Sonographic Evaluation of Pelvic Masses

1. Sonographic Evaluation of Pelvic
Masses
Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2. Contents
1.Parametrs of pelvic US
2.Transvaginal sonography of pelvic masses
3.Sonographic differential diagnosis
1.RuLes
2.Benign or malignant
3.Type
Summary
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3. 1. Parameters of pelvic US .
1. Confirmation
presence or absence
2. Determination of
1. Size
2. consistency
3. contour .
4. Origin
5. anatomic relationship
3. Determine
abnormalities associated with malignant
disease: ascites or metastatic lesions.
4. Guidance for
1. Aspiration
2. biopsy
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4. TVS and TA
TVS:
used as an adjunct to TAS.
evaluation of the uterus and adnexa.
tumor composition
location
its limited field of view and unusual image
orientation}
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5. Color Doppler sonography (CDS)
helpful in distinguishing
benign from malignant ovarian masses
evaluation of adnexal torsion
an adjunct to morphologic assessment of
ovarian lesions.
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6. 2. DD between benign and malignant
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7. Morphologic scoring by TVS.
Each of four parameters as assessed
Malignancies tended to have high scores (over 9).
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8. Simple ultrasound rules: 2012
5 ultrasonic features to predict a malignant tumour
(M features):
Irregular solid tumour (M1),
Ascites (M2),
At least four papillary structures (M3),
Irregular multilocular solid tumour with a largest
diameter of at least 100 mm (M4)
Very high colour content on colour Doppler
examination (M5).
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9. 5 ultrasonic features to predict a benign tumour (B
features):
Unilocular cyst (B1),
Presence of solid components for which the largest
solid component is <7 mm in largest diameter (B2)
Acoustic shadows (B3)
Smooth multilocular tumour (B4)
No detectable blood flow on Doppler examination
(B5).
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10. 3. Type of mass
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11.  Purely cystic:
more likely to be benign
 Complex cyst :
more likely to be malignant.
 Purely solid:
more likely to be benign.
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12. ovary
uterus
Unilocular, thin-walled, anechoic
I. CYSTIC
Simple Cystic
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13. Unilocular
Thin-walled
Anechoic
Follicular cyst ABOUBAKR ELNASHAR

14. Simple cysts
Corpus luteal or follicular cyst
Haemorrhagic cysts
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15. Massively enlarged
ovaries
Thin-walled septation
Ascites may be present
OHSS
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16. Hydrosalpinx
Tubular-shaped
structure
Anechoic content
Incomplete septum
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17. Low-level echo cysts
1. Endometrioma 95%
2. Hemorrhagic cyst 50%
3. Teratoma 18%
4. Malignant Neoplasm 12%
(Patel et al, 1999.)
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18. Anechoic with lacelike
internal echoes within cyst
Hemorrhagic C.
Corpus Luteum
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19. Low-level echo cysts + Characteristic
Features
Endometrioma
Hyperechoic wall foci (in
35%)
Hemorrhagic cyst :
Lacelike internal echoes (in 40%)
Teratoma
Regional bright echoes ( in 97% )
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20. Diffuse ‘ground glass’ pattern
{old blood}Endometrioma
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21. smooth-walled ovarian cyst. Same patient after 5 w.
complete regression of the
physiologic cyst.
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22. Completely cystic ovarian
masses in peri-menopausal
woman.
most small cystic ovarian
masses in pre- and
perimenopausal women are
physiologic
Completely cystic ovarian
masses in post menopausal
woman.
most postmenopausal cysts
are inclusion cysts.
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23. Septated cystic masses.
Mucinous cystadenoma.
cystic mass containing
multiple thin internal
septations
Mucinous cystadenoma.
septated mass with
echogenic material (*) in
upper loculated area.
The echogenic material was
mucin
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24. Mucinous cystadenocarcinoma
Malignancy was suspected
due to thickened septation
(arrow)
Malignant teratoma.
Papillary projections (arrow)
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25. 1-Dermoid Cyst
The commonest 36%
2-Endometriotic cyst 5%
3-Malignant Cyst 1-3%
II. COMPLEX CYST
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26. Dermoid
Complex mass solid and
cystic (fat, bone)
Fill in Pattern
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27. Echogenic mural nodule in cystic mass.
Papillary serous Cystadenoma
Few small papillae
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28. Mucinous Cystadenocarcinoma
Solid areas Many papillary. P
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29. COMPLEX
Dermoid cyst.
Transverse sonogram of
complex predominantly cystic
with calcific focus (arrow)
arising from tooth
luteal cyst
with fluid surrounding
adhesion.
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30. Mucinous cystadenoma
Sagittal and axial transvaginal sonogram:
multiloculated septated cystic mass with focal wall
thickening. This represented a with 1 locule containing thick
mucinous material
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31. Dermoid cyst
layer of echogenic sebum
(*).
Hemorrhagic ovarian cyst
irregular solid area
corresponding to
displaced hemorrhagic
ovarian tissue surrounding
area of hemorrhage.ABOUBAKR ELNASHAR

32. Ovarian cystadenocarcinoma
irregular solid areas.
Magnified transverse TAS of
cul-de-sac hemorrhage
(arrow) resulting from
ruptured ectopic pregnancy.
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33. Dermoid cyst
typical echogenic hairball
(arrows).
Dermoid cyst.
TV-CDS showing vessels
within the solid part
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34. Torsed right ovary.
(TAS)
solid mass (arrow) in cul-
de-sac
Transverse TAS of same
patient as in showing that left
ovary (straight arrow) is normal
in size and adjacent to torsed
right ovary (curved arrow).
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35. Interligamentous fibroid (*)
appearing as solid pelvic
mass.
Transabdominal sonogram of
predominantly solid undifferentiated
ovarian neoplasm (arrow) containing a few
cystic areas.
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36. Cystadenofibroma
TAS
solid pelvic mass
with calcifications (arrow) in
elderly patient.
Longitudinal TAS of pelvic
kidney (arrow). Pelvocalyceal
system accounts for central
echogenicity.
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37. Transverse TAS showing
solid left-adnexal mass
(between +’s), which
represented hemorrhagic
corpus luteum cyst.
Longitudinal TAS of solid
teratoma with calcified areas.
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38. Magnified TAS of solid mass (between +’s) representing
hemorrhagic corpus luteum cyst.
Sagittal and transverse
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39. TAS: 5 × 7 cm solid mass
associated with ascites.
This was ovarian cancer.
TVS
large solid tumor representing
a dysgerminoma
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40. Adnexal (ovarian) torsion
TVS: enlarged right ovary (between
+’s) with mildly echogenic area
resulting from internal hemorrhage
Cul-de-sac fluid adjacent to left side
of uterus in same patient
Two days later, the ovary (arrow) has
enlarged secondary to retorsion. On
TAS, enlarged size of ovary relative to
uterus can be better appreciated.
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41. SUMMARY
Although the sonographic features of a pelvic mass
may not allow a specific diagnosis, clinically useful
information can usually be obtained.
TVS is a useful adjunct to TAS because it adds
specificity in determining intraversus extraovarian
masses and endometrial and myometrial disorders.
TVS affords an accurate means for evaluation of the
ovaries and is particularly useful in obese,
postmenopausal women in whom the incidence of
ovarian carcinoma is especially high.
Although not always specific, sonographic assessment
of tumor morphology can lead to accurate diagnoses.
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42. Thank you
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