Diagnostic Ultrasound - Abdomen and Pelvis
Cystic Adnexal Mass Dermoid (Mature Cystic Teratoma) Complex Cyst (Mimic) (Left) Endovaginal US in a premenopausal woman shows a large thin-walled, adnexal cyst, which is predominately anechoic but contains a few specular reflectors. Dermoids can rarely mimic an anechoic cyst if they are predominately filled with sebum. (Right) Transverse endovaginal power Doppler US in a premenopausal woman shows a large, anechoic cyst with several small avascular mural nodules st. Pathology revealed a serous borderline tumor. Careful search for mural nodules should be performed. Differential Diagnoses: Female Pelvis Complex Cyst (Mimic) Complex Cyst (Mimic) (Left) Longitudinal transabdominal US in a premenopausal woman shows an anechoic left ovarian cyst ſt at 10 cm depth posterior to a fibroid uterus . (Right) Transverse endovaginal US in the same patient shows classic findings of a hemorrhagic cyst with lacy interstices/cobweb appearance. Note that transabdominal ultrasound may not show the detailed architecture of a cyst and transvaginal ultrasound should always be performed when feasible. Complex Cyst (Mimic) Adnexal Torsion (Left) Transverse transabdominal US of the right adnexa in the 3rd trimester shows dilated adnexal veins ſt, which should not be mistaken for a complex cystic adnexal mass. (Right) Endovaginal color Doppler US in a woman with acute pelvic pain shows a simple cyst with surrounding claw of edematous ovarian parenchyma ſt with no Doppler flow. A twisted pedicle could be seen in real time. Cysts may act as a lead point for ovarian torsion. 1031
Solid Adnexal Mass 1032 Differential Diagnoses: Female Pelvis DIFFERENTIAL DIAGNOSIS Common • Leiomyoma • Ectopic Pregnancy • Mature Teratoma (Dermoid) Less Common • Adnexal Torsion • Metastases, Ovary • Ovarian Fibroma • Solid Adnexal Mass (Mimics) ○ Hemorrhagic Ovarian Cyst ○ Endometrioma ○ Obstructed Uterine Duplication ○ Pelvic Kidney ○ Rectosigmoid Carcinoma • Primary Ovarian Malignancy ○ Mucinous Cystadenocarcinoma ○ Serous Cystadenocarcinoma ○ Endometrioid Carcinoma Rare but Important • Ovarian Lymphoma • Tubo-Ovarian Abscess • Tubal Carcinoma • Luteoma of Pregnancy • Adenofibroma • Granulosa Cell Tumor • Brenner Tumor • Atypical Germ Cell Tumors ○ Immature Teratoma ○ Dysgerminoma ○ Choriocarcinoma • Massive Ovarian Edema and Fibromatosis ESSENTIAL INFORMATION Key Differential Diagnosis Issues • Understanding typical appearance of benign lesions and mimics of malignant solid masses is important to avoid unnecessary work-up or surgery • Ovaries visualized separate from mass suggests nonovarian etiology • If mass appears fibrotic with shadowing, tends to be benign fibrous lesions ○ Pedunculated or broad ligament leiomyoma ○ Ovarian fibroma ○ Adenofibroma • Bilateral lesions ○ Primary ovarian malignancy ○ Metastases ○ Endometrioid carcinoma ○ Lymphoma • Hormonally active lesion ○ Thecoma ○ Granulosa cell tumor Helpful Clues for Common Diagnoses • Leiomyoma ○ May be subserosal, exophytic, pedunculated ○ Ovaries are seen separate from mass – Using transducer pressure to push away ovary can confirm this ○ Fibrous appearance with edge shadowing ○ Blood flow is seen connecting mass to uterus ○ MR helpful in establishing etiology if uncertain (leiomyoma vs. fibrous ovarian tumor) ○ Can grow/degenerate during pregnancy due to hormonal stimulation – Causes pain – Appears as growing, solid adnexal mass • Ectopic Pregnancy ○ Always should be suspected in premenopausal woman with pelvic pain and adnexal mass ○ Typically, small round adnexal mass (tubal ring) separate from ovary – With absent intrauterine pregnancy – Hypervascular rim on color Doppler □ Do not confuse with increased flow around corpus luteum ○ May see yolk sac or fetal pole but typically do not ○ When ruptured, if adherent, adnexal clot can be confused for large solid adnexal mass – Ovary and tubal pregnancy may not be seen separately from clot • Mature Teratoma (Dermoid) ○ Cystic mass with variety of imaging appearances that can mimic solid lesion – Typical: Heterogeneous cystic ovarian mass with echogenic shadowing mural nodule (Rokitansky nodule) – Posterior "dirty" shadowing, tip of iceberg sign – ± fat-fluid level – Dot-dash sign from hair – Rarely entirely echogenic and solid appearing but should lack central Doppler flow □ Beware of twinkling artifact mimicking true flow; use pulsed Doppler if unsure Helpful Clues for Less Common Diagnoses • Adnexal Torsion ○ Unilateral lesion in patient with severe ipsilateral pain ○ Enlarged ovary ○ Multiple, small, peripheral follicles or mass acting as lead point ○ Blood flow may be absent on affected side, but not all cases of torsion have abnormal blood flow • Metastases, Ovary ○ Patient with known primary carcinoma, most commonly from colon, gastric, breast, lung, or contralateral ovary ○ Krukenberg tumors are metastatic ovarian tumors that contain mucin-secreting signet-ring cells, usually of GI origin • Ovarian Fibroma ○ Typically seen in women age 40-60 ○ May be associated with hirsutism and amenorrhea if it secretes androgen ○ May be associated with endometrial thickening if it secretes estrogen • Solid Adnexal Mass (Mimics) ○ Hemorrhagic Ovarian Cyst
- Page 1002 and 1003: Diffuse Peritoneal Fluid Hemoperito
- Page 1004 and 1005: Solid Peritoneal Mass - Higher dens
- Page 1006 and 1007: Solid Peritoneal Mass Mimics Benign
- Page 1008 and 1009: Cystic Peritoneal Mass ○ Women of
- Page 1010 and 1011: Cystic Peritoneal Mass Pseudomyxoma
- Page 1012 and 1013: PART III SECTION 8 Prostate Enlarge
- Page 1014 and 1015: Enlarged Prostate Benign Prostatic
- Page 1016 and 1017: Focal Lesion in Prostate ○ Variab
- Page 1018 and 1019: Focal Lesion in Prostate Müllerian
- Page 1020 and 1021: PART III SECTION 9 Bowel Bowel Wall
- Page 1022 and 1023: Bowel Wall Thickening - Distal ileu
- Page 1024 and 1025: Bowel Wall Thickening Crohn Disease
- Page 1026 and 1027: Bowel Wall Thickening Clostridium D
- Page 1028 and 1029: PART III SECTION 10 Scrotum 1008
- Page 1030 and 1031: Diffuse Testicular Enlargement Test
- Page 1032 and 1033: Decreased Testicular Size Testicula
- Page 1034 and 1035: Testicular Calcifications Sertoli C
- Page 1036 and 1037: Focal Testicular Mass - Most common
- Page 1038 and 1039: Focal Testicular Mass Testicular Ly
- Page 1040 and 1041: Focal Extratesticular Mass - 3-50 m
- Page 1042 and 1043: Focal Extratesticular Mass Inguinal
- Page 1044 and 1045: Focal Extratesticular Mass Liposarc
- Page 1046 and 1047: Extratesticular Cystic Mass Varicoc
- Page 1048 and 1049: PART III SECTION 11 Female Pelvis
- Page 1050 and 1051: Cystic Adnexal Mass □ Hemorrhagic
- Page 1054 and 1055: Solid Adnexal Mass - May masquerade
- Page 1056 and 1057: Solid Adnexal Mass Fibrothecoma Hem
- Page 1058 and 1059: Extraovarian Adnexal Mass Helpful C
- Page 1060 and 1061: Extraovarian Adnexal Mass Paraovari
- Page 1062 and 1063: Extraovarian Adnexal Mass Lymph Nod
- Page 1064 and 1065: Enlarged Ovary - Often bilateral (5
- Page 1066 and 1067: Enlarged Ovary Theca Lutein Cysts T
- Page 1068 and 1069: Enlarged Uterus Leiomyoma Adenomyos
- Page 1070 and 1071: Abnormal Endometrium ○ Multiple e
- Page 1072 and 1073: Abnormal Endometrium Pregnancy and
- Page 1074 and 1075: Abnormal Endometrium Tamoxifen-Indu
- Page 1076 and 1077: INDEX A Abdominal aorta, 34, 40, 42
- Page 1078 and 1079: INDEX - myelolipoma vs., 590 - stag
- Page 1080 and 1081: INDEX Biliary cyst. See Choledochal
- Page 1082 and 1083: INDEX Caroli disease, 204-207 - bil
- Page 1084 and 1085: INDEX - solid renal mass vs., 968 -
- Page 1086 and 1087: INDEX diagnostic checklist, 839 dif
- Page 1088 and 1089: INDEX Efferent ductules, 130 Ejacul
- Page 1090 and 1091: INDEX Focal myometrial contraction
- Page 1092 and 1093: INDEX - hydrocele vs., 715 - sperma
- Page 1094 and 1095: INDEX Hepatocellular carcinoma (HCC
- Page 1096 and 1097: INDEX Inflammatory pseudotumor, sol
- Page 1098 and 1099: INDEX - focal extratesticular mass
- Page 1100 and 1101: INDEX irregular hepatic surface vs.
Cystic Adnexal Mass<br />
Dermoid (Mature Cystic Teratoma)<br />
Complex Cyst (Mimic)<br />
(Left) Endovaginal US in a<br />
premenopausal woman shows<br />
a large thin-walled, adnexal<br />
cyst, which is predominately<br />
anechoic but contains a few<br />
specular reflectors. Dermoids<br />
can rarely mimic an anechoic<br />
cyst if they are predominately<br />
filled with sebum. (Right)<br />
Transverse endovaginal power<br />
Doppler US in a<br />
premenopausal woman shows<br />
a large, anechoic cyst with<br />
several small avascular mural<br />
nodules st. Pathology<br />
revealed a serous borderline<br />
tumor. Careful search for<br />
mural nodules should be<br />
performed.<br />
Differential Diagnoses: Female <strong>Pelvis</strong><br />
Complex Cyst (Mimic)<br />
Complex Cyst (Mimic)<br />
(Left) Longitudinal<br />
transabdominal US in a<br />
premenopausal woman shows<br />
an anechoic left ovarian cyst<br />
ſt at 10 cm depth posterior to<br />
a fibroid uterus . (Right)<br />
Transverse endovaginal US in<br />
the same patient shows classic<br />
findings of a hemorrhagic cyst<br />
with lacy interstices/cobweb<br />
appearance. Note that<br />
transabdominal ultrasound<br />
may not show the detailed<br />
architecture of a cyst <strong>and</strong><br />
transvaginal ultrasound<br />
should always be performed<br />
when feasible.<br />
Complex Cyst (Mimic)<br />
Adnexal Torsion<br />
(Left) Transverse<br />
transabdominal US of the<br />
right adnexa in the 3rd<br />
trimester shows dilated<br />
adnexal veins ſt, which<br />
should not be mistaken for a<br />
complex cystic adnexal mass.<br />
(Right) Endovaginal color<br />
Doppler US in a woman with<br />
acute pelvic pain shows a<br />
simple cyst with surrounding<br />
claw of edematous ovarian<br />
parenchyma ſt with no<br />
Doppler flow. A twisted<br />
pedicle could be seen in<br />
real time. Cysts may act as a<br />
lead point for ovarian torsion.<br />
1031