prof soha talaat cairo university imaging in gynecology final
TRANSCRIPT
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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
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بسم الله الرحمن للرحيم
Prof Soha Talaat
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Imaging in gynecology
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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.
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Missed IUD.
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US first
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Missed IUD
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Imaging modalities
II. Contrast Studies :1. HSG .2. Vaginography .3. GIT studies .4. IVU .5. Arteriography (AVM , fibroid
embolization).
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Vaginography
• Technique
• Indications:
1. Fistula .
2. Congenital or acquired abnormalities of vagina .
3. To localize by reflux an ectopic ureter opening into vagina.
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Vaginagraphy
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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.
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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.
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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.
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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.
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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.
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TVS
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TVS Transverse pelvic plane
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Transperineal (translabial) US
Dietz. Pelvic floor ultrasound: a review. Am J Obstet Gynecol 2010. Prof Soha Talaat
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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
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Gross AnatomyGross AnatomySagittal SectionSagittal Section
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Stress incontinence
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Transperineal (translabial) USTRUS
• In virgins
• In suspected lower uterine anomalies
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Sonographic anatomy
• The uterus :1. Size .
2. Position .
3. Endometrial lining .
4. Myometrium
5. Cervix and endocervical canal
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Uterus• Size:• Varies with age and
parity .• Average:o Length=6– 8 cm .o Ap = 3-4 cm .o Transverse= 5cm
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Post menopausal
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Pre-pubertal uterus
• Tubular in shape .• Cervix to corpus ratio
1/1 .• Thin endometrial
stripe
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Infantile uterus
• 17ys female with primary amenorrhea
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Uterus Position
Mid line anteverted structure
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Positions of the uterus
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Retroverted uterus
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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
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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
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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)
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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.
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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].
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Uterine agenesis
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In uterine agenesisDon’t forget to look in inguinal region
Androgen insensitivity syndrome
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Uterine shape
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Septate uterus
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Subseptate
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Pregnancy in septate
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Bicornuate uterus
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Dideliphes
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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..
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unicornuateOne normally
developed mullerian duct while the
contralateral duct is either hypoplastic or
absent
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Arcuate
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Obstructive anomalies hematocolpos
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Hematometria &heamatocolpos
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Haematometra , vaginal atresia
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Uterusendometrium
phase AP diameter
Proliferative 4-8 mm
Periovulatory 6-10mm
Secretory 7-14mm
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Endometrium :how to measure
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Causes of endometrial thickening
• Polyp.
• Hyperplasia .
• Tamoxifen.
• Incomplete abortion
• Hydatiform mole
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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]
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Large polyp
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Is this the same
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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)
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Endometrial hyperplasia
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Take care of Doppler findings
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Endometrial carcinoma
• is the most common gynecological malignancy in many countries with the reported incidence of about 10% in postmenopausal patients presenting uterine bleeding .
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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
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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
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Endometrial mass
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?? Endometrial cancer
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Molar pregnancy
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Choriocarcinoma
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Sonohysterography
Normal uterine cavityProf Soha Talaat
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Sonohysterography
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Cervix
• Barrel shaped , homogenous moderately echoic, smooth walled structure .
• Central echogenic stripe >endocervical canal .
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Nabothian cysts
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Cervicitis
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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
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Cervical polyp
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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
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Cervical mass
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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
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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
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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)
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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.
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Fibroids
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Pedunculated fibroid
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Fibroid (interstitial)
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Interstitial fibroid
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Sub-mucous fibroid
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Intracavitary fibroid
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Interstitial fibroid
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Degenerated fibroid
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Fibroid with pregnancy
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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)
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Post-embolization pelvic angiography should be performed to document arterial occlusion
Pre-embolization Post - embolization
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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
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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
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ADENOMYOSIS ON U/S
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Adenomyosis
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Adenomyosis
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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
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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
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Pelvic US
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Pelvic US & Doppler
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Ovaries
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Dominant follicle
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Post menopausal ovary
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PCO
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PCO
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Ovarian cysts
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Corpus leuteum cyst
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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
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Simple cyst
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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
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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
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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
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Follicular development
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Follicular monitoringmulti-planer 3D
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Hyperstimulation
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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
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Non ruptured follicle
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Complex cyst
Echogenic non vascular parts Follow up post menstrual
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Complex cyst
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LargeFunctional
Cyst•Trick : harmonic
imaging is useful to ascertain that the
lesion is fluid-filled
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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 !!!
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Endometriosis
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Endometriosis &pelvic adhesions
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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
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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
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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
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Endometrioma
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•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
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Endometrioma
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Pelvic endometriosis
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Dermoid cyst
• Echogenic focus within a predominantly cystic mass .(tip of ice berg sign ).
• Echogenic focus with posterior shadowing .
• Fat or hair fluid level.
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Dermoid
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Dermoid
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Immature teratoma vascularized solid part
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Immature teratoma vascularized solid part
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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
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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
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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
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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,
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Serous / Mucinous cystadenoma
– Thin wall– Pure cystic content
Serous : unilocular Mucinous : multilocularProf Soha Talaat
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Cystadenocarcinoma:Typical malignant features
• US provides orientation tips• Malignant features :
– Solid-cystic lesion– Multiple papillary projections– Thick, irregular wall > 3 mm– Vascularized septations
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Cystadenocarcinoma
Color doppler : Vascularized vegetationsProf Soha Talaat
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Clear cell carcinoma :Uniloculated cyst with solid parietal nodules
Undifferenciated carcinoma : solid tumors with necrosis
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Solid ovarian mass
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Ovarian Fibroma•US features:
–Solid enlarged ovary–Homogenous content
–Arterial signal
•US is equivocal in case of “old” fibroma: –Heterogeneous
–Shadowing–Vessel paucity
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Ovarian Fibroma
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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
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Border line ov mass
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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.
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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).
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Masses Mimicking an Ovarian Origin
• Pedunculated sub-serous fibroma
• Chronic Hydrosalpinx
• Peritoneal cyst
• Pelvic abscess of intestinal origin
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Adnexal mass
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Chronic ectopic
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may reflect may reflect benign or benign or malignant malignant
processes of processes of the ovary.the ovary.
Bilateral Diffuse ovarian enlargement
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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.
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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.
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•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
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•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
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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
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Malignant diffuse enlargementKrukenberg
•Metastatic signet ring cell adenocarcinoma of the ovary. •uncommon, 1% to 2% of all ovarian tumors•80% bilateral
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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.
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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
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Lymphoma
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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 .
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Normal tube delineated by fluid
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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
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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.
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TOA
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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
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Histopathology
1-Benign tumors
2-malignant tumors
a- 1ry fallopian tumors
b- 2ry fallopian tumors
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Benign tumor:1- Adenomatoid tumor a-Most common benign tumor of fallopian tube
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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:
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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
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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
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Clinical picture:
Triad: (latzko triad)1-vaginal bleeding &serosangenous bleeding
2-hydrops lubae profluence
3-adenxal mass
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Diagnosis:
Ultrasound
MRI pelvis
Serum CA-125
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u/s images
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Pelvic adhesions (PID)
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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
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Prof Soha Talaat