Diagnostic ultrasound ( PDFDrive )

CHAPTER 16 The Adnexa 591
TABLE 16.3 Society of Radiologists in
Ultrasound Recommendations for Follow-Up
of Asymptomatic Adnexal Cysts
Patient
Population
Premenopausal
women
Description in
Report
Simple or
hemorrhagic
cysts 3-5 cm
Recommended
Follow-Up
Simple or hemorrhagic
cysts > 5 cm, 6
weeks to document
resolution
Yearly
Postmenopausal Cysts > 1 cm
women
Any age Hydrosalpinx No follow-up needed
Any age Dermoid, Yearly
endometrioma
With permission from Levine D, Brown DL, Andreotti RF, et al.
Management of asymptomatic ovarian and other adnexal cysts
imaged at US: Society of Radiologists in Ultrasound Consensus
Conference Statement. Radiology. 2010;256(3):943-954. 28
masses with solid components may be either benign or malignant
and should be further assessed for wall contour, septations, and
mural nodules. Irregular borders, thick irregular septations,
papillary projections, and echogenic solid nodules favor malignancy.
Color and spectral Doppler ultrasound may demonstrate
vascularity within the septa or nodules. Although ascites may
be associated with benign masses such as the mucinous cystadenoma
or ibroma, it is more commonly seen with malignant
disease. Malignant ascites oten contains echogenic particulate
matter.
If a pelvic mass is suspected of being malignant, the abdomen
should also be evaluated for evidence of ascites and peritoneal
implants, obstructive uropathy, lymphadenopathy, and hepatic
and splenic metastases. Hepatic and splenic metastases are
uncommon in ovarian carcinoma, but when they occur, they
are usually peripheral on the surface of the liver or spleen as a
result of peritoneal implantation. Hematogenous metastases
within the liver or splenic parenchyma may occur late in the
course of the disease.
Attempts have been made to standardize reporting of adnexal
features and preoperatively classify these masses. he largest
study to date analyzing features of ovarian and adnexal masses
has been performed by the International Ovarian Tumor Analysis
(IOTA) group. 209 Timmerman et al. 210 used these ultrasound-based
features to develop simple rules that can correctly classify the
majority of masses as benign or malignant (Table 16.4). If one
or more of the malignant (M) rules or one or more of the benign
(B) rules are present, the mass is classiied as benign or malignant.
If both M and B rules are present or no rules are present, the
mass cannot be classiied.
NONGYNECOLOGIC ADNEXAL
MASSES
Pelvic masses and pseudomasses may not be of gynecologic
origin. To make this diagnosis, it is important to visualize the
TABLE 16.4 Ten Simple Rules for
Identifying a Benign or Malignant Tumor
Rules for Predicting a
Malignant Tumor
(M-Rules)
Rules for Predicting a
Benign Tumor (B-Rules)
M1 Irregular solid tumor B1 Unilocular
M2 Presence of ascites B2 Presence of solid
components where the
largest solid component has
a largest diameter <7 mm
M3 At least four papillary B3 Presence of acoustic
structures
shadows
M4 Irregular multilocular B4 Smooth multilocular tumor
solid tumor with largest with largest diameter
diameter ≥100 mm <100 mm
M5 Very strong blood low B5 No blood low
If one or more M-rules apply in the absence of a B-rule, the mass is
classiied as malignant. If one or more B-rules apply in the absence of
an M-rule, the mass is classiied as benign. If both M-rules and
B-rules apply, the mass cannot be classiied. If no rule applies, the
mass cannot be classiied.
With permission from Timmerman D, Testa AC, Bourne T, et al.
Simple ultrasound-based rules for the diagnosis of ovarian cancer.
Ultrasound Obstet Gynecol. 2008;31(6):681-690. 210
uterus and ovaries separately from the mass. his is frequently
not possible because of displacement of the normal pelvic
structures by the mass. Nongynecologic pelvic masses most
frequently originate from the gastrointestinal or urinary tract
or may develop ater surgery. hese include bladder diverticulum,
urachal cysts, gut duplication cysts, and Tarlov cysts.
Postoperative Pelvic Masses
Postoperative masses may be abscesses, hematomas, lymphoceles,
urinomas, or seromas. Sonographically, abscesses are ovoidshaped,
hypoechoic masses with thick, irregular walls and
posterior acoustic enhancement. Variable internal echogenicity
may be seen, and high-intensity echoes with shadowing caused
by gas may be demonstrated. With optimized settings, color
Doppler usually demonstrates vascularity within the wall of the
abscess. Hematomas show a spectrum of sonographic indings,
varying with time. 211 During the initial hyperacute phase,
hematomas are anechoic. Ater organization and clot formation,
they become highly echogenic. With lysis of the clot, hematomas
develop a reticular pattern and/or concave margins due to
retracting clot, until inally, with complete lysis, they are again
anechoic. An abscess may be indistinguishable from a hematoma
sonographically requiring clinical correlation to make the inal
diagnosis.
Pelvic lymphoceles occur ater surgical disruption of lymphatic
channels, usually ater pelvic lymph node dissection or renal
transplantation. Sonographically, lymphoceles are anechoic, having
an appearance similar to that of urinomas, which are localized
collections of urine, or seromas, which are collections of serum.
Sonography-guided aspiration may be necessary to diferentiate
these conditions.