Ovaries & Adnexae
Ovaries & Adnexae
By:
Dr/ Ismail Sayed Ismail
1) Anatomy
2) Pathology
❑ Simple ovarian cysts
❑ Ovarian cancer
❑ Ovarian torsion
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➢Clinical picture:-
➢Pathology:-
❑The tumor may be found to contain fat and sometimes bone, teeth, or
hair. Rarely, an ovarian teratoma is malignant.
➢ Sonography:-
❑ The characteristic appearance is a complex, partially cystic mass in
the ovary that contains one or more highly echogenic regions (fat)
that may shadow (bone/ tooth).
❑ Echogenic lines and dots may be seen within the cystic areas of the
mass (hair).
❑ The fat may be seen floating on top of other fluid in the lesion,
leading to the sonographic finding of a fluid–fluid level.
❑ Other echogenic regions with shadowing may contain solid nodules
of tissue in the wall of the dermoid (fat) or densely calcified
structures (bone/ tooth).
❑ Dermoid tumors typically have little or no internal flow on color
Doppler imaging.
Ovarian dermoid tumor.
The ovary is filled with complex highly echogenic material representing fat.
Ovarian dermoid tumor.
Lobular regions of increased echogenicity representing fat and regions of
decreased echogenicity representing fluid.
Ovarian dermoid tumor.
Echogenic short lines and dots within the cystic portion, representing hair.
Ovarian dermoid tumor with fluid-fluid level.
Complex lesion containing hypoechoic and echogenic regions that form a linear
interface due to layering of fat and other fluid.
Ovarian dermoid tumor with echogenic solid nodule.
Large complex mass that is predominantly cystic but has an echogenic solid
nodule protruding from the wall and causing acoustic shadowing.
Ovarian dermoid tumor with echogenic solid nodule.
Ovarian dermoid tumor.
Large complex mass with poor sound transmission / shadowing (tip of iceberg).
Ovarian dermoid tumor.
Echogenic ball consistent with sebum, Rokitansky nodule (dermoid plug).
Ovarian dermoid tumor.
Long & short echogenic linear strands, consistent with hair content.
Small intra-ovarian dermoid tumor.
Ovarian immature teratoma (having neural element).
Papillary projections with internal vascularity.
Ovarian Benign Neoplasms
other than Teratomas
➢Ovarian neoplasms that arise from epithelial cells and surrounding stromal
cells can be malignant or benign.
The most common benign neoplasms are mucinous or serous cystadenomas.
Less common benign tumors arising from these cells include transitional cell
(Brenner) tumors.
➢Benign ovarian neoplasms can also arise from granulosa, theca, and Sertoli
and Leydig cells.
These neoplasms include ovarian fibromas, granulosa cell tumors, thecomas,
and Sertoli–Leydig cell tumors.
➢The distinction between benign and malignant ovarian neoplasms cannot be
made with certainty based on clinical presentation or imaging findings.
➢ Sonography:-
❑ Serous and mucinous cystadenomas of the ovary are typically
complex ovarian lesions with septations separating areas of anechoic
fluid.
❑ Blood flow can often be identified in the septations with color
Doppler.
❑ Mucinous cystadenomas tend to have more septations than serous
cystadenomas and sometimes the fluid in mucinous cystadenomas
contains low-level echoes.
❑ Some benign tumors contain both anechoic cystic regions and solid
or complex cystic areas.
❑ Occasionally, solid tumor nodules, containing vessels visible with
color Doppler, are seen in the wall of the neoplasm, although this
finding is more frequently seen with malignant than benign
neoplasms.
➢ Sonography:-
❑ Some benign tumors, such as fibromas and granulosa cell tumors,
appear as solid ovarian masses. These tumors are typically
homogeneous in echotexture and hypoechoic, sometimes causing
acoustic shadowing. Their appearance is similar to a uterine fibroid.
❑ Spectral Doppler arterial waveforms from the vessels of a benign
tumor typically have a high-resistance pattern, with a resistive index
more than 0.4.
❑ Although arteries in malignant tumors often have a resistive index
less than 0.4, Doppler cannot reliably differentiate benign from
malignant lesions.
Ovarian serous cystadenoma.
Cystic ovarian lesion with anechoic fluid and few thin septations.
Color Doppler shows blood flow within the septations.
Ovarian serous cystadenoma.
Color Doppler shows blood flow within the septations with (RI) of 0.43.
Ovarian mucinous cystadenoma.
A large cystic lesion. The fluid within the cystic mass contains low-level echoes
and multiple thin septations are present.
Ovarian papillary serous cystadenoma.
A complex mass with anechoic areas and a more complex, solid appearing area.
Color Doppler demonstrating blood flow within the solid portion of the tumor.
Ovarian papillary serous cystadenoma.
Spectral Doppler of flow within the mass demonstrates a fairly high resistance
waveform, with a resistive index of 0.61.
Ovarian fibroma.
Ovarian solid mass with homogenous echotexture and posterior shadowing,
similar to uterine fibroid, but uterus is completely separate from it.
Ovarian fibroma.
Ovarian solid mass with characteristic venetian blinds shadowing, seen attached
to the ovary & not freely mobile in the adnexa.
Pedunculated Leiomyoma
Pedunculated leiomyoma.
Adnexal solid mass with homogenous echotexture and extensive posterior
shadowing, the ovary is completely separate from it.
Ovarian Carcinoma
➢Ovarian cancer is typically an aggressive tumor.
In 75% of cases, the cancer has spread outside the ovary by the time of
diagnosis.
➢Doppler findings are less accurate than gray-scale sonographic findings in the
diagnosis and exclusion of ovarian cancer.
Because there is an overlap between the sonographic features of benign and
malignant ovarian tumors, the sonographic diagnosis of ovarian cancer cannot
be made with confidence based on ultrasound findings alone.
➢Sonography:-
❑ Blood flow within the septations, in the wall, and in solid nodules.
Malignant lesions often have resistive indices <0.4 and pulsatility indices <1.0.
Ovarian papillary serous cystadenocarcinoma.
Ovarian cystic mass with solid nodule projecting from the wall into the cystic
portion.
Ovarian papillary serous cystadenocarcinoma.
Color Doppler shows blood flow within the solid nodule & wall of the tumor.
Spectral Doppler demonstrating low resistance flow, with a low (PI) of 0.69.
Ovarian papillary serous cystadenocarcinoma.
Multiple papillary projections with vascularity within the papillary projections.
Ovarian papillary serous cystadenocarcinoma.
Multiple papillary projections with vascularity within the papillary projections.
Ovarian papillary / borderline serous cystadenocarcinoma.
Multiple papillary projections.
Ovarian/ borderline mucinous cystadenocarcinoma.
Multiple thick septations with septal vascularity.
Ovarian cancer (endometrioid carcinoma).
Predominantly solid mass with thick septations and low resistance internal flow.
Ovarian cancer.
Complex mass with cystic and solid components. Thickened wall with solid nodules
protrude into the cystic part of the mass, irregular outer contour with flow within the
solid portion of the tumor and within the wall.
Ovarian cancer.
Polycystic Ovarian Syndrome
➢Polycystic ovary syndrome is a metabolic disorder characterized by menstrual
irregularities, anovulation, hyperandrogenism, infertility, ….
➢Sonography:-
➢Sonography:-
❑ Fluid components of the complex mass are filled with echoes from
debris and pus, and there may be thick septations crossing the mass.
❑ Typically, the ovary cannot be identified in the adnexa because it is
encased by the inflammatory material of the abscess.
❑ With transvaginal scanning, patients are very tender on the affected
side. When pressure is applied with the transvaginal probe, adnexal
structures appear adherent to each other.
❑ The wall of the abscess is typically hypervascular on color Doppler.
Tubo-ovarian abscess.
A complex adnexal mass with poorly defined margins and regions containing
complex fluid.
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