[111, 112] In a prospective, randomized trial, symptomatic improvement was better and posttreatment pregnancy rates were higher when cystectomy rather than drainage and coagulation of endometriomas were performed. This means destroying any endometriotic deposits, removing ovarian cysts, dividing adhesions and removing as little healthy tissue as much as possibly safely gynecologists can.

The pathogenesis of intraovarian endometriomas may be different than that of endometriosis that occurs as superficial peritoneal implants. Patients with an adnexal mass were scanned by experienced sonologists using a standardized research protocol.

Several findings are highly associated with endometriosis. The pattern of calcifications within the ovary should be examined, as a more extensive peripheral rind of calcifications has been reported in a patient with endosalpingiosis and serous borderline ovarian neoplasms.

Rectangles are prediction nodes. Nevertheless, no rule was as good as subjective impression by an experienced sonologist for identifying endometriomas. FIGURE 28.20. These include early age of menarche, short menstrual cycle, long duration of menstrual flow, nulliparity, and positive family history.

Because of ease of use, cost-effectiveness, and accessibility, transvaginal ultrasonography has become the imaging modality of choice when evaluating the ovary for an endometrioma.123 The classic endometrioma has diffuse low-amplitude internal echoes, enhanced sound transmission, and a visible uniform wall, sometimes containing bright reflectors (Fig. The solid papillary projection (12 × 14 × 31 mm) contains internal flow. Sex cord–stromal neoplasms tend to present as solid ovarian masses but can sometimes have a mixed cystic and solid appearance, especially when large. The histological diagnosis was anaplastic tumor of the ovary (Stage IV). (d) Unilocular‐solid endometrioma (88 × 62 × 71 mm) in a 54‐year‐old patient. Endometriomas are usually readily detectable by ultrasound. Given the possibility of malignant transformation and of interval growth, which could increase the risk of ovarian torsion, annual sonographic follow-up of dermoids should be considered.

If the diagnosis remains uncertain, follow-up ultrasound imaging is often helpful in distinguishing a hemorrhagic cyst (with interval resolution of clot) from an ovarian neoplasm (with persistence, enlargement, or apparent development of internal blood flow). This predominantly cystic mass contains a solid nodular area (, (Courtesy of Kika Dudiak, MD, Rochester, MN. Endometriotic cysts (endometriomas or “chocolate cysts”) are an extreme form of endometriosis, by which one (usually) or more cysts are formed, leading to ovarian enlargement. Lack of detectable flow by Doppler imaging (using settings optimized to detect low-volume, low-velocity flow) within the apparently solid component, posterior acoustic enhancement, and awareness of this entity in premenopausal women can suggest this possibility.

(c) … Although some may be asymptomatic, patients most commonly present with pain, which may be cyclic, correlating with their menstrual cycle, or infertility. no vascularization to moderate vascularization) (Figure 1a and b) or a unilocular‐solid mass with ground glass echogenicity with a papillary projection, a color score of 1 or 2 and no flow inside the papillary projection (Figure 1c). Endometriosis in girls <17 years of age may be seen with obstructive Mullerian duct anomalies of the cervix and vagina. The right endometrioma is again seen (dashed arrow). However, it is clinically much less important to be able to recognize an endometrioma in postmenopausal patients compared with premenopausal patients. The cysts may be up to 20 cm in size although they are usually smaller (2-5 cm). A 53-year-old postmenopausal patient with several tiny peripheral echogenic foci in each ovary, some with associated comet-tail artifact (, Ovarian calcification. It is important to recognize the characteristic sonographic features that, when seen, are highly predictive of these benign entities.

Females commonly present with chronic pelvic pain, dyspareunia, and/or infertility. Leyendecker G, Bilgicyildirim A, Inacker M, et al.

Intermittent sharper exacerbations of pain may occur, with leakage of cyst contents. A dedicated MRI protocol is essential for identification of disease and surgical planning. Reinhold C, Tafazoli F, Mehio A, et al.

Endometriomas, also known as chocolate cysts or endometriotic cysts, are a localized form of endometriosis and are usually within the ovary. Clear cell cystadenocarcinoma of the ovary.

The color score is a subjective semiquantitative assessment of the amount of blood flow present and is based on color content score first suggested by the International Ovarian Tumor Analysis (IOTA) color score applied previously to ovarian masses.74 The color score is 1 (not zero by convention) when there is no flow within the endometrium, a score of 2 when minimal color can be detected, a score of 3 when moderate color is present, and a score of 4 when abundant color is detected (Fig.

Serous cystadenocarcinoma of the ovary. In the ovarian cortex biopsied around an endometrioma, Maneschi et al. The cyst wall is regular and thick (the largest diameter of the mass is 63 mm).

Detailed sonographic evaluation can prompt referral to gynecologic oncologists for management of adnexal masses that are likely to be malignant.

), Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Gynecologic Sonography in the Pediatric and Adolescent Patient, Evaluation of Pelvic Pain in the Reproductive Age Patient, Ultrasound Evaluation of the Fetal Face and Neck, Ultrasound Evaluation of the Placenta, Membranes, and Umbilical Cord, Ultrasound Evaluation of the Fallopian Tube, Ultrasound Evaluation of the Fetal Gastrointestinal Tract and Abdominal Wall, Callen's Ultrasonography in Obstetrics and Gynecology. tumors without papillations or tumors with papillations but without flow) as the important conditions to construct a rule to detect endometriomas.

The hyperechoic component, termed a Rokitansky nodule, typically corresponds to mixed hair and sebaceous material or occasionally to calcification, sometimes related to a bone or tooth. It can also be found in scar tissue, and has been reported in C-section scars within the uterine wall or anterior abdominal wall (Figure 4).11 Uterosacral ligaments are the most common location for DIE (Figure 5).

This work was supported by Research Council KUL: GOAAMBioRICS, CoE EF/05/006 Optimization in Engineering (OPTEC); FWO: G.0407.02 (support vector machines), G.0302.07 (SVM), G.0341.07 (Data fusion), research communities (ICCoS, ANMMM); IWT‐TBM 070706 (IOTA); Belgian Federal Science Policy Office. The optimal decision‐tree rule (i.e.

With increasing cyst size, however, there is a risk of inadequate assessment of the cyst wall for detection of small solid nodules or papillary formations, which, if present, increase the likelihood of malignancy. However, situations vary; moderate growth can trigger intense pain in some women while advanced growth causes less severe pain in other people.

In postmenopausal patients the focus is on identifying malignancy35, 36.

Calcifications can occur in dermoids, but calcification alone is not enough to make the definitive diagnosis.

Every woman's situation is exclusive and therefore expert medical evaluation is absolutely essential.

Although accurate and timely identification of ovarian malignancy is extremely important, most adnexal masses are benign and most have a typical sonographic appearance.

A ruptured hemorrhagic cyst may be difficult to distinguish from a ruptured ectopic pregnancy, thus necessitating correlation with serum human chorionic gonadotropin (hCG) level.

However, dermoids may present with symptoms related to large size resulting in compression of adjacent structures. Tanaka YO, Okada S, Yagi T, et al. An alternative to resection is fenestration of endometrioma and drainage of its contents. The presence of a solid component, with detectable flow by Doppler imaging, within a cystic ovarian mass is the most important sonographic feature for predicting ovarian malignancy. The procedure is guided by the color of the cyst wall; when it is white, the plane is correct, when it is red, the plane is wrong, and the plane should be identified using scissors and bipolar coagulation (Figs 28.19 and 28.20). In endometriosis epithelial cells, COUP-TF2 and PGE2/EP3 were downregulated, and since these are negative regulators of aromatase, their downregulation may contribute to the known estradiol synthesis that occurs in some endometriotic lesions (see earlier). (c) Solid mass in a 47‐year‐old patient with poor vascularization and necrotic aspect that proved to be an endometrioma. 488 Benign teratomas because of their sebum content, … On diffusion sequences, the cystic component of ovarian endometriomas can show diffusion restriction with low apparent diffusion coefficient (ADC) values due to their hemorrhagic/proteinaceous contents.

Several studies have described the ultrasound characteristics of endometriomas and attempted to define their typical ultrasound features14-22. Ten per cent of the endometriomas had papillary projection(s), and 2.5% had papillary projections with blood flow detectable by color Doppler (Figure 1d). A small number of endometriomas may contain a small solid-appearing area on ultrasound imaging, and, therefore, it can be difficult to distinguish these endometriomas from malignant lesions. In a small minority of patients, additional pelvic imaging with MRI may be helpful when ultrasound fails to clarify the origin of an adnexal mass, when the sonographic features are indeterminate, or when an adnexal mass is inadequately imaged with ultrasound (such as in an obese patient or in one who cannot undergo or declines transvaginal scanning). Its high sensitivity and specificity for ovarian malignancy, lack of ionizing radiation, relatively low cost, and wide availability make it an ideal method for evaluation of the ovary. Torsion has been reported in 3.5% of dermoids and is more common with larger lesions. The histological diagnosis was serous borderline tumor. Decidualized endometriosis typically regresses or resolves after childbirth or termination of pregnancy.9.

We found that using color Doppler to look for the presence or absence of flow in papillations helped to avoid classifying malignancies as endometriomas.



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