Adnexal Masses in the Pregnant Patient - SD

Introduction to Adnexal Masses in Pregnancy

Hello, this is Dr. Phyllis Glance from the University of Toronto.

We'll be talking for this session on adnexal masses in the pregnant patient, a diagnostic and management challenge.

Our learning objectives will be to review the spectrum of sonographic findings of common adnexal masses within the context of a pregnant population and to develop a diagnostic and management strategy for adnexal masses in pregnancy in the asymptomatic and symptomatic population.

Increased Detection and Visualization Challenges

The increased use of ultrasound for fetal evaluation has led to increased detection of maternal adnexal masses.

First trimester exams by standards recommend attempting to document the maternal ovaries.

The ovaries are easiest to identify in first trimester and as gestational age advances.

There is a significant reduction in ultrasound visualization of the normal maternal ovaries by either transvaginal or transabdominal sonography.

Hillow characterize this numerically where they found that in first trimester virtually a hundred percent of maternal ovaries could be visualized on ultrasound by second trimester only 75% and by third trimester down to 27%.

Despite careful transabdominal scanning, the best percentages achieved from maternal ovary visualization by third trimester was only 22%.

In looking at our own population, we could define that the drop in ovarian visualization and pregnancy with transvaginal scanning begins at about 10 weeks and progresses down to between the 10 to 14 week range.

Spectrum of Functional Cysts

It is important to be aware the spectrum of findings in the natural history of functional cysts, which represent the majority of adnexal masses detected during pregnancy.

The majority of scans will identify as simple cysts prior to eight weeks gestational age in the one to three centimeter range.

In fact, if we don't identify that these pregnancies are at greater risk for spontaneous loss, it becomes somewhat more challenging when we see the simple cyst or complex cyst that's greater than the three centimeter range.

However, these are still fairly frequent and typically still continue to represent physiological cysts.

The prevalence of simple cysts, which are larger than three centimeters prior to 14 weeks, is almost 5% by the end of the 14 week range, this has dropped to approximately 1.5%.

What we learned from those numbers is that when you have a larger simple cyst greater than or equal to three centimeters, the resolution begins approximately two weeks later at the 10 to 12 week area as compared to the corpus luteal cyst in which regression begins approximately two weeks earlier.

Types of Functional Cysts

What are all these cysts that we're looking at?

The majority of these are functional cysts or hormonally responsive cyst.

The follicular cyst occurs when a mature follicle fails to ovulate or involute.

The normal mature follicle typically does not go beyond two centimeters, and we use the term follicular cyst at 2.5 centimeter and again, one would expect spontaneous regression.

The corpus luteal cyst occurs from failure of absorption or excess internal bleeding.

However, the corpus luteal cyst of pregnancy is important to have present and may enlarge or insist typically reaching a maximum size at about eight weeks and then regressing.

A hemorrhagic cyst can occur either within a follicular or a corpus luteal cyst and typically presents with pain due to sudden enlargement.

Thecal lutian cysts are the largest of the functional cyst, classically bilateral multiloculated or large, and are associated with high levels of circulating cumin, chorionic, and atropin.

As we may see in gestational trophoblastic disease or ovarian hyperstimulation syndrome.

The corpus luteal cyst is the commonest of cysts that we're going to see functional hormonal responsive cysts in pregnancy.

In fact, they are required to maintain progesterone production prior to the placental production of progesterone.

Normal regression begins at about eight to eight and a half weeks.

The appearance is extremely variable from a simple to a complex cyst.

Color doppler can be helpful in identifying them as they typically have a circumferential rim of low resistive blood flow pattern or a ring of fire surrounding them and management is expectant.

Hemorrhagic Cysts

Hemorrhagic cysts are extremely common and can occur within corpus luteal or follicular cyst.

They have very typical features, the most common of which is the presence of multiple interdigitating septations or fishnet appearance.

These are secondary to fibrile strands which occur within the hemorrhage.

These strands are innumerable and typically discontinuous as on the upper two images.

The other characteristic feature is clot retraction where we can see either angular margins or concave margins consistent with clot retraction.

And certainly following these with the typical evolution over time will confirm that they're hemorrhagic cysts.

However, if we cannot confirm and identify hemorrhage at either the stage of the multiple interdigitating septations or clot retraction, this implies a benign etiology and is reassuring for the patient and her physician.

Non-Functional Cysts

Okay, The next category is the non-functional cyst or non hormonally responsive cyst, which does not change in size or character during menstrual cycle or under hormonal stimulation.

There are two categories here, the extra ovarian lesions and the ovarian lesions.

Extra-Ovarian Lesions

One of the most helpful ways of determining if a lesion is intra or extra ovarian is with this phrase probe with the probe which Dr. Ang has generated.

It is important to confirm apparel ovarian location.

As this permits us to designate a benign etiology and by probing with that probe, placing it between the cystic and the solid area, we may be able to separate what appeared to be an exophytic cyst into a per ovarian lesion, which implies benign etiology and the ability to follow.

And on this instance, we have a classic per ovarian lesion, which is a hiated of more Agnes, separated from the ovary.

Hydrocele pinks is fairly common and can be defined by its tubular curvaceous nature with incomplete septation and separate from the ovary.

Peritoneal inclusion cyst can be a little more complex.

However, the history of prior inflammatory pelvic disease or surgery with consequent adhesions and fluid trapped between adhesions resulting invariably size cysts, does present with atypical appearance as we see here with the ovary and trapped either at the periphery or centrally within the lesion suggesting the diagnosis.

So again, thinking about maternal adexo masses at the time of detection, the majority of our patients will be asymptomatic.

The majority of pregnancy associated cysts will resolve by 16 weeks.

The presumption that these are functional or hormonally responsive cysts and management remains expectant as they present no risk to the pregnancy.

However, if at a single point in time we see it in nexel mass, the positive diagnosis of a hemorrhagic lesion or a para ovarian lesion virtually excludes malignancy.

Malignancy, rarely hemorrhages if ever, and para ovarian cysts are almost never malignant.

Ovarian Lesions: Dermoids, Endometriomas, and Neoplasms

The next category of the non-functional cyst or adnexal mass that we'll look at are the ovarian lesions, dermoids endometriomas and neoplasms.

Benina Fial in 1997 looked at what common ovarian conditions can be correctly classified on the basis of som morphology alone and suggested that we can correctly classify 95% of dermoids, 80% of endometriomas, but disappointingly only 71% is simple cyst.

And the reason for this is that many benign cystadenomas may appear simple or contain single thin septations 10 years later.

These results have been confirmed by yazbek etal in 2007 with slightly different percentages, but similar findings.

Again, 11.4% of their unilocular apparently simple cyst, turned out to be borderline ovarian tumors.

The implication from these studies are that we may never on ultrasound alone, be able to confidently distinguish all benign from malignant lesions.

Our role perhaps is to distinguish the clearly benign lesions with classic features such as hemorrhagic cysts, dermoids and endometriomas, and beware of the persistent simple larger cysts.

Dermoid Lesions

Looking at classic features for the dermoid lesion, the most common appearance is regional bright echogenic nodules with acoustic shadowing behind them.

Often in a background, a diffuse low level echoes.

This brightly reflective nodule typically represents hair, fat and sebaceous material.

The dermoid mesh on the bottom is the another typical appearance which represents multiple hairs floating within sebum represented as bright lines and dots, which are interdigitating.

Perhaps the most classical feature has been coined as the tip of the iceberg phenomena where the echogenic mixture of sebum and hair is visualized, but has very strong acoustic shadowing, obscuring the back wall of this apparently large mass giving rise to the descriptor tip of the iceberg.

Sometimes as on the image on your left, the appearance is somewhat worrisome with a vascular nodule present.

However, when we see with that vascular nodule the classic tip of the iceberg phenomenon, I believe that we can still safely make the diagnosis of a dermoid lesion, the mature teratoma or dermoid lesions.

When we look at them on pathology, the thick sebaceous filling of the cyst, is often associated with a tangle of hair, which corresponds to the dermoid mesh that we see.

Sometimes there are only rare hairs as we see here, two single hairs, but in this case a calcification or tooth is present in the lower half helping us make the diagnosis in both of these mature teratomas.

The yellow arrows point to corpus luteal cysts in various and these will often coexist endometrioma.

Endometriomas

The typical appearance is that of homogeneous low level echoes.

Increase in diagnostic specificity occurs when these are multilocular, and even more so when they have these small hyper coic wall foci.

If we can assure ourselves that we have the homogeneous low-level echoes, the multilocular and these small hyper coic wall foci.

In the absence of neoplastic features, it is strongly predictive of endometrioma.

The hypoechoic wall foci are highly specific but only occur in approximately 35% of endometriomas.

So even the homogeneous low level echoes and multilocular when associated with an absence of neoplastic features remain strongly predictive for endometrioma.

So sono morphology has classic diagnostic criteria which can help us the simple cyst, ocular koic, smooth internal borders with acoustic enhancement, the dermoid lesion, echogenic solid portions with acoustic shadowing and multiple hyper coic interfaces or a dermoid mesh, the endometrioma characterized by homogeneous low level echoes.

Suspicious Features and Neoplasms

The next two categories, which we have not addressed, are the complex cystic lesion with papillary projections, irregular borders, thick septations, vascular nodules, and sep and vascular septations, which are concerning som morphology for neoplasm or the solid mass.

So our suspicious features on sono morphology, which will require further diagnostic and management decisions include mural, wall nodularity, vascular nodules, thick and vascular septations, and possibly large size.

Our goal in ultrasound is to decrease the number of intrapartum surgical interventions, and we do this by recognizing the common appearances and natural history of the functional cysa pregnancy, utilizing sono morphology to diagnose common benign lesions so that we can identify which lesions require no immediate intervention as our primary goal collar doppler and spectral analysis or adjuncts to som morphology.

An MRI has a role to play in complex or suspicious cases.

Detection Rate of Malignancies

What is the actual detection rate of malignancies in adexo masses in pregnant women?

Ovarian malignancy is more common in the older age group.

However, approximately 6.9% of ovarian cancers do occur in women under 40 years of age, and the elderly grave woman is becoming a more common phenomena.

There is a wide range from way less than 1% to as high as 8% in the reported incidences of malignancies detected in maternal at nyl masses.

This wide range reflects different inclusion and exclusion criteria, evolving sonographic equipment and the evolving use of ultrasound in management protocols.

One of the more recent papers by Smith et al looked at over almost 5 million pregnant women in a California registry base.

Of these 9,375 had an ovarian mass diagnosed in pregnancy.

The occurrence rates were just under 1% or 0.93% in cancers per total number of ovarian masses in pregnancy.

Looking at this group more critically, 36 of the 87 were germ cell tumors or dermoid and teratoma tumors as one might expect in the population.

In fact, they had no frank malignancies.

So although 1% may be the most commonly quoted rate for malignancy, it is likely an overrepresentation.

Appearance of Malignancies

What do malignancies look like?

We go from the benign serious cystadenoma whose common appearance is a large ocular simple cyst or cyst with septation, often with very subtle low level background echoes and perhaps occasional papillary projections, with the correspondent pathology, with the intact S cyst and the ity present to the more complex typically appearing mucinous cyst adenoma where we see more background echogenicity and more population or nodulation perhaps with internal vascularity.

However, when we look at the actual pathology, on our left is a borderline mucinous cyst adenoma on our right, a papillary serous cyst adenoma carcinoma.

So frankly malignant on the right but borderline on the left and yet both have numerous papillary projections.

So on the basis of ultrasound som morphology, it is unlikely that we will be able to distinguish the benign tumor of low malignant potential or borderline from the frank carcinoma.

Clinical Approach to Benign Tumors

So in terms of clinical approach as in this patient with a mucinous cystadenoma initially picked up at six weeks, a large complex mass with low level echoes and multiple septations large in size 16 by 14 centimeter persisting and unchanged by 16 weeks.

The management team may opt to go in and surgically resect as this lesion was.

When we think about the appearance of the benign tumors such as cystadenomas, We see the appearance of multiple septations.

I'd like to contrast this to the image on your right where we still have multiple septations, but the ovaries entrapped within it.

And this makes us think of the peritoneal inclusion cysts, which we have looked at previously.

But perhaps most importantly, I would like to bring back an early image of the hemorrhagic cyst and compare it in the hemorrhagic cysts.

The septations are innumerable versus countable.

They are short and discontinuous versus longer and continuous, helping us make the distinction between the classic hemorrhagic cyst and the septations of benign ovarian tumors.

However, even in the setting of a benign tumor, there is concern for malignancy.

Many of these tumors are considered borderline or low malignant potential.

This patient had a tumor resected three years previously and presented in late second trimester with a painful cul-de-sac mass on ultrasound posterior to the cervix.

We can see a solid mass with irregular or infiltrative borders.

The patient elected to wait till the postpartum period for biopsy, which revealed a recurrent neoplasm, which was now frankly malignant.

Pregnancy-Associated Ovarian Lesions

We are going to look at a separate category of ovarian lesions, those that are specifically associated with pregnancy.

There are three hyperstimulated ovaries, which is a normal response to elevated levels of human chorionic, an atropin hyperreal lutein S, which is an abnormal or hypersensitive response to circulating levels of human chorionic in atropin and thecal lu cysts, which are associated with hi four moles or a molar pregnancy.

One of the helpful features about these three conditions is that they are typically bilateral.

Ovarian Hyperstimulation Syndrome

This is a case of ovarian hyperstimulation syndrome, which can be an iatrogenic complication of ovulation induction.

This does not always occur, but it can be a normal response to the increased circulating levels of human chorionic and atropin.

They generally regress spontaneously over a few weeks and we can see these massively enlarged ovaries with the larger cysts being prone to complexity and internal hemorrhage.

One of the concerns is that they may be accompanied by rapid large fluid shifts with ascites and pleural effusions to the extent that they are life threatening.

Therapy is supportive as they will naturally regress as the levels of circulating hormone decrease.

However, the enlarged ovaries can be predisposed to complications of torsion rupture or bleeding.

Hyperreactive Lutein Cysts

We contrast this to hyperreactive lutein Alis.

This is where there are high levels of endogenous circulating cumin chorionic in atropin, which may be found in conditions such as fetal hydrops or higher order or multiple pregnancies, or where there is a normal level of human chorionic gonadotropin, but a hypersensitive response to the ovaries to these normal levels.

We distinguish this by the ovaries have a typically normal appearance early in pregnancy, but by second and third trimester have this abnormal enlarged appearance.

There are no rapid fluid shifts unlike or very rare rapid fluid shifts unlike ovarian hyperstimulation syndrome.

These enlarged ovaries, however remain predisposed to complications of torsion rupture or bleeding.

And the differential diagnosis does include multicystic neoplasm as they appear at some point in pregnancy, perhaps in second and third trimester.

However, their bilateral nature, brings us to think of the diagnosis of hyperreactive Lutein Ali.

Thecal Lutein Cysts

Fecal lu in cyst are a normal response of the ovaries to what are essentially elevated levels of endogenous human chorionic, an atropin and present with these appearances of bilateral enlarged ovaries with multiple cysts, again predisposed to complications of torsion rupture or bleeding, and typically seen in association with HID four mole or gestational trophoblastic disease.

Symptomatic Adnexal Masses

Symptomatic maternal and nyl masses are treated in a different fashion.

We have a patient here who presented at 33 weeks gestation with acute left lower quadrant pain.

Ultrasound findings were an enlarged ovary, 95 ccs VA volume with no internal vascularity, and so she went to surgery and indeed a necrotic ovary was removed.

The reported incidence of ovarian torsion in pregnancy can vary between less than 1% to as high as 6% incomplete.

Ovarian Torsion Cases

Ovarian torsion can also occur as in this case with an early intrauterine pregnancy and acute left-sided pain.

The patient, went to surgery and a hemorrhagic ovarian cyst, which had undergone incomplete torsion was removed.

In this case a more complex appearing mass.

In third trimester at 34 weeks was diagnosed.

There was acute right-sided pain, so that torsion was suspected and at surgery a mucinous cystadenoma, which had undergone internal hemorrhage and necrosis was removed with incomplete torsion.

This patient at 26 weeks also presented with right-sided acute pain, and what we identified was a solid avascular mass contiguous, but clearly separate from the right ovary and a twisted vascular pedicle could be identified originating from the uterus on the basis of the sonographic diagnosis of adnexal fibroid undergoing torsion.

The plan was expectant management and surgery was avoided.

Fibroid Torsion and Degeneration

So fibroid lesions are the commonest solid nexel mass, and we look for the characteristic sonographic findings and for the vascular pedicle.

When pedunculated, in order to make this diagnosis in a degenerating fibroid, which is subserosal, as in this case with a clear bridge of tissue connecting the degenerating fibroid to the uterus, the diagnosis is much simpler.

This patient at 29 weeks presented with acute left-sided pain and the ultrasound diagnosis was consistent with degenerating fibroid permitting, the avoidance of surgery and expected management.

Utilizing our probe to identify the area of tenderness can be quite helpful, and when probe pressure is placed directly over these torrid or degenerating fibroids, the patient will say, this is my pain.

Other Complications in Hyperstimulated Ovaries

Hyperstimulated ovaries, if we mentioned, are prone to many complications.

This is a post ovulation induction patient, an infertility patient who presented at nine weeks with severe left-sided pain tenderness and an elevated white blood cell count.

On the clinical basis and on the appearance of these enlarged ovaries, the diagnosis of two ovarian abscess within a hyperstimulated left ovary was made.

The management was percutaneous drainage and antibiotics.

Unfortunately, she went on to lose the pregnancy several weeks later at 12 weeks.

Appendicitis Mimicking Adnexal Mass

Appendicitis is one of the more challenging diagnosis we are asked to make during pregnancy.

These patients present often with right lower quadrant pain and fever.

However, the pain may be very poorly localized and appendicitis may not be the first thought.

The appendix can be identified virtually anywhere as it is dragged up and outta place as the enlarging graft uterus takes more and more room up within the abdomen.

In this particular case, the enlarged abnormal appendix was seen wrapping itself around the right ovary mimicking an adnexal mass and was safely removed without complication.

At laparoscopic surgery, it is often not that simple and it is a progressively challenging ultrasound diagnosis as gestation advances and the differential diagnosis of right lower quadrant pain is extensive and we will not go into it any further for the purposes of this talk.

Conclusion and Management Strategies

So in conclusion, management is symptomatic at nexel.

Masses in pregnancy may precipitate emergency intervention at any point in the pregnancy.

Ovarian torsion and appendicitis both require urgent surgical intervention.

Two, ovarian abscess may be treated medically percutaneously or surgically enlarging.

Symptomatic simple cysts are questionable and required team management and degenerating fibroids.

The commonest solid Nextel lesion are generally treated.

Expectantly complex cases may require the input of a multidisciplinary team involving medical imaging specialists, maternal fetal medicine specialists, gynecological oncologists, minimally invasive surgeons, and gynecology pathologists.

Surgery is contemplated in third trimester when there is a late diagnosis, a fast-growing mass and s or severe or acute symptoms.

In this setting, one should consider transfer of the patient to a hospital with a tertiary perinatal care unit and consider antenatal steroids to enhance lung maturity.

The optimum time for surgical excision if one cannot wait for the postpartum period is an early second trimester.

The rationale is as follows, this avoids increased risk of spontaneous abortion in first trimester and avoids inadvertent excision of the corpus luteal cyst of pregnancy.

It avoids the increased risk of preterm labor and difficult surgical access of third trimester.

It also avoids the increased risk of fetal loss, which is associated with emergency surgery and avoids delay in treatment of ovarian tumors, which may harbor malignant potential.

Case Examples

We'll spend the next few minutes looking at several case examples.

Large Simple Cyst Challenges

The large simple cyst is a challenge.

We know that some of these do not represent simple cyst, but in fact represent tumors of low malignant or borderline potential.

However, we have a 13 week gestational age fetus post ovulation induction, so an infertility patient who presented with progressive pain and an enlarging 17 by 28 centimeter right-sided cyst.

The clinical concern was the massive growing cyst was compressing the uterus, and so it was elected after discussion to undergo percutaneous aspiration of the cyst.

5.5 liters was removed with immediate relief, no recurrence and negative cytology.

So the diagnostic dilemma here was to do percutaneous therapy with the risk of draining in neoplasm versus surgical intervention and risk of fetal loss in an infertility patient.

In fact, aspiration of simple cyst is quite controversial.

Caspi etal in his series of aspiration of 10 cases with benign appearance larger than six centimeters had dismal results.

Five resolved however, two slowly recurred and two rapidly recurred, one of which was a mucinous cystadenoma, and one of which was a serous cystadenoma and one underwent torsion three weeks later.

So aspiration is a controversial decision, an individualized patient approach and multidisciplinary team consultation is recommended.

We have here another large simple cyst, asymptomatic but no regression by 16 weeks, and this underwent surgical excision with the pathological diagnosis of serous cyst adenoma.

As we've mentioned, cyst adenomas commonly appear as a simple cyst or a cyst with a single thin septation.

So persistence of a large, simple cyst may warrant surgical removal.

Complex Cystic Mass with Vascular Nodule

In this case, the initial diagnosis at six weeks was made of an incidental or asymptomatic complex cystic mass, measuring only 4.5 centimeter, but with a vascular mural nodule bringing up suspicion for neoplasm.

The management plan was initial observation with if the lesion persisted or enlarged plan for removal in early second trimester.

By 11 weeks, the lesion had doubled in size and the patient underwent surgical resection of the lesion at 16 weeks.

The final diagnosis was CYS cystadenoma of low malignant potential.

So again, the diagnostic dilemma is when the optimum timing of surgery is, and the management plan elected to wait till early second trimester to minimize potential fetal loss.

Summary of Predictors and Management Algorithm

In summary, the predictors of persistence of adnexal masses in pregnancy, the very best predictors are size and complexity.

Persistent. Simple cysts greater than six centimeters or complex lesions greater than three and a half centimeters require further evaluation.

Dermoid lesions will be the commonest of the complex lesions.

Persistent, larger simple cysts may in fact represent benign neoplasms, and a substantial percentage will ultimately represent tumors of low malignant potential or borderline ovarian tumors.

Malignant lesions are very rarely identified, so our goal is to balance the risk of spontaneous abortion or preterm labor associated with surgical intervention versus a small but real risk of malignancy and a small but increased risk of fetal loss associated with emergency surgical conditions.

So looking at a management algorithm when the patient is symptomatic, our choices are easier.

Medical therapy, percutaneous drainage or surgery as most appropriate in the asymptomatic patient.

When we have a simple cyst greater than five to six centimeters or a complex mass when they persist beyond 16 weeks, a repeat ultrasound is indicated.

If it is a simple cyst, conservative therapy is typically recommended.

Controversial question to drain.

If it is symptomatic, if there is a classic appearance of endometrioma or dermoid, conservative therapy is recommended with consideration of MRI or surgical excision postpartum.

If the lesion is a complex mass cystic, or solid, a decision needs to be made with consultation, whether it is removed in early second trimester or whether one weighs until the postpartum period.

So multidisciplinary consultation is appropriate in this last category.

In conclusion, the majority of simple cysts and complex masses will resolve spontaneously by 16 weeks.

Gestational age, suspicious sonographic features or persistent lesions should initiate a multidisciplinary team approach to optimize diagnostic and management strategy.

Thank you very much.