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

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09.07.2019 Views

Parovarian Cyst TERMINOLOGY Abbreviations • Paratubal cyst Definitions • Cyst originating from wolffian duct in mesosalpinx or broad ligament IMAGING General Features • Best diagnostic clue ○ Unilocular cyst near but separate from ovary – Often unilateral • Size ○ Mean diameter: 40 mm (range: 15-120 mm) • Morphology ○ Well-defined, round or oval cystic mass – Rarely may be complicated by torsion or hemorrhage Ultrasonographic Findings • Adnexal cyst medial to ovary ○ Lack of follicles distinguishes from ovary ○ Separate from ovary ○ Usually does not indent ovary • Unilocular in 95% • Multilocular in 5% ○ May contain septa that are thin, smooth, complete ○ May represent multiple cysts on same side • Fluid is anechoic in 91% • Small, floating echoes (probably hemorrhage) in 9% • Thin outer wall (< 3 mm) ○ Some with 2-5 mm papillae Imaging Recommendations • Best imaging tool ○ Transvaginal ultrasound • Protocol advice ○ Study any adnexal mass from border to border – Decide ovarian vs. extraovarian □ Evaluate cyst characteristics ○ Study cyst mobility with vaginal probe – "Split" sign or "pelvic slide test" (cyst moves separate from ovary) CT Findings • Round or oval cystic structure, close but separate from ovary MR Findings • Round or oval cystic structure, close but separate from ovary • Hypointense on T1WI and hyperintense on T2WI ○ If complicated by torsion or hemorrhage, may be hyperintense on T1WI and have thick walls ○ If soft tissue component, consider neoplasm DIFFERENTIAL DIAGNOSIS Peritoneal Inclusion Cyst (PIC) • Loculated, peritoneal fluid producing unilocular or multilocular cystic mass ○ May be ovoid or irregular in contour ○ May contain internal echoes or septa ○ No perceptible walls ○ Surrounds normal ovary Hydrosalpinx • Tubular morphology with separate ovary • Hyperechoic mural nodules common True Ovarian Cyst • Unilocular or complex • Look for ovarian tissue at cyst borders ○ Inseparable from ovary PATHOLOGY Gross Pathologic & Surgical Features • 98% benign serous cyst • 2% with malignant features ○ Cystadenoma or cystadenocarcinoma CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Asymptomatic – Found at time of imaging of pelvis for other reasons ○ Adnexal mass • Other signs/symptoms ○ Torsion, growth, and malignancy are rare complications Demographics • Epidemiology ○ 10-20% of all adnexal masses – Most common in 3rd and 4th decade Treatment • Surgery avoided if cyst < 5 cm and no papillae DIAGNOSTIC CHECKLIST Consider • Often misdiagnosed as true ovarian cyst Image Interpretation Pearls • Do not assume every cystic adnexal mass is ovarian • Correct diagnosis important to avoid surgery • MR superior for identification of normal ovary when origin of large lesion cannot be determined with ultrasound SELECTED REFERENCES 1. Suzuki S et al: Two cases of paraovarian tumor of borderline malignancy. J Obstet Gynaecol Res. 39(1):437-41, 2013 2. Damle LF et al: Giant paraovarian cysts in young adolescents: a report of three cases. J Reprod Med. 57(1-2):65-7, 2012 3. Kiseli M et al: Clinical diagnosis and complications of paratubal cysts: review of the literature and report of uncommon presentations. Arch Gynecol Obstet. 285(6):1563-9, 2012 4. Laing FC et al: US of the ovary and adnexa: to worry or not to worry? Radiographics. 32(6):1621-39; discussion 1640-2, 2012 5. Patel MD: Pitfalls in the sonographic evaluation of adnexal masses. Ultrasound Q. 28(1):29-40, 2012 6. Moyle PL et al: Nonovarian cystic lesions of the pelvis. Radiographics. 30(4):921-38, 2010 Diagnoses: Female Pelvis 839

Peritoneal Inclusion Cyst Diagnoses: Female Pelvis TERMINOLOGY • Synonyms: Peritoneal pseudocyst, benign cystic mesothelioma • Not true cyst but peritoneal or ovarian fluid trapped by peritoneal adhesions IMAGING • Unilocular or multilocular pelvic cystic lesion • Boundaries defined by pelvic structures • Unilateral 65%, bilateral 35%, midline if large • Normal ovary surrounded or displaced by fluid and septations • Entrapped ovary: "Spider in web" appearance • Fine septations most common • Thick septations with nodules possible • Blood flow can be seen in septations, especially if thick • Transvaginal ultrasound first-line to localize ovary and exclude signs of malignancy KEY FACTS • MR most useful if peritoneal inclusion cyst (PIC) is large and normal ovaries cannot be found using ultrasound • CT useful for large PIC and for excluding malignant peritoneal disease but less sensitive at locating ovaries TOP DIFFERENTIAL DIAGNOSES • Ovarian cystic neoplasm • Hydrosalpinx • Paraovarian cyst • Endometriosis PATHOLOGY • PIC development requires functioning ovary and peritoneal adhesions CLINICAL ISSUES • Almost exclusively premenopausal women • Pelvic pain, palpable mass, abdominal distension • Tend to recur after drainage (Left) Coronal transvaginal ultrasound of the left ovary shows a dominant follicle . The ovary is surrounded by simple fluid with thin septa . (Right) Axial T2 TSE MR of the same patient at a later time shows the fluid conforming to the peritoneal cavity . A thin adhesion is present . The left ovarian follicle is smaller; the right ovary has developed a larger cyst . (Left) Sagittal transabdominal ultrasound shows a peritoneal inclusion cyst superior and posterior to the uterus . Internal echoes were found to be from hemorrhage at surgery. (Right) Coronal CECT of the same patient shows the extent of the huge peritoneal inclusion cyst , displacing bowel. Thin septa are present. The bladder was normal . 840

Peritoneal Inclusion Cyst<br />

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

TERMINOLOGY<br />

• Synonyms: Peritoneal pseudocyst, benign cystic<br />

mesothelioma<br />

• Not true cyst but peritoneal or ovarian fluid trapped by<br />

peritoneal adhesions<br />

IMAGING<br />

• Unilocular or multilocular pelvic cystic lesion<br />

• Boundaries defined by pelvic structures<br />

• Unilateral 65%, bilateral 35%, midline if large<br />

• Normal ovary surrounded or displaced by fluid <strong>and</strong><br />

septations<br />

• Entrapped ovary: "Spider in web" appearance<br />

• Fine septations most common<br />

• Thick septations with nodules possible<br />

• Blood flow can be seen in septations, especially if thick<br />

• Transvaginal ultrasound first-line to localize ovary <strong>and</strong><br />

exclude signs of malignancy<br />

KEY FACTS<br />

• MR most useful if peritoneal inclusion cyst (PIC) is large <strong>and</strong><br />

normal ovaries cannot be found using ultrasound<br />

• CT useful for large PIC <strong>and</strong> for excluding malignant<br />

peritoneal disease but less sensitive at locating ovaries<br />

TOP DIFFERENTIAL DIAGNOSES<br />

• Ovarian cystic neoplasm<br />

• Hydrosalpinx<br />

• Paraovarian cyst<br />

• Endometriosis<br />

PATHOLOGY<br />

• PIC development requires functioning ovary <strong>and</strong> peritoneal<br />

adhesions<br />

CLINICAL ISSUES<br />

• Almost exclusively premenopausal women<br />

• Pelvic pain, palpable mass, abdominal distension<br />

• Tend to recur after drainage<br />

(Left) Coronal transvaginal<br />

ultrasound of the left ovary<br />

shows a dominant follicle .<br />

The ovary is surrounded by<br />

simple fluid with thin septa<br />

. (Right) Axial T2 TSE MR of<br />

the same patient at a later<br />

time shows the fluid<br />

conforming to the peritoneal<br />

cavity . A thin adhesion is<br />

present . The left ovarian<br />

follicle is smaller; the right<br />

ovary has developed a larger<br />

cyst .<br />

(Left) Sagittal transabdominal<br />

ultrasound shows a peritoneal<br />

inclusion cyst superior <strong>and</strong><br />

posterior to the uterus .<br />

Internal echoes were found to<br />

be from hemorrhage at<br />

surgery. (Right) Coronal CECT<br />

of the same patient shows the<br />

extent of the huge peritoneal<br />

inclusion cyst , displacing<br />

bowel. Thin septa are<br />

present. The bladder was<br />

normal .<br />

840

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