 Now the next of course very important question is this disoverein master. It's not one of these things we can recognize Do they are they likely to be malignant and so again the performance of sonography in the hand of expert? Sonographers is really excellent And what is very good is combining grayscale with color Doppler or grayscale with color and Doppler spectrum And that's really the best way to characterize this ovarian lesions So again in the simple who lesions are very likely to be believe them if they're solid and Have vascularity, especially disorganized vascularity Or if they're cystic So if they're cystic you have irregular wall thick septations neural nodules or papillary projections or internal echoes and Always important if you have a neural soft tissue to look at the vascularity here And you can see that there is you know high low resistance flow within this vascularity And also if you have a site is of course and this turned out to be an endometroid cancer and Vascularity is also important because what we're trying to do is is confirm the presence of tumor vessels They can be preferred or whether or in the central portion of the of the lesion and These vessels are abnormal they lack they tend to like smooth muscle They tend to have a be shunting and so they will have this forward-to-end diastole with no resistive index Now some people use these measurements I don't personally think they're very helpful if you just look at the lesion We don't need the color dot would power the dot perspective to tell you this is likely to be more You know, so just look at the lesion and look at the dot perspective So this is another example of a solid mass this patient actually presented with abdominal distention Because she had a site is that was for presenting symptoms So if you have a site is in an older woman, of course, that's also a very Indicative like communication that they're very mass may be malignant And so what we're trying to detect of course is in the invasive ovarian cancer, which is represented about 25% of gynecological cancers Usually affect older women peak at 50 to 60 years of age And it's really the fourth leading cause of cancer death in women because unfortunately most of the time These are silent tumors that are diagnosed late and we already talked about risk factor the the black girl one and the RAC one and two gene and Lynch syndrome and the vast majority are surface Epithelial tumors and the most common among them is cirrhosis dead nopacinoma But there are new Sinus cancer although many of the new Sinus tumors can actually be benign And there's also other varieties such as endometriotic cancer and clear cell cancer This is causing a metosis that I think you can really detect an ultrasound if you're careful Or if the patient has implants in the spleen as in this case So these are subcaps over implants and of course you can see over until taking very easily on CT Now what about this case so this is a 26 year old woman and she has a mass that looked like the cystic mass But there is a big nod you're here and again. She's young, right? So if you see a mass like this in a patient who is young one of the things to think about is that The the fact that this woman could have a borderline serious tumor and that's what she had so these are tumors of normal even potential And it's important to recognize because in this patient what they did was because she was young and she Attempt to preserve fertility. Did you just see the right infractomy at the time? And then she came a few days two years later and now we're looking at her left ovary And she's a very small lesion, but if you look at the lesion here, this doesn't quite look like a haemorrhagic particle, right? It is a little bit too modular and it has flow within the soft tissue, right? so this turned out to be a serious tumor and the contralateral ovary but fortunately in between the two years She was at least able to have one child. So again, you know, how to describe things really important in terms of management for these patients So these are what present about 15 percent of ovarian epithelial neoplasms They tend to be in use in us, but they can be serious. There's no strong or invasion. They usually affect younger women and again in these patients we have to think about the possibility of fertility to project preservation to try to do maybe less aggressive surgery because a vast majority of Fibroid one so they have a very excellent survivor weight Now another tumor is a nuisance ovarian tumor So this is they tend to be very very large at presentation as this case it was 20 almost 24 centimeters They may have internal echoes multiple locus and septations little vascularity And although you can have you seen assisted no cost you know mother vast majority about 80% of the nine This is another example. They can be very very complex This was actually a young patient where we suspected ovarian torsion and black water me She had no torsion, but she had a benign nuisance ovarian tumor However, of course, this is a miracle of this region. This is this patient had bilateral ovarian lesions They look kind of like a nuisance tumor, but this was Metastatic nuisance colon cancer So ovarian metastasis is what present about 10% of malignant ovarian masses The primal common primary tumors are colorectal stomach, pancreas, breast and lung cancer The clinical history is key. Of course in this patient had not only this bilateral ovarian lesion But she also had a echogenic mass in the liver Now to finish I want to talk about ovarian mass that do not fit the previous pattern, right? So they're not clearly benign. They're not clearly malignant So that what do we do and this is where am I really plays a critical role? So this is a good example This is a 57 year old woman with a palpable mass, and this is what we see the left and next up that you look at it It is very Hypocritic and there is some shadowing right so that's a good it looks like a fibroid except it's in the ovaries So that's a very good Probability that this could be an ovarian fibroma, which is a benign lesion But you want to make sure that you you are confirmed on T1s T1 dark just like fibroids are And it's also T2 dark and so the DMR will confirm that this behaves also if you do a diffusion and you do Contrast that will again confirm that this is in ovarian fibroma And so these is a very far from my is part of the ovarian sex courts normal tumors Which are less common and they include fibroma and the coma granulosa cell tumor and sort of tumors They can be solid and hypoechoic, but they can also be large and cystic particularly granulosa cell tumors and again MR increased specificity didn't help guide management So this is another example of an ovarian fibroma so hypoechoic mass with acoustic shadowing Dark on T1 dark on T2 and we can have some delayed mild enhancement Post contrast and again the surgery confirmed that this was an ovarian fibroma But the thing is in this particular case we can tell the gynecologist It's likely to be a ovarian fibroma, and they may like to do laparoscopy Not do an open laparotomy But unless invasive surgery So this is an interesting case This is a 62 year old woman with either a history of proselytism and high serum testosterone And so if you look at her white ovaria, she has a very small lesion But it's very vascular at the edge with this low resistance flow And what this turned out to be at surgery was a benign so totally lighted tumor Which is the most common ovarian tumor So what is the value of color to summarize well? I think it's really sometimes helpful not just in showing the tumor vessels or a very high resistive flow in benign lesion but in differentiating Cystic from solid mass if you look at just a waist scale between this fibrocylcoma and the anonitroma They don't look that much different But if you if you see the color here you can see that there is flow within the lesion So this is not going to be a cystic lesion this has to be solid versus here There's only flow at the edge. So I think this is how I think sometimes that Color is really helpful in these kind of difficult borderline cases And finally, are we always right? Well, this was an 88 year old woman who had a CT scan first for abdominal pain And they saw this kind of aggressive looking Lesion in the right with nexa enhancing rain and so, you know, they thought it was an ovarian mass and On ultrasound the ultrasound was really not much better than the CT Do you see the same like a cystic and solid mass? And again, we thought that was an ovarian cancer most likely But what's only for her it turns out to be an appendiceal Access which had ruptures with focal perforation and perhaps we could have picked up on the office on that There was a loop of bowel intimate related to this anyway. It was lucky for her. So In summary, I hope I've shown you that's really important to offer a specific diagnosis when you cannot just say This is a mass and it could be anything What we need to tell the clinician is that it's an ovarian mass something we can readily diagnose and it's a very common thing Or is it likely benign or could be an ovarian? raising of Because they're really critical management implications for indeterminate mass. I would recommend an MR If you suspected an ovarian cancer on ultrasound, they can do directly for CT for staging Also, whether the patient should be referred to organic or on conscious if you're suspecting. It's a ovarian cancer Whether you can do laparoscopy versus laparotomy So if it's a you think it's a fibroma laparoscopy is probably okay If you think it's an ovarian cancer, obviously the patient will go will need to be referred to a tertiary center to undergo laparotomy And also think about possibility of preserving fertility in younger women So our role is really to help tailor management to the individual women and that's what we need to put in our report