Sonographic characteristics of massive ovarian edema

O-RADS Ultrasound Version 1: A Scenario-Based Review of Implementation Challenges

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk stratification and management system was first published by the American College of Radiology in 2020. It provides standardized terminology for evaluation of ovarian and adnexal masses, aids risk stratification, and provides management guidelines for different categories of lesions. This system has been validated by subsequent research and found to be a useful diagnostic and management tool. However, as noted in the system's governing concepts, in some clinical scenarios, such as patients with acute symptoms or with a history of ovarian malignancy, O-RADS US does not apply, or the system's standard management may be adjusted. Additional scenarios, such as an adnexal mass in pregnancy, present challenges in the application of O-RADS US to assist diagnosis and management. The purpose of this article is to highlight 10 clinical scenarios in which O-RADS US version 1 may not apply, may be difficult to apply, or may require modified management. Additional scenarios in which O-RADS US can be appropriately applied are also described.

Massive ovarian edema with paraovarian cyst torsion treated with laparoscopic surgery: A case report

Massive ovarian edema is a rare gynecological entity resembling a solid ovarian tumor due to the accumulation of edematous fluid within the ovarian stroma. This condition can be easily mistaken for a neoplasm, resulting in overtreatment by removal of the whole affected ovary. The present study describes the case of a 28-year-old woman who experienced massive ovarian edema with paraovarian cyst torsion treated with laparoscopic surgery. The patient experienced lower abdominal pain lasting for 1 week and visited a local clinic. The ultrasonographic examination revealed two loculated ovarian masses and the patient was then referred to the hospital. Transvaginal ultrasonographic examination revealed a 77.9-mm cystic lesion and a 57.7-mm solid lesion in the left adnexa. A magnetic resonance imaging examination revealed a 55-mm lesion with multiple peripheral ovarian follicles, which was isointense on T1-weighted images and hyperintense on T2-weighted images, and a 75-mm cystic lesion, without a solid component, which was hypointense on T1-weighted images and hyperintense on T2-weighted images in the left adnexa. There were no observed abnormalities of the right adnexa or uterus. Laparoscopic surgery was performed, based on a clinical suspicion of massive ovarian edema with paraovarian cyst torsion. Intraoperatively, a paraovarian cyst was identified in the left adnexa that was twisted 360˚. The size of the enlarged left ovary was reduced to almost normal following the detorsion of the left adnexa. The final diagnosis was that of a massive ovarian edema, which was treated by resecting the paraovarian cyst, while preserving the whole left ovary. The pathological examination of the resected paraovarian cyst revealed a serous cystadenoma. Therefore, the present study suggests that the presence of massive ovarian edema should be taken into consideration when encountering a complex solid ovarian mass with multiple peripheral ovarian follicles, particularly in cases with a history of recurrent abdominal pain.

Peripheral hypervascularity of the corpus luteum with ovarian edema (CLOE) may decrease false positive diagnoses of ovarian torsion

INTRODUCTION

In patients with pelvic pain, corpus luteum with associated ovarian edema (CLOE) may be mistaken for ovarian torsion on ultrasound or CECT.

METHODS

This was a multi-reader, blinded, retrospective review performed at a single academic center from 2012 to 2018. Cases of CLOE that were misdiagnosed as torsion and cases of ovarian torsion without a lead-point mass were analyzed. Evaluated ultrasound features included presence of a corpus luteum, ovarian and corpus luteum volume, Color Doppler vascularity of the corpus luteum rim compared to that of the ovarian stroma, peripheral follicular displacement, twisted vascular pedicle, and free fluid. Evaluated CT features included presence of a corpus luteum, ovarian and corpus luteum volume, corpus luteum rim enhancement, twisted vascular pedicle, and free fluid.

RESULTS

39 cases of CLOE and 30 cases of ovarian torsion without lead-point mass were reviewed. A corpus luteum was present in 56.7% of torsed ovaries. In CLOE cases, peripheral hypervascularity of the corpus luteum (manifested as enhancement at CECT or flow signal at Doppler US) was present in 67.7% (21/31) of cases on ultrasound, and in 95.7% (22/23) of cases on CT. No peripheral hypervascularity of the corpus luteum was seen in cases of torsion (p < 0.001). Torsed ovaries were significantly larger than CLOE cases. Other findings were not significantly different between the two groups.

CONCLUSION

Increased blood flow in the periphery of a corpus luteum on color Doppler ultrasound or on CECT is a strong negative predictor for ovarian torsion.

Corpus luteum with ovarian stromal edema is associated with pelvic pain and confusion for ovarian torsion

PURPOSE

To distinguish the corpus luteum with adjacent ovarian stromal edema as an entity associated with pelvic pain, with confounding ultrasound features that may lead to false-positive diagnosis of ovarian torsion.

METHODS

This is a blinded, retrospective study of 243 corpora lutea on transvaginal ultrasound. Imaging parameters included ovarian and corpus luteum volumes, central cystic space within the corpus luteum, vascularity around the corpus luteum, peripherally displaced follicles, and complex free fluid. Residual volume (ovarian volume minus corpus luteum volume) was used as a surrogate for ovarian stromal edema. Clinical parameters included age, pregnancy, and location/acuity of pain if present. Concern for ovarian torsion in radiology reports was documented.

RESULTS

51.0% (124/243) of patients presented with pain. Multivariate regression analysis of factors significantly associated with pain (including age, p = 0.001; larger corpus luteum volume, p = 0.002; larger residual volume, p < 0.001; complex free fluid, p = 0.002; and peripherally displaced follicles, p < 0.001) left only increased residual volume as significantly associated with pain [OR 1.02-1.16; p = 0.01]. False-positive concern for ovarian torsion on ultrasound was present in 12.9% (16/124) of patients with pain, associated with enlarged ovaries (p < 0.001) and peripherally displaced follicles (p < 0.001). High correlation between location of pain and side of the corpus luteum was demonstrated in patients with pain < 14 days duration (p < 0.001).

CONCLUSION

Corpus luteum with ovarian stromal edema is associated with pelvic pain and can mimic ovarian torsion on ultrasound. Further research should explore diagnostically useful differences between cases of ovarian torsion and cases of ovarian edema related to corpora lutea.

Acute abdomen with a misleading clinical entity

Massive ovarian edema is a rare, non-neoplastic solid tumor-like lesion. It results from compromised venous and lymphatic drainage due to partial or intermittent torsion of ovarian pedicle. Pain, distension or abdominal mass, menstrual irregularities, infertility and hormone-related symptoms can be the clinical presentation. We report a case of massive ovarian edema in a 28-year-old female who presented with acute pain abdomen. She was diagnosed clinico-radiologically with solid ovarian tumor and massive ovarian edema on histology. Massive ovarian edema should be suspected in female of reproductive age group presenting with abdominal pain, solid enlargement of ovary on radiology and normal serum tumor markers.

Emergent ultrasound evaluation of the pediatric female pelvis

Ultrasound is the primary imaging modality of the pediatric female pelvis and is often requested to evaluate girls with pelvic or abdominal pain or abnormal bleeding. The US interpretation can help guide the clinician toward medical or surgical management. Here we discuss the normal US anatomy of the female pelvis and illustrate, through case examples, conditions encountered when performing emergent pelvic US for common and uncommon clinical scenarios.

Multimodality imaging findings of massive ovarian edema in children

BACKGROUND

Massive ovarian edema is a rare benign condition that predominantly affects childbearing women as well as preadolescent girls. It is thought to result from intermittent or partial torsion of the ovary compromising the venous and lymphatic drainage but with preserved arterial supply. The clinical features of massive ovarian edema are nonspecific and can simulate tumors, leading to unnecessary oophorectomy.

OBJECTIVE

To demonstrate imaging features that should alert radiologists to consider the diagnosis of massive ovarian edema preoperatively so that fertility-sparing surgery may be considered.

MATERIALS AND METHODS

We identified five girls diagnosed with massive ovarian edema at pathology. Presenting symptoms, sidedness, imaging appearance, preoperative diagnosis, and operative and histopathological findings were reviewed.

RESULTS

Age range was 9.6-14.3 years (mean age: 12.5 years). Common imaging findings included ovarian enlargement with edema of the stroma, peripherally placed follicles, isointense signal on T1-W MRI and markedly hyperintense signal on T2-W MRI, preservation of color Doppler flow by US, and CT Hounsfield units below 40. The uterus was deviated to the affected side in all patients. Two of the five patients had small to moderate amounts of free pelvic fluid. Mean ovarian volume on imaging was 560 mL (range: 108-1,361 mL).

CONCLUSION

While the clinical presentation of massive ovarian edema is nonspecific, an enlarged ovary with stromal edema, peripherally placed follicles and preservation of blood flow may be suggestive and wedge biopsy should be considered intraoperatively to avoid unnecessary removal of the ovary.

Massive Ovarian Oedema- A Case Report

Massive ovarian oedema is defined by WHO as formation of tumour like enlargement of one or both ovaries by oedema fluid. We report a case of a 18-year-old unmarried girl who presented with three months amenorrhoea and left sided lower abdominal pain with clinical and radiological diagnosis of cystic ovarian neoplasm. Patient underwent lapratomy with left salpingo-oophorectomy. A definitive diagnosis of Massive Ovarian Oedema (MOE) was offered on histopathological examination. The MOE should be differentiated from ovarian fibromatosis, ovarian fibroma, sclerosing stromal tumour and ovarian myxoma. The usual management of massive oedema of ovary is unilateral salpingo-oophorectomy, as the lesion is mistaken for primary ovarian neoplasm at laparotomy. Recognition of MOE is of great importance to prevent unnecessary oophorectomy in young patients and can be managed conservatively. We report this case of MOE for its rarity.

Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women

Acute-onset pelvic pain is an extremely common symptom in premenopausal women presenting to the emergency department. After excluding pregnancy in reproductive-age women, ultrasonography plays a major role in the prompt and accurate diagnosis of adnexal causes of acute pelvic pain, such as hemorrhagic ovarian cysts, endometriosis, ovarian torsion, and tubo-ovarian abscess. Its availability, relatively low cost, and lack of ionizing radiation make ultrasonography an ideal imaging modality in women of reproductive age. The primary goal of imaging in these patients is to distinguish between adnexal causes of acute pelvic pain that may be managed conservatively or medically, and those requiring emergency/urgent surgical or percutaneous intervention.

Are Ultrasonographic Findings Suggestive of Ovarian Stromal Edema Associated with Ischemic Adnexal Torsion?

OBJECTIVE

To study whether sonographic findings suggestive of ovarian stromal edema are associated with tissue ischemia in patients with adnexal torsion.

METHODS

A study of 79 patients with adnexal torsion was performed. Patients were divided into an ischemic group, in which the twisted adnexa were seen as blue or black, and a non-ischemic group, in which the adnexa retained normal color and appeared viable. Clinical and ultrasonographic findings, specifically the presence of ultrasonographic signs suggestive of ovarian stromal edema, were compared between the two groups.

RESULTS

Of the 79 patients with torsion, in 44 (55.7%) the adnexa appeared ischemic at surgery. The presence of ischemia was not associated with age, pregnancy, duration of pain, vomiting or findings at physical examination. There was no significant difference between the ischemic and the non-ischemic group in the proportion of patients with signs of ovarian stromal edema (59 vs. 40%, p = 0.11), in the proportion of patients with absent/diminished stromal Doppler flow (36 vs. 28%, p = 0.12%) or in the proportion of patients with both signs of stroma edema and absent/diminished stromal Doppler flow (20 vs. 12%, p = 0.36).

CONCLUSION

Ultrasonographic signs of ovarian stromal edema do not assist in differentiating between ischemic and non-ischemic adnexal torsion.

A clinical update on massive ovarian oedema - a pseudotumour?

OBJECTIVE

Benign massive ovarian oedema is a rare clinical entity arising from the ovaries, and it poses a significant clinical challenge as it can be easily mistaken for neoplasm. Due to the lack of pathognomonic clinical features or characteristic hallmarks on non-invasive diagnostic modalities and the dependence on the final histopathology, the efforts of the surgeon have been deviated from performing fertility-sparing surgery on young women. The lack of standardised guidelines due to the rarity of this condition calls for a review of the literature to enable the clinician to formulate treatment guidelines.

METHODS AND MATERIAL

A Medline search on the PubMed database for literature published in English from 1969 to 2011 was done using the keywords 'massive ovarian oedema, massive ovarian oedema case report or case series, and pseudotumour of ovary'. A total of 177 women who had undergone a variety of treatments were retrieved. We also report the management options we used for four women presenting to us between August 2000 and October 2011, as well as a review of the literature.

RESULT

A total of 177 cases of massive ovarian oedema were identified. Out of these cases 151 (85.3%) were primary massive ovarian oedema; secondary massive ovarian oedema was identified in 26 (14.7%) cases. A salpingo-oophorectomy was done in 145 (81.9%) cases, 12 (6.8%) cases had an abdominal hysterectomy with bilateral salpingo-oophorectomy. A total of 76 (42.9%) cases intraoperatively were found to have ovarian torsions, and one patient with primary massive ovarian oedema had ascites. Conservative treatment was carried out in 20 (11.3%) patients; 14 of these had a wedge biopsy with frozen section and with or without ovarian suspension, one patient had diagnostic laparotomy, and five cases had only ultrasonographic or magnetic resonance imaging monitoring and symptomatic treatment. The four cases treated at the regional cancer institute from 2000 to 2011 revealed that the first three cases had salpingo-oophorectomy and the fourth case received a successful conservative treatment.

CONCLUSION

The majority of massive ovarian oedemas will respond to judicious use of intraoperative wedge resection and frozen section for the confirmation of diagnosis. The detorsion and transfixation of the ovary or partial debulking and drainage of fluid accumulated in the cyst may be more appropriate to preserve hormonal function and fertility in these young women.

Massive ovarian edema and contralateral mature cystic teratoma: asymptomatic presentation in a premenarchal female

BACKGROUND

Massive ovarian edema is a rare entity, which in most cases occurs in adult females presenting with abdominal pain. We present an unusual case associated with contralateral teratoma in a premenarchal female.

CASE

A 13-year-old asymptomatic female presenting with an abdominopelvic mass was referred to the gynecological oncology unit with complex bilateral pelvic masses seen on ultrasound. A combination of computed tomography and repeat ultrasound demonstrated a solid mass containing numerous subcentimeter cysts inseparable from a mature teratoma. Exploratory surgery resulted in unilateral oophorectomy and contralateral cystectomy. Pathology confirmed massive ovarian edema and contralateral mature teratoma.

SUMMARY AND CONCLUSION

Recognition of this rare condition is important to avoid overtreatment of massive ovarian edema. Intraoperative biopsy is recommended as an alternative to oophorectomy in this patient group.

Massive ovarian oedema: an unusual abdominal mass in infancy

We describe a 13-month-old female who presented with vaginal bleeding, breast and pubic hair development and an abdominal mass. She underwent emergency laparotomy and left-sided salpingoophorectomy. Histological examination of the resected ovary revealed massive ovarian oedema, a rare non-neoplastic enlargement of the ovary. Consideration of this diagnosis in patients with an abdominal mass and endocrine disturbance may allow conservative surgery and preservation of fertility.

Transient bilateral ovarian enlargement associated with large retroperitoneal lymphoma

Bilateral ovarian enlargement may reflect benign or malignant processes of the ovary. Benign causes of ovarian enlargement include luteomas, tumors such as mature cystic teratomas, fibrothecomas, cystadenomas and rare conditions including capillary hemangioma and massive edema of the ovaries. Ovarian malignancies include epithelial, stromal and germ-cell tumors. Primary malignancies that may exhibit metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma. We present an unusual case in which a patient presenting with weakness and mild lower abdominal and pelvic pain was noted at sonography to have bilaterally enlarged ovaries with features similar to those of massive ovarian edema as described previously, which has been associated with venous and lymphatic obstruction. Subsequent computerized tomography (CT) imaging depicted a large retroperitoneal tumor, CT-guided biopsy of which revealed diffuse large B cell lymphoma. The patient responded well to chemotherapy with significant shrinkage of the tumor, and reappearance of normal findings on ovarian sonography. This case demonstrates that bilaterally enlarged ovaries may be the first clinical evidence of a large retroperitoneal tumor and that in such cases CT imaging may be warranted.

Laparoscopic plication of partially twisted ovary with massive ovarian edema

Massive ovarian edema (MOE) is a rare entity characterized by an accumulation of stromal edema fluid and occurs primarily in young women. The etiology is not clear, but is suspected to be the result of partial torsion of the ovary. After the establishment of a correct diagnosis, organ-sparing surgical treatment is the standard treatment. With the assistance of laparoscopy, we diagnosed and managed MOE in a 26-year-old woman who had a 4-year history of primary infertility and intermittent lower abdominal pain that had lasted for more than 6 months. With de-torsion, wedge resection, and plication of the ovary, the patient was successfully relieved of the abdominal pain and experienced no recurrence in the follow-up period. A later spontaneous pregnancy demonstrated the practicality of this conservative treatment.

Effect of pituitary down-regulation on the ovary before in vitro fertilization as measured using three-dimensional power Doppler ultrasound

OBJECTIVE

To evaluate the changes taking place in the ovaries during pituitary down-regulation.

DESIGN

Prospective observational study of women undergoing IVF treatment.

SETTING

A tertiary referral center for assisted reproduction.

PATIENT(S)

Forty women who received the long buserelin acetate treatment protocol. Transvaginal three-dimensional power Doppler ultrasound examinations before and after pituitary down-regulation.

INTERVENTION(S)

Ovarian volume, number of follicles, vascularization index (VI), flow index (FI), vascularization flow index (VFI), and mean gray value (MG).

RESULT(S)

Before the pituitary down-regulation, the dominant ovary was larger in volume and had a lower MG than the nondominant ovary. After the down-regulation, there was a significant decrease in the volume and number of follicles and an increase in MG. After pituitary down-regulation, the dominant and nondominant ovaries did not differ from each other in any of the parameters. Polycystic ovaries were larger than normal ones before and after the down-regulation, without any differences in MG, VI, FI, or VFI. Right and left ovaries did not differ from each other after the down-regulation.

CONCLUSION(S)

The differences observed between dominant and nondominant ovaries seem to disappear after pituitary down-regulation. In addition, polycystic ovaries were always larger than the normal ones, but no differences could be detected in the stromal brightness or vascularity either before or after the administration of GnRH agonist therapy.

Massive ovarian edema causing early puberty

Massive ovarian edema is a rare tumor-like condition found predominantly in young women. Patients usually present with abdominal pain and/or abdominal mass. Pre-operative diagnosis is often difficult. Awareness of this rare and benign lesion in young women may allow conservative management and prevention of oophorectomy in some patients.