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Multicultural Media Outreach Program. Cancer Reporting Fellowships. Advisory Board Meetings. Social Media Events. Cancer Currents Blog. Contributing to Cancer Research. Strategic Planning. Previous NCI Directors. Advisory Boards and Review Groups. NCI Congressional Justification. Current Congress. However, the utero-ovarian ligament and the suspensory ligament of the ovary have variable degrees of laxity and behave more like mesenteries than as tightly fixating or rigid support structures , 2 , , 6.
Consequently, the actual position and the orientation of the ovaries are variable in different patients and in the same patient at different times , 9. Furthermore, the ovaries may assume unusual locations in the upper pelvis or lower abdomen, particularly in the presence of a large ovarian or extraovarian pelvic mass , 2. The variable position of the ovaries hinders their identification with computed tomography CT.
When the ovaries are located at or near the pelvic sidewalls, they are difficult to distinguish from enlarged lymph nodes.
Where are the ovaries?
Determining the site of origin of a pelvic mass is often a challenging task, since ovarian and extraovarian masses may have similar morphologic appearances and large masses distort the pelvic anatomy. In particular, pedunculated subserosal uterine leiomyomas projecting into the adnexal region, iliac fossa, or lower abdomen can simulate solid or complex ovarian lesions , 10 and some cystic leiomyomas closely resemble malignant cystic ovarian tumors , A thorough understanding of the pertinent pelvic anatomy, including the anatomic relationship between the ovaries and other pelvic structures, is essential for the confident recognition of the ovaries at CT and may facilitate identifying the ovarian origin of such pelvic masses.
In this article, we describe identification of the ovaries and ovarian masses with CT. Specific topics discussed are the pertinent anatomy, recognition of normal ovaries with CT, identifying surgically transposed ovaries, distinguishing the ovaries from enlarged lymph nodes, and identifying the ovarian origin of pelvic masses. In nulliparous women, the ovary is typically located close to the lateral pelvic sidewall in a shallow peritoneal depression called the ovarian fossa , 5 , , 8 , , 9 , , 12 , , 13 and also known as the fossa of Waldeyer , The ovarian fossa is bounded posteriorly by the ureter and internal iliac artery, superiorly by the external iliac vein, and anteriorly by the obliterated umbilical artery , 1 , , 5 , , 12 , , 13 , Fig 1.
During the first pregnancy, the ovaries are pulled up into the abdomen by the enlarging uterus and the stretched or widened broad ligament. After delivery, the ovaries often do not return to their original position in the pelvis and the broad ligament may remain enlarged or elongated and redundant, thus allowing more ovarian mobility , 8. In general, the ovarian position is influenced by uterine size, ovarian size, degree of filling of the urinary bladder, degree of distention of the rectosigmoid colon, and the presence of a pelvic mass , 3.
However, because the mesovarium anchors the ovary to the posterior layer of the broad ligament, the normal ovary is generally located in the posterior pelvic compartment or above the uterine fundus but not between the urinary bladder and the uterus or in the anterior cul-de-sac , 3. The potential ovarian locations include the adnexal regions lateral to the uterus, the posterior cul-de-sac, and superior or posterior to the uterine fundus. When the uterus is retroverted, either or both ovaries can be ventral and lateral to the uterus , 2.
The broad ligament is a double fold of the peritoneum that extends from the lateral uterine margins to the pelvic sidewalls bilaterally and incompletely divides the true pelvis into anterior and posterior compartments , Fig 2.http://officegoodlucks.com/order/43/734-como-rastrear-un.php
The Ovaries - Structure - Ligaments - Vascular Supply - Function
It is formed by the two peritoneal layers covering the anterior and posterior surfaces of the uterus. The two layers of the broad ligament are continuous with each other cephalad at the free edge, where they enclose the fallopian tube , Fig 3. The extreme lateral part of the tube the ampulla and the fimbriated infundibulum is not enclosed , 5 , , 8 , , The mesovarium is a short, double-layered peritoneal fold that extends backward from the posterior layer of the broad ligament and attaches to the anterior border of the ovary the mesovarian border , Fig 3.
The hilum of the ovary is located at this anterior border and is enclosed by the attachment of the mesovarium.
The ovarian blood vessels and lymphatic vessels pass in between the two layers of the mesovarium and enter or exit the ovary through the hilum. In particular, the anastomotic branches of the ovarian and uterine arteries and the plexus of veins draining the ovary are located in the mesovarium , 1 , , 3 , , 5 , , 9 , , The suspensory ligament of the ovary is a peritoneal fold that suspends the ovary from the posterolateral pelvic wall , 15 , near the brim of the true pelvis, and is derived from the superior lateral part of the broad ligament , 8 , , 16 , Figs 2 , , 4. It is formed by a fan-shaped band of intertwined fibromuscular fibers and the overlying peritoneum, which is thickened in this region and is elevated by the band into a triangular fold , 3 , , 7.
The suspensory ligament can be 4—5 cm long , 16 , is attached to the tubal end of the ovary, and extends cephalad over the external or common iliac vessels to blend with the connective tissue and the peritoneum covering the psoas major muscle , 1 , , 5 , , 7. The tubal end of the ovary usually faces the external iliac vein, and to it is also attached the ovarian fimbria of the fallopian tube , 5 , , The ovarian blood vessels and lymphatic vessels pass through the suspensory ligament to reach the mesovarium and subsequently the ovarian hilum.
The arterial system involutes with age to a greater extent than the venous system, and eventually the veins constitute the main component of the suspensory ligament , The suspensory ligament has also been referred to by many authors and clinicians as the infundibulopelvic ligament , 1 — , 3 , , 6 — , 9 , , 14 , , However, Netter , 13 describes them as two contiguous distinct ligaments extending from the superior lateral aspect of the broad ligament; the infundibulopelvic ligament attaches the extreme lateral part of the fallopian tube the infundibulum and ampulla to the pelvic sidewall , 13 , , 14 , whereas the suspensory ligament attaches the ovary to the pelvic sidewall and transmits the ovarian blood vessels to and from the mesovarium , The utero-ovarian ligament or ligament of the ovary is a rounded fibromuscular band that extends from the uterine end of the ovary to the uterine cornu, immediately posterior and inferior to the fallopian tube, and is enclosed between the two layers of the broad ligament , 3 , , 5 , , 7 , , 13 , Figs 2 , , 5.
The uterine end of the ovary usually faces the pelvic floor , 5. The ovarian branches of the uterine artery and vein pass through the utero-ovarian ligament and anastomose in the mesovarium with the branches of the ovarian blood vessels , 2. The ovarian artery originates from the abdominal aorta slightly below the renal artery, courses caudally and laterally ventral to the psoas major muscle, and crosses over the external or common iliac vessels , Fig 6.
It then passes through the suspensory ligament of the ovary near the pelvic brim, courses inferiorly and medially between the two layers of the broad ligament near the mesovarian border, and sends multiple branches that reach the ovarian hilum via the mesovarium , 1 , , 5 , , 6. The artery usually has a tortuous course that is maximal near the level of the ovary , The veins draining the ovary form the pampiniform plexus of veins in the mesovarium and suspensory ligament.
The plexus of veins merge to usually form a single ovarian vein that leaves the pelvis along the side of the ovarian artery. In some individuals, the plexus of veins may merge to form two or more veins, but they commonly become a single vein by the time they reach the abdomen , 1. The left ovarian vein drains into the left renal vein. The right ovarian vein drains into the inferior vena cava below the level of the renal vessels , 1 , , 6 , , 8.
The ovarian artery and vein are medial to the ureter near the level of the lower renal poles, cross obliquely anterior to the ureter at about the middle to lower lumbar region, and are lateral to the ureter in the lower abdomen and pelvis. The vein is larger than the usually small-caliber artery and is typically readily identifiable lateral to it along the anterior surface of the psoas major muscle.
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- Ovary - Definition, Location, Function and Quiz | Biology Dictionary.
Tracking the ovarian vein, from near the level of the renal vessels caudally to the pelvis, leads to the region of the suspensory ligament in the immediate vicinity of the ovary and can thus be most helpful in identifying the ovary and in differentiating between ovarian and nonovarian masses. The CT recognition of the ovaries is facilitated by knowledge of the morphologic features and of the relationship of the ovary to the ureter, the course of the ovarian vein and artery, and the ligamentous attachments of the ovaries. The ovaries are ovoid parenchymatous structures that are frequently present at either side of the uterus.
Their morphologic features vary with age and the hormonal status of the patient. In women of childbearing age, the majority of normal ovaries can be identified , 17 and usually contain visible cystic follicles or physiologic cysts, which can be distinctly depicted as fluid-attenuation areas and are characteristic of the ovaries , , , , , Fig 7d.
Ovarian Pain: Possible Causes, Diagnosis, and Treatments
The ovarian parenchyma devoid of cysts, or surrounding the cystic areas, has uniform soft-tissue attenuation. When there are many minute cystic follicles, too small to be resolved, the ovary may have a low-attenuation appearance. Postmenopausal ovaries are small, difficult to recognize, and often not identified , Although small ovarian cysts can normally be seen after menopause, the ovaries in most postmenopausal women typically have featureless soft-tissue attenuation.
It is unusual to find follicular activity 4—5 years after menopause, even at histologic examination , 2. The ovaries in premenarchal girls are less frequently identified than in menstruating women , The ovary in its typical location at the ovarian fossa , Figs 1 , , 5 , , , , , , 7c is usually anterior or anteromedial to the pelvic ureter. The ovarian vein can be readily identified with CT and followed, along the anterior surface of the psoas major muscle, to the true pelvis and often may be visualized to the level of the suspensory ligament in the immediate vicinity of the ovary , , , , , Figs 7 , , , , , 8.
The ovarian artery is smaller and less confidently or consistently identifiable with CT than the vein. The suspensory ligament leads to the ovary , Figs 4 , , 5 , to which it is attached, and is a good anatomic landmark for localizing the ovary , The suspensory ligament transmits the ovarian artery and vein and may be depicted with CT , , , , , Figs 7b , , , , , 8b , in continuity with the ovarian vessels, as a short and narrow fan-shaped soft-tissue band that widens as it approaches the ovary and is slightly thick at its ovarian attachment or as a linear band slightly thicker than the ovarian vein leading into it.
This depicted ligamentous band is actually a summation of the peritoneal fold and the enclosed ovarian vessels, nerves, and fibromuscular fibers. In our experience, the suspensory ligament is more commonly identifiable with CT than the other ovarian ligamentous attachments, and recognizing it is facilitated by tracking the ovarian blood vessels caudally to the adnexa. When visualized on axial CT scans, the suspensory ligament usually extends from the ovary along the direction of the external or common iliac vessels.
The broad ligament and the mesovarium , Figs 2 , , 3 are usually not obvious at CT unless surrounded by a large amount of ascites , 19 , , , Fig 9. In this setting, the ovaries can be seen suspended from the posterior surface of the broad ligament.
The utero-ovarian ligament , Figs 2 , , 5 may occasionally be visualized with CT , 19 and is depicted as a short and narrow soft-tissue band extending between the uterus and ovary , Fig Young patients anticipated to undergo therapeutic irradiation of the pelvis may have the ovaries surgically transposed out of the radiation field in order to preserve their function. The procedure involves mobilizing the ovary together with the suspensory ligament and the contained ovarian blood vessels , 20 — , The ovaries are most commonly repositioned laterally either to the lower paracolic gutters, close to the lateral aspect of the colon near the iliac fossa level, or to the posterior intraperitoneal space in the upper pelvis, lateral or anterolateral to the psoas muscle , One or two large metallic surgical clips are typically affixed to each ovary to mark its location.
Lateral transposition is performed in patients with cervical cancer, vaginal cancer, pelvic sarcoma, and Hodgkin disease. Midline transposition can be performed in patients with Hodgkin disease, in which case the ovaries are placed in the midline of the true pelvis and sutured to the surface of the uterus , The CT identification of the surgically transposed ovaries is aided by recognizing the characteristic morphologic features of ovaries containing physiologic cysts, identifying the surgical clips marking the ovarian locations , 21 , and tracking the ovarian blood vessels toward the ovaries , 20 , Figs 11 , , The ovarian vessels in lateral transposition typically deviate laterally near the iliac fossa rather than coursing inferiorly into the pelvis.
Familiarity with the CT features of ovarian transposition is essential in preventing diagnostic errors resulting from mistaking a featureless ovary placed close to the colon for a colonic or peritoneal mass, as well as from mistaking cystic or complex ovarian masses for peritoneal cystic lesions, abscess, hematoma, or even appendiceal mucocele , The ovaries are intraperitoneal structures and are therefore always located internal to the parietal peritoneum which may be seen near the pelvic sidewalls, especially when there is abundant intrapelvic fat.
The lymph nodes at the pelvic sidewalls are extraperitoneal, lateral or posterolateral to the ureter , Fig 13 , and closely related to the iliac vessels and sidewall musculature. A large lymph node mass at the pelvic sidewall may displace the ureter medially or anteromedially and can efface or encase the iliac vessels , Figs 14 , , , , 15 or efface the sidewall musculature , A large ovarian mass may displace the ureter posteriorly or posterolaterally , A lymph nodal metastatic mass may have a necrotic or cystic appearance , 23 , , , Fig 15 and can be differentiated from a complex adnexal mass by recognizing the extraperitoneal location of the nodal mass, as reflected by its relationship to the ureter and pelvic sidewall structures.
Distinguishing ovarian from nonovarian intraperitoneal pelvic masses is aided by determining the relationship of the mass to the anatomic pelvic structures , 24 , including any discernible ovarian parenchyma or ligament, and the effect of the mass on the ureter. An ovarian mass not fully replacing the ovary may be draped by recognizable normal ovarian parenchyma, which reveals the true origin of the mass , Fig The location of the ureter relative to a pelvic mass can be a most helpful hint to the ovarian origin of the mass , 24 , , , Fig A mass arising from an ovary in its typical location at the ovarian fossa is usually anterior or anteromedial to the ureter, and when large enough it will displace the ureter posteriorly or posterolaterally.
However, a large uterine, bladder, or even bowel mass can also displace the ureter posteriorly or posterolaterally , 24 , Fig The unequivocal visualization of the ovarian suspensory ligament leading to and merging with a pelvic mass is a highly reliable finding that indicates the mass is ovarian. The suspensory ligament is in direct continuity with the main ovarian blood vessels but is not consistently depicted with CT as a distinct structure readily distinguishable from the ovarian blood vessels leading into it.
Consequently, tracking the ovarian vein along the ventral surface of the psoas muscle caudally to the pelvis may lead to a recognizable suspensory ligament attached to an ovary or ovarian mass , , , Fig 19 , or the ovarian vein may appear to lead directly to an ovary or ovarian mass , , , Fig 20 without discernible features of a ligament. In the latter situation, the location of the nondiscernible ligament is reflected by the most caudal aspect of the ovarian vein. Identification of the suspensory ligament can be very challenging, especially in the presence of very large pelvic masses such as the one in , , , Fig Furthermore, masses arising from the fallopian tube , , , Fig 21 are usually difficult to distinguish from ovarian masses because of the intimate relationship of the fallopian tube to the ovary , 6 and the ovarian ligamentous attachments.
In particular, in some clinical practices, hydrosalpinx is a fairly common finding that is often challenging to distinguish from a cystic ovarian mass , 25 , especially when a normal-appearing ipsilateral ovary is not identified. Thus, it is not consistently feasible to determine, with a high degree of accuracy, whether an adnexal lesion is ovarian or tubal. However, this terminology and the associated anatomic description do not conform to the established conventional anatomy as described in the English-language references.
In fact, the mesovarium is actually the primary route of transit for blood vessels entering and exiting the ovarian hilum , 3 and the anatomic main ovarian artery and vein do not directly join the ovarian hilum.
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Furthermore, it seems that the described ovarian vascular pedicle in two of the published images from the aforementioned series , 26 corresponds to the suspensory ligament, which is in continuity with the ovarian artery and vein. The ovarian suspensory ligament sign appears to be more reliable than the ovarian vein sign in indicating the ovarian origin of a mass. Large nonovarian pelvic masses can abut or compress the ovarian vein and thus result in an appearance that simulates the direct joining of the ovarian vein to a pelvic mass.
In the aforementioned study , 26 , the false-positive results associated with such an appearance were encountered with large subserosal uterine myomas measuring more than 20 cm. False-positive results can also be encountered with tubal lesions and nongynecologic masses that obscure the ovary and abut the ovarian vein, but such lesions or masses were not included in the series , When the suspensory ligament is not discernible, a pelvic mass depicted directly joined by the tracked ovarian vein is most likely ovarian but can be tubal, uterine, or occasionally a nongynecologic mass.
Identifying an ipsilateral ovary separate from the mass indicates a nonovarian origin, but often the ovary is obscured or is not clearly evident and identifiable , US is the recommended modality of choice for the initial imaging of the female pelvis , 10 and for further evaluation of the uterus and adnexa when the CT findings are indeterminate. US may be particularly helpful in searching for an ipsilateral ovary distinct from a pelvic mass, in revealing the tubular nature of a hydrosalpinx or morphologic features indicative of tubal rather than ovarian disease, and in further evaluating the internal architecture of cystic ovarian masses.
Furthermore, several nonmalignant gynecologic mass lesions can be accurately characterized with US , 10 and some morphologic findings associated with an increased risk for malignancy, such as solid papillary projections and septa with vascular flow, can be detected with US in cystic masses that appear featureless at CT. The size and morphology of an adnexal mass, the results of clinical assessment, and laboratory findings such as cancer antigen CA level together indicate whether conservative management is prudent or aggressive surgical therapy is warranted , US follow-up is an option for patients treated conservatively , 27 , as most processes in this category are benign and many will be shown to have resolved or remained stable at repeat imaging.
The ovary and its relationship to the anatomic pelvic structures are usually well depicted with CT , A thorough understanding of the ovarian morphologic features and ligamentous attachments, the relationship of the ovary to the ureter, and the course of the ovarian artery and vein is necessary to confidently identify the ovaries and facilitates accurate CT interpretation of the female pelvis.
In problematic cases, tracking the ovarian vein to the pelvis is often helpful in locating the region of the ovary and determining whether a pelvic mass is ovarian. 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. 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. 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.
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. 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. 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.
Figure 7a. CT features of normal ovaries. The left suspensory ligament is seen as a narrow soft-tissue band that demonstrates subtle widening as it approaches the ovary. Figure 7b. Figure 7c. Figure 7d. Figure 8a. CT scans of normal ovaries located relatively high in the pelvis. The right ovary demonstrates a typical relationship to the ureter, being just anterior to it. The left ovary is not close to the ureter. Figure 8b. Figure 8c. Figure 9a. Visualization of the broad ligament with CT. 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.
Figure 9b. Figure Postmenopausal ovaries identified by means of their ligamentous attachments.