prof soha talaat cairo university imaging in gynecology final
TRANSCRIPT
الرحيم الرحمن الله بسمأوتوا يرفع” والذين منكم آمنوا الذين الله
درجات “العلمالله صدق
العظيم: وسلم عليه اله صلى الله رسول قال
الله ” سهل علما فيه يلتمس طريقا سلك منلتضع المالئكة وإن الجنة إلى طريقا له
وإن يصنع بما رضا العلم لطالب أجنحتهاومن السماوات فى من له يستغفر العالموفضل الماء فى الحيتان حتى األرض فى
سائر على القمر كفضل العابد على العالم“ االنبياء ورثة العلماء وإن الكواكب
الله رسول صدق
الرحيم الرحمن الله الرحيم بسم الرحمن الله بسمدرجات ”” العلم أوتوا والذين منكم آمنوا الذين الله درجات يرفع العلم أوتوا والذين منكم آمنوا الذين الله ““يرفع
العظيم الله العظيم صدق الله صدق
Prof Soha Talaat
بسم الله الرحمن للرحيم
Prof Soha Talaat
Imaging in gynecology
Prof Soha Talaat
Imaging modalitiesI.Plain film :
Soft ovoid density seprated by fat planes
Abnormality: Soft tissue tumefaction : distended
bladder , ovarian cyst, fibroid uterus .
Obliteration of normal fat planes>>infection.
Calcifications: fibroid, ovarian(dermoid).
Ascites ,hemo/pnemo-peritonium.
Prof Soha Talaat
Missed IUD.
Prof Soha Talaat
US first
Prof Soha Talaat
Missed IUD
Prof Soha Talaat
Imaging modalities
II. Contrast Studies :1. HSG .2. Vaginography .3. GIT studies .4. IVU .5. Arteriography (AVM , fibroid
embolization).
Prof Soha Talaat
Vaginography
• Technique
• Indications:
1. Fistula .
2. Congenital or acquired abnormalities of vagina .
3. To localize by reflux an ectopic ureter opening into vagina.
Prof Soha Talaat
Vaginagraphy
Prof Soha Talaat
Gynecologic US
I. Scanning technique:A. TAS:• Uses transducers 3-5MHZ range.• Requires filling of the urinary bladder (ideal 1-
2 cm above the uterine fundus).• Obtained in sagittal and transverse planes
(oblique image may be needed)• To view adnexa move transducer from side to
side.• Main advantage providing an overview of the
pelvis.
Prof Soha Talaat
B.TVS• Performed with 5-9
MHZ transducers .• Empty bladder: To minimize discomfort Brings uterus and
ovaries into focal zone.• Probe should be
disinfected , Us gel applied to transducer head ,use condom .
• AP& transverse pelvic planes.
Prof Soha Talaat
TVS
• Indications :1. Early and second trimester pregnancy.2. Lower uterine segment in late pregnancy.3. Ectopic pregnancy.4. Retroverted or retroflexed uterus.5. Obese and gaseous patients.6. Emergency cases where bladder is empty.7. Follicular monitoring in ovulation induction.8. Pulsed and colour Doppler.
Prof Soha Talaat
TVS
• Advantages:
1. Can be performed quickly without full bladder.
2. Determine source of pain more accurately.
3. Facilitates use of Doppler.
4. Biopsy guides :follicular aspiration ,cyst& abscess drainage , tumour biopsy.
Prof Soha Talaat
TVS
• Disadvantage :
1. Occasional confusion with anatomic orientation due to unfamiliar scan planes.
2. Limited field of view which allow only visualization of true pelvis .
3. Probe caliber may be painful to patients with narrow interoitus such as nullipara ,postmenopausal women.
Prof Soha Talaat
TVS
Prof Soha Talaat
TVS Transverse pelvic plane
Prof Soha Talaat
Transperineal (translabial) US
Dietz. Pelvic floor ultrasound: a review. Am J Obstet Gynecol 2010. Prof Soha Talaat
Transperineal (translabial) US 1.Pelvic floor disorders
Recurrent urinary tract infections
● Urgency, frequency, nocturia, and/or
• urge urinary incontinence
● Stress urinary incontinence
● Insensible urine loss
● Bladder-related pain
● Persistent dysuria
● Symptoms of voiding dysfunction
• Symptoms of prolapse, ie, sensation of lump or dragging sensation
● Symptoms of obstructed defecation, eg,
• straining at stool, chronic constipation,
• vaginal or perineal digitation, and
• sensation of incomplete bowel emptying
• Fecal incontinence• Pelvic or vaginal pain ,Vaginal
discharge or bleeding after
Anti incontinence or prolapse surgery
Prof Soha Talaat
Gross AnatomyGross AnatomySagittal SectionSagittal Section
Prof Soha Talaat
Stress incontinence
Prof Soha Talaat
Prof Soha Talaat
Transperineal (translabial) USTRUS
• In virgins
• In suspected lower uterine anomalies
Prof Soha Talaat
Sonographic anatomy
• The uterus :1. Size .
2. Position .
3. Endometrial lining .
4. Myometrium
5. Cervix and endocervical canal
Prof Soha Talaat
Uterus• Size:• Varies with age and
parity .• Average:o Length=6– 8 cm .o Ap = 3-4 cm .o Transverse= 5cm
Prof Soha Talaat
Post menopausal
Prof Soha Talaat
Pre-pubertal uterus
• Tubular in shape .• Cervix to corpus ratio
1/1 .• Thin endometrial
stripe
Prof Soha Talaat
Infantile uterus
• 17ys female with primary amenorrhea
Prof Soha Talaat
Uterus Position
Mid line anteverted structure
Prof Soha Talaat
Positions of the uterus
Prof Soha Talaat
Prof Soha Talaat
Retroverted uterus
Prof Soha Talaat
Embryology
• The female reproductive system develops from the müllerian ducts , two ducts that originate in embryonic mesoderm lateral to each wolffian duct .
• The paired müllerian ducts grow in medial and caudal directions .The most cephalad parts of the ducts remain separate and form the fallopian tubes .The lower parts of the ducts fuse (lateral fusion ) .The midline septum disappears ,leaving a single canal :the uterus and upper two -thirds of the vagina
Prof Soha Talaat
Embryology • The lower third of the vagina develop from the bilateral sinovaginal
bulbs which arise from the urogenital sinus .The sinovaginal bulbs fuse into solid mass called the vaginal plate ,which undergoes canalization in the second trimester ,the sinovaginal bulb fuses with the lower müllerian system (vertical fusion) .
• The close developmental relationship of the müllerian and wolffian ducts explains the frequent association of anomalies of the female genital system and urinary tract
Prof Soha Talaat
Müllerian duct anomalies are categorized most commonly into 7 classes
according to (AFS) Classification Scheme (1988) :
• Class I (hypoplasia/agenesis)• Class II (unicornuate uterus) • Class III (didelphys uterus) • Class IV (bicornuate uterus) • Class V (septate uterus)• Class VI (arcuate uterus) • Class VII (diethylstilbestrol-related anomaly)
Prof Soha Talaat
The modified American Fertility Society (AFS) by Rock and Adam
• Class 1: Dysgenesis of müllerian ducts. This class includes agenesis or hypoplasia of the müllerian duct derivatives: the uterus and upper two-thirds of the vagina. The most common form is the Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH syndome), which is combined agenesis of the uterus, cervix, and upper portion of the vagina.
• Class 2: Disorders of vertical fusion. These anomalies are due to failure of fusion of the müllerian system with the sinovaginal bulb. They include cervical dysgenesis and obstructive and non obstructive transverse vaginal septa.
Prof Soha Talaat
The modified American Fertility Society (AFS) by Rock and Adam
• Class 3: Disorders of lateral fusion : result in a duplicated or partially duplicated reproductive tract. The disorders are due to impaired fusion and/or septal resorption of fusing müllerian ducts attempting to form the uterus, cervix, and upper vagina. Failure of fusion of the paired müllerian ducts (as in didelphic and bicornuate uteri) and failure of midline septum resorption after fusion (as in septate uterus). Disorders due to lateral fusion defects are further subclassified into (a) the symmetric non obstructive form seen in five types: unicornuate, bicornuate, didelphic, septate, and DES-related uteri and (b) the asymmetric obstructive form seen in three types: unicornuate uterus with obstructed horn, double uterus with unilaterally obstructed horn, and double uterus with unilaterally obstructed vagina.
• Class 4: Unusual configurations and combinations of defects [14].
Prof Soha Talaat
Uterine agenesis
Prof Soha Talaat
In uterine agenesisDon’t forget to look in inguinal region
Androgen insensitivity syndrome
Prof Soha Talaat
Uterine shape
Prof Soha Talaat
Septate uterus
Prof Soha Talaat
Subseptate
Prof Soha Talaat
Pregnancy in septate
Prof Soha Talaat
Bicornuate uterus
Prof Soha Talaat
Dideliphes
Prof Soha Talaat
Differentiation between bicornuate and septate uterus
• US may demonstrate two uterine cavities with normal endometrium.
• A reliable means of distinguishing bicornuate from septate uteri is a concave fundus with a fundal cleft greater than 1 cm.
• An increased intercornual distance (>4 cm) in bicornute uterus
• 3D US may play a useful role in making this diagnosis..
Prof Soha Talaat
unicornuateOne normally
developed mullerian duct while the
contralateral duct is either hypoplastic or
absent
Prof Soha Talaat
Arcuate
Prof Soha Talaat
Obstructive anomalies hematocolpos
Prof Soha Talaat
Hematometria &heamatocolpos
Prof Soha Talaat
Haematometra , vaginal atresia
Prof Soha Talaat
Uterusendometrium
phase AP diameter
Proliferative 4-8 mm
Periovulatory 6-10mm
Secretory 7-14mm
Prof Soha Talaat
Endometrium :how to measure
Prof Soha Talaat
Prof Soha Talaat
Prof Soha Talaat
Causes of endometrial thickening
• Polyp.
• Hyperplasia .
• Tamoxifen.
• Incomplete abortion
• Hydatiform mole
Prof Soha Talaat
Endometrial polyp • An endometrial polyp or uterine polyp is a
polyp or lesion in the endometrium that takes up space within the uterine cavity.
• Commonly occurring, they are experienced by up to 10% of women.
• They may have a large flat base (sessile) or (pedunculated).[5][6]
• Pedunculated polyps are more common than sessile ones.[7]
• They range in size from a few millimeters to several centimeters.[6]
• If pedunculated, they can protrude through the cervix into the vagina.[5][8] Small blood vessels may be present in polyps, particularly large ones.[5]
Prof Soha Talaat
Prof Soha Talaat
Large polyp
Prof Soha Talaat
Is this the same
Prof Soha Talaat
Prof Soha Talaat
Causes of Postmenopausal Bleeding
• Atrophic endometritis/vaginitis
• Endometrial or cervical polyps
• Exogenous estrogens
• Endometrial hyperplasia
• Endometrial cancer
• Miscellaneous (e.g., cervical cancer, uterine sarcoma, urethral caruncle, trauma)
Prof Soha Talaat
Endometrial hyperplasia
Prof Soha Talaat
Take care of Doppler findings
Prof Soha Talaat
Endometrial carcinoma
• is the most common gynecological malignancy in many countries with the reported incidence of about 10% in postmenopausal patients presenting uterine bleeding .
Prof Soha Talaat
ENDOMETRIAL CARCINOMAENDOMETRIAL CARCINOMA
•The post menopausal endometrium usuallyThe post menopausal endometrium usually atrophies measuring less than 3mm.atrophies measuring less than 3mm.•A double layer thickness >5mm is abnor.A double layer thickness >5mm is abnor.
•Grade I carcinoma presents as widening of the Grade I carcinoma presents as widening of the endometrial stripe on U/S examinationendometrial stripe on U/S examination
•A thickness of 7mm is accepted in women underA thickness of 7mm is accepted in women under hormonal therapyhormonal therapy
Prof Soha Talaat
ENDOMETRIAL CARCINOMAENDOMETRIAL CARCINOMA
STAGINGSTAGING
STAGE I: STAGE I: Confined to corpusConfined to corpus
STAGE II: STAGE II: Spread to cervixSpread to cervix
STAGE III: STAGE III: Vaginal ext, spread to adnexa, periton.Vaginal ext, spread to adnexa, periton. iliac or paraortic LN metastasesiliac or paraortic LN metastases
STAGE IV: STAGE IV: Distant metastases or bowel or bladderDistant metastases or bowel or bladder invasioninvasion
Prof Soha Talaat
Endometrial mass
Prof Soha Talaat
Prof Soha Talaat
Prof Soha Talaat
?? Endometrial cancer
Prof Soha Talaat
Molar pregnancy
Prof Soha Talaat
Prof Soha Talaat
Choriocarcinoma
Prof Soha Talaat
Sonohysterography
Normal uterine cavityProf Soha Talaat
Sonohysterography
Prof Soha Talaat
Cervix
• Barrel shaped , homogenous moderately echoic, smooth walled structure .
• Central echogenic stripe >endocervical canal .
Prof Soha Talaat
Nabothian cysts
Prof Soha Talaat
Cervicitis
Prof Soha Talaat
Cervical polyp• A cervical polyp is a common
benign polyp or tumor on the surface of the cervical canal.
• They can cause irregular menstrual bleeding or increased pain but often show no symptoms.[
• Treatment consists of simple removal of the polyp and prognosis is generally good.
• About 1% of cervical polyps will show neoplastic change which may lead to cancer.
MedlinePlus Encyclopedia Cervical polyps
Prof Soha Talaat
Cervical polyp
Prof Soha Talaat
Prof Soha Talaat
Prof Soha Talaat
Cervical carcinoma• The most frequent gynecologic
carcinoma in women under 50 years of age and the third most common
gynecologic malignancy in postmenopausal women following endometrial and ovarian cancer .
• In Egypt , WHO estimates indicate that every year, 2713 women are
diagnosed with cervical cancer and 2178 die from the disease. About 10.3 % of women in the general population
are estimated to harbor cervical human papilloma virus (HPV) infection
at a given time .Prof Soha Talaat
Cervical mass
Prof Soha Talaat
Stage Revised FIGO staging
Stage o Carcinoma in situ, intraepithelial carcinoma
Stage I:
Ia
Ia1
Ia2
Ib
Ib1
Ib2
Carcinoma strictly confined to cervix
Preclinical carcinoma of cervix (microinvasive)
Invasion of stroma < 3 mm in depth and < 7 mm in widthInvasion of stroma > 3 mm but < 5 mm in depth and no wider than 7 mm
Lesions confined to cervix or preclinical lesions greater than stage IA
Clinical lesions 4 cm or smaller
Clinical lesions larger than 4 cm
Stage II:
IIa
IIb
Carcinoma extending beyond the cervix but not to the pelvic wall; carcinoma involves the upper two third of
the vagina
No obvious parametrial involvement
Obvious parametrial involvement
Stage III:
IIIa
IIIb
Carcinoma extending to pelvic wall; and nvolves lower third of vagina
Involvement of lower third of vagina
Stage IV:
IVa
IVb
Carcinoma extending beyond true pelvis or involving bladder or rectum
Spread to adjacent organs
Spread to distant organs
Prof Soha Talaat
Prof Soha Talaat
UTERINE PERFUSION
• The main blood supply of the uterus is the uterine artery.
• The uterine arteries give rise to the arcuate arteries, which give rise to the radial arteries, which give rise to the basal and the spiral arteries
Prof Soha Talaat
Uterine artery flow
Proliferative phase of the menstrual
Cycle. a small amount of enddiastolic flow and a characteristic
notch (RI=0.92)
secretory phase :sharp increase of an enddiastolic blood flow leading to decrease of the resistance index (Rl=0.81)
Prof Soha Talaat
Myometrium
• Fibroids are very common. They occur in 2 or 3 out of every 10 women over age 35.
• It is common to have more than one fibroid. Some women may have as many as a hundred.
• Fibroids occur most often in women between ages 30 and 50, although women in their 20s sometimes have them.
• Three out of every 10 hysterectomies in the United States are performed because of fibroids.
Prof Soha Talaat
Fibroids
Prof Soha Talaat
Pedunculated fibroid
Prof Soha Talaat
Fibroid (interstitial)
Prof Soha Talaat
Interstitial fibroid
Prof Soha Talaat
Sub-mucous fibroid
Prof Soha Talaat
Prof Soha Talaat
Intracavitary fibroid
Prof Soha Talaat
Interstitial fibroid
Prof Soha Talaat
Degenerated fibroid
Prof Soha Talaat
Fibroid with pregnancy
Prof Soha Talaat
The Ideal Patient for uterine fibroid embolization
• Pre-menopausal pt not desiring fertility
• Post-menopausal pt with failure of spontaneous regression
• Pt has failed medical management
• Fibroid is of moderate size (3-7cm)
• Absolute contraindication to surgery (including pt preference)
Prof Soha Talaat
Post-embolization pelvic angiography should be performed to document arterial occlusion
Pre-embolization Post - embolization
Prof Soha Talaat
Pathological subtypes Incidence
Leiomyosarcoma 25-30% Endometrial stromal tumors 10-15%
Endometrial stromal noduleEndometrial stromal sarcoma-low gradeUndifferentiated sarcoma
Mixed epithelial-mesenchymal tumorsAdenosarcoma 5%Carcinosarcoma (Mixed Mullerian Tumor) 45-
50%HomologousHeterologous
Undifferentiated 5%
Uterine Sarcomas
Prof Soha Talaat
ADENOMYOSISADENOMYOSIS
• ADENOMYOSIS IS IMPLANTATION ADENOMYOSIS IS IMPLANTATION OF ENDOMETRIUM IN THE UTERINE OF ENDOMETRIUM IN THE UTERINE WALLWALL
• DURING MENSTRUATION BLOOD IS DURING MENSTRUATION BLOOD IS ENTRAPPED INSIDE THE MYOMETRIUMENTRAPPED INSIDE THE MYOMETRIUM•THE MYOMETRIUM IS HYPERTOPHIEDTHE MYOMETRIUM IS HYPERTOPHIED•AND THE UTERUS IS ENLARGEDAND THE UTERUS IS ENLARGED
Prof Soha Talaat
ADENOMYOSIS ON U/S
Prof Soha Talaat
Adenomyosis
Prof Soha Talaat
Adenomyosis
Prof Soha Talaat
A pyometra is a collection of pus distending the uterine cavity. It occurs principally when there is a stenosed cervical os, usually due to uterine or cervical malignancy and treatment with radiotherapy. However other causes include:
Fibroid degeneration Cervical occlusion following surgery (e.g. prolapse
surgery,1 endometrial ablation2) Senile cervicitis Puerperal infections Congenital cervical anomalies3 Forgotten intra-uterine device4 Genital tuberculosis Following egg retrieval in IVF5
Pyometra
Prof Soha Talaat
is a serious medical condition, because of both its association with malignant disease and the danger of spontaneous perforation, which carries significant morbidity and mortality
Although rare, ruptured pyometra should be considered in the differential diagnosis of acute abdomen in elderly women, especially those with malignant disorders of the genital tract.
The treatment of pyometra rupture is immediate laparotomy, peritoneal lavage and drainage, or simple hysterectomy
Pyometra
Prof Soha Talaat
Pelvic US
Prof Soha Talaat
Pelvic US & Doppler
Prof Soha Talaat
Prof Soha Talaat
Ovaries
Prof Soha Talaat
Prof Soha Talaat
Dominant follicle
Prof Soha Talaat
Post menopausal ovary
Prof Soha Talaat
PCO
Prof Soha Talaat
PCO
Prof Soha Talaat
Ovarian cysts
Prof Soha Talaat
Corpus leuteum cyst
Prof Soha Talaat
Functional Ovarian Cyst
• Extremely common• Failure of a follicle to
rupture• Size > 30 mm• US features :
– Anechoic– Posterior
enhancement– Thin, smooth wall < 3
mm
• Strategy :– Next cycle US
follow-up (Day 5-7)– Disappearance of
the cyst, although…
– A functional cyst can be present during several months
– Give time…..Prof Soha Talaat
Simple cyst
Prof Soha Talaat
Paraovarian Cyst
• Wolfian duct remnant in the mesovarium
• Detection on routine US• Size : 2-5 cm or more
• Clues :– Cyst besides a normal
ovary– Thin wall, anechoic
content– Beak sign with the ovary
Prof Soha Talaat
PERITONEAL INCLUSION CYSTS
• Nonneoplastic reactive mesothelial proliferations. Abnormal functioning ovaries and peritoneal adhesions are usually present.
• These cysts occur exclusively in premenopausal women with a history of previous abdominal surgery, trauma, PID, or endometriosis.
• Patients usually present with pelvic pain or mass.
• Radiographic features
• Extraovarian location• e Spider web pattern
(entrapped ovary): peritoneal adhesions extend to surface of ovary distorting ovarian contour
• Oblong loculated collection simulating hydro- or pyosalpinx
• * Complex cystic appearance simulating paraovarian cyst
• Irregular thick septations accompanied by complex cystic mass, simulating
• ovarian neoplasmProf Soha Talaat
Pelvic adhesions( due to previous surgery and PID) surround the ovary and create complex cystic masses.
US depicts a normal-appearing ovary that is surrounded by loculated fluid, in a pattern resembling a spider web. Ovary
Prof Soha Talaat
Follicular development
Prof Soha Talaat
Follicular monitoringmulti-planer 3D
Prof Soha Talaat
Hyperstimulation
Prof Soha Talaat
Luteal Cyst• Detected during the secretory phase
(D 15-28) of the menstrual cycle• Size : 2-7 cm• Polymorphism :
– Heterogeneous content with fibrin septa: « fish net »
– Clot simulating vegetation– Pseudo-solid cyst
• Color Döppler :– Non vascular septa– Vascularized thick wall– May be misdiagnosed as a
cystadenocarcinoma US Follow-up 2 months later (1 month is
too early !!!)Prof Soha Talaat
Non ruptured follicle
Prof Soha Talaat
Prof Soha Talaat
Complex cyst
Echogenic non vascular parts Follow up post menstrual
Prof Soha Talaat
Complex cyst
Prof Soha Talaat
LargeFunctional
Cyst•Trick : harmonic
imaging is useful to ascertain that the
lesion is fluid-filled
Prof Soha Talaat
Color Döppler?• Color Döppler is not
accurate :– In 30 % of functional
ovarian cyst walls, arteries are detected
– Presenting with a low resistive index
• Do not take it for malignancy !!!
Prof Soha Talaat
Endometriosis
Prof Soha Talaat
Prof Soha Talaat
Endometriosis &pelvic adhesions
Prof Soha Talaat
Anatomic location of endometriosis• Endometrial glands +
stroma in ectopic location – Ovary: endometrioma– Peritoneum
• Bladder 6.4%• Intestine 9.9%
– Subperitoneal space (posterior endometriosis)
• Utero-sacral ligaments and torus uterinus 69%
• Vagina / rectovaginal pouch 14.5% (painful defecation)
Fauconnier A et al, Fertil Steril 2002; 78: 719Prof Soha Talaat
Imaging protocol• Ultrasound• transabd. + transvaginal + Color Doppler
• MRI • Fasting and IM injection of peristaltic
inhibitor• T2 in 3 orientations: TR/TE 4000/90
– 512x256 matrix, 30cm FOV, 3-4 mm, subcut anterior sat bands
– Check best orientation at T2 for three T1– Native T1– T1 with fat saturation– T1 fat sat with IV contrast (bladder, bowel,
vagina)Kinkel et al, Eur Radiol 2006; 16: 285Prof Soha Talaat
Endometrioma
• Various sonographic appearance from anechoic to echogenic depending on the amount and coagulation of blood components
• 88% shows posterior acoustic enhancement .
• Borders may be irregular due to adhesions
Rarely, sediment or clots
Prof Soha Talaat
Endometrioma
Prof Soha Talaat
•Neovascularization detected in the cyst wall •Absence of color flow in some echogenic portions like blood clots in hemorrhagic cysts and endomertiomas suggest their benign cystic nature .
Role of colour Doppler
Prof Soha Talaat
Endometrioma
Prof Soha Talaat
Prof Soha Talaat
Pelvic endometriosis
Prof Soha Talaat
Dermoid cyst
• Echogenic focus within a predominantly cystic mass .(tip of ice berg sign ).
• Echogenic focus with posterior shadowing .
• Fat or hair fluid level.
Prof Soha Talaat
Dermoid
Prof Soha Talaat
Dermoid
Prof Soha Talaat
Prof Soha Talaat
Immature teratoma vascularized solid part
Prof Soha Talaat
Immature teratoma vascularized solid part
Prof Soha Talaat
Scoring system for cystic teratoma based on TVS& Doppler
Score
Reproductive age 2
B MODE:
Unilateral
Serial sonography positive
2
2
Thick walls.
Thin echogenic band like echoes
Echogenic tubericle within the ovary
2
2
2
Colour Doppler :no vascularity 2Prof Soha Talaat
Prof Soha Talaat
using gray scale US, color Doppler and magnetic resonance imaging in
evaluating adnexal masses
TAS ↓
TVS with complementary C D(To assess internal echo pattern and exact site of origin)
↓ ↓ ↓ Non hyperechoic solid cystic anechoic cystic
echoicParts, papillae & border line thick Septation & other, masses signs of malignancy. ↓ ↓ ↓ Malignant lesion. Benign lesion pelvic MRI is recommended
Prof Soha Talaat
Prof Soha Talaat
Prof Soha Talaat
Doppler findings ofbenign and maliqnant adnexal masses
Benign ovarian tumors• Regular distribution of blood vessels• Blood vessels are equally calibrated• Blood vessels have muscle fibers with moderate-to-high
resistance index values (RI=0.42)
Malignant ovarian tumors• Irregular distribution of blood vessels• Blood vessels have irregular diameter• Low resistance index values (RI<0.42)• Display of tumoral lakes and arterio-venous shunts
Prof Soha Talaat
Ovarian tumoursClassification:Histogenetic classification: As the ovary is composed of surface epithelium, germ cell apparatus
and stroma, ovarian tumours are classified into:1- Epithelial tumours 2- Germ cell tumours 3- Stromal tumours
Clinical classification:As ovarian tumours may be cystic or solid or complex and either of
them may be benign or malignant,
Prof Soha Talaat
Serous / Mucinous cystadenoma
– Thin wall– Pure cystic content
Serous : unilocular Mucinous : multilocularProf Soha Talaat
Cystadenocarcinoma:Typical malignant features
• US provides orientation tips• Malignant features :
– Solid-cystic lesion– Multiple papillary projections– Thick, irregular wall > 3 mm– Vascularized septations
Prof Soha Talaat
Prof Soha Talaat
Cystadenocarcinoma
Color doppler : Vascularized vegetationsProf Soha Talaat
Clear cell carcinoma :Uniloculated cyst with solid parietal nodules
Undifferenciated carcinoma : solid tumors with necrosis
Prof Soha Talaat
Solid ovarian mass
Prof Soha Talaat
Ovarian Fibroma•US features:
–Solid enlarged ovary–Homogenous content
–Arterial signal
•US is equivocal in case of “old” fibroma: –Heterogeneous
–Shadowing–Vessel paucity
Prof Soha Talaat
Ovarian Fibroma
Prof Soha Talaat
Borderline ovarian tumors• These tumors are benign, but have the potential
for malignancy• Cyst with papillary vegetations
– US is not able to differentiate a Borderline tumour from a cystadenocarcinoma
– MRI might be useful to detect subtle vegetations
• Recurrence is common : – The recommendation is to perform ovariectomy and
and a close follow-up of the controlateral ovary
Prof Soha Talaat
Prof Soha Talaat
Border line ov mass
Prof Soha Talaat
Complex adnexal mass
• Haemorrhagic cyst-contains diffuse internal echoes or an irregular clump of echoes due to clot. Repeat scans helpful to show change.
• Ruptured cyst-typical history, irregularly-shaped cyst with surrounding fluid.
• Torsion of cyst or ovary-heterogeneous enlarged ovary with or without a thick-walled cyst with internal echoes.
• Endometriosis:a clump of solid echoes within the cyst due to clot. Follow-up
• Acute / chronic tubo-ovarian abscess.• Dermoid cyst-complex mass with cystic and solid areas,
fat change in the appearance of the internal echoes confirming its and/or calcification.
Prof Soha Talaat
Complex adnexal mass
• Neoplastic ovarian tumours, benign and malignant.• Pedunculated fibroid differentiation from an ovarian
mass• Ectopic pregnancy-should always be considered in a
patient of child-bearing age. Pregnancy test important.• Other inflammatory masses-e.g. appendix or diverticular
mass.• Other neoplastic masses-e.g. arising from the bowel or
peritoneum (benign peritoneal mesothelioma).
Prof Soha Talaat
Masses Mimicking an Ovarian Origin
• Pedunculated sub-serous fibroma
• Chronic Hydrosalpinx
• Peritoneal cyst
• Pelvic abscess of intestinal origin
Prof Soha Talaat
Prof Soha Talaat
Adnexal mass
Prof Soha Talaat
Chronic ectopic
Prof Soha Talaat
may reflect may reflect benign or benign or malignant malignant
processes of processes of the ovary.the ovary.
Bilateral Diffuse ovarian enlargement
Prof Soha Talaat
Diffuse ovarian enlargment Benign causes of ovarian enlargement
• Luteomas.
• Tumors such as mature cystic teratomas, fibrothecomas, cystadenomas .
• rare conditions including capillary hemangioma and massive edema of the ovaries.
Prof Soha Talaat
Benign diffuse enlargmentTorsion( edema)
• Ovarian torsion (adnexal torsion) is an infrequent but significant cause of acute lower abdominal pain in women.
• This condition is usually associated with reduced venous return from the ovary as a result of stromal edema, internal hemorrhage, hyperstimulation, or a mass.
Prof Soha Talaat
•An enlarged ovary (>5 cm)• Prominent peripheral nonovulatory follicles .•Small amount of free fluid•May depict the cyst (or, less commonly, the mass) that predisposed the ovary to torsion.
US
Prof Soha Talaat
•Imaging modality of choice •An absence of arterial waveforms or high resistance to arterial flow with absent venous flow are highly suggestive. • Particularly when those findings are accompanied by ovarian enlargement. •However normal arterial waveforms do not rule out torsion.
Doppler
Prof Soha Talaat
Diffuse ovarian enlargment Ovarian malignancies include epithelial, stromal and germ-cell
tumors. Primary malignancies that may exhibit
metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma
Prof Soha Talaat
Malignant diffuse enlargementKrukenberg
•Metastatic signet ring cell adenocarcinoma of the ovary. •uncommon, 1% to 2% of all ovarian tumors•80% bilateral
Prof Soha Talaat
Ovarian lymphoma
• Primary female reproductive system lymphomas are distinctly uncommon.
• genital involvement is more likely a component of widely disseminated disease. NHL of the ovary may be a source of pelvic retroperitoneal masses completely engulfing the internal female genitalia.
Prof Soha Talaat
Ovarian lymphoma
• lymphoma of the ovary may appear as a discrete hypoechoic mass or a large confluent aggregate mass that may fill the pelvis. Hyperemia is often observed
• CT may reveal low-attenuation solid masses involving the uterus or confluent masses displacing or engulfing the pelvic organs
Prof Soha Talaat
Lymphoma
Prof Soha Talaat
Sonographic anatomy
• The fallopian tubes: Normal tubes could not be detected by US. Test for tubal patency(sonohysterography)
• The cul de sac; Most dependent part of peritoneal cavity. Normal findings a small amount of peritoneal
fluid .
• Urinary bladder : anechoic , normal wall thickness .
Prof Soha Talaat
Normal tube delineated by fluid
Prof Soha Talaat
Hydrosalpinx• Hydrosalpinx, pyosalpinx,
and hematosalpinx are used to describe a dilated fallopian tube filled with fluid, pus, or blood, respectively.
• Blockage usually occurs at the fimbriated end of the fallopian tubes and is caused by adhesions from infectious or inflammatory processes.
• The most common causes of hydrosalpinx are pelvic inflammatory disease and endometriosisProf Soha Talaat
Prof Soha Talaat
Pyosalpinx
• Color Doppler US image shows a hypoechoic tubular structure(arrow) containing echogenic debris. There is no internal blood flow; however, there is increased surrounding vascularity.
Prof Soha Talaat
TOA
Prof Soha Talaat
What about
fallopian cancer
Fallopian tube cancer is the least common of gynecological malignancies (0.3%) . It was first described by Renaud in 1847.1 Since then, there have been over 1500 cases
Prof Soha Talaat
Histopathology
1-Benign tumors
2-malignant tumors
a- 1ry fallopian tumors
b- 2ry fallopian tumors
Prof Soha Talaat
Benign tumor:1- Adenomatoid tumor a-Most common benign tumor of fallopian tube
Prof Soha Talaat
Malignant tumors:1-1ry tumors a- Primary adenocarcinoma: has a papillary features, it is the most common 1ry tumor of the tubes represent 90% of the cases b-gross:
Prof Soha Talaat
b-other types: 1-clear cell carcinoma 2-squamous cell carcinoma 3-mixed carcinoma 4-endometrioid carcinoma 5-sarcomabut all these types are LESS common
N.B. The common mullerian origin of fallopian tube and ovarian cancer could explain the cytological and histological similarities between them. Difficulties in diagnosis exist due to the similarities shared between fallopian tube carcinoma and epithelialovarian carcinoma
Prof Soha Talaat
2-2ry tumors:• Tubal involvement often by ovarian borderline
tumors and carcinomas, cervical and endometrial carcinoma (invasive or in-situ) and pseudomyxoma peritonei
• Metastases from extra-genital site are rare
Mode of transmission
*direct
*lymphatic
*blood
*transcelomicProf Soha Talaat
Clinical picture:
Triad: (latzko triad)1-vaginal bleeding &serosangenous bleeding
2-hydrops lubae profluence
3-adenxal mass
Prof Soha Talaat
Diagnosis:
Ultrasound
MRI pelvis
Serum CA-125
Prof Soha Talaat
u/s images
Prof Soha Talaat
Pelvic adhesions (PID)
Prof Soha Talaat
PELVIC VARICES• Transvaginal Ultrasound:• Identification of multiple dilated
structures around the uterus and ovaries with venous blood Doppler signal
• Dilated pelvic vein with a diameter greater than 4 mm
• Slow blood flow (about 3 cm/sec)
• Dilated arcuate vein in the myometrium communicating between bilateral pelvic varicose veins
• More than 50% of women have associated cystic ovaries
Prof Soha Talaat
Prof Soha Talaat
Prof Soha Talaat
Prof Soha Talaat
Prof Soha Talaat
Prof Soha Talaat