question

In postmenopausal woman, ovaries enlarged; if mass is seen, may be ____________ ____________ to ____________ with papillae within.

answer

mixed texture to solid

question

Well-defined anechoic lesions more likely to be benign; lesions with irregular walls, thick irregular septations, mural nodules, and solid echogenic elements favor malignancy

answer

True

question

Sonographic Evaluation of Ovarian Neoplasms

answer

-Doppler examination shows low-resistive pattern -Extension beyond ovary into omentum or peritoneum and liver metastases should be evaluated. -Malignant ascites may be present. -Unilocular or thinly septated cysts more likely to be benign

question

Multilocular, thickly septated masses and masses with solid nodules are more likely to be ____________.

answer

malignant

question

In advanced stages, _____________ ____________ with malignant ascites and peritoneal implants can be seen.

answer

peritoneal carcinomatosis

question

Sonographic Evaluation of the ovaries

answer

-Any change in ovarian echogenicity or volume of more than 20 ml should be considered suspicious. -In postmenopausal women, ovaries become atrophic and often do not have follicles. -Only women receiving hormone replacement therapy continue to have normal-sized ovaries. -Abnormal ovaries suggestive of malignancy defined as enlarged echogenic ovaries

question

Ovarian Carcinoma

answer

-kills more women than cancer of uterine cervix and body combined and is the fourth leading cause of cancer death. -Approximately 1 in 70 women develop the disease. -60% of ovarian malignancies occur in women between 40 and 60 years of age.

question

Symptoms and sonographic findings of Ovarian Carcinoma

answer

-Relative absence of symptoms early in disease -Commonly not detected until advanced, having spread beyond capsule but still within pelvis (stage II) or into abdomen (stage III) -Adnexal finding on physical examination variable, ranging from almost "normal" to slightly enlarged firm irregular ovaries to pelvic masses

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Sonographic finidings (continuation)

answer

-In advanced disease, ascites and omental masses may be palpated. -Can present as either complex, cystic, or solid mass -More likely predominantly cystic -As many as 20% bilateral

question

Diagnosing Ovarian Carcinoma

answer

-Blood chemistry test CA 125 helpful in some patients; disappointing as screening test because of inability to detect many cases of ovarian cancer -Has many false-positive and false-negative results; elevated levels found in only 50% of patients with stage III ovarian cancer

question

Differential diagnosis of Ovarian Carcinoma

answer

-endometriosis -hemorrhagic ovarian cyst -ovarian torsion -PID -benign ovarian neoplasms

question

Masses 10 cm more likely to be ______________.

answer

benign malignant **Increasing patient age correlates with increased incidence of malignancy.

question

Incidence of ovarian cancer greatly increased in women who have had ______________ & _____________ cancer.

answer

breast and colon

question

Which genes is Ovarian Carcinoma primarily related to?

answer

-Appears primarily related to genetic mutations in BRCA1 and BRCA2 genes **Less commonly in MSH2 and MLH1 genes

question

Risk Factors for OC

answer

-Strongest risk factor is family history of ovarian or breast cancer -Women with carcinoma of breast have increased risk of developing ovarian cancer; women with ovarian cancer 3 to 4 times more likely to develop breast cancer **Other risk factors include -increasing age, -nulliparity, -infertility, -uninterrupted ovulation, -and late menopause.

question

Clinical symptoms of OC

answer

-vague abdominal pain -swelling, indigestion -frequent urination -constipation -weight change (ascites). **Over 70% of women first seen by doctors are in advanced stages of disease

question

Stages of cancer

answer

-STAGE I: Limited to ovary -STAGE II: Limited to pelvis -STAGE III: Limited to abdomen -STAGE IV: Hematogenous disease

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STAGE I

answer

a. Limited to 1 ovary b. Limited to 2 ovaries c. Positive peritoneal lavage (ascites)

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STAGE II

answer

a. Involvement of uterus/fallopian tubes b. Extension to other pelvic tissues c. Positive peritoneal lavage (ascites)

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STAGE III

answer

intraabdominal extension outside pelvis/retroperitoneal nodes/extension to small bowel/omentum

question

STAGE IV

answer

Hematogenous disease (liver parenchyma)/spread beyond abdomen

question

Lavage

answer

means the irrigation or washing out of an organ as the stomach or bowel 2. to wash out or irrigate

question

The cortex of the ovary

answer

After puberty, the cortex forms most of the volume of the ovary. It is composed of a series of stromal cells arranged in 'whorls', together with a network of collagen fibers. It houses the developing gametes in structures known as ovarian follicles.

question

Follicular or stromal cells

answer

are a single layer of flat supporting cells that surround oocytes present in the cortex of the ovary. They support the oocyte and nourish it.

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theca folliculi

answer

The stromal cells surrounding the follicle start to condense to form the theca folliculi

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primary follicle

answer

The follicles begin developing multi-layers of cuboidal supporting cells, known as granulosa cells. -These secrete follicular fluid within the interstitial space.

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Secondary follicles

answer

-Similar to primary follicles in many ways, however they are larger (approx. 200 µm in diameter) and have more developed theca folliculi. -they now consist of an inner layer (theca interna) and outer layer (theca externa). Only a few primary follicles develop into secondary follicles.

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Epithelial Tumors

answer

-Gynecologic tumors that arise from surface epithelium and cover ovary and underlying stroma are called surface epithelial-stromal tumors. -Account for 65% to 75% of all ovarian neoplasms and 80% to 90% of all ovarian malignancies -Most common types are serous and mucinous tumors -Mixed solid to cystic ovarian masses typical of all epithelial ovarian tumors

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Serous tumors

answer

-most common; comprise 30% of all ovarian neoplasm -cystadenoma and cystadenocarcinoma

question

Mucinous tumors

answer

-account for 20% to 25% of ovarian neoplasms. -less frequently bilateral than are serous type

question

During peak fertile years, only ________ malignant; ratio becomes 1 in 3 after age 40.

answer

-1 in 15 -40

question

More sonographically complex the tumor, more likely to be malignant, especially if associated with ascites.

answer

True

question

Epithelium of mucinous tumors tubal in type; may be one or multiple cysts.

answer

Fasle - serous tumors are tubal in type & may consist of one or multiple cysts

question

Sonographic evaluation of Epithelial tumors

answer

-One fourth bilateral; most occur in women >40 Large and often fill pelvic cavity -Ovary with volume twice that of opposite side generally considered abnormal -When solid mass found, care taken to identify connection with uterus to differentiate ovarian lesion from pedunculated fibroid -Color Doppler helpful by using color to identify vascular pedicle between uterus and mass, as can often be identified with pedunculation

question

Mucinous Cystadenomas

answer

-More complex internal echo pattern than serous cystadenomas -Contain fine medium level echoes -Contain coarse echoes of relatively high amplitude -May become very large tumors and can only be appreciated with a transabdominal sonogram.

question

adenoma

answer

Benign or low-malignancy potential form of tumor

question

adenocarcinoma

answer

malignant form of tumor

question

fibroma

answer

added if tumor is more than 50% fibrous

question

Spreading of Epithelial Tumors

answer

-Metastatic spread primarily intraperitoneal -Direct extension to surrounding structures and lymphatics not uncommon -Hematogeneous spread usually occurs late in course of disease.

question

Mucinous Cystadenoma

answer

-Type of epithelial tumor lined by mucinous elements of endocervix and bowel -Constitutes 20% to 25% of all benign ovarian neoplasms -Is usually found in woman between ages of 13 and 45 years old -80% to 85% of mucinous tumors benign -Can be very large, measuring 15 to 30 cm in diameter, and weighing more than 100 pounds

question

Mucinous Cystadenoma characteristics

answer

-Most common cystic tumor -Usually unilateral -Cyst filled with sticky, gelatin-like material -Multilocular cystic spaces -Benign type more common than malignant **Clinical findings: Pressure, pain, increased abdominal girth

question

Sonographic Findings of Mucinous Cystadenoma

answer

-In 75% of patients with mucinous tumors, ultrasound examination shows simple or septate thin-walled multilocular cysts -Contain internal echoes with compartments differing in echogenicity caused by mucoid material in dependent portions

question

Mucinous Cystadenocarcinoma

answer

-Most frequently occurs in women 40 to 70 years old -Accounts for 5% to 10% of all primary malignant ovarian neoplasms -15% to 20% bilateral when malignant - 10% occur in menopausal women -Can also become very large and more likely than benign form to rupture -If tumor ruptures, associated with pseudomyxoma peritoneum -Causes loculated ascites with mass effect

question

Sonographic Findings of Mucinous Cystadenocarcinoma

answer

-Malignant cysts tend to have thick, irregular walls and septations with papillary projections and echogenic material. -Generally have sonographic appearance similar to serous cystadenocarcinomas

question

Adjustments in equipment features with auto optimization may help the sonographer to better determine the thickness of the septations within the large ovarian mass.

answer

True

question

other sonographic appearance of Mucinous Cystadenocarcinoma

answer

-Bilateral -May occur in menopausal women (10%) -Large, likely to rupture—ascites

question

Clinical evaluations of Mucinous Cystadenocarcinoma

answer

-Pelvic pressure; pain when ruptured -Sonographic Findings: Ascites appears as hypoechoic fluid with bright punctate echoes; thick, irregular walls and septations

question

Serous Cystadenoma

answer

-Second most common benign tumor of ovary (after dermoid cyst) -Represents 20% to 25% of all benign ovarian neoplasms -Is usually unilateral; 20% are bilateral

question

Sonographic Findings of Serous Cystadenoma

answer

-Usually unilocular or multilocular with thin septations -Smaller than mucinous cysts (up to 20 cm); borders irregular with loss of capsular definition -Multilocular cysts contain small amount of solid tissue in chambers of varying size with occasional internal septum or mural nodules

question

Sonographic appearance of Serous Cystadenoma

answer

-Usually unilateral -Smaller than mucinous cysts -Multilocular cysts with septations Clinical: Pelvic pressure, bloating Sonographic Findings: Multilocular cyst; may have nodule

question

Serous Cystadenocarcinoma

answer

External papillary mass adhesions and infection lead to bilateral involvement Loss of capsular definition and tumor fixation; calcifications Peritoneal implants; ascites; metastases to omentum, lymph nodes, liver, and lungs Clinical: Pelvic fullness, bloating

question

Sonographic Findings of Serous Cystadenocarcinoma

answer

Cystic structure with septations and/or papillary projections; internal and external papillomas usually present

question

Germ Cell Tumors

answer

-Germ cell tumors derived from primitive germ cells of embryonic gonad -Account for 15% to 20% of ovarian neoplasms, with approximately 95% being benign cystic teratomas -Besides teratomas, germ cell tumors include dysgerminoma, embryonal cell carcinoma, choriocarcinoma, and transdermal sinus tumor -Often occur as mixed tumors with elements of two or three varieties of germ cell tumors

question

Germ Cell Tumors is associated with elevated alpha-fetoprotein (AFP) and hCG levels.

answer

True

question

Dermoid Cysts

answer

-Classified as a Germ Cell tumor -Represent 10-20% of benign ovarian cysts -Contain derivatives of all three germ layers -8-15% of Dermoid cysts are bilateral -Composed of varying tissue composition making them the ultrasound chameleon of ovarian tumors -Most commonly contain: skin, hairs, and sebaceous glands. -They may also contain fat, cartilage, nerve tissue, bone , respiratory tissue, teeth and gastrointestinal tissue

question

Clinical symptoms of Germ cell tumors

answer

-Clinical symptoms include pelvic and/or abdominal pain and palpable mass (average diameter 15 cm) -Usually unilateral; 40% of tumors will calcify -Ranges in texture from homogeneously solid (3%), predominantly solid (85%), to predominantly cystic (12%)

question

Teratoma: Dermoid Tumors

answer

-Size ranges from small to 40 cm -Unilateral, round to oval mass -Contains fatty, sebaceous material, hair, cartilage, bone, teeth

question

Teratoma: Dermoid Tumors clinical symptoms

answer

Asymptomatic to abdominal pain, enlargement and pressure; pedunculated; subject to torsion

question

Sonographic Findings of Teratoma: Dermoid Tumors

answer

Cystic/complex/solid mass; echogenic components; acoustic

question

Sonographic patterns of Teratoma

answer

A. completely cystic mass B. cystic mass with very echogenic nodule along mural wall representing "dermoid plug" C. fat-fluid level D. high-amplitude echoes with shadowing (e.g., teeth or bone) E. complex mass with internal septations

question

Immature and Mature Teratomas

answer

-Immature teratomas uncommon; occur in girls and young women 10 to 20 years of age -Rapidly growing, solid malignant tumors with many tiny cysts -AFP elevated in 50% of patients -Unilateral and small in size; may grow to larger dimension

question

Dysgerminoma

answer

-Rare malignant germ cell tumor bilateral in 15% of cases -Mass constitutes 1% to 2% of primary ovarian neoplasms and 3% to 5% of ovarian malignancies -Entirely solid ovarian mass in woman <30 years of age usually dysgerminoma -Dysgerminoma and serous cystadenoma are two most common ovarian neoplasms seen in pregnancy

question

Endodermal Sinus Tumor (yolk sac tumors)

answer

-Endodermal sinus tumors rare rapidly growing tumors also called yolk sac tumors. -Usually occurs in women <20 years of age; is almost always unilateral -Increased serum AFP may be seen.

question

Yolk sac tumors (YSTs) can be seen in males and females, involving the testis, ovary, and other sites, such as the mediastinum.

answer

True

question

Endodermal Sinus Tumor /Yolk sac tumors (YSTs

answer

-occurs rarely in older women -associated with a variety of ovarian epithelial tumors elevated serum levels of ?-fetoprotein that roughly correlate with the amount of the YST component. -should be suspected in postmenopausal women with an ovarian mass and elevated serum levels

question

Endodermal Sinus Tumor sonographic appearance

answer

-Endodermal sinus tumor has poor prognosis. -Second most common malignant ovarian germ cell neoplasm after dysgerminoma -Sonographic appearance similar to dysgerminoma

question

Stromal Tumors

answer

-Sex cord-stromal tumors typically solid adnexal masses that arise from sex cords of embryonic gonadal and/or ovarian stroma -Includes granulosa cell tumor, thecoma, fibroma, and Sertoli-Leydig cell tumors (androblastoma and arrhenoblastoma) -Accounts for 5% to 10% of all ovarian neoplasms and 2% of all ovarian malignancies

question

Sertoli-Leydig cell tumor

answer

-is a rare cancer of the ovaries. -The cancer cells produce and release a male sex hormone.Sertoli-Leydig cell tumor is an androgen producing ovarian tumor that is most prevalent between 20 and 25 years of age. -It may occur at any age, however, heavy androgen production by the tumor incites a rapidy progessive virilization, with hirsutism, acne, clitoral hypertrophy, deepen of the voice, and an increas in muscle. Srum testosterone levels are markedly elevated. -considered types of testicular cancer

question

classified under Sertoli-Leydig cell tumour

answer

arrhenoblastoma and androblastoma

question

Fibroma and Thecoma

answer

-Both fibroma and thecoma tumors arise from ovarian stroma; are pathologically similar -Tumors with abundance of thecal cells called thecomas, and those with abundance of fibrous tissue called fibromas -Thecomas usually benign and unilateral, comprising 1% of all ovarian neoplasms; 70% occur in postmenopausal women -Frequently show signs of estrogen production

question

Fibroma

answer

-Fibromas are very rare type of ovarian tumor. -They are benign and most often unilateral. -They are most prevalent in the perimenopausal age group. -Ovarian fibroma appears sonographically as a sharply circumscribed, solid oblong tumor with relatively low-level, homogenous internal echo pattern.

question

clinical evaluation of fibroma

answer

-Compromise 4% of ovarian neoplasms -Rarely associated with estrogen production -Clinical signs include lack of symptoms if tumor small -If large, increasing pressure and pain apparent -Ascites has been reported in up to 50% of patients with fibromas >5 cm in diameter

question

Fibroma cont.

answer

-Associated ascites along with pleural effusion -Referred to as Meigs syndrome; occurs in 1% to 3% of patients with fibroma -Not specific; it can occur with other ovarian neoplasms as well -Found in postmenopausal women

question

Meigs' syndrome

answer

is the triad of ascites, pleural effusion and benign ovarian tumor (fibroma, Brenner tumour and occasionally granulosa cell tumour) **Bilateral ovarian fibromas accompanied by ascites and hydrothorax are observed in Meigs syndrome

question

Sonographic Findings of Fibroma

answer

-Usually unilateral (90%) -Size ranges from small to melon size, with variable sonographic appearance -Hypoechoic mass with posterior attenuation seen from homogeneous fibrous tissue -Larger tumors pedunculated and prone to torsion, edema, and cystic degeneration

question

Granulosa

answer

-Feminizing neoplasm composed of cells resembling graafian follicle -Most common hormone-active estrogenic tumor of ovary -More common after menopause (50%) -Also seen in reproductive ages (45%) and in adolescence (5%)

question

Clinical symptoms of Granulosa

answer

-Clinical symptoms of estrogen production may include precocious puberty or vaginal bleeding and full breasts -Pain, pressure, fullness may also be present -May twist on itself to cause torsion or rupture, leading to Meigs syndrome -Malignant transformation rare, but when it occurs, lesion spreads via lymphatics and bloodstream

question

Sonographic Findings of Granulosa

answer

-Variable appearance -Mass without torsion -Similar to endometrioma or cystadenoma, with low-level homogeneous echoes -If torsion occurs, multilocular cyst containing blood or fluid seen -Solid masses may have echogenicity similar to uterine fibroids

question

Metastatic Disease

answer

-Ovaries more involved with metastatic disease than any other pelvic organ -Metastases often mimic appearance of advanced stage II to III primary ovarian cancer -Approximately 5% to 10% of ovarian neoplasms are metastatic in origin. -The liver is a frequent site of metastasis for cancers of the breat uterus, ovaries and gastrointestinal tract.

question

Metastatic cancer can arise from breast, upper GI tract, and other pelvic organs by direct extension or by___________ ___________.

answer

lymphatic spread

question

Krukenberg tumors

answer

-tumor is a special metastatic form arising from signet-ring cell- forming gastric carcinoma, appear as large, solid, bilateral ovarian lesions with a nonhomogenous echo pattern caused by extensive necrosis and intratumoral hemorrhage -"drop" metastases to ovaries from GI tract, primarily from stomach, but also from biliary tract, gallbladder, pancreas

question

Approximately 6% of ovarian carcinomas are metastatic.

answer

True

question

Signet ring cell carcinoma

answer

-is an epithelial malignancy characterized by the histologic appearance of signet ring cells. -It is a form of adenocarcinoma, and it is most often found in the glandular cells of the stomach, but it may develop in other areas of the body such as the prostate, bladder, gallbladder, breast, colon, ovarian stroma and testis.

question

Sonographic Findings of Metastatic disease

answer

-to ovaries frequently bilateral and often associated with ascites -Metastases usually completely solid or solid with "moth-eaten" cystic pattern that occurs when necrotic

question

Lymphoma involving the ovary is usually ___________ ; __________ and also frequently bilateral

answer

diffuse and disseminated ** Sonographically, the mass appears as solid hypoechoic tumor similar to lymphoma elsewhere in body.

question

Carcinoma of the Fallopian Tube

answer

-Least common (;1%) of all gynecologic malignancies -Adenocarcinoma most common histological finding -Occurs most frequently in postmenopausal women with pain, vaginal bleeding, pelvic mass -Usually involves distal end; may involve entire length of tube

question

Sonographic Findings of carcinoma of the fallopian tube

answer

-Appears as sausage-shaped, complex mass, with cystic and solid components often with papillary projections -Clinical and sonographic findings similar to those of ovarian carcinoma

question

Other Pelvic Masses

answer

-Pelvic kidneys -Omental cysts -Distended impacted feces in rectosigmoid colon -Distended bladder -Hydroureters -Colonic cancer or masses -Diverticular abscesses -Retroperitoneal masses -Ectopic pregnancy

question

Distinguish solid ovarian masses from pedunculated myomas by identifying ____________ ____________ and searching for ovary

answer

uterine connection

question

Any fluid present in pelvis can be used to outline dependent portions of pelvic organs by ____________ patient, using ______________ approach, or both

answer

-tilting -transvaginal

question

Obvious signs of malignancy, such as sonolucent liver metastases or nodular peritoneum outlined by ascites, assist in __________ ____________.

answer

preoperative assessment

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