Ovarian Tumors 

What is the clinical setting when you will consider an ovarian mass?

• You would consider an ovarian mass, in any woman who comes in complaining of pressure symptoms. 
• These symptoms include urinary frequency, pelvic discomfort, and constipation. 
• Abdominal swelling, along with fatigue and abdominal pain are the most common symptoms. 
• Irregular vaginal bleeding can accompany any ovarian neoplasm. 
• Some of the ovarian tumors (Sertoli-Leydig and Granulosa) secrete androgens and estrogens, respectively. 
• With the Sertoli-Leydig tumors a woman may present not only with an abdominal mass, but also with virilization. 

What are the common ovarian masses?

• Ovarian cyst
• Ovarian cancer

What are the useful imaging modalities in evaluating an ovarian mass?

• Ultrasound
• Pelvic CT
• MRI 

What is the utility of each procedure?

The radiographic evaluation of the patient depends on the age and clinical suspicion.  

• Ultrasound: 
  • It is the primary way to evaluate pelvic masses.
  • If a trans vaginal ultrasound is performed, it increases the positive predictive value and negative predictive value of the test. 
  • The best type of ultrasound to use, is one with Doppler. 
  • Doppler looks for  blood flow into the ovary.
• CT:
  • Not used for the primary evaluation of the adenxa, because it is difficult to visualize normal ovaries. 
  • But this is very good technique in evaluating the extent of metastatic disease for patients with known or suspected ovarian cancer.
• MRI:
  • This is an expensive test, offers no additional information to CT. 
  • Soft tissue extension of tumor into the pelvis is well seen.

What are the Imaging findings of ovarian cyst?

• On ultrasound, the cysts are characterized by anechoic (black) fluid filling the cyst cavity and thin walls. 
• Simple cysts are less than 20-25 mm in diameter. 
• If an ovarian cyst has recently ruptured, one will see fluid in the pelvis. 
• If there are echoes within the cyst, it may be from hemorrhage.

What are the radiological findings of a malignant ovarian mass?

Any solid component on the ultrasound is a possible feature of malignancy.
Complex cystic and solid mass
A thick wall can be seen, but some benign cysts also have a thick wall.  The other characteristics that are associated with malignancy are septations.
Doppler also improves the specificity of ultrasound. Malignant masses are more likely to have detectable flow and flow that is centrally located.  No flow in mass.

Case 1:

Patient is a 37 yr/o G3P2012 who comes to the ER complaining of severe abdominal pain.  Patient has had a similar pain in the past.  Patient has regular periods, which come every 28-30 days. Her LMP was 2 weeks ago.  She is afebrile.  On physical exam, she has right lower quadrant tenderness, with no rebound or guarding. Patient has no cervical discharge, no cervical motion tenderness, but does have right adenxal tenderness. Resident ordered CT.

Case 2: