Intern Ultrasound of the Month: Complex Ovarian Cystic Lesions
The Case
30yo F otherwise healthy presented to the emergency department for 1 week of right lower abdominal pain, initially intermittent and crampy, now constant, sharp, and stabbing in nature. The pain was exacerbated when bending forward. Not affected by eating and no alleviating factors. ROS otherwise negative. She had an IUD placed a few years prior to this, and she reported regular menses, LMP 2 wks ago. Her medical history was otherwise significant for prior c-section and carpal tunnel syndrome, and she was not taking any medications.
On exam she was well-appearing. Vitals were stable. Findings notable for right-sided abdominal firmness and mild tenderness in right periumbilical region. Not peritonitic.
Labs and urine pregnancy test were ordered.
POCUS performed…
POCUS Findings: large cystic lesion in the right lower quadrant with internal echogenic septations. Not shown here but no flow was seen with Color Doppler.
The bottom image shows the lesion on the left in relation to the uterus seen right center (transverse view). If you look closely you can see the IUD within the uterus near the end of the clip.
Case continued: Labs were unremarkable including pregnancy test. She received Tylenol and toradol with resolution of pain. Because of POCUS findings, CT abdomen/pelvis was obtained and was read as a large 10 x 15 x 15 complex cystic lesion in the right adnexa with multiple internal septations, concerning for cystic ovarian neoplasm; IUD was confirmed in place and ovaries/uterus were normal-appearing.
Gynecology was consulted — recommended TVUS (which patient opted to do outpatient) with close outpatient follow up for surgical planning.
Ovarian Cystic Lesions & POCUS
Evaluation for ovarian cysts/lesions is not included in the general indications for POCUS (particularly using a transabdominal approach), but it’s good to recognize patterns and pick up on abnormalities when you see them, as it can guide further workup, management, and need for follow up.
Wide variety of pathology, varies with age & reproductive status
Higher risk for ovarian cancer post menopause
Benign lesions more commonly seen during reproductive age
Management largely dependent on symptoms, pre- vs post-menopause, and/or concern for malignancy
Brief Review of Transabdominal Pelvic POCUS [1]
Curvilinear probe
Adequate depth, i.e. pelvic structures should fill the majority, but not the entirety, of the screen. Need to visualize the space deep to the structures of interest to ensure no obvious abnormality, such as free fluid, in the surrounding areas.
Obtain sagittal and transverse views
Fan all the way through the bladder/uterus
Key indications/clinical questions:
Is there an IUP - yes or no?
Is there free fluid - yes or no?
Always apply Color Doppler to anything that looks fluid-filled or abnormal
A full bladder provides a good acoustic window & helps optimize view
Normal ovaries often difficult to visualize on transabdominal US; may see with standard views (probe in midline) but may require sliding probe laterally to better assess adnexa. They’re generally seen lateral to the cornual region of the uterus and medial to the iliac vessels and appears as ovoid structures containing hypoechoic follicles (“chocolate chip cookie” appearance). Ovarian enlargement and/or pathology usually more readily seen
*Here’s a simplified overview of ovarian cystic lesions…
Sonographic findings of Cysts [2-3]
Simple cysts
Thin walled, round or ovoid, anechoic with posterior acoustic enhancement
< 3cm are considered physiologic
Corpus luteal cysts
Thicker vascular walls, seen in early pregnancy
Often anechoic but may have some internal hemorrhage (spiderweb like appearance)
Hemorrhagic cysts
Thin smooth walls, largely hypoechoic but may contain internal echogenic material. Usually no flow on Color Doppler.
Variable appearance due to varying degrees of hemorrhage & resorption but often difficult to differentiate from endometriomas, cystadenomas, etc.
A few mimickers
Endometrioma — low level echogenicity, “ground glass”, representing old blood in the cyst cavity
Cystadenoma — smooth, thin walled, anechoic, fluid-filled structure. May contain fine septations or areas of echogeneity from hemorrhage.
Dermoid cyst/teratoma — highly variable appearance though typically echogenic fatty material. May contain calcifications, teeth, hair, etc.
Many others including non-ovarian or other abdominal processes (appendicitis, bowel, aneurysm, etc)
Findings concerning for malignancy [2,4]
Larger cysts >7 cm
*> 10cm associated with 13% chance being malignant [5]
Thick septations > 3mm
Solid components
Mural nodules or focal wall thickening with increased flow with doppler
Secondary findings such as ascites, regional LAD, nearby masses, etc.
https://radiologyassistant.nl/abdomen/ovarium/common-ovarian-cystic-lesions
https://radiologyassistant.nl/abdomen/ovarium/common-ovarian-cystic-lesions
Indeterminant Findings
*Usually benign but warrant closer evaluation
Multiple thin septations
Solid nodule without flow using Doppler
Irregularity or small areas of wall thickening
What next? [2-3]
Close follow up recommended for::
Simple cysts >5 cm if reproductive age, >1cm if post-menopausal
Hemorrhagic/complex-appearing cyst
Findings concerning for malignancy warrant surgery evaluation
A quick note on Intrauterine Devices [6]
IUDs should be visualized within the endometrial canal with the IUD stem following the path of the canal. The arms of the IUD should extend laterally at the fundus.
Sonographic appearance varies based on the type of IUD — copper IUDs are more easily visualized than hormonal IUDs tend to be echogenic only at each end. Often see reverberation and/or posterior shadowing.
A positive pregnancy test in the presence of an IUD is an ectopic until proven otherwise
POST BY: DR. LUKE OFFUTT, PGY1
FACULTY EDITING BY: DR. LAUREN MCCAFFERTY
References
Fox JC, Lambert MJ. Gynecologic concepts. In: Ma OJ, Mateer JR, Reardon RF, Joing SA, eds. Ma and Mateer’s Emergency Ultrasound. 3rd edition. McGraw-Hill; 2014:(Ch) 16.
Levine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR, Coleman B, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010; 256: 943-954.
Jones R, Goldstein J. Point-of-Care OB Ultrasound. American College of Emergency Physicians, 2016. Apple Books. https://books.apple.com/us/book/point-of-care-ob-ultrasound/id1155648846
Brown DL, Doubilet PM, Miller FH et al.. Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features. Radiology. 1998;208(1):103–110.
Ghezzi F, Cromi A, Bergamini V et al.. Should adnexal mass size influence surgical approach? A series of 186 laparoscopically managed large adnexal masses. BJOG. 2008;115(8):1020–1027.
Peri N, Graham D, Levine D. Imaging of intrauterine contraceptive devices. J Ultrasound Med. 2007; 26(10):1389-1401.
For a good overview, diagrams, illustrations, etc., check out Roadmap to Evaluate Ovarian Cysts