Diagnostic ultrasound ( PDFDrive )

CHAPTER 16 The Adnexa 575
A B C
U
U
U
D E F
FIG. 16.11 Endometriosis: Spectrum of Appearances. TVS images. (A)-(D) Uniform low-level echoes within a cystic ovarian mass. (A)
Typical peripheral echogenic foci. (B) Fluid-luid level. (C) Avascular marginal echogenic nodules. (D) Bilateral disease. (E) Deep penetrating implant
on posterior surface of uterus (arrows). (F) Filling the pouch of Douglas (arrows). U, Uterus. See also Videos 16.3, 16.4, and 16.5.
products to settle into layers. In a retrospective study, Patel et al. 81
found difuse, low-level internal echoes in 95% of endometriomas.
hey concluded that this inding in the absence of neoplastic
features is highly likely to be an endometrioma, especially if
multilocularity or hyperechoic wall foci are present, whereas an
endometrioma is highly unlikely when no component of the
mass contains low-level echoes. A prospective study by Dogan
et al. 82 found a positive predictive value of 97% for typically
appearing endometriomas with low-level internal echoes, regular
margins, round shape, and thick walls.
Diferentiation of endometriosis from benign and malignant
neoplasms is occasionally required. Papillary wall projections
have been frequently described. Patel et al. demonstrated small,
linear, hyperechoic foci sometimes present in the wall of the cyst
that were thought to represent cholesterol deposits accumulating
in the cyst wall. 81 Guerriero et al. 83 described papillations projecting
within the cyst with a height of greater than 3 mm and no
internal Doppler low that were felt to represent adjacent ibrin
or blood products (Video 16.4). In rare cases in pregnant women,
decidualization of the wall of an endometrioma may occur,
resulting in a solid vascular mural mass that cannot be diferentiated
from malignancy 84,85 (Fig. 16.12). Calciication is occasionally
present in an endometrioma and can be confused with a
dermoid. 86 Endometriomas may serve as precursors of borderline
endometrioid and clear cell tumors that may eventually become
low-grade invasive carcinoma and therefore, if not surgically
removed, these are followed yearly. 50,87
Endometriomas may be present in postmenopausal women,
although their appearance generally difers. Instead of the
unilocular cyst containing low-level echoes, the postmenopausal
endometrioma more oten has the appearance of a multilocular
mass. When cyst luid is present, it is more frequently anechoic
or comprised of a more heterogeneous echogenicity. 88
he appearance of an endometrioma may be similar to a
hemorrhagic ovarian cyst because both are cystic masses that
contain blood products of variable age. However, a hemorrhagic
cyst more frequently demonstrates a reticular internal pattern
rather than the pattern of homogeneous low-level echoes and
is more frequently associated with free luid in the cul-de-sac.
A hemorrhagic cyst will resolve or show a signiicant decrease
in size over the next few menstrual cycles, whereas endometriomas
tend to show little change in size and internal echo pattern.
Clinically, most women with a symptomatic hemorrhagic cyst
present with acute pelvic pain, whereas women with an endometrioma
have more chronic discomfort associated with their
menses.
Endometriosis is frequently accompanied by the presence of
pelvic adhesions. he evaluation of adhesions of the uterus and
ovaries as well as obliteration of the pouch of Douglas can be
challenging with ultrasound although techniques have been
reported that can be performed successfully by experienced
operators. 89,90 Movement of the normally mobile uterus and
ovaries by abdominal palpation or pressure with the abdominal
probe can show adherence of these structures to the adjacent