Tuboovarian pathologies us hrpb edited 2019

TUboovarian mass Ultrasound lecture

1. TUBO-OVARIAN
PATHOLOGIES
Dato’ Dr. ARUKU NAIDU
MD, FRCOG,CU, AM
Department of O&G, Hospital RPB Ipoh
www.aruku-naidu.blogspot.com

2. A/P Roy Ng Snr Cons & Head
Urogynaecology & Pelvic
Reconstructive Surg Dept O&G
National University Hosp S'pore
2
MCH IPOH

3. MCH IPOH

4. Possible tubo-ovarian pathologies
•Ovarian tumor
–Benign cyst / tumours
–Malignant tumours
•Tubo-ovarian abscess/complex
•Salpingitis/ tubal masses
•Others eg fimbrial cyst

5. Purpose of scanning for a
tubo-ovarian pathology
•To find out what pathology it is
•Benign vs. malignant
•Decide if need treatment or not
•Plan surgery
–Timing of surgery
–Type of incision/surgery
–Where to do the surgery

6. Beware
•Ultrasound cannot make a definite
diagnosis of benign or malignant ovarian
tumor
•We need histopathology of the tumor to do
the above

7. Making a provisional diagnosis
•History
•Examination
•Investigation
–Tumour markers
–TAS/TVS- its limited field of view & unusual
image orientation ( adjunct)
–Other imaging modalities

8. Basics on ovarian & tubal
anatomy

9. Ovaries
•Oval solid structure, 1.5 cm in thickness,
2.5 cm in width and 3.5 cm in length
respectively.
•Each weights about 4–8 gm.
•Ovary is located on each side of the
uterus, below and behind the uterine tubes

14. Fallopian tubes

15. Describing a tubo-ovarian tumour
•Where is it
•How many
•Unilateral vs. bilateral
•Size in 3 dimensions
•Shape
•Cystic vs. solid or mixed
•Unilocular vs. multilocular
•Irregularity
•Presence of ascites
•Color Doppler

16. Pattern recognition
•Subjective evaluation of the mass with
grayscale image evaluation ( TAS / TVS /
Colour doppler)
•Can help to differentiate benign vs.
malignant
•Superior to other classification systems
(Valentin, 1999)
•IOTA classification (Zimmerman, 2000)

17. Follicular cysts

18. Corpus luteal cysts

19. Mature cystic teratomas
•Second largest ovarian tumour (20%)
•Germ cell tumour
•AKA Dermoid cyst
•Contain fat, hair, teeth, bone
•Affect younger age (mean 30 years)
•Slow growth and often asymptomatic

20. Mature cystic teratomas
•Cystic echo
•Echogenic shadow inside the cyst - White
ball (hair and sebum)
•Echogenicity may be same as bowel –
may be missed during scanning

21. Mature cystic teratomas

22. Mature Cystic teratoma

23. Mature Teratoma

24. Endometriomas
•Typical ground glass appearance
•May have one or more solid masses from
cyst wall (blood clots or fibrin)
•May be confused with
–Teratomas
–Malignancy
–Abscesses
–Haemorrhagic cysts
–Fibromas

25. Endometriomas

26. Endometriomas

27. Haemorrhagic corpus luteum cyst
•Cyst that contains spiderweb like material
•Bizarre blood clots
•May be mistaken for papillary projections
•May take up to 4 months to regress

28. Haemorrhagic corpus luteum cyst

29. Benign ovarian solid tumors
•Fibromas, thecomas, Brenner tumor
•May look like pedunculated fibroids
–Solid
–Round or oval
–Smooth outline
–Regular striped echogenicity

30. Benign ovarian solid tumors

31. Benign ovarian cyst
( Fibroma)

32. Benign ovarian cyst
( Serous adenoma)

33. Benign ovarian cyst ( Torsion)

34. Simple US rules
(5 Features to predict Benign tumour)
•Unilocular cyst/tumour (B 1)
•Smooth multilocular tumour ( B 2)
•Presence of solid component for which the
largest solid component is <7mm in the
largest diameter ( B 3)
•Acoustic shadows ( B 4)
•No detectable blood flow on colour Doppler
examination ( B 5)

35. Simple US rules
(5 Features to predict malignancy)
•Irregular solid cystic tumour (M 1)
•Irregular multilocuted solid tumour with
largest diameter of at least 100mm ( M 2)
•At least 4 papillary structures, >3mm ( M 3)
•Presence of ascities ( M 4)
•Very high colour content on colour Doppler
examination ( M 5)

36. Malignant ovarian tumors
(irregular solid-cystic areas)

37. Malignant ovarian tumors
( irregular wall/ breach in capsule)

38. Malignant ovarian tumour
( papillary projections)

39. Malignant ovarian tumors
( ascities)

40. Malignant ovarian Tumour
(Omental caking)

41. Malignant ovarian tumors
( high dopplar colour uptake)

42. Simple US rules
(To differentiate malignancy VS Benign
tumours)
•If one or more M features were present in the
absence of a B features  we classify the mass as
malignancy ( Rule 1)
•If one or more B features were present in the
absence of a M features  we classify the mass as
Benign ( Rule 2)
•If both M features & B features were present, or if
none of the features was present the simple rule
were inclusive ( Rule 3) . Need other modality to
assist the diagnosis

43. Pelvic inflammatory disease
•Hydro-pyo-hemato-salpinx
•Correlate with clinical findings
•Fallopian tube
–Fluid filled sausage shaped cystic structure
–Presence of incomplete septa
–May contain hyperechogenic material (pus –
pyosalpinx)

44. Pelvic inflammatory disease
( Hydrosalphix)

45. Pelvic inflammatory disease
Tubo-ovarian abscess
•Unilocular or multilocular
•Thick walls and septa
•Homogenous echogenic material (ground
glass appearance)
•Difficult to differentiate with pelvic abscess

46. Pelvic inflammatory disease
( Pyosalphix)

47. Pelvic inflammatory disease
(Pelvic abcess)

48. Others ( PCOS)

50. Others ( Fimbrial cyst)

51. Summary
•Accurate description of mass in the pelvis
may help in making a diagnosis
•Need to correlate scan findings with clinical
findings & other modalites like tumour
makers, other imaging techniques/ scope
•Pattern recognition may help in diagnosis of
ovarian tumor ( practice)
•HPE needed to confirm benign or malignant
tumor

52. THANK
YOU