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Ultrasound Obstet Gynecol 2014; 44: 354–360

Published online in Wiley Online Library ( DOI: 10.1002/uog.13323

Imaging in gynecological disease (10): clinical and

ultrasound characteristics of decidualized endometriomas
surgically removed during pregnancy
*Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy; †Gynecology and Early Pregnancy
Ultrasound Unit, Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy; ‡Department of Obstetrics and
Gynecology, Karolinska University Hospital, Stockholm, Sweden; §Department of Obstetrics and Gynecology, New York University School
of Medicine, New York, NY, USA; ¶Department of Gynecology, Policlinico Abano Terme, Abano Terme, Italy; **Department of
Obstetrics and Gynecology, Università degli Studi di Roma Tor Vergata, Rome, Italy; ††Department of Radiology and Obstetrics and
Gynecology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; ‡‡Department of Obstetrics and Gynecology,
Skåne University Hospital Malmö, Lund University, Malmö, Sweden

K E Y W O R D S: decidualization; endometriosis; pattern recognition; retrospective study; transvaginal ultrasound

ABSTRACT borderline in eight women (44%), and invasive malig-

nancy in one (6%) woman. Seventeen decidualized
Objectives To describe the clinical history and ultrasound
endometriomas contained a papillary projection, and in
findings in women with decidualized endometriomas
16 of these at least one of the papillary projections was
surgically removed during pregnancy.
vascularized at power or color Doppler examination. The
Methods In this retrospective study, women with a his- number of cyst locules varied between one (n = 11) and
tological diagnosis of decidualized endometrioma during four. No woman had ascites. When using pattern recog-
pregnancy who had undergone preoperative ultrasound nition, most decidualized endometriomas (14/17, 82%)
examination were identified from the databases of seven were described as manifesting vascularized rounded pap-
ultrasound centers. The ultrasound appearance of the illary projections with a smooth contour in an ovarian
tumors was described on the basis of ultrasound images, cyst with one or a few cyst locules and ground-glass or
ultrasound reports and research protocols (when appli- low-level echogenicity of the cyst fluid.
cable) by one author from each center using the terms
and definitions of the International Ovarian Tumor Anal- Conclusions Rounded vascularized papillary projections
ysis (IOTA) group. In addition, two authors reviewed with smooth contours within an ovarian cyst with cyst
together available digital ultrasound images and used contents of ground-glass or low-level echogenicity are
pattern recognition to describe the typical ultrasound typical of surgically removed decidualized endometriomas
appearance of decidualized endometriomas. in pregnant women, most of whom are asymptomatic.
Copyright © 2014 ISUOG. Published by John Wiley &
Results Eighteen eligible women were identified. Median Sons Ltd.
age was 34 (range, 20–43) years. Median gestational age
at surgical removal of the decidualized endometrioma
was 18 (range, 11–41) weeks. Seventeen women (94%) INTRODUCTION
were asymptomatic and one presented with pelvic pain.
In three of the 18 women an ultrasound diagnosis of Aim
endometrioma had been made before pregnancy. The
original ultrasound examiner was uncertain whether the To describe the clinical characteristics and ultrasound
mass was benign or malignant in 10 (56%) women and findings in women with decidualized endometriomas
suggested a diagnosis of benignity in nine (50%) women, surgically removed during pregnancy.

Correspondence to: Dr A. C. Testa, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Largo Agostino
Gemelli 1, 00168 Rome, Italy (e-mail:
Accepted: 22 January 2014

Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. ORIGINAL PAPER
Clinical and US characteristics of decidualized endometriomas in pregnancy 355

Background to the rupture of pelvic vessels caused by deep infiltrating

decidualized endometriosis11,12 , or rectal perforation
Epidemiology caused by decidualization of the rectal wall13 . No clinical
Decidualization during pregnancy has been described complications seem to have been described for ovarian
since the beginning of the 20th century1,2 . Decidualization decidualized endometriomas7 .
means conversion of the normal endometrium during
pregnancy into a specialized uterine lining adequate Prognosis
for optimal accommodation of the pregnancy. This
change is induced mainly by progesterone and involves There are only a few case reports describing expectant
hypertrophy of the endometrial stromal cells leading management of women with an imaging diagnosis of
to thickening of the normal endometrium and giving decidualized endometrioma in pregnancy. In all cases
rise to the decidua. Formation of ectopic decidua of conservative management a sonographic or magnetic
during pregnancy is attributed to hormonal effects on resonance examination after pregnancy revealed an
ectopic endometrium, i.e. endometriosis3 , or on normal unremarkable typical endometrioma with shrinkage of
subcelomic mesothelium4,5 . It has been hypothesized that the cyst7,14,15 .
decidualization represents a physiological reaction of the
peritoneal stromal cells to pregnancy5 . However, to the METHODS
best of our knowledge, the prevalence of decidualized
endometriomas has not been reported. This was a retrospective cross-sectional observational
study. From the ultrasound databases of each of seven
Macroscopy contributing ultrasound centers (listed at the end of the
main text), 18 women with a histological diagnosis of
Ectopic decidual peritoneal foci may sometimes be visible decidualized endometrioma during pregnancy who had
on macroscopic examination as variably sized, soft, tan to undergone preoperative ultrasound examination by an
hemorrhagic nodules or patches5 . They are usually only experienced ultrasound examiner (at least 10 years’ expe-
seen microscopically5 , but sometimes they may result in rience in gynecological ultrasound) between 2003 and
large peritoneal nodules mimicking malignancy and even 2011 were identified: five women from Rome, six from
obstructing labor6 . Bologna, three from New York, and one from each of the
Despite an extensive literature search, we found no other four centers. Five of these women were included
publications, with the exception of four case reports7 – 10 , in the International Ovarian Tumor Analysis (IOTA)
describing the macroscopic appearance of decidualized study and so had been examined using a standardized
endometriomas in pregnancy. Our clinical experience technique and following a strict research protocol with
is that decidualized endometriomas surgically removed predefined clinical and ultrasound information collected
during pregnancy are characterized by the presence of prospectively. For women who had been examined
large excrescences arising from the internal cyst wall of outside the IOTA protocol, one author from each center
the endometrioma. retrospectively reviewed stored images and ultrasound
reports, and described the adnexal masses on the basis
Microscopy of this information using the IOTA terminology16 . In
three centers (Rome, Bologna, Stockholm) the ultrasound
An ectopic decidual reaction may be encountered within examinations performed outside the IOTA study were
the ovarian stroma as an isolated finding or as part carried out using the technique recommended by the
of a more widespread decidual transformation of the IOTA group, while in the other four centers they were
sub-peritoneal pelvic mesenchyma. An ovarian decidual carried out according to the local protocol. Clinical
reaction usually represents a response of the indigenous information for patients not included in the IOTA studies
stroma cells to the hormonal milieu of pregnancy. was retrieved retrospectively from patient records and
Ectopic decidua may be seen as early as the 9th week so was missing information for patients included in the
of gestation and is present in almost all ovaries at IOTA studies. The study was approved by the local
term. The decidual cells usually occur singly, as small institution review board in each participating center.
nodules or as confluent sheets in the superficial cortical All women were examined with transvaginal ultrasound
ovarian stroma and on the ovarian surface, and often supplemented with a transabdominal scan if necessary. All
also in periovarian adhesions. Smooth muscle cells ultrasound examinations were carried out using high-end
may be admixed. Distended capillaries and numerous ultrasound equipment, the frequency of the vaginal probes
lymphocytes are typically found within the decidual foci5 . varying between 5.0 and 9.0 MHz and that of the
abdominal probes between 3.5 and 5.0 MHz. Results
Clinical symptoms of Doppler examinations are reported in terms of color
score and presence of flow within papillary projections16 .
Even if decidualization during pregnancy is usually The results of the last ultrasound examination
asymptomatic, very serious complications have been performed before surgery were used for statistical
reported, e.g. massive intraperitoneal hemorrhage due analysis. In addition to presenting results using the IOTA

Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2014; 44: 354–360.
356 Mascilini et al.

terminology, we also present those derived from pattern Table 1 Ultrasound findings as described using International
recognition: two experienced ultrasound examiners Ovarian Tumor Analysis (IOTA) group terminology in 18 women
with histologically confirmed decidualized endometriomas
(A.C.T., F.M.) reviewed together all available digital
surgically removed during pregnancy
ultrasound images (n = 17) and used pattern recognition
to describe the ultrasound appearance of decidualized Ultrasound finding Value
Bilateral tumors* 3 (17)
All clinical and ultrasound information was entered
Maximum diameter of lesion (mm) 66 (41–121)
into a dedicated Excel file, which was used for statis- Type of tumor
tical analysis (Microsoft Office Excel 2003; Redmond, Unilocular 1 (6)
WA, USA). Unilocular-solid 10 (56)
Multilocular-solid 7 (39)
Number of locules† 3 (2–4)
RESULTS Echogenicity of cyst fluid
Anechoic 2 (11)
The median age of the 18 women included in our study Low-level 4 (22)
was 34 (range, 20–43) years and 17 (94%) were nulli- Ground-glass 12 (67)
parous. In three of the 18 women an ultrasound diagnosis Color score
1 3 (17)
of endometrioma had been made before pregnancy. Only
2 2 (11)
one woman complained of symptoms (pelvic pain) at 3 13 (72)
the diagnosis of the mass. Median gestational age at Presence of papillary projections 17 (94)
the last ultrasound examination before surgery was 14 Number of papillary projections
(range, 11–39) weeks and the median interval between 0 1 (6)
the last ultrasound examination and surgery was 1 (range, 1 4 (22)
2 3 (17)
0–19) week. A median of 2.5 (range, 1–26) weeks elapsed
3 6 (33)
between the detection of the lesion during pregnancy ≥4 4 (22)
and surgery, median gestational age at surgery being 18 Maximum diameter of largest papillary 28 (6–79)
(range, 11–41) weeks. Results of serum CA-125 measure- projection (mm)
ments were available for nine women (median 61 (range, Height of largest papillary projection (mm) 18 (3–33)
12–285) IU/mL), three (33%) having values < 35 IU/mL, Surface of papillary projection‡
Irregular 3/17 (18)
two (22%) having values between 35 and 65 IU/mL, and
Smooth 14/17 (82)
four (44%) having values > 65 IU/mL. In 13 cases the Crescent sign present§ 5/17 (29)
decidualized endometrioma was surgically removed dur- Color or power Doppler signals in papillary
ing pregnancy because malignancy could not be entirely projections
excluded. Five decidualized endometriomas were removed Present 16/17 (94)
at Cesarean section planned for obstetric reasons: in one Absent 1/17 (6)
case the endometrioma appeared as a unilocular 55-mm Results are shown as median (range) or n (%). *One mass
cyst with ‘ground-glass’ echogenicity of cyst fluid and no contralateral to the decidualized endometrioma included in this
signs of malignancy (Figure 1), in the other four cases study was a histologically confirmed ovarian fibroma; two were
the endometrioma was described as a unilocular-solid or unilocular cysts with typical ultrasound features of endometrioma
but they were not surgically removed. †Results shown for the seven
women with multilocular-solid tumors. ‡Results for 17 patients
with papillary projections. If any of several papillary projections
had irregular surface, irregular surface was judged to be present.
§Results available for 17 of 18 cases.

multilocular-solid cyst with papillary projections. In all

five cases the clinicians decided on surgical removal of
the ovarian cyst despite the ultrasound diagnosis being
a benign cyst. The sonographic characteristics of the
decidualized endometriomas included in this study as
described using IOTA terminology are shown in Table 1.
The median maximum diameter of the lesions at the last
examination before surgery was 66 (range, 41–121) mm.
All but one tumor contained solid components and the
echogenicity of the cyst content was usually ground-glass
or low-level. All but one decidualized endometrioma
Figure 1 Power Doppler ultrasound image of a decidualized contained papillary projections, and in most cases the
endometrioma appearing as a unilocular cyst with ground-glass papillary projections were multiple. In 16 decidualized
echogenicity, removed during Cesarean section performed for endometriomas with papillary projections (94%) at least
obstetric reasons. No papillary projections were visible on
one of the papillary projections was vascularized at power
ultrasound in this histologically confirmed ovarian decidualized
endometrioma. or color Doppler examination. Figure 2 shows typical

Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2014; 44: 354–360.
Clinical and US characteristics of decidualized endometriomas in pregnancy 357

Figure 2 Gray-scale (a) and color Doppler (b) ultrasound images of a decidualized endometrioma. This was a unilocular-solid cyst with
ground-glass echogenicity of the cyst fluid and multiple papillary projections that were richly vascularized on color Doppler examination.
Note the rounded shape of the papillary projections.

Table 2 Diagnosis suggested by original ultrasound examiner in

preoperative ultrasound report on basis of subjective evaluation in
18 women with a histological diagnosis of decidualized

Parameter n (%)

Suggested diagnosis
Benign mass 9 (50)
Borderline tumor 8 (44)
Malignant tumor 1 (6)
Suggested risk of malignancy
Certainly benign 3 (17)
Probably benign 4 (22)
Uncertain 10 (56)
Probably malignant 1 (6)
Certainly malignant —
Suggested specific diagnosis Figure 3 Power Doppler ultrasound image of a decidualized
Decidualized ovarian endometrioma 9 (50) endometrioma incorrectly suggested to be a primary ovarian cancer
Borderline ovarian tumor 8 (44) by the original ultrasound examiner, who reported the presence of
Primary ovarian cancer 1 (6) papillary projections in a unilocular-solid cyst with ground-glass
echogenicity. One papillary projection (arrow) appeared
vascularized on power Doppler.
gray-scale and color Doppler images of a decidualized
endometrioma with papillary projections. The ovarian cases. In the three patients with bilateral tumors the mass
crescent sign was observed in five (29%) of 17 lesions17 . contralateral to the decidualized endometrioma included
No woman had ascites or fluid in the pouch of Douglas. in this study was a histologically confirmed ovarian
The diagnoses suggested by the original ultrasound fibroma in one; in the other two patients the contralateral
examiners in their preoperative reports are presented in mass was a unilocular cyst with typical ultrasound features
Table 2. In 10 (56%) of the 18 women the ultrasound of endometrioma but they were not surgically removed.
examiner was uncertain whether the lesion was benign or The two authors (A.C.T., F.M.) using pattern recog-
malignant. Using subjective evaluation of the ultrasound nition to describe the masses agreed reasonably well in
image, the original ultrasound examiner correctly sug- their descriptions of decidualized endometrioma and,
gested a diagnosis of decidualized endometrioma in nine after discussions between them, they reached consensus
women (50%), the examiner being absolutely certain of that the typical ultrasound appearance of a decidualized
benignity in three of these cases, rather certain in four endometrioma was as follows: a cystic ovarian mass with
cases and uncertain about benignity in two cases. One one or a few cyst locules containing rounded (i.e. with
of the remaining nine endometriomas was suggested by base and height of similar size) vascularized papillary
the original ultrasound examiner to be a primary invasive projections with smooth contour and with cyst contents
tumor (Figure 3) and eight were suspected to be borderline with ground-glass or low-level echogenicity (Figure 5).
ovarian tumors (Figure 4), but the ultrasound examiner This pattern was present in 82% (14/17) of all the
was uncertain about malignancy in eight of these nine decidualized endometriomas for which electronic images

Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2014; 44: 354–360.
358 Mascilini et al.

Figure 4 Gray-scale (a) and color Doppler (b) ultrasound images of a decidualized endometrioma incorrectly suggested by the original
ultrasound examiner to be a borderline ovarian tumor. It appeared as a unilocular-solid cyst with ground-glass echogenicity and several
large vascularized papillary projections. Note the rounded shape of the papillary projections (this case has been described in a report by
Fruscella et al.8 ).

Figure 5 Gray-scale (a) and power Doppler (b) ultrasound images of a decidualized endometrioma with rounded vascularized papillary
projections with smooth contour within an ovarian cyst with ground-glass echogenicity of the cyst fluid. Two experienced ultrasound
examiners found this pattern to be typical of decidualized endometriomas.

were available. Rounded papillary projections are sug- ultrasound – distinguished the papillary projections in
gested to be a typical ultrasound feature of decidualized decidualized endometriomas from those in borderline
endometriomas in pregnancy. malignancies, where papillary projections usually have
an irregular surface.
To the best of our knowledge this is the only study
with the primary aim of describing the ultrasound char-
Our results show that the most typical ultrasound fea- acteristics of decidualized endometriomas in pregnancy.
tures of decidualized endometriomas surgically removed It is a strength of the study that the ultrasound findings
during pregnancy were rounded vascularized papillary were described using a standardized terminology. It is
projections with smooth contour within an ovarian a limitation that the study is retrospective (we cannot
cyst (usually unilocular but sometimes with 2–4 cyst guarantee that all cases have been identified, and
locules) with ground-glass or low-level echogenicity of retrospectively collected information is less reliable than
the cyst fluid. The smooth rounded appearance of the prospectively collected information). A second limitation
papillary projections was the ultrasound feature that is that we had access only to still images. Digital clips
two experienced ultrasound examiners felt – on the basis might have been more informative. Moreover, our study
of their long personal experience with gynecological sample is highly selected, because the indication for

Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2014; 44: 354–360.
Clinical and US characteristics of decidualized endometriomas in pregnancy 359

surgery was uncertainty about the lesion being benign both from our study and from published case reports7 ,
in 13 of the 18 cases. It is important to emphasize that that decidualized endometriomas with papillary projec-
our study casts no light on how often decidualization tions cause substantial diagnostic difficulties, especially
occurs in endometriomas during pregnancy, nor on how if the woman has not had an ultrasound diagnosis
often such decidualization results in the development of of endometrioma before pregnancy. This is because
papillary projections. To elucidate this, women with an papillary projections are a sign of malignancy, papillary
ultrasound diagnosis of endometrioma would need to be projections being particularly common in borderline
followed-up with ultrasound throughout pregnancy and ovarian malignancies8,18 – 22 . Moreover, papillary projec-
have their endometrioma surgically removed at the latest tions may be a sign of malignization in an endometriotic
immediately after delivery, irrespective of the ultrasound cyst23 . If it were possible to distinguish with certainty
appearance of the endometrioma. Such a study would papillary projections representing decidualized tissue in
be difficult to defend ethically. It would be fully possible, endometriomas from malignant papillary projections
however, to follow-up women with endometriomas with much would be gained, because unnecessary surgery
ultrasound throughout pregnancy and then continue with during pregnancy could then be avoided.
ultrasound follow-up after delivery. This would clarify Our results suggest that papillary projections in decid-
how often papillary projections develop in endometri- ualized endometriomas do look different from those in
omas during pregnancy, how often they regress and when malignancies in that they have a typically rounded appear-
they regress. Such a study would be ethically defensible ance. The ability of this sign to discriminate between
provided that papillary projections representing decidu- decidualized endometriomas and malignancies will need
alized benign tissue can be distinguished from malignant to be assessed in a study in which ultrasound examiners
papillary projections with reasonable certainty. are exposed to ultrasound images from pregnant women
In two cases with bilateral masses, the mass contralat- with adnexal lesions with papillary projections, some of
eral to the surgically removed decidualized endometrioma which are decidualized endometriomas and others are
was a unilocular cyst with ultrasound features typical other benign lesions or malignancies. We need to await
of endometrioma. It would be interesting to know if the results of such a study before an evidence-based state-
these two cysts were also decidualized endometriomas ment can be made on how to manage ovarian cysts with
despite the absence of papillary projections, or if for papillary projections detected during pregnancy. Based
some reason decidualization occurred in only one of the on available evidence, it seems reasonable to suggest
bilateral endometriomas. These two cases illustrate our expectant management of cysts with papillary projections
lack of understanding of the process of decidualization of detected during pregnancy only if an endometrioma
endometriomas. was diagnosed with ultrasound – or some other reliable
In an article published in 2009, Barbieri et al.7 summa- imaging technique – in the same ovary before pregnancy
rized the literature from 1990 to 2008 on endometriomas and, in addition, if the cyst manifests the typical signs of
in pregnancy with an ultrasound image mimicking decidualized endometrioma described in this work.
malignancy. They also described three cases of their own.
In all 17 cases included in their article, the ultrasound
Contributing Ultrasound Centers
images showed the presence of ‘intracystic excrescences’
(corresponding to what we call papillary projections), University of Catholic University of Sacred Heart, Rome,
and in 12 of 14 cases for which information on Doppler Italy;
ultrasound results was available, the excrescences were Department of Obstetrics and Gynecology, New York
vascularized. All but two lesions were unilocular, and University, New York, NY, USA;
in no case was there fluid in the pouch of Douglas. The Department of Obstetrics and Gynecology, Università
diagnosis of decidualized endometrioma was confirmed degli Studi di Roma ‘Tor Vergata’, Italy;
histologically in 16 of the 17 cases. One lesion was Department of Radiology and Obstetrics and Gynecology,
followed-up with ultrasound and the excrescences had Brigham and Women’s Hospital, Harvard Medical
disappeared 6 weeks after a miscarriage at 10 weeks’ School, Boston, MA, USA;
gestation. The results presented in the study of Barbieri Department of Gynaecology and Obstetrics, Policlinico
et al.7 agree very well with ours with the exception that a Abano Terme, Padova, Italy;
higher proportion of decidualized endometriomas in our Department of Obstetrics and Gynecology, S. Orsola
series contained more than one cyst locule. Malpighi Hospital, University of Bologna, Italy;
There are two case reports describing ultrasound Department of Obstetrics & Gynecology, Karolinska
follow-up of three pregnant women with an ultrasound University Hospital, Stockholm, Sweden.
diagnosis of decidualized endometrioma with papillary
projections7,14 and there is one case report describ-
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Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2014; 44: 354–360.