blood flow.
And I urged the surgeon to bring the patient to the
or sooner rather than later
because if the torsion got any tighter she might cut off the blood supply
to that ovary and it might necros.
And the surgeon was so gratified when he went to the OR
and saw that this was a viable ovary.
That's very important.
Obviously by the time it's necrotic
and dead there's nothing you can do but take it out.

So here's another case
that's an important challenge case We see the left ovary is
slightly bigger than the right, the follicles are smaller,
they're being pushed to the periphery of the ovary
and this woman's tender over that left ovary all worrisome
for an acute ovarian torsion.
Furthermore, when we look transabdominally, we realize
that the ovary is in an unusual location deep
in her cul-de-sac.
So everything is great in line
for an acute torsion of the ovary.
If you look at the clip here,
it looks like there's a pedicle that may be tors at least
to a certain degree the ovary is large and swollen.
But when we put color on here,
notice there is hyperemia to that ovary.
Certainly not lack of flow but increased flow.

So the question is why is the flow so hyperemic?
Well as we mentioned ovaries contour
and then they can detour.
And in the process of detouring, also known as mis torsion,
you can suddenly have a period
of hyperemia that's transient.
And if you can see it like this,
you can suggest this ovary has just detoured.

So what should happen clinically to a patient like this?
It's very important to get this woman to the operating room
because she's gonna be at risk to tors again, take her
to the operating room and just do a pxi if you will,
or tack the ovary down so she will not have the ominous
complication of a subsequent torsion.
And certainly you might wanna look at the other OV as well
'cause often these lax ligaments are bilateral.

5. Microcalcifications

Now what about women who have these
multiple small echogenic foci typically at the per
of the ovary as a dotted
or even a very linear appearance in this more dramatic
example, do you worry or not worry when you see this?
We certainly know that if we see these little echogenic foci
and you're dealing in a testicle, you would be labeled
as having testicular micro essis.
And there has clearly been a reported association of this
with testicular neoplasm.
So it's the same thing true in a woman
who has these little micro lists.

These are small non shadowing
and as we said about 95%
are in the periphery of the ovary.
So you recognize them
and I will quickly tell you not to worry about these
study came out of the Brigham Hospital, rusty Brown, one
of my colleagues took ovaries like this
and when they were gonna be removed we had the opportunity
to look at these ovaries vis-a-vis the pathologic specimen.
And so you can see this little tiny calcification in
association with the small peripheral cyst.
These are called inclusion cysts, which are things
that happen after ovulation.
So it's sort of a remnant of prior ovulation.

Here's a very dramatic example.
Again, it looks like a rim calcification can even be seen
on a CT scan.
And at pathology we can see hundreds
and hundreds of these little cysts with these echogenic
foci representing the micro calcification.
So this is a condition where it's not something we need
to worry about most commonly these are calcifications
associated with inclusion cyst or prior ovulation.
There have been other conditions not as common,
but we do not worry about these
'cause these are not pre-malignant lesions.
And I would suggest if you do put this in the report
and there's question whether you need to,
but if you do, please be clear in the report
to say this is not a worrisome finding.

Now sometimes these little calcifications can get bigger.
We followed them actually up to 13 millimeters
and only one of these cases went to surgery
and that proved to be a corporate albicans
or basically a scar in the ovary.
Due to a prior ovulation.
And a report was published based on these cases there
were 28 cases.
The bottom line is these do not change with time and
therefore we do not worry about them.
There's no amass associated with them.
So these are not dermoids.
And if you see such a finding, if you wanna follow it,
follow it maybe for a year and then don't worry about it
because this is not gonna be, you know,
we're worried about cancer.

6. Dermoids (Germ Cell Tumors)

So coming up to the subject of neoplasm, we can see
that ovarian tumors are very,
very deadly if you summate the mortality
of them vis-a-vis the other gynecologic
neoplasms being uterine
or cervical it more than summate those other two
gynecologic neoplasms.
So although fortunately it's not all
that common halfway between cervical
and uterine cancer, unfortunately these are very malignant tumors
And if you look how we've done with imaging
and talking about ultrasound over the years in terms of
lessening the mortality that we have not done, if anything,
mortality is higher than ever.
So it is a really a terrible condition to have
and something that fortunately is not too common,
but we should recognize it now.

Ovarian neoplasms come in four different types
as we can see here from the least common sex cord.
Sex cord stromal tumors to the epithelial tumors.
Let's start with sex cord stromal tumors.
As the name implies, these arise from the s stroma
of the ovary or the scaffolding in which if you would,
if you will, which contain the germ cells
and the epithelial tissue
that form other kinds of neoplasms.
So this comes from the stroma of the ovary.
They come in three different types.
The most common is the granulosis cell tumor
and these are all solid.
Two of these tumors are associated with hormone production,
the granulosis tumor with estrogen
and the slic glide with androgen production.
So if you have a post-menopausal patient
and she suddenly has symptoms,
maybe she's getting her period again,
that sound like she's got feminizing hormone on board,
she probably has a granulosis cell tumor.
And in contrast, if mascul symptoms appear,
you're gonna think about a slic glide lido tumor.
Fibrotic coma is the third tumor
that develops from the stromal elements of the ovary.
And it as every medical student knows, is associated
with MEG syndrome, which I've seen all
of two cases I think in my 40 year career.
And these are patients who have effusions
with a benign tumor, ascites, pleural effusions,
pericardial effusions and these are benign.
The other two tumors fortunately have low malignant
potential grade one tumors.
So these are not wildly anaplastic the way the
epithelial tumors are.

What about these cases?
Two different patients with rounded relatively small mass,
large mass in the ovary with doppler flow that is consistent
with a neoplasm?
Well if you have these appearances in a woman,
these don't look like normal ovaries,
they're rounder than a normal ovary
and we do not see the follicles.
These are patients who have ultimately proven
stromal tumors in association with feminizing
and masculinizing symptoms.
So knowing if it's masculine
or feminine in terms of their symptomatology
and excess hormone can help you decide which it is.
But overall I let the pathologist give me the results of
what these solid tumors are.

A third solid tumor can be associated with
acoustic shadowing due to attenuation of sound
and reflection of sound
and similar to OMA of the ovary.
These are fibroma the coma
and they're related like fibroma to the fibroid tumors,
fibro settlements.
And these can absorb sound
as we see in these examples.
So if you ever see a mass that has some shadowing
that this is not what a dermoid looks like,
it's coming from the solid component of the tumor, think
of ovarian fibroma, the coma.
And here we show you in contrast a normal ovary
with its normal shape, ovarian masses tend to be round
as opposed to ovarian normal ovaries which tend to be elliptical.

What about metastatic tumors?
About 10%
of ovarian tumors arise from metastatic disease.
About half or more than half come from the GI
tract or the breast.
And then the rest we see from other tumors
and basically these tend to be solid
or cystic with a large solid component within them.
And this is Dr. Netter's depiction of a patient
who has a solid tumor with some small cystic elements.
Anytime you see bilaterally enlarged solid ovaries.
Think of metastatic disease first though
gastric cancer in this case with so-called berg tumor,
another patient with lymphoma.

What about germ cell tumors?
Well they come in a variety of types.
We're gonna focus on the mature dermoid if you will,
which is certainly the most common if you're dealing
with an adult population.
So what do these look like?
Well 18% of them up to that number are bilateral
and as the name teratoma implies they're associated
with the germ cells of a variety of types.
But we tend to focus our attention on the epidermal elements
or the hair or sebum within dermoids.

Now when I ask residents
to tell me what's causing the psychogenic area
with the gradual acoustic shadowing,
I often get the wrong answer.
So let's think about this.
It's actually the hair that is hyper genic
with the gradual acoustic shadowing
as the hairball if you will absorbs
and reflects sound giving you a relative
gradual acoustic shadowing.
The sebum is actually the liquid at body temperature.
It's like taking butter or fat and lard, crisco
and heating it up to become liquified at body temperature.
So this is the liquid due to the sebum
with varying echogenicity.
Sometimes it's very genic, sometimes it's quite echo poor.
And here we have case number six in our grouping
of a classic dermoid.
We're seeing a focal hairball if you will, comparing it
to the CT making you realize that the sebaceous material
is typically liquid at body temperature
and has varying degrees of genicity within them.
So you should be able to recognize these classic dermoids.

But there are variations here we have patient who has
what looks like mural nodules in a cyst.
I'm not gonna let those slide by me,
that will come out fairly soon
although this one does have acoustic shadowing.
If you were to do a CT in this case, each
of these are dermoids within the wall of a simple cyst.
These are too small to resolve even today by ct.
So that is called a dermoid plug.
Here we see calcification in a dermoid, very bright echo
with acoustic shadowing
and that is another example of why we missed dermoids.
Here we have a third case, which we have a large
what looks like a solid component
but it's really sebum filled with echogenic fluid.
And here's the hairball floating in the fluid.
And finally the fourth variation
that we see is here's the hairball
and these echoes are linear.
If I showed you a clip,
they would be undulating and sparkling.
This has been published as the spaghetti sign,
but I would like to suggest a better name
for it might be a bad hair day
with hair flying into the liquid of the dermoid
for examples of variations.

So what did the consensus statements say about dermoids?
Initially consider doing a relatively short term
but do follow them up maybe in six to 12 months
and then maybe yearly.
Many dermoids are small and they do not grow
and they stay there or they grow very slowly,
which is why the idea was
that they don't all have to come out.
Fortunately, malignancy and dermoids are very rare
but not unheard of.
Maybe two or 3% will have malignant components
and when they do, these are bad actors.
They often are squamous tumors in these dermoids
and these can be highly lethal.
So if you see a dermoid that is growing
probably should come out.

There are some unusual but specific appearances to dermoids.
I had to go to the literature to find these cases.
Remember I showed you the endometrioma
with the fluid debris level
and the debris is dependent if you ever see a fluid debris
level, but the debris is superficial.
Think about epigenic fluid in a dermoid
with the floating fat.
And that's seen here and that's also seen on the CT scan.
So that is distinctly unusual
to have a an echogenic fluid collection in the near field
and a relatively echo poor
a component in the far field floating fat.

The last unusual variation are call these hair balls
or fat balls if you will.
And here you can see these are just case
reports in the literature.
This was more liquified at body temperature
and then they solidified
and there's hair in these floating balls
and that is supposed to be very specific for a dermoid.
But unfortunately they're rare.
So the literature does not have a lot about them in there.
But if you should see something like this,
think about a dermoid.

Now dermoids because
of the floating hairball on the fat can be
difficult to identify.
And here we have such an example in the right side,
it's we really, it's we're pressed to see a mass here.
But if I told you clinically the woman had a right adnexal
mass and you do not see the right ovary, step back
and think about this case as to whether
or not this could be an epigenic hair ball floating on fat.
Very hard to see in this kind of a clip,
but if you push on it as we're doing here on the other clip
now I think it's much more convincing that we're dealing
with a focal mass
because it's not being impressed upon
with transducer compression.
And notice the subtle
but definite gradual acoustic shadowing.
So now we're dealing with a hairball in a dermoid.
That is a very subtle finding
and I think that's why a lot of people missing dermoids.

So consider doing clips of a variety of types
and if you have a transducer where you're pushing
and interacting with the patient, think of this as similar
to doing a classic pelvic exam with your fingers
but having a picture or camera at the end of your finger.
Very, very good way to pick up these dermoids.

Epithelial Tumors

Finally, the last category,
the epithelial tumors in the ovary.
These arise from the surface epithelium,
they come in a variety of types.
Serous, mucinous, benign, malignant
and based on biologic behavior.
Some have low malignant potential but far
and away about 90% of ovarian cancer
is gonna subsequently be proven to be this type of tumor.
And that is unfortunate.
They do have a variety of types.
The serous, the mucinous, you can see Dr. Netter's picture.
And these are the deadly cancers in many, many instances.

This is sort of the index example of an ovarian cystadenoma
complex has thickening septations and whatnot.
But notice this is a benign cystadenoma despite its 25
centimeter size.
Here's another example showing the extreme variation in
these neoplasms.
This too is a benign cystadenoma,
but it is 11 centimeters in diameter
and hence is not as worrisome for being a malignancy
'cause it looks very benign, being simple
but should come out because of its large size.

So I don't temp to tell a pathologist beforehand
what I'm dealing with, especially if I'm dealing
with a lesion that looks like this.
If I see metastatic disease
and I certainly look for it, then I can suggest malignancy.
But these should all come out
and let the pathologist tell us what we're dealing with.

Now I just wanna draw your attention to some subtle findings
so that hopefully you're not gonna find yourself in trouble.
Here is a postmenopausal woman
and it looks like she has a simple cyst or ovary,
but I always put color on the ovaries
and in this case I saw flow, which is an excess of
what I should see in a postmenopausal ovary,
which led me also to look harder.
And then I see the subtle mural thickening.
And this patient therefore has a, not a simple mass,
but a mass that has a solid component
and has too much blood flow.
So she has a neoplasm in the ovary
and she should go to surgery.
And this is fortunately a borderline cystatin carcinoma.

What about this next case? This is a small lesion.
If it's a young woman
and this was actually a 23-year-old woman,
you might be tempted to just say this is a hemorrhagic cyst
and let it go, but never conclude that
before you put color on.
And here we can see there clearly is some
blood flow within this.
My colleague who did this at the Brigham,
if he did do a duplex, he did not photograph it, but he did for sure note
that this was a vascularized area within this small mass
and wanted the patient to come back
for short-term follow-up, which she did.
And there was no change at this point. This has to come out.
And fortunately for her, this was a small tumor,
only a grade one.
But look at her age, she was 23 years old.
So this is a certainly an eye-opener if you will
because by all rights it should be a hemorrhagic cyst,
but you can never make that conclusion
before you put color on.

So now what about those cysts
that we really worry about the cancers,
the malignant neoplasms?
Well these don't look anything like
what we've been talking to up to.
Now these, if they're complex cysts,
have large solid components.
They do have septations,
they have blood flow in the septation,
they have flow in the solid components.
They're thick, they're irregular septation,
often they're associated with free fluid.
And the free fluid carries the malignancy throughout the
abdominal cavity.
And since it's in malignant ne sitis,
it shouldn't surprise you that it often affects the edge
of organs like the perforated of the liver.
It can directly invade the peritoneum itself
and it can cause involvement of the omentum which can cause thickening
and they tend to be large.

So these masses look nothing like what I showed you before.
All three of these people have ovarian cancer
and it's important to recognize that.
The appearance just does. It looks very ominous.
So these should all come out. They have flow.
They really shouldn't cause you confusion
because they look
so different than the six lesions I've shown you.
Flow in. Septations can't be ignored,
although not will be,
they will not always be due to malignancy.
Fortunately for this woman, this was a benign lesion.
What that was septated.
And sometimes you can see that with an endometrioma,
but they must come out.

And finally, occasionally you can have masses that look
ominous and the pathology tells you that they are not cancer,
they are benign, often benign neoplasms.
So here we have a case where there is ascites, there was
an ovarian mass to give you the opportunity
to evaluate it further.
Change your transducer now to a superficial transducer
and realize that you're dealing with an,
with an implant here in the peritoneum itself
or go to the outside of the liver here, the periphery
of liver, that's where tumors like to go.
The periphery of organs.
So that is a tumor implant in a lady
who has a small ovarian cancer.
And here we also have a peritoneal implant in addition.
So that patient has both.
Here we have o mental thickening
with bowel displaced away from the abdominal wall.

What about this case? I believe this may be my last case.
Looks like it could be complex fluid,
but you can never say that
because you don't know until you put color on.
This component had no flow so it's probably hemorrhagic
so you might not need to follow it.
But the other component unfortunately was not cystic,
was not complex in terms of complex cyst, was a solid mass.
And this has obviously flow.
We have to be worried and
therefore we were right to be worried.
This patient actually presented with
a primary tumor in the lung of unknown etiology.
And by doing this ultrasound, we were able to say for sure
that this was not a hemorrhagic process.
This was a solid mass in a ovary due to,
in this case, ovarian cancer.

Summary

So now we have the big six.
I hope you know, as you're looking at them
to recognize them, know what to do for them not
to worry about them.
Patients will often go to surgery based on their clinical
presentation with these,
not necessarily based on ultrasound.

So to put everything into summary, premenopausal woman
who has what looks like a small follicle
or corpus lium probably don't need to even report it
and certainly don't need to follow it up
because this is part of a normal menstrual cycle.
As we get larger, you wanna report it,
but no need to do a follow up
because these should resolve on their own
as functioning follicles
and functioning corpus ludia, premenopausal cyst.
Still ocular, getting larger,
probably do wanna follow it up.
Make sure that it is not growing or if it is growing
and it's if it's growing probably should come out
because these will be neoplasms but benign.
Those cystadenomas that we were discussing, only when we get
to be greater than seven centimeters should we
consider taking them out.
According to the people who wrote the consensus statement,

hemorrhagic cysts initially do a short term follow up
because most likely it will be a
a functioning cyst at this point and will resolve.
But if they are large, followed up,
because sometimes endometriomas can also have this
appearance and can crossover in their appearance with that
of a hemorrhagic cyst.

If you have a post-menopausal woman
and you have a very small that is less than a centimeter
cyst, consider not even mentioning it in your report greater
than a centimeter between it
and seven centimeters do yearly follow up
because we are thinking that these are gonna be
benign neoplasm.
That means a benign cyst cystadenoma.
If you have a hemorrhagic cyst
and the woman is early postmenopausal,
our gynecology clinicians urged us to do
a short-term follow-up
because most likely if it dis if it's shortly
after menopause, it may still be a functioning cyst.
They mention that women can occasionally ovulate within five
years of menopause, which came as a surprise to me.
But after five years, they said, you do not ovulate anymore
and you would be worried about a neoplasm.
Frankly, I am worried about all hemorrhagic processes
after the menopause.
Even these early ones.
Remember I said that ovarian cancer rarely hemorrhages,
but occasionally it can.
And so I would be worried about a neoplasm because I never wanna miss a neoplasm
if I can help it.

And finally, if you have a pre
or postmenopausal process that looks like a dermoid,
it probably will be one
and you can follow those providing there are less than seven
centimeters if it's unilocular
and large, it's gonna be a benign neoplasm such
as a cystadenoma, which our pathology colleagues,
again suggested, does not transform
into a malignant cystatin, no carcinoma.
All the other appearances that we see, septation,
mine nodule solid masses, we will worry about a neoplasm
and those should come out because we cannot say
unless you see ascites and spread of tumor, if it's benign
or malignant, that's the pathologist's job
and we're happy to let him do his job
after these ovaries are removed.

So fortunately, most women have ovarian
ovaries that look normal.
We recognize them,
but when we see things that are variations
or out of the normal range, we know now how to handle them.
Many of these are gonna be physiologic
or functional processes that will go away.
Some will be neoplasms, such as dermoids, that we know
what they rec, we recognize them or hemorrhagic cysts.
So we recognize those also and know how to treat them.
I, again, thank Dr. Netter
for his help in preparing this talk
and certainly I thank you also for your attention.