DOI: 10.1148/rg.24si045507
Recognition of the Ovaries and Ovarian Origin of Pelvic Masses with CT1
Faysal A. Saksouk, MD and
Samuel C. Johnson, MD
1 From the Department of Radiology, Wayne State University School of Medicine, Harper University Hospital, and Hutzel Hospital, Detroit, Mich. Recipient of a Magna Cum Laude award for an education exhibit at the 2003 RSNA scientific assembly. Received February 13, 2004; revision requested March 17 and received May 5; accepted May 11. Both authors have no financial relationships to disclose. Address correspondence to F.A.S., 19 Lakeside Ct, Grosse Pointe, MI 48230-1906 (e-mail: fsaksouk@med.wayne.edu).
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Figure 1. Illustration shows the ovarian fossa at the posterolateral pelvic sidewall. The fossa is bounded posteriorly by the ureter and superiorly by the external iliac vein. The ovary is draped by the fallopian tube, which arches over much of the ovarian surface.
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Figure 2. Posterior view shows the broad ligament and ovarian attachments with the fallopian tube separated from the ovary. The suspensory ligament extends from the superolateral part of the broad ligament to the pelvic sidewall. The medially located utero-ovarian ligament is enclosed between the two peritoneal layers of the broad ligament.
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Figure 3. Sagittal view shows the mesovarium anchoring the ovary to the posterosuperior aspect of the broad ligament. The mesovarium is the primary route of transit for blood vessels entering and exiting the ovarian hilum.
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Figure 4. Illustration shows the suspensory ligament anchoring the ovary to the posterolateral wall of the pelvis. The typically fan-shaped ligament widens as it approaches the ovary. The ovarian blood vessels passing through it are somewhat obscured by the overlying peritoneal fold.
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Figure 5. View from above shows the left ovary and its attachments within the true pelvis. (This view simulates the appearance of the right hemipelvis at cross-sectional imaging.) The utero-ovarian ligament extends between the ovary and uterine cornu. The suspensory ligament transmits the ovarian vein and artery near the pelvic brim.
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Figure 6. Illustration shows the ovarian artery and vein without the overlying peritoneum and suspensory ligament. The vessels are medial to the ureter in the upper abdomen, cross obliquely anterior to the ureter in the middle to lower lumbar region, and are lateral to the ureter in the lower abdomen and pelvis.
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Figure 7a. CT features of normal ovaries. (a) CT scan shows the ovarian blood vessels (OBV) coursing in the upper pelvis lateral to the ureters. (b) CT scan shows that the ovarian blood vessels are continuous with the suspensory ligaments (SL), which are visualized near the external iliac vessels. The left suspensory ligament is seen as a narrow soft-tissue band that demonstrates subtle widening as it approaches the ovary. U = ureter. (c) CT scan shows that the suspensory ligaments lead to the ovaries (Ov), which are typically located in the ovarian fossa and bounded by the ureters (U) and external iliac veins. SLA = ovarian attachment of the left suspensory ligament. (d) CT scan shows that the ovaries (Ov) have a characteristic morphologic appearance, with distinct cystic follicles seen in the right ovary. U = ureter.
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Figure 7b. CT features of normal ovaries. (a) CT scan shows the ovarian blood vessels (OBV) coursing in the upper pelvis lateral to the ureters. (b) CT scan shows that the ovarian blood vessels are continuous with the suspensory ligaments (SL), which are visualized near the external iliac vessels. The left suspensory ligament is seen as a narrow soft-tissue band that demonstrates subtle widening as it approaches the ovary. U = ureter. (c) CT scan shows that the suspensory ligaments lead to the ovaries (Ov), which are typically located in the ovarian fossa and bounded by the ureters (U) and external iliac veins. SLA = ovarian attachment of the left suspensory ligament. (d) CT scan shows that the ovaries (Ov) have a characteristic morphologic appearance, with distinct cystic follicles seen in the right ovary. U = ureter.
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Figure 7c. CT features of normal ovaries. (a) CT scan shows the ovarian blood vessels (OBV) coursing in the upper pelvis lateral to the ureters. (b) CT scan shows that the ovarian blood vessels are continuous with the suspensory ligaments (SL), which are visualized near the external iliac vessels. The left suspensory ligament is seen as a narrow soft-tissue band that demonstrates subtle widening as it approaches the ovary. U = ureter. (c) CT scan shows that the suspensory ligaments lead to the ovaries (Ov), which are typically located in the ovarian fossa and bounded by the ureters (U) and external iliac veins. SLA = ovarian attachment of the left suspensory ligament. (d) CT scan shows that the ovaries (Ov) have a characteristic morphologic appearance, with distinct cystic follicles seen in the right ovary. U = ureter.
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Figure 7d. CT features of normal ovaries. (a) CT scan shows the ovarian blood vessels (OBV) coursing in the upper pelvis lateral to the ureters. (b) CT scan shows that the ovarian blood vessels are continuous with the suspensory ligaments (SL), which are visualized near the external iliac vessels. The left suspensory ligament is seen as a narrow soft-tissue band that demonstrates subtle widening as it approaches the ovary. U = ureter. (c) CT scan shows that the suspensory ligaments lead to the ovaries (Ov), which are typically located in the ovarian fossa and bounded by the ureters (U) and external iliac veins. SLA = ovarian attachment of the left suspensory ligament. (d) CT scan shows that the ovaries (Ov) have a characteristic morphologic appearance, with distinct cystic follicles seen in the right ovary. U = ureter.
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Figure 8a. CT scans of normal ovaries located relatively high in the pelvis. (a) The ovarian blood vessels (OBV) are lateral to the ureters (U) in the lower abdomen. (b) The ovarian blood vessels are continuous with the suspensory ligaments (SL), which appear thicker than the vessels. (c) The suspensory ligaments lead to the ovaries (Ov), which are located near the level of the iliac fossa. The right ovary demonstrates a typical relationship to the ureter, being just anterior to it. The left ovary is not close to the ureter.
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Figure 8b. CT scans of normal ovaries located relatively high in the pelvis. (a) The ovarian blood vessels (OBV) are lateral to the ureters (U) in the lower abdomen. (b) The ovarian blood vessels are continuous with the suspensory ligaments (SL), which appear thicker than the vessels. (c) The suspensory ligaments lead to the ovaries (Ov), which are located near the level of the iliac fossa. The right ovary demonstrates a typical relationship to the ureter, being just anterior to it. The left ovary is not close to the ureter.
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Figure 8c. CT scans of normal ovaries located relatively high in the pelvis. (a) The ovarian blood vessels (OBV) are lateral to the ureters (U) in the lower abdomen. (b) The ovarian blood vessels are continuous with the suspensory ligaments (SL), which appear thicker than the vessels. (c) The suspensory ligaments lead to the ovaries (Ov), which are located near the level of the iliac fossa. The right ovary demonstrates a typical relationship to the ureter, being just anterior to it. The left ovary is not close to the ureter.
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Figure 9a. Visualization of the broad ligament with CT. (a) CT scan shows a large amount of ascites outlining the right cephalic free edge of the broad ligament (BL), where the fallopian tube is enclosed. The subtle soft-tissue structure (white arrow) extending from the posterolateral aspect of the broad ligament toward the right ovary is most consistent with the mesovarium. Ut = uterine fundus. (b) CT scan obtained just superior to a shows that the suspensory ligament attachment at the anterolateral margin of the right ovary (Ov) is contiguous to the mesovarium (white arrow in a). BL = broad ligament, M = complex mass in the left ovary.
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Figure 9b. Visualization of the broad ligament with CT. (a) CT scan shows a large amount of ascites outlining the right cephalic free edge of the broad ligament (BL), where the fallopian tube is enclosed. The subtle soft-tissue structure (white arrow) extending from the posterolateral aspect of the broad ligament toward the right ovary is most consistent with the mesovarium. Ut = uterine fundus. (b) CT scan obtained just superior to a shows that the suspensory ligament attachment at the anterolateral margin of the right ovary (Ov) is contiguous to the mesovarium (white arrow in a). BL = broad ligament, M = complex mass in the left ovary.
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Figure 10. Postmenopausal ovaries identified by means of their ligamentous attachments. CT scan shows that the ovaries (Ov) appear featureless and in an unusual position, anterolateral to the ureter (U) and next to the iliac bone. The ovaries were identified by means of the ligamentous attachment to the uterus, which is known as the utero-ovarian ligament (UOL). The left utero-ovarian ligament is visualized more clearly than the right. The uterus contains leiomyomatous calcifications.
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Figure 11. Surgically transposed ovary in a young patient with cervical cancer. CT scan shows the right ovary (Ov) positioned close to the colon at the level of the iliac fossa; the ovary is characterized by its multiple physiologic cysts. The laterally placed surgical clip (SC) is a marker for the ovary. In cases of lateral transposition, the ovarian blood vessels typically course laterally near the iliac fossa and lead to the suspensory ligament (SL), which is seen joining the ovary.
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Figure 12. Cysts replacing a surgically transposed ovary in a young patient with cervical cancer (same patient as in Fig 11). CT scan shows multiple cystic loculi (OC) posterior to the ascending colon. The ovarian origin of the loculi is indicated by the laterally placed surgical clip (SC), which is a marker for the surgically transposed right ovary. The ovarian vein (OBV) leading to the cystic ovary is not well visualized.
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Figure 13. Differentiation of the ovaries from enlarged lymph nodes in a patient with metastatic cervical cancer. CT scan shows that the intraperitoneal ovaries (Ov) are medial to the ureters (U) and contain cystic follicles. The enlarged iliac lymph nodes (LN) are lateral to the ureters and closely related to the iliac vessels and pelvic sidewalls. SLA = ovarian attachment of the left suspensory ligament.
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Figure 14. Normal ovary and an enlarged lymph node at the pelvic sidewall in a patient with metastatic cervical cancer. CT scan shows two structures at the left pelvic sidewall. The anterior structure is identified as the ovary (Ov) because of its ovoid shape and the multiple minute cystic follicles. The posterior structure is an enlarged lymph node (LN), which slightly impresses and obscures the margin of the external iliac vein.
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Figure 15a. Cystic lymph node mass simulating an adnexal mass. CT scans show a large cystic mass between the uterus and the left pelvic sidewall. The mass was determined to be a lymph node mass (LN) because of its effacement and obscuration of the external iliac vein (EIV) and its location lateral to the ureter, which was visualized on images obtained at higher levels. These findings indicate an extraperitoneal nodal location of the mass. This impression is confirmed by identification of the cystic left ovary (Ov) just anterior to the uterine fundus. The patient was known to have cervical cancer, which is partly visualized as an area of low attenuation in b. The cystic consistency of the nodal mass is not unusual for metastatic cervical carcinoma (23).
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Figure 15b. Cystic lymph node mass simulating an adnexal mass. CT scans show a large cystic mass between the uterus and the left pelvic sidewall. The mass was determined to be a lymph node mass (LN) because of its effacement and obscuration of the external iliac vein (EIV) and its location lateral to the ureter, which was visualized on images obtained at higher levels. These findings indicate an extraperitoneal nodal location of the mass. This impression is confirmed by identification of the cystic left ovary (Ov) just anterior to the uterine fundus. The patient was known to have cervical cancer, which is partly visualized as an area of low attenuation in b. The cystic consistency of the nodal mass is not unusual for metastatic cervical carcinoma (23).
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Figure 16. Pelvic cysts of ovarian origin. CT scan shows a simple cyst in each ovary. Both cysts are bordered by recognizable normal ovarian parenchyma, which indicates their ovarian origin. SLA = ovarian attachment of the right suspensory ligament.
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Figure 17a. Determining the origin of pelvic masses in a 32-year-old woman. CT scans show a complex cystic mass in the left lower pelvis, which was identified as ovarian because of its location medial to the ureter (U in a) and by recognizing the attachment of the suspensory ligament (SLA) to the mass. A structure in the right lower pelvis contains a small cystic mass; this structure was also medial to the ureter (not shown) and was confirmed to be the ovary (Ov in b) because the suspensory ligament (SL) leads to it. The bilateral cystic lesions proved to be endometriomas. ULM = uterine leiomyoma pedunculated from the fundus.
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Figure 17b. Determining the origin of pelvic masses in a 32-year-old woman. CT scans show a complex cystic mass in the left lower pelvis, which was identified as ovarian because of its location medial to the ureter (U in a) and by recognizing the attachment of the suspensory ligament (SLA) to the mass. A structure in the right lower pelvis contains a small cystic mass; this structure was also medial to the ureter (not shown) and was confirmed to be the ovary (Ov in b) because the suspensory ligament (SL) leads to it. The bilateral cystic lesions proved to be endometriomas. ULM = uterine leiomyoma pedunculated from the fundus.
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Figure 18. Posterolateral displacement of the ureter by a large myomatous uterus. CT scan shows a large leiomyomatous uterus (Ut) displacing the effaced left ureter (U) posterolaterally against the psoas muscle. The left ovary (Ov), which contains a simple cyst, is uplifted into the anterior upper pelvis away from the ureter. The ureter would be similarly displaced posterolaterally by a large adnexal, bladder, or even bowel mass.
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Figure 19a. Tracking the ovarian vein to a recognizable suspensory ligament joining a pelvic mass in a 48-year-old woman. CT scans show a dilated left ovarian vein leading to the fan-shaped suspensory ligament (SL in b), which joins a large complex cystic mass. The tumor proved to be an ovarian mucinous adenocarcinoma. U in a = ureter.
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Figure 19b. Tracking the ovarian vein to a recognizable suspensory ligament joining a pelvic mass in a 48-year-old woman. CT scans show a dilated left ovarian vein leading to the fan-shaped suspensory ligament (SL in b), which joins a large complex cystic mass. The tumor proved to be an ovarian mucinous adenocarcinoma. U in a = ureter.
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Figure 20a. Ovarian vein leading to a pelvic-abdominal mass in a 32-year-old woman. CT scans (a obtained superior to b) show a dilated right ovarian vein, which can be tracked to the posterolateral aspect of a large cystic mass, where it appears to merge with the mass. There are no recognizable features of the suspensory ligament through which the vein passes. The tumor proved to be a mucinous intraepithelial carcinoma arising from the right ovary.
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Figure 20b. Ovarian vein leading to a pelvic-abdominal mass in a 32-year-old woman. CT scans (a obtained superior to b) show a dilated right ovarian vein, which can be tracked to the posterolateral aspect of a large cystic mass, where it appears to merge with the mass. There are no recognizable features of the suspensory ligament through which the vein passes. The tumor proved to be a mucinous intraepithelial carcinoma arising from the right ovary.
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Figure 21a. Fallopian tube lesion simulating an exophytic ovarian cyst in a 28-year-old woman. CT scans show a large cyst in the right lower abdomen and upper pelvis. The dilated right ovarian vein is tracked to the cystic right ovary (Ov in b), which is seen to border the inferior part of the cyst. Thus, the cyst was thought to be an exophytic cystic ovarian neoplasm that was probably benign. At surgery, however, the cyst was found to arise from the fallopian tube and was strongly adherent to the ovary. It was considered to be a benign tubal cyst or an unusually large hydrosalpinx.
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Figure 21b. Fallopian tube lesion simulating an exophytic ovarian cyst in a 28-year-old woman. CT scans show a large cyst in the right lower abdomen and upper pelvis. The dilated right ovarian vein is tracked to the cystic right ovary (Ov in b), which is seen to border the inferior part of the cyst. Thus, the cyst was thought to be an exophytic cystic ovarian neoplasm that was probably benign. At surgery, however, the cyst was found to arise from the fallopian tube and was strongly adherent to the ovary. It was considered to be a benign tubal cyst or an unusually large hydrosalpinx.
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Copyright © 2004 by the Radiological Society of North America.
