a case study: radiologic assessment of ovarian...

A Case Study: Radiologic Assessment of Complex and Solid Ovarian Masses

Kia L. Byrd Harvard Medical School, Year III Gillian Lieberman, MD Beth Israel Deaconess Medical Center April 26, 2016

Kia Byrd, MS3

Gillian Lieberman, MD

Overview

• Patient Presentation

• Pelvic Anatomy

• Menu of Tests for Evaluating Adnexal Masses – Ultrasound

– MRI

– CT

• Differentiation between simple and complex cysts

• Features of benign vs. malignant lesions

Kia Byrd, MS3


2

Patient History

• 26 year-old G0P0 female who presented to the ED with two months of heavy menses and severe pelvic pain. Pelvic pain is greater on right than left and worsens with urination.

• PMH: hx of anxiety, asthma, headaches, and obesity

• Family History – Father (deceased): pancreatic cancer, age 50

– Mother: endometrial cancer, age 49

– No hx of colon, ovarian, or cervical cancer

Kia Byrd, MS3


3

Additional History and Initial Work-Up

• Pelvic Exam revealed a displaced cervix and solid nodular mass in the the anterior cul-de-sac on bimanual exam

• Past GYN History:

– Menarche at age 13, q monthly menses with heavy bleeding and associated pain

– No history of pelvic infections or abnormal Pap smears

• Initial Work-Up: pelvic ultrasound to evaluate clinically suspected adnexal mass

Kia Byrd, MS3


4

Findings on Pelvic US included an enlarged 3 x 5.1 x 3.4 cm RT ovary that

contained a 2.8 x 2.8 cm mildly heterogeneous, predominantly

hypoechoic focus with internal color flow.

Kia Byrd, MS3


5

Female Pelvic Anatomy

McDermott, C (2014). Lecture: Male and Female Reproductive Systems [PowerPoint slides]. Retrieved from Harvard Medical School Human Body MyCourses: https://v2mycourses.med.harvard.edu

Kia Byrd, MS3


6

Anatomy of the Ovary

Kia Byrd, MS3


From Anatomical Chart Company, General Anatomy http://www.uptodate.com/contents/ovarian-cysts-beyond-the-basics

7

Adnexal Masses

• An adnexal mass is any mass present in the ovaries, fallopian tubes, or surrounding connective tissue

• 10% of adnexal masses in women of reproductive age are malignant(1)

• For a woman in the US, there is a 5-10% lifetime risk that she will undergo surgery for a suspected ovarian neoplasm (2)

Kia Byrd, MS3


8

Ovarian Cancer: Epidemiology • Each year, 20,000 women in the US develop ovarian cancer • 8th most common cancer and 5th leading cause of cancer

death • Ovarian cancer causes more deaths than any other cancer

of the female reproductive system • Accounts for 3% of all cancers in women(3)

• Risk factors

– Middle aged or older – Family history of ovarian cancer – Genetic mutation (BRCA1 or BRCA2) – History of breast, colon, or cervical cancer – Endometriosis

Kia Byrd, MS3


9

Menu of Tests for Suspected Adnexal Mass

• Ultrasound

– Pelvis Transvaginal

– Pelvis Transabdominal

– Duplex Doppler Pelvis

• MRI without and with contrast

• CT pelvis with contrast

Kia Byrd, MS3


10

Transvaginal Ultrasound (TVS)

• Endovaginal US is the first-line imaging modality

• With use of Doppler, sensitivity for identifying malignant adnexal masses is 92-99%; specificity 85.9%

• Can be used to differentiate between cystic, complex, and solid masses

• Use of Doppler can detect vascularity of the wall

• When mass is beyond field of TVS, transabdominal is recommended

Kia Byrd, MS3


11

Normal Ovary on Transvaginal US

Kia Byrd, MS3


Anechoic follicles

ovary

This demonstrates a normal left ovary, measuring 3 x 1.9 x 2.2 cm, on sagittal view at the time of initial US. Anechoic foci represent normal ovarian follicles.

PACS, BIDMC

12

Our Patient: Initial Transvaginal Ultrasound Findings

Kia Byrd, MS3


Hypoechoic focus

Solid component

Ovarian mass

This demonstrates an ovarian mass in the patient’s right ovary that demonstrates both a hypoechoic, cystic component and a solid component. The mass measures 2.8 x 2.8 cm. The right ovary is also enlarged.

13

Our Patient: Initial Transvaginal Ultrasound

Blood flow within solid component

This image demonstrates increased vascularity within the solid component of the right ovarian mass. Solid masses with increased blood flow raise suspicion for malignancy.

Kia Byrd, MS3


ovarian mass

14

Comparative Patients: Simple vs. Complex Cysts

Anechoic mass with enhanced through transmission

• Anechoic lesions • Posterior acoustic enhancement • Thin, smooth walls • No solid components or

neovascularization

Simple Cysts Complex Cysts

• Anechoic lesions with foci of increased echogenicity

• May feature septation • Regions of cyst wall may be

thicker than others

Hypoechoic area

Solid component

Veldhuis, W., Smithius, R., Akin, O., Hricak, H. www.radiologyassistant.nl Brown, D., Dudiak, K., Laing, F. pubs.rsna.org/doi/full/10.1148/radiol.09090552

15

DDX: Complex Ovarian Cyst in Pre-menopausal Women

• Hemorrhagic Ovarian Cyst

• Endometrioma

• Dermoid Cyst (mature cystic teratoma)

• Cystadenoma

– Mucinous

– Serous

• Primary or Secondary Ovarian Malignancy

16

Comparative Patient: Benign Endometrioma

This comparative patient’s ultrasound demonstrates a hypoechoic cystic area with areas of low-level echo. Color Doppler demonstrates an absence of blood flow within the cyst. These features are consistent with a benign lesion.

Thin wall Areas of low-level echo

Hypoechoic area with absence of blood flow

17

DDX: Solid Ovarian Mass

• Benign Ovarian Tumors

– Teratoma

– Fibroma

– Thecoma

• Malignant Ovarian Tumor

– Primary and metastatic

• Torsed Ovary

18

After initial US, our patient was scheduled for a six-week follow-up

and repeat transvaginal US.

19

Our Patient: Follow-Up Transvaginal Ultrasound Findings

These images demonstrate an area of echogenicity within the ovary, suggesting a solid tumor. Normal ovarian architecture is absent. Vascularization and increased blood flow within the solid mass is also apparent.

Echogenic, solid area of mass

Blood flow within solid component

20

MRI • Valuable for characterizing indeterminate as seen

on ultrasound • In follow-up studies, both US and MRI are highly

sensitive for characterizing malignancy, but MRI more specific – Women with clinical low risk for malignancy but

present with complex on US benefit most from MRI

• Scenarios when MRI is most beneficial when mass – Is very large – Is located superiorly or laterally in the pelvis – Has atypical features on US – Is of unclear origin

Kia Byrd, MS3


21

Our Patient: MRI Findings

Coronal T2 Post Contrast: This image demonstrates enlarged right and left ovaries with heterogeneous enhancement.

Axial T2 FS: This image demonstrates enlarged right and left ovaries with peripheral follicles. Pelvic free fluid is also apparent.

Peripheral follicles Heterogeneous

enhancement

Free fluid

22

Our Patient: MRI Findings

Sagittal T2 Post Contrast: This image again demonstrates enlarged left and right ovaries with peripheral follicles apparent. Ovaries also demonstrate heterogeneous enhancement.

Heterogeneous enhancement

Peripheral follicles

Left ovary Right ovary

Peripheral follicles

Left ovary

Heterogeneous enhancement

23

CT

• Usually reserved to evaluate for spread of ovarian malignancy

• Beneficial for staging primary ovarian cancer or identifying primary cancers in the abdomen that metastasize to ovaries

• Increasing concern for exposure to ionizing radiation

Kia Byrd, MS3


24

Our Patient: CT Findings

Axial CT with contrast: This image shows a hypodense area within the upper pole of the right kidney. Findings also included retroperitoneal lymphadenopathy (not shown).

Kia Byrd, MS3


Hypodense area

25

Bone marrow aspirate and core biopsy was performed, and a diagnosis was made of B-cell Acute Lymphoblastic Lymphoma.

Kia Byrd, MS3


26

Diagnosis: B-cell Acute Lymphoblastic Lymphoma (B-ALL)

• Accumulation of B-lymphoblasts

• Occurs most frequently in childhood but also seen in adults with median age of 39

• By definition, patients with B cell lymphoblastic lymphoma present with a mass lesion and have <25% blasts in the bone marrow.

• Mediastinal masses are rare, but lymph nodes and extranodal sites are common

• CNS involvement is common

Kia Byrd, MS3


27

B-ALL: Treatment

• Combination chemotherapy is primary treatment modality

• Most regimens incorporate CNS prophylaxis • With these regimens, more than 80% of newly

diagnosed adults with ALL enter complete remission • Our patient: Hyper CVAD with intrathecal methotrexate

and cytarabine – Cyclophosphamide – Vincristine – Adriamycin – Dexamethasone

Kia Byrd, MS3


28

Summary Slide and Learning Points

• Reviewed relevant female pelvic anatomy • Define adnexal masses and discussed

epidemiology of ovarian cancer • Reviewed the menu of tests for work-up of

adnexal masses- first line: transvaginal ultrasound • Highlighted differences between simple and

complex cysts and differentiated between benign and malignant features

• Discussed B-acute lymphoblastic lymphoma and standard treatment options

Kia Byrd, MS3


29

References • American College of Radiology ACR Appropriateness Criteria. (2012). Retrieved April 24, 2016, from

https://acsearch.acr.org/docs/69466/Narrative/

• Anatomical Chart Company, General Anatomy http://www.uptodate.com/contents/ovarian-cysts-beyond-the-basics

• Douglas L. Brown, Kika M. Dudiak, and Faye C. Laing. Adnexal Masses: US Characterization and Reporting. Radiology 2010 254:2, 342-354

• Kinkel K, Lu Y, Mehdizade A, Pelte MF, Hricak H. Indeterminate ovarian mass at US: incremental value of second imaging test for characterization—meta-analysis and Bayesian analysis. Radiology. 2005 July. 236 (1): 85-94

• Levine, D., Brown, D., Andreotti, R., Benacerraf, B., Benson, C., Brewster, W., Coleman, B., DePriest, P., Doubilet, P., Goldstein, S., Hamper, U., Hecht, J., Horrow, M., Hur, H., Marnach, M., Patel, M., Platt, L., Puscheck, E., Smith-Bindman, R. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010 Sept. 256 (3): 943-954

• McDermott, C (2014). Lecture: Male and Female Reproductive Systems [PowerPoint slides]. Retrieved from Harvard Medical School Human Body MyCourses: https://v2mycourses.med.harvard.edu

• National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening, treatment, and follow-up. Gynecol Oncol. 1994; 55(3 Pt 2): S4

• Ovarian Cancer Statistics. (2015). Retrieved April 21, 2016, from http://www.cdc.gov/cancer/ovarian/statistics/index.htm

• Veldhuis, W., Smithius, R., Akin, O., Hricak, H., The Radiology Assistant www.radiologyassistant.nl

Kia Byrd, MS3


30

http://www.uptodate.com/contents/ovarian-cysts-beyond-the-basics

Acknowledgments

• Deborah Levine, MD

• Gillian Lieberman, MD

• Colin McArdle, MD

• Lisa Napolitano

• Katie Armstrong

31

a case study: radiologic assessment of ovarian...

Documents