The characteristic ultrasound features of specific types of ovarian pathology (review)

Abstract

Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment. Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient. For example predicting a mucinous borderline tumor gives the opportunity for fertility sparing surgery, and will highlight the need for further gastrointestinal assessment. For benign disease, predicting the presence of an endometrioma and possible deeply infiltrating endometriosis is important when considering both who should perform and the extent of surgery. An examiner's subjective assessment of the morphological and vascular features of a mass using ultrasonography has been shown to be highly effective for predicting whether a mass is benign or malignant. Many masses also have features that enable a reliable diagnosis of the specific pathology of a particular mass to be made. In this narrative review we aim to describe the typical morphological features seen on ultrasound of different adnexal masses and illustrate these by showing representative ultrasound images.

Figure 1

Follicular ‘physiological’ cyst. Note the bright white hyperechoic posterior wall enhancement.

Figure 2

The cob-web sign, which represents the fibrin strings of a recently formed clot within a hemorrhagic corpus luteum cyst (A), and after clot retraction (B).

Figure 3

Multilocular peritoneal inclusion cysts.

Figure 4

A non-septated peritoneal pseudocyst with the ovary seen separately containing an endometrioma and follicles in the cortex. The patient has a clinical history of multiple surgical procedures for endometriosis.

Figure 5

A paraovarian cyst with a normal ovary seen separate to it.

Figure 6

Incomplete septum in a hydrosalpinx.

Figure 7

Acute salpingitis demonstrating incomplete septae and thick walls. (A) An example of increased vascularity in an incomplete septum using color Doppler TVS. (B) Another example using power Doppler TVS.

Figure 8

The cogwheel sign.

Figure 9

A tubo-ovarian complex. (A) Ultrasound appearances. (B) The same case at laparoscopy.

Figure 10

Serous cystadenoma. (A) Unilocular serous cystadenoma. (B) Multilocular cystadenoma.

Figure 11

Mucinous cystadenomas. (A) Unilocular. (B) Multilocular.

Figure 12

A mucinous cystadenoma with variable echogenicity among the cyst locules.

Figure 13

Serous cystadenofibromas. (A) Unilocular solid with a papillary projection and acoustic shadows. (B) Multilocular solid. (C) Another example of serous cystadenofibroma with unilocular solid morphology.

Figure 14

Ultrasound features of dermoid cysts. (A) Rokitansky nodule with a strong acoustic shadow. (B) Acoustic shadows and bright echoes representing hair in the cyst. (C) Unusual but interesting presentation of a dermoid cyst which has been described as ‘floating balls’ - secondary to hyperechoic intracystic fat balls.

Figure 15

Typical endometriomas.

Figure 16

Atypical endometriomas with solid papillary projections. (A) Multilocular solid endometrioma. (B) Unilocular solid endometrioma.

Figure 17

Decidualized endometrioma in pregnancy with vascularized papillary projections.

Figure 18

Typical round regular ovarian fibroma with (A) acoustic shadows and (B) minimal peripheral vascularity on color Doppler.

Figure 19

Ovarian fibroma with cystic changes.

Figure 20

Struma ovarii showing (A) multilocularity and struma pearl formation (arrow) as well as (B) central vascularity (arrow pointing toward the ‘pearl’). (C and D) Laparoscopic features of the same cyst at the time of cystectomy.

Figure 21

Brenner tumors. (A and B) Solid Brenner tumor with marked acoustic shadowing. (C) Brenner tumor with mucinous cystadenoma.

Figure 22

Primary invasive ovarian epithelial cancers. (A) Stage 1 clear cell carcinoma of the ovary. (B) Unilocular solid early invasive cancer with increased vascularity on color Doppler.

Figure 23

Advanced primary ovarian cancers. (A) Multilocular solid ovarian serous adenocarcinoma with increased vascularity. (B) Peritoneal deposits from late stage primary ovarian cancer in in the pouch of Douglas with ascites.

Figure 24

Ovarian serous borderline tumors. (A) Papillary projection with irregular surface. (B) Papillary projections in cases of serous BOT with their 3D images.

Figure 25

Mucinous endocervical BOT. (A) B mode image. (B) Color Doppler image.

Figure 26

Mucinous intestinal BOTs. (A) Honeycomb or cribriform sign. (B and C) Intense multilocularity in intestinal type mucinous BOT.

Figure 27

Breast cancer with metastasis to the ovaries. (A) Lead vessel sign in color Doppler 2D image. (B) Lead vessel sign in power Doppler 2D image. (C) Lead vessel sign in 3D power Doppler image.

Figure 28

Metastatic cancers to the ovary appear as solid tumors. (A) Lymphoma. (B) Gastric adenocarcinoma. (C) Gastric adenocarcinoma with metastasis to the ovary with using power Doppler 2D image.

Figure 29

Colon cancer with metastasis to the ovary.

Figure 30

Pancreatic cancer with metastasis to the ovaries.