ImagingImaging Ovarian Ovarian EndometriomasEndometriomas

Tina Marie GeorgeTina Marie GeorgeHarvard Medical School Year IIIHarvard Medical School Year III

Gillian Lieberman, MDGillian Lieberman, MD

November 2008

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ObjectivesObjectives

Clinical Presentation of Clinical Presentation of EndometriomaEndometriomaBrief Review of Brief Review of PathophysiologyPathophysiologyMenu of TestsMenu of TestsTypical Imaging FindingsTypical Imaging FindingsDifferential Diagnosis of Imaging FindingsDifferential Diagnosis of Imaging Findings

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Index Patient: Clinical PresentationIndex Patient: Clinical Presentation22yo woman presenting w/ abdominal 22yo woman presenting w/ abdominal

discomfort that progressed to sharp, discomfort that progressed to sharp, stabbing stabbing periumbilicalperiumbilical pain within hourspain within hoursMultiple episodes of bilious vomitingMultiple episodes of bilious vomitingUnable to have a bowel movement in 24hrs Unable to have a bowel movement in 24hrs On ROS: currently menstruating. In the past On ROS: currently menstruating. In the past few months, she’s been having irregular, few months, she’s been having irregular, heavy periods lasting >10 days heavy periods lasting >10 days

Because of the high clinical suspicion for SBO, a CT was ordered…..

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Transition Point

Our Index Patient: Pelvic CT

Lumenal Dilation 3.2mm PACS-BIDMC

Axial C+ CT

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And on CT just a few slices below…And on CT just a few slices below…

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Our Index Patient: Pelvic CT Findings of Bilateral Multiloculated Adnexal Cysts

Bilateral Large Cystic Masses with loculations

PACS-BIDMCAxial C+ CT

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To further evaluate these large To further evaluate these large cystic, cystic, adnexaladnexal masses, a masses, a

transvaginaltransvaginal ultrasound was ultrasound was performed…..performed…..

88PACS-BIDMC

Our Index Patient: Transvaginal US

PACS

Left adnexa on transverse view transvaginal us

Right adnexa on transverse view transvaginal us

Homogeneous low- levelechoes and thickened wall

Large lesion with loculations

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Differential Diagnosis of Cystic Differential Diagnosis of Cystic Mass in the Pelvis Based on CT/USMass in the Pelvis Based on CT/US

COMMONCOMMONDermoidDermoid CystCystEctopic PregnancyEctopic PregnancyEndometriomaEndometriomaHydropsalpinxHydropsalpinxPhysiologic Ovarian CystPhysiologic Ovarian CystOvarian serous or Ovarian serous or mucinousmucinous tumortumorParaovarianParaovarian CystCystUrinary Trace Mass (e.g. Urinary Trace Mass (e.g. urachalurachal cyst)cyst)

UNCOMMONUNCOMMONTuboTubo--ovarian abscessovarian abscessLoculatedLoculated ascitesascitesHematomaHematomaHydatidHydatid CystCystLymphoceleLymphoceleMesenteric CystMesenteric CystPeritoneal Inclusion CystPeritoneal Inclusion CystPolycystic OvaryPolycystic Ovary

From: REEDER AND FELSON’S GAMUTS IN RADIOLOGY

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EndometriomaEndometrioma: Definitions: Definitions

EndometriomaEndometrioma (“chocolate cyst”):(“chocolate cyst”):BloodBlood--containing containing pseudocystpseudocyst resulting from resulting from ovarian endometriosis with hemorrhage. ovarian endometriosis with hemorrhage. Characteristically adherent to surrounding Characteristically adherent to surrounding structures, such as the peritoneum, fallopian structures, such as the peritoneum, fallopian tubes, and bowel. tubes, and bowel. –– Definitive diagnosis based on histopathology Definitive diagnosis based on histopathology

(endometrial tissue and (endometrial tissue and hemosiderinhemosiderin laden laden macrophages)macrophages)

–– US/imaging evidence is supportiveUS/imaging evidence is supportive

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Typical Clinical Presentation of Typical Clinical Presentation of EndometriomaEndometrioma

Chronic or acute pelvic painChronic or acute pelvic painDysmenorrheaDysmenorrheaDyspareuniaDyspareuniaInfertility Infertility Diagnosed in patients with or without Diagnosed in patients with or without h/oh/odiagnosed endometriosis. N.B. diagnosed endometriosis. N.B. EndometriomaEndometrioma is the most common is the most common manifestation of endometriosis and the manifestation of endometriosis and the longest lasting. longest lasting.

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PathophysiologyPathophysiology: Implantation and : Implantation and Retrograde MenstruationRetrograde Menstruation

Shedding Shedding endometriumendometriumtransported through transported through the fallopian tubes the fallopian tubes into the pelvis during into the pelvis during menstruation. menstruation. InvaginationInvagination of of ovarian cortex over ovarian cortex over endometrial deposits endometrial deposits creates creates endometriomaendometrioma..

Wellbery, www.aafp.org

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OB/GYN Anatomy ReviewOB/GYN Anatomy Review

www.medicalart-dank.com

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Menu of TestsMenu of Tests

TransvaginalTransvaginal UltrasoundUltrasoundDoppler UltrasoundDoppler UltrasoundCTCTMRIMRI

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Menu of TestsMenu of Tests1.1. TransvaginalTransvaginal Ultrasound: Ultrasound: Test of ChoiceTest of Choice

Low level internal echoesLow level internal echoesThick walledThick walledHomogeneous “ground glass” appearanceHomogeneous “ground glass” appearanceUnilocularUnilocular or or MultilocularMultilocularOften solidOften solid--appearing or cysticappearing or cysticCan show varying degrees Can show varying degrees echogenicityechogenicity (even (even anechoic) in anechoic) in loculeslocules with fluid levelswith fluid levelsCan show Can show punctatepunctate echogenicechogenic foci (wall or foci (wall or central calcification) with distal shadowingcentral calcification) with distal shadowingRound ShapeRound ShapeRegular MarginsRegular Margins

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Importance of Accurate Diagnosis“An adnexal mass with diffuse low-level internal echoes and absence of particular neoplasticfeatures is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present”

From Patel et al. “From Patel et al. “Endometriomas: Diagnostic Performance of US.” Radiology . Mar 1999;210(3): 739-45

Accurate diagnosis is imperative since endometriomas are often surgically removed because of the risk for malignant transformation

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Our Index Patient: Ultrasound of Our Index Patient: Ultrasound of Left Left AdnexaAdnexa

Homogeneous low-levelechoes and thickened wall

PACS-BIDMC

Hyperechoic

Focus

Post-cyst enhancement

Left Adnexa, transverse view on transvaginal ultrasound

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Our Index Patient: Ultrasound of Our Index Patient: Ultrasound of Right Right AdnexaAdnexa

Index Patient Right Adnexal Mass with Multiple Loculations

PACS-BIDMC

Free Fluid

Distal Enhancement

Right Adnexa transverse view on trasvaginal ultrasound

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Companion Patient 1: UltrasoundCompanion Patient 1: Ultrasound

Cystic lesion with coarse internal echoes accompanied by thin-walled cystic lesions

24 yo w/ pelvic pain

PACS-BIDMC

Wall Thickness

Border of Ovary

(arrows)

Right Adnexa sagital view on trasvaginal ultrasound

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Companion Patient 1: Multiple Companion Patient 1: Multiple Cysts on UltrasoundCysts on Ultrasound

•Multiple thin-walled accompanying cystic lesions

•Possibly represent polycystic ovary syndrome or simple follicles

• Border of ovary

PACS-BIDMCRight Adnexa transverse view on trasvaginal ultrasound

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ThinThin--walled, anechoic cysts can be walled, anechoic cysts can be easily differentiated from easily differentiated from

endometriomasendometriomas, as we’ll see on the , as we’ll see on the next images.next images.

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Companion Patients 2 and 3: Companion Patients 2 and 3: Comparison of Ovarian CystsComparison of Ovarian Cysts in Normal and PCOS Ovariesin Normal and PCOS Ovaries

www.massgeneral.org/pcos/pcos_w hatis.html

Note the thin-walls and anechoic appearance of these cysts on companion patients 2 and 3.

This is notably different from the coarse texture and thick walls of endometriomas

Comp. Pt 1

Comp. Pt 2

Transvaginal Ultrasounds

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EndometriomasEndometriomas don’t always don’t always demonstrate “classical” demonstrate “classical”

appearance. Let’s look at some appearance. Let’s look at some variant appearances. variant appearances.

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Companion Patients 4 & 5: Companion Patients 4 & 5: EndometriomaEndometrioma VariantsVariants

Companion Patient 4Endometrioma:Diffuse low-levelinternal echoes w/ punctate peripheral echogenic foci (arrows)and distal shadowing (circle) Patel et al

Companion Patient 5Endometrioma:Diffuse low-levelechoes and focal wall nodularity (arrow) Patel et al

Transvaginal Ultrasound oblique view Transvaginal Ultrasound transverse view

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It’s also important to differentiate It’s also important to differentiate endometriomasendometriomas from common from common

mimics. mimics. Endometriomas are most commonly misdiagnosed as

dermoid or hemorrhagic cysts. Each image is accompanied by a Each image is accompanied by a description of the features that description of the features that differentiate this lesion from differentiate this lesion from

endometriomaendometrioma..

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Companion Patients 6 &7: Companion Patients 6 &7: Differentiating Differentiating

EndometriomaEndometrioma from Other Common Ovarian Lesionsfrom Other Common Ovarian LesionsFollicular cyst

Differentiating Features

•Thin walls

•Anechoic echogenicity

•Multiple, separate lesions

Both Images: Hoffman, UpToDate

Corpus luteum cystw/ Central Blood Clot

Differentiating Features

•Complexity

•Heterogeneity

•Irregular Borders

•Unusual shape

Transvaginal Ultrasound transverse view

Transvaginal Ultrasound transverse view

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Companion Patients 7 & 8: Dermoids and Hemorrhagic Cysts

Hemorrhagic cyst

This lesion shows low-level internal echoes, clean margins, and rounded shape that could be confused with endometrioma.

Dermoid cystDifferentiating Features:

•Mixed hypoechoic and hyperechoic areas

•Irregular Borders

•Unusual Shape

Hoffman, UpToDate

Patel et al

Transvaginal Ultrasound-Longitudinal ViewTransvaginal Ultrasound on transverse

view

Margin of Ovary

Margin of Lesion

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Point of DifferentiationPoint of Differentiation

Distal shadowingDistal shadowing–– CalcificCalcific foci in foci in endometriomasendometriomas tend to show tend to show

distal shadowingdistal shadowing–– EchogenicEchogenic foci in foci in dermoidsdermoids can be composed can be composed

of calcium or fat. of calcium or fat. CalcificCalcific foci will demonstrate foci will demonstrate distal shadowing, but foci of fat will not. distal shadowing, but foci of fat will not.

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Ovarian Cancer:

Differentiating Features:

• Heterogeneity echo-texture

• Irregular border and shape

• Multiple scattered, hetergeneous foci

Hoffman, UpToDate

Polycystic Ovary

Differentiating Features:

•Multiple ovarian cysts of similar size

•Cysts in ring formation

•Cysts have thin walls

•Cysts are anechoic

Companion Patients 9 & 10 on UltrasoundHoffman, UpToDate

Transvaginal ultrasound, transverse view

Transvaginal ultrasound, transverse view

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Menu of TestsMenu of Tests

2. Doppler Ultrasound: Gives information 2. Doppler Ultrasound: Gives information about the blood flow and resistance to about the blood flow and resistance to flow present in a lesion. Lower resistive flow present in a lesion. Lower resistive indices (RI) are concerning for indices (RI) are concerning for malignancy. Generally, it is reassuring malignancy. Generally, it is reassuring when when endometriomasendometriomas show no internal show no internal vascularityvascularity..

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Let’s first take a look at a Let’s first take a look at a dopplerdoppler that is reassuring for a benign that is reassuring for a benign endometriomaendometrioma as opposed to a as opposed to a

malignant neoplasm. malignant neoplasm.

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Companion Patent 1: Doppler UltrasoundCompanion Patent 1: Doppler Ultrasound

Lack of Blood FlowPACS-BIDMCTransvaginal Ultrasound w/

Dopper. Sagital View

This doppler shows a lack of blood flow cetrally in the lesion. This is reassuring.

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Companion Patient 11: Doppler Ultrasound Concerning for Malignant Neoplasm

Daly, http://www.emedicine.com /radio/images/336139- 402313-403435-403543.jpg

This lesion is more concerning for neoplasm because of the level of blood flow within the lesion. There’s also another consideration.

This lesion has a Resistive index of 0.4, which is a low- resistance waveform concerning for ovarian neoplasm. The RI is a measure to the ease of blood flow. Lower numbers are correlated with malignant lesions.

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Companion Patient 12: Doppler Companion Patient 12: Doppler Ultrasound Showing Ultrasound Showing VascularizedVascularized

SeptationsSeptations in in EndometriomaEndometrioma Suggestive Suggestive of Neoplasmof Neoplasm

Asch, AB and D. Levine, 2007

This is a benign endometrioma with a misleading finding:A solid, vascularized areas that arise from the lesion wall and extend into the cyst. This pattern is suggestive of neoplasm.

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Again, Again, transvaginaltransvaginal ultrasound is ultrasound is the test of choice for identifying the test of choice for identifying

endometriomasendometriomas, but other , but other modalities can be helpful. Let’s modalities can be helpful. Let’s

move on to CT.move on to CT.

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Menu of Tests:Menu of Tests:

3. CT3. CTNot typically used Not typically used b/cb/c findings are findings are nonspecificnonspecificEndometriomasEndometriomas appear as cystic massesappear as cystic massesCan show high attenuation lesion with Can show high attenuation lesion with

dependent fluiddependent fluidGood for complications of Good for complications of endometriomaendometriomalike bowel and like bowel and ureteralureteral obstruction obstruction

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Transition Point

Our Index Patient: Pelvic CT Finding of Obstruction

Lumenal Dilation 3.2mm PACS-BIDMCAxial C+ CT

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Our Index Patient: Pelvic CT Findings of Bilateral Multiloculated Adnexal Cysts

Loculations

PACS-BIDMC

Enhancement

46 HU

4.6 x 5.3cm

Thick Wall

Axial C+ CT

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Now, we’ll move on to MRI.Now, we’ll move on to MRI.

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Menu of TestsMenu of Tests

4. MRI4. MRICystic mass with very high signal intensity Cystic mass with very high signal intensity on T1 and very low signal intensity on T2on T1 and very low signal intensity on T2T2 images shows shading that can occur T2 images shows shading that can occur in a graded shadowing pattern in a graded shadowing pattern Shadowing pattern results from blood Shadowing pattern results from blood degradation products (protein and iron)degradation products (protein and iron)Again, complications seen wellAgain, complications seen well

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Companion Patient 13: T2 Weighted MRI of Companion Patient 13: T2 Weighted MRI of Right Right AdnexalAdnexal Mass (white arrow)Mass (white arrow)

Daly, http://www.emedicine.com/radio/TOPIC250.HTM#Multime diamedia5

Findings:

•Hypointensity

•Graded shadowing

Bladder

Uterus

T2 Weighted MRI with contrast

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Companion Patient 14: T1 Weighted Companion Patient 14: T1 Weighted MRI of Right MRI of Right AdnexalAdnexal Mass (arrow)Mass (arrow)

Daly,http://www.emedicine.com/radio/TOPIC250.HT M#Multimediamedia5

Bladder

Uterus

Note Hypointensity of Lesion

T1 Weighted MRI with contrast

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Now that we have a general idea of Now that we have a general idea of the appearance of the appearance of endometriomasendometriomas on ultrasound, let’s take a look at a on ultrasound, let’s take a look at a slightly more complicated patient. slightly more complicated patient.

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Companion Patient 15Companion Patient 15This patient is a 42 yo woman with chronic pelvic pain and a h/o endometriosis who presented with worsening SOB.

FINDING: Right Pneumothorax

Because of suspicion for catamenial pneumothorax, and MRI of the pelvis was performed…

PACS-BIDMCFrontal CXR

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Companion Patient 15: T2 MRICompanion Patient 15: T2 MRI

Fluid-Fluid Level

Thickened Wall

PACS-BIDMCGraded Texture T2 Weighted MRI with

contrast

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We have reviewed the ultrasound, We have reviewed the ultrasound, dopplerdoppler, CT, and MRI findings for , CT, and MRI findings for endometriomasendometriomas. Let’s now briefly . Let’s now briefly

discuss treatment options and discuss treatment options and followupfollowup on our index patient. on our index patient.

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Management Management When these lesions are asymptomatic and found When these lesions are asymptomatic and found incidentally, they are typically monitored by incidentally, they are typically monitored by transvaginaltransvaginal ultrasound every 3ultrasound every 3--6 months.6 months.EndometriomasEndometriomas are managed in the same are managed in the same manner as endometriosis. manner as endometriosis. Initial management is Initial management is OCPsOCPs with NSAIDS for with NSAIDS for pain as needed.pain as needed.More refractory disease merits other hormonal More refractory disease merits other hormonal treatments such as treatments such as GnRHGnRH, , ProgestinsProgestins, , AromataseAromatase Inhibitors, or Inhibitors, or DanazolDanazol..LaproscopicLaproscopic ablation/resection is recommended ablation/resection is recommended in patients with severe symptoms and disease in patients with severe symptoms and disease unresponsive to medical therapy.unresponsive to medical therapy.

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FollowupFollowup for Our Index Patientfor Our Index Patient

Our Index Patient underwent exploratory Our Index Patient underwent exploratory laparotomylaparotomy and had a left partial ovarian and had a left partial ovarian cystectomycystectomy with drainage of the right cyst.with drainage of the right cyst.Confirmed diagnosis on tissue pathologyConfirmed diagnosis on tissue pathologyShe was ultimately lost to GYN She was ultimately lost to GYN followupfollowup..

General Info on Recurrence:General Info on Recurrence:30% recurrent 30% recurrent endometriomaendometrioma within 3within 3--5yrs after 5yrs after laproscopiclaproscopic interventionintervention

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Routine Routine followupfollowup is very is very important for important for endometriomasendometriomas

because of risk for many because of risk for many complications, including rupture. complications, including rupture.

Let’s look at the imaging Let’s look at the imaging findings in ruptured findings in ruptured

endometriomaendometrioma..

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Companion Patient 16: Ruptured Companion Patient 16: Ruptured EndometriomaEndometrioma

Patient presented w/ fever and increased WBC: • Heterogeneous complex fluid with multiple septations• On Doppler, septations show blood flow.

Asch and Levine 2007

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ReviewReviewEndometriomaEndometrioma can present with pelvic pain, infertility, can present with pelvic pain, infertility, or, in severe cases, symptoms from mass effect on or, in severe cases, symptoms from mass effect on surrounding structuressurrounding structuresEndometriomaEndometrioma possibly due to retrograde menstruationpossibly due to retrograde menstruationAccurate diagnosis is imperative, and definitive diagnosis Accurate diagnosis is imperative, and definitive diagnosis is based on histopathologyis based on histopathologySupportive imaging usually US, but can include MR and Supportive imaging usually US, but can include MR and CT CT Remember, on US, “Remember, on US, “An adnexal mass with diffuse low-level internal echoes and absence of particular neoplasticfeatures is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present.”

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AcknowledgementsAcknowledgements

Larry Barbaras Larry Barbaras Gillian Lieberman, MDGillian Lieberman, MDMaria Maria LevantakisLevantakisDavid Li, MDDavid Li, MDRich Rich RanaRana, MD, MDJay Jay PahadePahade, MD , MD

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ReferencesReferencesAsch, E, Levine, D.Asch, E, Levine, D. Variations in appearance of Variations in appearance of endometriomasendometriomas.. J J Ultrasound MedUltrasound Med.. AugAug 2007;26(8):9932007;26(8):993--1002.1002.Daly, S. Daly, S. EndometriomaEndometrioma/Endometriosis. /Endometriosis. EmedicineEmedicine. 2007. . 2007. http://www.emedicine.com/radio/TOPIC250.HTMhttp://www.emedicine.com/radio/TOPIC250.HTMHoffman, M.S. Differential diagnosis of the Hoffman, M.S. Differential diagnosis of the adnexaladnexal mass. mass. UpToDateUpToDate. May 2008. May 2008Levy, B.S.,Levy, B.S., BarbieriBarbieri, R.L. Diagnosis and management of ovarian , R.L. Diagnosis and management of ovarian endometriomasendometriomas. . UpToDateUpToDate.. May 2008May 2008Patel, M., Feldstein V., Chen, D., Lipson, S.,Filly, R. Endometriomas: diagnostic performance of US. Radiology. Mar 1999;210(3): 739-45.Reeder, M. Reeder, M. REEDER AND FELSON'S GAMUTS IN RADIOLOGYREEDER AND FELSON'S GAMUTS IN RADIOLOGY. . Rittenhouse Digital Library, 2003.Rittenhouse Digital Library, 2003.WellberyWellbery, C. Diagnosis and treatment of endometriosis. , C. Diagnosis and treatment of endometriosis. American American Family Physician. Family Physician. Oct 1999. Oct 1999. http://www.aafp.org/afp/991015ap/1753.htmlhttp://www.aafp.org/afp/991015ap/1753.html