 Hello everyone and welcome once again to the Sunday edition of our video tutorial. This is now our fourth year and we thank you for being with us. Before I begin this tutorial which is on cystic adnecks and masses on ultrasound, I wish to talk about two things. One is of Sonova's 2023 that is going to be held very shortly now from Jan 6 to 8 at the Saharashtra Mumbai. It is an action packed event with lots of lectures, demos, workshops and Sonova's nights as well. So if you haven't registered as yet I would suggest you do. We also have a lot of group packages and discounts for radiology residents who will be hearing ultrasound lectures from international faculty who come from across the world. So it's a great time to come and enhance your knowledge. The second thing that I wish to speak to you is about our radiology app. We've launched a beta version or a soft copy of this app which is available both on android as well as on the iOS platform. It is mainly targeted for radiology residents and I would suggest that you download this. It's free with a few in-app purchases available for some exciting courses that will come up next year. The links to both these apps is in the description below. Thank you very much for being with us and enjoy your Sunday. So these are videos done during routine pelvic examinations. Either the patient has come with pelvic pain or some menstrual irregularity. So we start with our first case which is a simple one actually. So you can see a thin walled cystic structure in the right type nexa. You can see a little bit of fluid around it but if you come and look at the cystic structure it arises from the ovary. You can see tiny follicles next to it and it is thin walled. We don't always see posterior acoustic enhancement but it is thin walled. It's clear. There's no debris or internal echoes within this and the diagnosis is quite simple. This is in fact a simple ovarian cyst. Now if we learn a little bit more about simple ovarian cysts or ovarian cysts in general we should know that our cut-off to call a cystic lesion within the ovaries is about three centimeters. Below that we would still refer to it as a follicle or a small cystic lesion. These cysts can be functional and can produce hormones. For example, follicular cysts of the ovaries produce estrogen and corpus luteus cysts produce progesterone. And we should also be aware of complications that can occur in functional cysts such as hemorrhage, enlargement, rupture and of course torsion. Now how do we deal with this cyst once you diagnose it? There are certain guidelines which have been put up by the Society of Radiologists in ultrasound that was made in 2019 and in premenopausal women if it's less than three centimeters in fact there is no need to report it. We would rather call it a follicle. If it is between three to five centimeters we report the presence of a simple cyst and give an impression that it's a benign finding and usually there is no follow-up for cysts that are below five centimeters as we expect them to regress in size as time goes by. If however cysts are more than five centimeters these will need follow-up sonography either in two to six months time just to evaluate whether they've resolved or no or if there is a change in the imaging morphology. For postmenopausal women almost a similar rule applies however cysts between three to five centimeters will still be followed up up to a period of after about three to six months. That's it with simple cysts and we move on to our next case and again you see a cystic lesion seen in the right ovary but this is a little different you can see internal echoes within it almost a smooth homogeneous ground glass appearance and these are endometriotic cysts and here's another case you can again see a small cystic lesion with internal echoes and a smooth homogeneous pattern within the left ovary you can see tiny follicles next to it and again this happens to be a small endometriotic cyst. When scanning patients with endometriosis or when you do find an endometriotic cyst it's very important for us to look for other signs of endometriosis be it hematosalpings and also small deposits which line up posterior to the uterus so once you diagnose endometriosis you should be looking for signs of deep infiltrating endometriosis and the other signs that we look for are tiny nodules seen along the pod as well as along the anterior wall of the rectum as we can see in this picture. You can also see nodules on the cirrhosis surface of the uterus and these are seen as solid hypoechoic masses. Another important test that you need to do is the sliding sign and once you do the sliding sign where you gently push the ovary and you see it moving away from the uterus you know that there are no pelvic adhesions however if the ovaries lie posterior to the uterus and lie almost plastered along the pouch of Douglas you get a negative sliding sign and the patient also complains of pain when you are carrying out this particular motion so once you see endometriosis you have to consider conducting the sliding side on either side for the ovaries as well as look for small endometriotic nodules along the pod as well as along the anterior wall of the rectum. Here's another case this is a 35 year old female with primary infertility and when we are scanning this patient you can see normal follicles in this ovary however you can also see an echogenic mass lesion rising from the ovary. You can also see a couple of important signs over here as you can see at the top of the lesion an echogenic mass with posterior sound attenuation which is usually due to sebaceous material and hair within the cyst cavity this is also known as the tip of the iceberg sign and we also seeing very tiny thin echogenic bands caused by the hair in the cyst cavity a dot dash pattern or a dermoid mesh pattern right here so this is a classic picture of a dermoid cyst within the ovary usually we tend to get confused about this condition with endometriosis so here are both these lesions side by side to the left of the screen we can see a dermoid lesion that I just showed you on ultrasound and to the right we can see a chocolate cyst or an endometriotic cyst within the ovary you can see the nature of the cyst the contents of the endometriotic cyst are much darker smooth homogenous and almost like a ground glass appearance whereas the dermoid lesion has these special signs like the tip of iceberg sign as well as this little thin lacy pattern that helps to differentiate us from endometriotic cysts sometimes however the differentiation may not always be possible and then one can ask for an MRI pelvis to differentiate between these two move on from cystic lesions within the ovary to cystic structures which might be outside the ovary and here we find thin walled tubular cystic structures but very distinct from the ovary you can see a thin walled cystic structure here in the right adnexa adjacent to the right ovary as well as on the left side so the ovaries are normal there is no cyst within the ovary but tubular structure seen adjacent to the ovaries it's a simple diagnosis you're looking at hydro salpings it's not a bad idea always to put on color and exclude pelvic varices here's another case you can see a nice large follicle within the ovary and there happens to be again a tubular structure just adjacent to this ovary what is important is that you see the contents within this it's not clear if it were a simple hydro salpings the contents of this tubular structure would be almost like that of the follicle besides it but it's not there are internal echoes within it and it almost looks like the chocolate cyst imaging morphology that i showed you earlier so this happens to be hematosalpings in a known case of endometriosis i'm showing here also is the sliding sign where we're gently pushing the probe back and forth to separate the lesion from the ovary you can see it moving away here's another case it's a 45 year old with past history of endometriosis you can see a dilated tube again not very dense contents but few septae and tubular structure points towards hematosalpings and if i move and start checking the other side you can see a small endometriotic cyst within the left ovary so the presence of this endometriotic cyst as well as the presence of that large tubular structure is likely of hematosalpings and the diagnosis is recurrence of endometriosis in this patient and now here's another case now i don't have a video of this but what you can see is again dilated tubular structure with a lot of septations almost like a cogwheel pattern and if you look closely you can see a lot of debris on the lower part of the tube and this happened to be a case of pyosalpings now thin walled parovirin cysts are also very common you can see this a little rounded structure adjacent to the left ovary again a sliding sign helps us push that cyst away and demonstrate it's extra ovary in origin you can call them parovirin cysts and here's another one you can see the ovary separate and you can see the parovirin cyst clearly getting pushed away once we employ the sliding sign and here's another case now thin walled structure but almost tubular and we did call it parovirin although there was a little septae or a fold in the mid part of this particular cystic area this turned out to be an hydrosalpings on laparoscopy and coming back again to that simple cyst that i showed you yes we describe the criteria for simple cyst and when we need to follow up and when cysts can get complicated but here is another one you can see septations and you can see small nodules and the moment you start seeing a little bit of color flow within the solid areas it's time to step the gears up get a ca125 done and get further imaging to rule out the possibility of malignancy and now coming to our last case cystic adenxil masses is usually all about ovarin cysts and hydrosalpings and hematosalpings and parovirin cysts and dermoids and endometriosis but we can't forget this again there was no classic history of missed periods but we see the ovary and we can see a cystic structure adjacent to it you can in fact see cardiac activity within that lesion this is the gestational sac which is tubulin origin it's an ectopic pregnancy so this also is an important condition that we need to keep in mind when scanning patients with pelvic pain and using simple ultrasound skills following protocols of performing the sliding sign use of color doppler can help us in diagnosing most of these conditions quite easily on simple ultrasound at the first sitting itself however sometimes lesions can be indeterminate and once we aren't sure of a definite diagnosis it is always better to get additional imaging tests such as an MRI pelvis to establish a definitive diagnosis that's it from me now for today i hope you enjoyed this little video tutorial on cystic adenxil masses and if you did i'd like you to please like share or subscribe to our channel and continue watching us for more radiology material thank you and goodbye