Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Nabothian Cyst TERMINOLOGY Synonyms • Retention cyst • Cervical cyst • Ovula nabothi • Nabothian follicle Definitions • Mucus-filled cystic dilatation of endocervical gland • Tunnel cluster: Type of nabothian cyst characterized by complex multicystic dilatation of endocervical glands IMAGING General Features • Best diagnostic clue ○ Circumscribed superficial unilocular cyst in wall of cervix • Location ○ Usually superficial, along endocervical canal or ectocervix – Superficial cysts visible on speculum exam ○ Anterior, posterior or lateral cervical lip – Not in cervical canal ○ Deep cysts only visible with imaging • Size ○ Usually 10-15 mm in diameter ○ Rarely > 4 cm ○ Often multiple • Morphology ○ May distort endocervical canal ○ Can mimic multicystic mass ○ Can enlarge cervix if large or multiple Ultrasonographic Findings • Grayscale ultrasound ○ Simple superficial cervical cystic lesion – Imperceptible thin wall – Posterior acoustic enhancement (increased through transmission) – Anechoic fluid most common – Can have proteinaceous debris □ Diffusely echogenic – Rare septations □ More likely multiple cysts than true septations ○ Large nabothian cysts – Can occupy most of cervix – Displaces endocervical canal □ Rare cause of cervical stenosis – Can mimic cervical os dilatation □ Confusing in pregnancy ○ Multiple cysts common – Can obscure endocervical canal – May mimic adnexal or cervical cystic mass □ Multiple lateral cysts □ Identification of separate ovary necessary • Color Doppler ○ Absence of internal or peripheral flow MR Findings • T1WI: Variable, often mildly increased signal intensity • T2WI: High signal intensity secondary to mucous • T1WI C+: No enhancement CT Findings • NECT: Usually isodense or hypodense to cervix • CECT: Nonenhancing hypodense cervical lesion Imaging Recommendations • Best imaging tool ○ TV ultrasound ○ MR helpful for complicated cases – Intravenous contrast required to differentiate from neoplasm – Identify separate ovary • Protocol advice ○ Identify relationship between nabothian cyst and endocervical canal – If fluid in canal, consider alternate diagnosis ○ Debris within cysts is common – Not associated with malignancy ○ Use color Doppler if cyst appears potentially solid DIFFERENTIAL DIAGNOSIS Adenoma Malignum (Minimal Deviation Adenocarcinoma) • Low-grade mucinous carcinoma affecting deep endocervical glands • Multilocular cystic mass in cervix • Deeply penetrating into cervical stroma; distinguish from more superficial nabothian cysts • Typical clinical presentation of copious watery vaginal discharge • Associated with Peutz-Jeghers syndrome Endocervical Hyperplasia • Thickening of endocervical mucosa ± cystic change • Associated with oral progestational agents, pregnancy, and postpartum • Appearance can overlap with adenoma malignum Uterine Cervicitis • Clinical: Tenacious, yellow or turbid, jelly-like discharge • Associated with pelvic pressure or discomfort • Can appear as retention cysts in cervix Cystic Endometrial Polyp • May contain cysts and arise from, or prolapse into, cervix • Endocavitary mass; not within cervical stroma • Doppler shows flow in stalk Cervical Cancer • Bulky large cervix, difficult to identify cervical canal ○ Cervical width > 4 cm • Solid mass much more common than cystic • Endometrial fluid from cervical stenosis • Mucin producing carcinoma can mimic nabothian cyst ○ Both are high signal on T2WI MR ○ Carcinoma enhances irregularly Cervical Ectopic Pregnancy • Implantation of conceptus within cervical stroma • Thick-walled cystic mass ○ Echogenic rim Diagnoses: Female Pelvis 727

Nabothian Cyst 728 Diagnoses: Female Pelvis ○ Doppler shows trophoblastic flow • Internal sac structures often visible ○ Yolk sac ○ Embryo, ± cardiac activity Abortion in Progress • Detached gestational sac in cervical canal ○ Teardrop shape • Internal sac structures sometimes visible ○ Yolk sac ○ Embryo – Cardiac activity almost always absent – If living embryo, must rule out cervical ectopic • No trophoblastic flow around sac ○ If blood flow seen, must rule out cervical ectopic PATHOLOGY General Features • Etiology ○ Healing process of chronic cervicitis – Endocervical glands become covered by squamous epithelium – Columnar epithelial cells continue to secrete mucus – Trapped mucus becomes cyst ○ Tunnel cluster – Most commonly, result of stimulatory effects during pregnancy – Type A: Small, nondilated tunnels – Type B: Obstruction of type A tunnels leads to larger cysts ○ Progestogenic therapy – Due to failure of cyclic flow of cervical mucus Gross Pathologic & Surgical Features • Yellow or white cysts on surface of cervix • Round cysts with clear fluid Microscopic Features • Lined by columnar epithelium • Retained mucus • Tunnel cluster ○ Type A: Small-caliber tunnels lined by tall columnar epithelium ○ Type B: Cystic tunnels lined by cuboidal or flattened cells CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Rarely symptomatic ○ Incidental finding – Superficial cysts observed by gynecologist during speculum exam – Deep cysts seen incidentally during transvaginal ultrasound ○ Large cysts may be palpable • Other signs/symptoms ○ Enlarged cervix – Patient discomfort – Cervical stenosis ○ Rarely infected Demographics • Age ○ Women of reproductive age ○ More common in women who have had children ○ Tunnel clusters almost always in multigravid women > 30 years old • Epidemiology ○ Most common pathologic process of cervix Natural History & Prognosis • Slow growing, do not resolve spontaneously Treatment • Rarely necessary • Symptomatic nabothian cysts ○ Electrocautery ○ Cryotherapy ○ Drainage DIAGNOSTIC CHECKLIST Consider • Nabothian cysts are common • Requires further evaluation with MR if ○ Solid components ○ Copious vaginal discharge ○ Deep cervical invasion Image Interpretation Pearls • Well-defined, small, unilocular simple cysts in cervix • Superficial location along cervical canal • Large cysts can mimic endocervical fluid ○ Identify cervical canal separate from cyst • Pregnant patients may have other significant cervical problems SELECTED REFERENCES 1. Bin Park S et al: Multilocular cystic lesions in the uterine cervix: broad spectrum of imaging features and pathologic correlation. AJR Am J Roentgenol. 195(2):517-23, 2010 2. Dujardin M et al: Cystic lesions of the female reproductive system: a review. JBR-BTR. 93(2):56-61, 2010 3. Rezvani M et al: Imaging of cervical pathology. Top Magn Reson Imaging. 21(4):261-71, 2010 4. Sosnovski V et al: Complex Nabothian cysts: a diagnostic dilemma. Arch Gynecol Obstet. 279(5):759-61, 2009 5. Oguri H et al: MRI of endocervical glandular disorders: three cases of a deep nabothian cyst and three cases of a minimal-deviation adenocarcinoma. Magn Reson Imaging. 22(9):1333-7, 2004 6. Li H et al: Markedly high signal intensity lesions in the uterine cervix on T2- weighted imaging: differentiation between mucin-producing carcinomas and nabothian cysts. Radiat Med. 17(2):137-43, 1999 7. Janus C et al: Nabothian cysts stimulating an adnexal mass. Clin Imaging. 13(2):157-8, 1989 8. Fogel SR et al: Sonography of Nabothian cysts. AJR Am J Roentgenol. 138(5):927-30, 1982

Nabothian Cyst<br />

728<br />

Diagnoses: Female <strong>Pelvis</strong><br />

○ Doppler shows trophoblastic flow<br />

• Internal sac structures often visible<br />

○ Yolk sac<br />

○ Embryo, ± cardiac activity<br />

Abortion in Progress<br />

• Detached gestational sac in cervical canal<br />

○ Teardrop shape<br />

• Internal sac structures sometimes visible<br />

○ Yolk sac<br />

○ Embryo<br />

– Cardiac activity almost always absent<br />

– If living embryo, must rule out cervical ectopic<br />

• No trophoblastic flow around sac<br />

○ If blood flow seen, must rule out cervical ectopic<br />

PATHOLOGY<br />

General Features<br />

• Etiology<br />

○ Healing process of chronic cervicitis<br />

– Endocervical gl<strong>and</strong>s become covered by squamous<br />

epithelium<br />

– Columnar epithelial cells continue to secrete mucus<br />

– Trapped mucus becomes cyst<br />

○ Tunnel cluster<br />

– Most commonly, result of stimulatory effects during<br />

pregnancy<br />

– Type A: Small, nondilated tunnels<br />

– Type B: Obstruction of type A tunnels leads to larger<br />

cysts<br />

○ Progestogenic therapy<br />

– Due to failure of cyclic flow of cervical mucus<br />

Gross Pathologic & Surgical Features<br />

• Yellow or white cysts on surface of cervix<br />

• Round cysts with clear fluid<br />

Microscopic Features<br />

• Lined by columnar epithelium<br />

• Retained mucus<br />

• Tunnel cluster<br />

○ Type A: Small-caliber tunnels lined by tall columnar<br />

epithelium<br />

○ Type B: Cystic tunnels lined by cuboidal or flattened cells<br />

CLINICAL ISSUES<br />

Presentation<br />

• Most common signs/symptoms<br />

○ Rarely symptomatic<br />

○ Incidental finding<br />

– Superficial cysts observed by gynecologist during<br />

speculum exam<br />

– Deep cysts seen incidentally during transvaginal<br />

ultrasound<br />

○ Large cysts may be palpable<br />

• Other signs/symptoms<br />

○ Enlarged cervix<br />

– Patient discomfort<br />

– Cervical stenosis<br />

○ Rarely infected<br />

Demographics<br />

• Age<br />

○ Women of reproductive age<br />

○ More common in women who have had children<br />

○ Tunnel clusters almost always in multigravid women > 30<br />

years old<br />

• Epidemiology<br />

○ Most common pathologic process of cervix<br />

Natural History & Prognosis<br />

• Slow growing, do not resolve spontaneously<br />

Treatment<br />

• Rarely necessary<br />

• Symptomatic nabothian cysts<br />

○ Electrocautery<br />

○ Cryotherapy<br />

○ Drainage<br />

DIAGNOSTIC CHECKLIST<br />

Consider<br />

• Nabothian cysts are common<br />

• Requires further evaluation with MR if<br />

○ Solid components<br />

○ Copious vaginal discharge<br />

○ Deep cervical invasion<br />

Image Interpretation Pearls<br />

• Well-defined, small, unilocular simple cysts in cervix<br />

• Superficial location along cervical canal<br />

• Large cysts can mimic endocervical fluid<br />

○ Identify cervical canal separate from cyst<br />

• Pregnant patients may have other significant cervical<br />

problems<br />

SELECTED REFERENCES<br />

1. Bin Park S et al: Multilocular cystic lesions in the uterine cervix: broad<br />

spectrum of imaging features <strong>and</strong> pathologic correlation. AJR Am J<br />

Roentgenol. 195(2):517-23, 2010<br />

2. Dujardin M et al: Cystic lesions of the female reproductive system: a review.<br />

JBR-BTR. 93(2):56-61, 2010<br />

3. Rezvani M et al: Imaging of cervical pathology. Top Magn Reson Imaging.<br />

21(4):261-71, 2010<br />

4. Sosnovski V et al: Complex Nabothian cysts: a diagnostic dilemma. Arch<br />

Gynecol Obstet. 279(5):759-61, 2009<br />

5. Oguri H et al: MRI of endocervical gl<strong>and</strong>ular disorders: three cases of a deep<br />

nabothian cyst <strong>and</strong> three cases of a minimal-deviation adenocarcinoma.<br />

Magn Reson Imaging. 22(9):1333-7, 2004<br />

6. Li H et al: Markedly high signal intensity lesions in the uterine cervix on T2-<br />

weighted imaging: differentiation between mucin-producing carcinomas<br />

<strong>and</strong> nabothian cysts. Radiat Med. 17(2):137-43, 1999<br />

7. Janus C et al: Nabothian cysts stimulating an adnexal mass. Clin Imaging.<br />

13(2):157-8, 1989<br />

8. Fogel SR et al: Sonography of Nabothian cysts. AJR Am J Roentgenol.<br />

138(5):927-30, 1982

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