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

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Functional Ovarian Cyst TERMINOLOGY Abbreviations • Follicular cyst (FC) • Corpus luteum cyst (CLC) Definitions • 2 types of functional cysts ○ Follicular cyst forms from persistent follicle, ovulation does not occur – Associated with elevated serum estrogen ○ Corpus luteum cyst forms from graafian follicle following ovulation IMAGING General Features • Best diagnostic clue ○ FC: Thin-walled cyst persisting after ovulation expected to occur ○ CLC: Thick-walled cyst seen after ovulation Ultrasonographic Findings • FC ○ Intraovarian cystic lesion with thin walls ○ No increased flow on Doppler evaluation ○ Tend to occur in 1st half of menstrual cycle or after missed ovulation • CLC ○ Occur after ovulation in latter part of menstrual cycle ○ Intraovarian cystic lesion – Thick, hyperechoic wall – Central anechoic/hypoechoic cavity ○ May appear solid if significant hemorrhage or sac collapse – Retracting clot seen on follow-up scans ○ Commonly complicated by hemorrhage – Look for fluid-fluid level – Thin septations with lacy, reticular pattern – No internal flow on Doppler evaluation ○ Doppler findings – Marked vascular flow within CLC wall: "Ring of fire" appearance – Low-resistance waveform on pulsed Doppler CT Findings • In nonpregnant population presenting with acute pain, CT is often performed • Low-attenuation adnexal mass unless hemorrhagic ○ If so, may see high-attenuation blood products or fluidfluid level • CT poor at evaluation of internal architecture of fluid attenuation structures • CECT may show enhancing wall of CLC corresponding to "ring of fire" MR Findings • Appearances are highly variable depending on presence of associated hemorrhage Imaging Recommendations • Best imaging tool ○ Transvaginal ultrasound • For thick-walled cysts, use Doppler to exclude solid component ○ Blood flow in solid tissues, not in clot ○ "Ring of fire" commonly seen around corpus luteum ○ Follow-up masses of concern in 6-12 weeks – Decreasing size and clot retraction confirm diagnosis of corpus luteum cyst • Exophytic CLC may be difficult to differentiate from ectopic pregnancy ○ Use transvaginal ultrasound probe with gentle abdominal pressure to better evaluate adnexa ○ CL cyst moves with ovary – Tubal ectopic can be separated from ovary DIFFERENTIAL DIAGNOSIS Ectopic Pregnancy • Extraovarian • "Ring of fire" in adnexa, separate from ovary ○ Slide test: Ectopic mass can often be displaced away from ovary using gentle transvaginal probe pressure ○ Ring is typically more echogenic in ectopic than in CLC • Adnexal mass (hematoma) with echogenic free fluid Ovarian Neoplasm • Benign cystic tumors ○ Serous cystadenoma ○ Mucinous cystadenoma ○ Cystic teratoma • Solid tumors ○ Thecoma-fibroma • Ovarian malignancy Heterotopic Pregnancy • Usually history of fertility treatments • Intrauterine pregnancy documented • Additional ectopic pregnancy, usually tubal Normal Follicle • Ovulation generally occurs when dominant follicle reaches about 22 mm diameter • Correlate with menstrual history ± serum hormone levels if concern PATHOLOGY Gross Pathologic & Surgical Features • Corpus luteum cyst ○ Rim of bright yellow luteal tissue – Corpus luteum means "yellow body" ○ If no embryo implants, CLC degenerates after about 14 days and becomes corpus albicans ○ Highly variable in size – Pathologists use > 3 cm diameter for definition of CLC Microscopic Features • Corpus luteum cyst ○ Contains luteinized granulosa cells ○ Central cystic cavity with fluid and fibrin – Often with hemorrhage ○ With conception, granulosa-lutein cells enlarge Diagnoses: Female Pelvis 801

Functional Ovarian Cyst Diagnoses: Female Pelvis – Placental human chorionic gonadotropin stimulates CL progesterone production by granulosa-lutein cells – Maintains uterine endometrium to receive embryo for implantation – CL progesterone production declines by end of 2nd month of gestation □ Placenta takes over production of progesterone – CL present throughout pregnancy, though significantly reduced in metabolic activity □ Obliteration begins by 5th month of pregnancy and is complete by term CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Majority of functional cysts are asymptomatic ○ Clinical presentation with pelvic pain due to – Large size → capsular distension – Rupture: 25% of women experience mittelschmerz or ovulation pain – Hemorrhage: Occurs into FC or CLC, acute bleed may → rupture/hemoperitoneum – Torsion: Cyst enlarges ovary, may → torsion, infarction • Other signs/symptoms ○ Palpable ovarian enlargement on clinical examination ○ FC may be discovered during infertility work-up ○ CLC incidentally noted on 1st trimester scan Demographics • Age ○ Follicular and CL cysts occur during reproductive years ○ Most fetal ovarian cysts are follicular • Epidemiology ○ ~ 30% of menstruating women will have functional cyst at some point ○ 25-60% of ovarian lesions in children are functional ovarian cysts Natural History & Prognosis • Follicular cyst ○ May be associated with infertility: Oligo/anovulation ○ Estrogen levels are elevated: May interfere with ovulation induction for assisted reproduction ○ When seen in female fetus, may be present with intrauterine torsion – Look for fluid-fluid level – Most infants are asymptomatic at birth even if torsion occurred – Elective surgery may be indicated to fix contralateral ovary • Corpus luteum cyst ○ May enlarge initially with fertilization and pregnancy – Peak size usually around 7 weeks ○ Should diminish in size with progression of pregnancy ○ Most no longer seen by sonography by early 2nd trimester (16 weeks) ○ If cystic mass persists after pregnancy, consider ovarian epithelial neoplasm • Majority of functional ovarian cysts will resolve spontaneously • Torsion more common on right side and with cysts > 4 cm in diameter • Malignancy rate in unilocular simple cysts < 1% Treatment • Society of Radiologists in Ultrasound (SRU) consensus statement on ovarian cyst management ○ Simple cyst – Reproductive age women □ No follow-up necessary ≤ 5 cm □ > 5 and≤ 7 cm: Annual follow-up ultrasound – Postmenopausal □ > 1 and≤ 7 cm: Annual ultrasound – Any age group with simple cyst > 7 cm □ Refer for further imaging (MR) or surgical evaluation • Symptomatic treatment if painful ○ Oral contraceptive pill helpful if recurrent cysts • If persistent may require laparoscopic surgery ○ Fenestration vs. cystectomy ○ Goal is preservation of normal ovarian tissue DIAGNOSTIC CHECKLIST Consider • Functional cysts are common in reproductive age women • Most do not require follow-up ultrasound Image Interpretation Pearls • CLC may have "ring of fire" appearance; located within ovary ○ Beware of incorrectly diagnosing ectopic or heterotopic pregnancy, which should be outside ovary ○ If uncertain whether intraovarian or adjacent to ovary, use slide test – Ectopic mass can often be displaced away from ovary using gentle transvaginal probe pressure • Even if CLC is persistent, may monitor through pregnancy if no malignant features ○ Most likely a persistent functional cyst SELECTED REFERENCES 1. Rosenkrantz AB et al: US of incidental adnexal cysts: adherence of radiologists to the 2010 Society of Radiologists in Ultrasound guidelines. Radiology. 271(1):262-71, 2014 2. Ghosh E et al: Recommendations for adnexal cysts: have the Society of Radiologists in Ultrasound consensus conference guidelines affected utilization of ultrasound? Ultrasound Q. 29(1):21-4, 2013 3. Valentin L et al: Risk of malignancy in unilocular cysts: a study of 1148 adnexal masses classified as unilocular cysts at transvaginal ultrasound and review of the literature. Ultrasound Obstet Gynecol. 41(1):80-9, 2013 4. Faschingbauer F et al: Subjective assessment of ovarian masses using pattern recognition: the impact of experience on diagnostic performance and interobserver variability. Arch Gynecol Obstet. 285(6):1663-9, 2012 5. Levine D et al: Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 256(3):943-54, 2010 6. Timmerman D et al: Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery: prospective validation by IOTA group. BMJ. 341:c6839, 2010 802

Functional Ovarian Cyst<br />

TERMINOLOGY<br />

Abbreviations<br />

• Follicular cyst (FC)<br />

• Corpus luteum cyst (CLC)<br />

Definitions<br />

• 2 types of functional cysts<br />

○ Follicular cyst forms from persistent follicle, ovulation<br />

does not occur<br />

– Associated with elevated serum estrogen<br />

○ Corpus luteum cyst forms from graafian follicle following<br />

ovulation<br />

IMAGING<br />

General Features<br />

• Best diagnostic clue<br />

○ FC: Thin-walled cyst persisting after ovulation expected<br />

to occur<br />

○ CLC: Thick-walled cyst seen after ovulation<br />

Ultrasonographic Findings<br />

• FC<br />

○ Intraovarian cystic lesion with thin walls<br />

○ No increased flow on Doppler evaluation<br />

○ Tend to occur in 1st half of menstrual cycle or after<br />

missed ovulation<br />

• CLC<br />

○ Occur after ovulation in latter part of menstrual cycle<br />

○ Intraovarian cystic lesion<br />

– Thick, hyperechoic wall<br />

– Central anechoic/hypoechoic cavity<br />

○ May appear solid if significant hemorrhage or sac<br />

collapse<br />

– Retracting clot seen on follow-up scans<br />

○ Commonly complicated by hemorrhage<br />

– Look for fluid-fluid level<br />

– Thin septations with lacy, reticular pattern<br />

– No internal flow on Doppler evaluation<br />

○ Doppler findings<br />

– Marked vascular flow within CLC wall: "Ring of fire"<br />

appearance<br />

– Low-resistance waveform on pulsed Doppler<br />

CT Findings<br />

• In nonpregnant population presenting with acute pain, CT<br />

is often performed<br />

• Low-attenuation adnexal mass unless hemorrhagic<br />

○ If so, may see high-attenuation blood products or fluidfluid<br />

level<br />

• CT poor at evaluation of internal architecture of fluid<br />

attenuation structures<br />

• CECT may show enhancing wall of CLC corresponding to<br />

"ring of fire"<br />

MR Findings<br />

• Appearances are highly variable depending on presence of<br />

associated hemorrhage<br />

Imaging Recommendations<br />

• Best imaging tool<br />

○ Transvaginal ultrasound<br />

• For thick-walled cysts, use Doppler to exclude solid<br />

component<br />

○ Blood flow in solid tissues, not in clot<br />

○ "Ring of fire" commonly seen around corpus luteum<br />

○ Follow-up masses of concern in 6-12 weeks<br />

– Decreasing size <strong>and</strong> clot retraction confirm diagnosis<br />

of corpus luteum cyst<br />

• Exophytic CLC may be difficult to differentiate from ectopic<br />

pregnancy<br />

○ Use transvaginal ultrasound probe with gentle<br />

abdominal pressure to better evaluate adnexa<br />

○ CL cyst moves with ovary<br />

– Tubal ectopic can be separated from ovary<br />

DIFFERENTIAL DIAGNOSIS<br />

Ectopic Pregnancy<br />

• Extraovarian<br />

• "Ring of fire" in adnexa, separate from ovary<br />

○ Slide test: Ectopic mass can often be displaced away<br />

from ovary using gentle transvaginal probe pressure<br />

○ Ring is typically more echogenic in ectopic than in CLC<br />

• Adnexal mass (hematoma) with echogenic free fluid<br />

Ovarian Neoplasm<br />

• Benign cystic tumors<br />

○ Serous cystadenoma<br />

○ Mucinous cystadenoma<br />

○ Cystic teratoma<br />

• Solid tumors<br />

○ Thecoma-fibroma<br />

• Ovarian malignancy<br />

Heterotopic Pregnancy<br />

• Usually history of fertility treatments<br />

• Intrauterine pregnancy documented<br />

• Additional ectopic pregnancy, usually tubal<br />

Normal Follicle<br />

• Ovulation generally occurs when dominant follicle reaches<br />

about 22 mm diameter<br />

• Correlate with menstrual history ± serum hormone levels if<br />

concern<br />

PATHOLOGY<br />

Gross Pathologic & Surgical Features<br />

• Corpus luteum cyst<br />

○ Rim of bright yellow luteal tissue<br />

– Corpus luteum means "yellow body"<br />

○ If no embryo implants, CLC degenerates after about 14<br />

days <strong>and</strong> becomes corpus albicans<br />

○ Highly variable in size<br />

– Pathologists use > 3 cm diameter for definition of CLC<br />

Microscopic Features<br />

• Corpus luteum cyst<br />

○ Contains luteinized granulosa cells<br />

○ Central cystic cavity with fluid <strong>and</strong> fibrin<br />

– Often with hemorrhage<br />

○ With conception, granulosa-lutein cells enlarge<br />

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

801

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