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The preferred imaging method to evaluate the majority of adnexal cysts is ultrasonography, which can help characterize the cyst type. Common benign adnexal cyst types include simple, hemorrhagic, endometrioma, and mature teratoma (dermoid cyst). In this part 2 of a 4-part series on cystic adnexal pathology, we focus on imaging signs for, and follow-up of, endometriomas and mature teratomas.
Endometriomas
Endometriomas are common, typically benign, cysts that produce homogenous, low-level internal echoes and a “ground glass” appearance on ultrasonography. No internal flow is apparent on color Doppler. The presence of tiny echogenic wall foci can distinguish an endometrioma from a hemorrhagic cyst.
Rarely, endometriomas may undergo malignant transformation. Usually this occurs with cysts greater than 9 cm and in patients aged 45 years or older. A malignancy often exhibits rapid growth or the development of a solid nodule with flow on color Doppler.
Management
Although surgery remains the first-line management for women with symptomatic or enlarging endometriomas, there appears to be a role for sonographic observation, with continuous progestational treatment, in women with small (< 5 cm) asymptomatic endometriomas.
The Society of Radiologists in Ultrasound 2010 Consensus Conference Statement recommended1:
- Short-interval follow-up (6 to 12 weeks) in reproductive-aged women to ensure acute hemorrhagic cysts are not mistaken for endometriomas
- If not removed surgically, sonographic follow-up is recommended, with frequency of follow up based on patient age and symptoms and cyst size and characteristics.
In FIGURES 1 through 11 (slides of image collections), we present several cases, including one of a 25-year-old patient presenting with pelvic pain and dyspareunia who was later found to have bilateral endometriomas.
Mature teratomas
Mature cystic teratomas display several telltale signs on imaging, including:
- hyperechoic lines/dots (“dermoid mesh”) corresponding to hair/skeletal components
- “Rokitanski nodule” – a peripherally placed mass of sebum, bones, and hair
- posterior acoustic shadowing
- cystic or floating spherical structures
- no internal flow on color Doppler
Rarely, dermoid cysts may undergo malignant transformation. Usually this occurs in cysts greater than 10 cm and in patients aged 50 years or older. Internal flow on color Doppler, branching, or invasion into adjacent structures can indicate malignancy.
Management
The traditional treatment for dermoid cysts is surgical. However, given the ability for accurate diagnosis with vaginal ultrasonography, there appears to be a role for sonographic observation in asymptomatic women with small dermoids.2
If the cyst is not surgically removed, the Society of Radiologists in Ultrasound 2010 Consensus Conference Statement recommended initial sonographic follow up at no more than 6 months to 1 year to ensure no change in size or internal architecture.1
In FIGURES 12 through 24 below (slides of image collections), we offer imaging from the case presentation and follow-up of a 19-year-old patient with pelvic pain who has a history of ovarian cystectomy for dermoid cyst, as well as 6 additional case illustrations.
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Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
1. Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010;256(3):943–954.
2. Hoo WL, Yazbek WL, Holland T, Mavrelos D, Tong EN, Jurkovic D. Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome? Ultrasound Obstet Gynecol. 2010;36(2): 235–240.
Dr. Ozcan is Assistant Professor and Associate Program Director, Obstetrics and Gynecology Residency, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville.
Dr. Kaunitz is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. Dr. Kaunitz serves on the OBG Management Board of Editors.
The authors report no financial relationships relevant to this article.
Dr. Ozcan is Assistant Professor and Associate Program Director, Obstetrics and Gynecology Residency, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville.
Dr. Kaunitz is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. Dr. Kaunitz serves on the OBG Management Board of Editors.
The authors report no financial relationships relevant to this article.
Dr. Ozcan is Assistant Professor and Associate Program Director, Obstetrics and Gynecology Residency, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville.
Dr. Kaunitz is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. Dr. Kaunitz serves on the OBG Management Board of Editors.
The authors report no financial relationships relevant to this article.
The preferred imaging method to evaluate the majority of adnexal cysts is ultrasonography, which can help characterize the cyst type. Common benign adnexal cyst types include simple, hemorrhagic, endometrioma, and mature teratoma (dermoid cyst). In this part 2 of a 4-part series on cystic adnexal pathology, we focus on imaging signs for, and follow-up of, endometriomas and mature teratomas.
Endometriomas
Endometriomas are common, typically benign, cysts that produce homogenous, low-level internal echoes and a “ground glass” appearance on ultrasonography. No internal flow is apparent on color Doppler. The presence of tiny echogenic wall foci can distinguish an endometrioma from a hemorrhagic cyst.
Rarely, endometriomas may undergo malignant transformation. Usually this occurs with cysts greater than 9 cm and in patients aged 45 years or older. A malignancy often exhibits rapid growth or the development of a solid nodule with flow on color Doppler.
Management
Although surgery remains the first-line management for women with symptomatic or enlarging endometriomas, there appears to be a role for sonographic observation, with continuous progestational treatment, in women with small (< 5 cm) asymptomatic endometriomas.
The Society of Radiologists in Ultrasound 2010 Consensus Conference Statement recommended1:
- Short-interval follow-up (6 to 12 weeks) in reproductive-aged women to ensure acute hemorrhagic cysts are not mistaken for endometriomas
- If not removed surgically, sonographic follow-up is recommended, with frequency of follow up based on patient age and symptoms and cyst size and characteristics.
In FIGURES 1 through 11 (slides of image collections), we present several cases, including one of a 25-year-old patient presenting with pelvic pain and dyspareunia who was later found to have bilateral endometriomas.
Mature teratomas
Mature cystic teratomas display several telltale signs on imaging, including:
- hyperechoic lines/dots (“dermoid mesh”) corresponding to hair/skeletal components
- “Rokitanski nodule” – a peripherally placed mass of sebum, bones, and hair
- posterior acoustic shadowing
- cystic or floating spherical structures
- no internal flow on color Doppler
Rarely, dermoid cysts may undergo malignant transformation. Usually this occurs in cysts greater than 10 cm and in patients aged 50 years or older. Internal flow on color Doppler, branching, or invasion into adjacent structures can indicate malignancy.
Management
The traditional treatment for dermoid cysts is surgical. However, given the ability for accurate diagnosis with vaginal ultrasonography, there appears to be a role for sonographic observation in asymptomatic women with small dermoids.2
If the cyst is not surgically removed, the Society of Radiologists in Ultrasound 2010 Consensus Conference Statement recommended initial sonographic follow up at no more than 6 months to 1 year to ensure no change in size or internal architecture.1
In FIGURES 12 through 24 below (slides of image collections), we offer imaging from the case presentation and follow-up of a 19-year-old patient with pelvic pain who has a history of ovarian cystectomy for dermoid cyst, as well as 6 additional case illustrations.
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 9
Figure 10
Figure 11
Figure 12
Figure 13
Figure 14
Figure 15
Figure 16
Figure 17
Figure 18
Figure 19
Figure 20
Figure 21
Figure 22
Figure 23
Figure 24
Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
The preferred imaging method to evaluate the majority of adnexal cysts is ultrasonography, which can help characterize the cyst type. Common benign adnexal cyst types include simple, hemorrhagic, endometrioma, and mature teratoma (dermoid cyst). In this part 2 of a 4-part series on cystic adnexal pathology, we focus on imaging signs for, and follow-up of, endometriomas and mature teratomas.
Endometriomas
Endometriomas are common, typically benign, cysts that produce homogenous, low-level internal echoes and a “ground glass” appearance on ultrasonography. No internal flow is apparent on color Doppler. The presence of tiny echogenic wall foci can distinguish an endometrioma from a hemorrhagic cyst.
Rarely, endometriomas may undergo malignant transformation. Usually this occurs with cysts greater than 9 cm and in patients aged 45 years or older. A malignancy often exhibits rapid growth or the development of a solid nodule with flow on color Doppler.
Management
Although surgery remains the first-line management for women with symptomatic or enlarging endometriomas, there appears to be a role for sonographic observation, with continuous progestational treatment, in women with small (< 5 cm) asymptomatic endometriomas.
The Society of Radiologists in Ultrasound 2010 Consensus Conference Statement recommended1:
- Short-interval follow-up (6 to 12 weeks) in reproductive-aged women to ensure acute hemorrhagic cysts are not mistaken for endometriomas
- If not removed surgically, sonographic follow-up is recommended, with frequency of follow up based on patient age and symptoms and cyst size and characteristics.
In FIGURES 1 through 11 (slides of image collections), we present several cases, including one of a 25-year-old patient presenting with pelvic pain and dyspareunia who was later found to have bilateral endometriomas.
Mature teratomas
Mature cystic teratomas display several telltale signs on imaging, including:
- hyperechoic lines/dots (“dermoid mesh”) corresponding to hair/skeletal components
- “Rokitanski nodule” – a peripherally placed mass of sebum, bones, and hair
- posterior acoustic shadowing
- cystic or floating spherical structures
- no internal flow on color Doppler
Rarely, dermoid cysts may undergo malignant transformation. Usually this occurs in cysts greater than 10 cm and in patients aged 50 years or older. Internal flow on color Doppler, branching, or invasion into adjacent structures can indicate malignancy.
Management
The traditional treatment for dermoid cysts is surgical. However, given the ability for accurate diagnosis with vaginal ultrasonography, there appears to be a role for sonographic observation in asymptomatic women with small dermoids.2
If the cyst is not surgically removed, the Society of Radiologists in Ultrasound 2010 Consensus Conference Statement recommended initial sonographic follow up at no more than 6 months to 1 year to ensure no change in size or internal architecture.1
In FIGURES 12 through 24 below (slides of image collections), we offer imaging from the case presentation and follow-up of a 19-year-old patient with pelvic pain who has a history of ovarian cystectomy for dermoid cyst, as well as 6 additional case illustrations.
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 9
Figure 10
Figure 11
Figure 12
Figure 13
Figure 14
Figure 15
Figure 16
Figure 17
Figure 18
Figure 19
Figure 20
Figure 21
Figure 22
Figure 23
Figure 24
Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
1. Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010;256(3):943–954.
2. Hoo WL, Yazbek WL, Holland T, Mavrelos D, Tong EN, Jurkovic D. Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome? Ultrasound Obstet Gynecol. 2010;36(2): 235–240.
1. Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010;256(3):943–954.
2. Hoo WL, Yazbek WL, Holland T, Mavrelos D, Tong EN, Jurkovic D. Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome? Ultrasound Obstet Gynecol. 2010;36(2): 235–240.
