Genital Tract Diseases

WOMEN’S IMAGINGWOMEN’S IMAGINGGenital Tract DiseasesGenital Tract Diseases

Maria Theresa M. Navarro, Maria Theresa M. Navarro, MDMD

Fourth Year Radiology ResidentFourth Year Radiology ResidentDepartment of Medical ImagingDepartment of Medical Imaging

Quirino Memorial Medical CenterQuirino Memorial Medical Center

SOURCE: Ultrasonography in Obstetrics and Gynecology, 4th ed by Peter W. Callen, MD

ULTRASOUND ULTRASOUND OF THE OF THE UTERUSUTERUS

ANATOMY OF THE ANATOMY OF THE UTERUSUTERUS

UTERUS UTERUS uterus is located in the true pelvis uterus is located in the true pelvis

between the urinary bladder anteriorly between the urinary bladder anteriorly and rectosigmoid posteriorlyand rectosigmoid posteriorly

anterior surface is covered with anterior surface is covered with peritoneum to the level of the junction peritoneum to the level of the junction between the uterine corpus and cervixbetween the uterine corpus and cervix

vesicouterine pouch or anterior cul-de-vesicouterine pouch or anterior cul-de-sac – peritoneal space anterior to the sac – peritoneal space anterior to the uterusuterus

posterior cul-de-sac – peritoneal posterior cul-de-sac – peritoneal reflection extends to the posterior reflection extends to the posterior fornix of the vaginafornix of the vagina

UTERUS UTERUS lateral peritoneal reflection forms lateral peritoneal reflection forms

the broad ligamentthe broad ligament uterus has two major body parts : uterus has two major body parts :

body or fundusbody or fundus cervix – lower cylindrical portion that cervix – lower cylindrical portion that

projects into the vaginaprojects into the vagina isthmus – narrow portion of the isthmus – narrow portion of the

uterus that corresponds to the uterus that corresponds to the approximate position of the approximate position of the internal os and is the separation internal os and is the separation between the corpus and cervix.between the corpus and cervix.

Size Of The UterusSize Of The Uterus

Length Length (cm)(cm)

Width Width (cm)(cm)

AP AP Diameter Diameter

(cm)(cm)

NulliparNulliparousous 6.0 – 8.56.0 – 8.5 3- 53- 5 2- 42- 4

MultiparMultiparousous 8 – 10.58 – 10.5 4 - 54 - 5 3- 53- 5

MenopauMenopausese 3.5 – 7.03.5 – 7.0 2 - 42 - 4 1.7 – 3.3 1.7 – 3.3

UTERUS UTERUS Uterine PositionUterine Position

anteversion – cervix and vagina form a anteversion – cervix and vagina form a 90 deg angle 90 deg angle

retroversion, retroflexion, and tilting of retroversion, retroflexion, and tilting of the uterus to the right or the left the uterus to the right or the left normal variantsnormal variants

Zonal Anatomy of the Body of the Uterus Zonal Anatomy of the Body of the Uterus (MRI)(MRI) centrally centrally endometrium endometrium

demonstrates high signal intensitydemonstrates high signal intensity junctional zone junctional zone inner myometrial inner myometrial

layer shows low signal intensitylayer shows low signal intensity outer myometrium outer myometrium intermediate intermediate

signal intensitysignal intensity

Zonal Anatomy

Endometrium Endometrium (UTZ)(UTZ) thin echogenic stripe thin echogenic stripe thickness and sonographic appearance of the thickness and sonographic appearance of the

endometrium change cyclically with the endometrium change cyclically with the menstrual cyclemenstrual cycle

Ultrasound of the UterusUltrasound of the Uterus

Transabdominal and transvaginal Transabdominal and transvaginal ultrasoundultrasound

Hysterosonography – endometrial Hysterosonography – endometrial imagingimaging may confidently diagnose may confidently diagnose

submucosal fibroids and may submucosal fibroids and may distinguish between a hyperplastic distinguish between a hyperplastic endometrium and a polyp.endometrium and a polyp.

UterusUterus

HysterosonographyHysterosonography

A. Hysterosalpingogaphy catheter is inserted into the lower uterine segment with a distended occluding balloon.

B. Coronal hysterosongoram obtained after instillation of saline shows air within the occluding balloon of the catheter, with a resultant artifact along the left uterine wall

Sagittal transvaginal US (A) demonstrates the inflated balloon of the sonohysterographic catheter (*) within the endometrial canal. Following the instillation of 40 cc of sterile saline (B), fluid distends the endometrial canal.

SonohysterographySonohysterography

HysterosalpingogramHysterosalpingogram

Congenital Congenital MalformationsMalformations

diagnosed during work-up for infertility, diagnosed during work-up for infertility, frequent miscarriages, or menstrual frequent miscarriages, or menstrual disordersdisorders

Three different causes:Three different causes:

1.1. arrested development of mullerian arrested development of mullerian ductsducts

2.2. failure of fusion of the mullerian ductsfailure of fusion of the mullerian ducts

3.3. failure of resorption of the median failure of resorption of the median septumseptum

CONGENITAL CONGENITAL MALFORMATIONSMALFORMATIONS

Unicornuate UterusUnicornuate Uterus agenesis of a agenesis of a

unilateral unilateral mullerian ductmullerian duct

poorest fetal poorest fetal survivalsurvival

most difficult to most difficult to diagnose diagnose (confused as (confused as small uterus )small uterus )

CONGENITAL MALFORMATIONSCONGENITAL MALFORMATIONS

Didelphic UterusDidelphic Uterus complete failure of fusion of the complete failure of fusion of the

mullerian ductmullerian duct has two complete uteri, has two complete uteri,

including endometria, including endometria, myometria and serosal myometria and serosal surfaces on each sidesurfaces on each side

may extend down to the cervix may extend down to the cervix and may also involve a and may also involve a septated vaginaseptated vagina


Bicornuate UterusBicornuate Uterus partial fusion of the mullerian partial fusion of the mullerian

ductsducts has some fusion of the lower has some fusion of the lower

uterine segment, but there are uterine segment, but there are two uteri in the superior two uteri in the superior segment complete with segment complete with endometrial cavities, endometrial cavities, myometria, and covering myometria, and covering serosaserosa

Bicornuate UterusBicornuate Uterus

Bicornuate uterus with pregnancy in one horn

Bicornuate Uterus


Septate UterusSeptate Uterus failure of resorption of the septum failure of resorption of the septum

after complete fusion of the mullerian after complete fusion of the mullerian ductsducts

may have thick or thin fibrous may have thick or thin fibrous septation, including a significant septation, including a significant myometrial componentmyometrial component

Arcuate UterusArcuate Uterus characterized by a small dimple or characterized by a small dimple or

concave superior surface of the fundus.concave superior surface of the fundus. variant than a deviant of normalvariant than a deviant of normal

BENIGN UTERINE CONDITIONSBENIGN UTERINE CONDITIONS ADENOMYOSISADENOMYOSIS migration of endometrial glands from migration of endometrial glands from

the stratum basale into the myometriumthe stratum basale into the myometrium ectopic glands tend to be 2 – 3 mm ectopic glands tend to be 2 – 3 mm

below the endometrial-myometrial below the endometrial-myometrial junctionjunction

Sonography and MRISonography and MRI round appearance of the uterus round appearance of the uterus

without a discrete mass or contour without a discrete mass or contour deformitydeformity

BENIGN UTERINE CONDITIONSBENIGN UTERINE CONDITIONS ADENOMYOSISADENOMYOSIS TVS : abnormal heterogenous TVS : abnormal heterogenous

myometrium with areas of myometrium with areas of increased or decreased increased or decreased echogenicityechogenicity

Color Doppler Imaging : Color Doppler Imaging : hypervascularity throughout the hypervascularity throughout the lesion (vs. fibroids – peripheral lesion (vs. fibroids – peripheral flow)flow)

AdenomyosisAdenomyosisSagittal (A) and axial (B) T2-weighted MR images through the pelvis demonstrate focal junctional zone widening and multiple punctate high signal intensity foci with the areas of thickening (*, A, B) characteristic of focal adenomyosis. Sagittal (C) and axial (D) T2-weighted MR images in a different patient demonstrate widening of the entire junctional zone (*, C, D) which contains multiple foci of high signal intensity that represent endometrial rests. Appearances are typical of diffuse adenomyosis.

BENIGN TUMORSBENIGN TUMORS LEIOMYOMASLEIOMYOMAS most commonmost common neoplasm of the neoplasm of the

uterus (20% to 30% of women older uterus (20% to 30% of women older than 30 yo)than 30 yo)

misnamed fibromyomas or fibroidsmisnamed fibromyomas or fibroids interleaved bundles of smooth interleaved bundles of smooth

muscle with varying amounts of muscle with varying amounts of fibrous connective tissuefibrous connective tissue

BENIGN TUMORSBENIGN TUMORS LEIOMYOMASLEIOMYOMAS

Submucosal Submucosal (5%- 10%) (5%- 10%) most symptomaticmost symptomaticmay cause menorrhagia, metrorrhagia, may cause menorrhagia, metrorrhagia, or postmenopausal bleedingor postmenopausal bleeding

Intramural (Intramural (most common)most common) and and Subserous Subserous (10% - 20%)(10% - 20%)if large may cause pressure effects on if large may cause pressure effects on the adjacent pelvic organs or ligamentsthe adjacent pelvic organs or ligaments

Leiomyoma, MRI. T2-weighted sagittal MRI. A subserosal leiomyoma (arrows) distends the posterior aspect of the uterus,

displacing the endometrium

LeiomyomaLeiomyoma

BENIGN TUMORSBENIGN TUMORS LEIOMYOMASLEIOMYOMAS

acute symptoms are seen if the acute symptoms are seen if the leiomyomas undergo torsion or leiomyomas undergo torsion or necrosisnecrosis

Broad-ligament Broad-ligament myomas can myomas can simulate adnexal massessimulate adnexal masses

estrogen dependentestrogen dependent

BENIGN TUMORSBENIGN TUMORS LEIOMYOMASLEIOMYOMAS Ultrasound appearance depends on size, site, and Ultrasound appearance depends on size, site, and

age of tumorage of tumor sole manifestation of fibroids may simply be sole manifestation of fibroids may simply be

uterine enlargement or nodularity of the contour.uterine enlargement or nodularity of the contour. may also displace or distort the endometrial echo may also displace or distort the endometrial echo

or alter the homogeneous midecho of the or alter the homogeneous midecho of the myometriummyometrium

great “mimickers” and may masquerade as great “mimickers” and may masquerade as endometrial polyp, ovarian masses or even endometrial polyp, ovarian masses or even stool-filled large bowelstool-filled large bowel

BENIGN TUMORSBENIGN TUMORS

LeiomyomasLeiomyomasFrequently, fibroids can be Frequently, fibroids can be

diagnosed sonographically by diagnosed sonographically by their decreased echogenicity and their decreased echogenicity and decreased sound through-decreased sound through-transmission (shadowing), even transmission (shadowing), even though the relationship to the though the relationship to the uterus is obscured.uterus is obscured.

LeiomyomasLeiomyomas

Transvaginal US demonstrating hypo- to isoechoic well-defined intramural heterogeneous masses (T), the typical ultrasound appearance of leiomyomas

LeiomyomaLeiomyoma

BENIGN TUMORSBENIGN TUMORS

LeiomyomasLeiomyomasDefinitive diagnosis can be Definitive diagnosis can be

made by showing the made by showing the ““claw claw sign”sign”,, analogous to renal analogous to renal masses, of stretching of masses, of stretching of myometrium around the base myometrium around the base of the lesionof the lesion

BENIGN TUMORSBENIGN TUMORS ENDOMETRIAL HYPERPLASIAENDOMETRIAL HYPERPLASIA

MOST COMMONMOST COMMON cause of vaginal cause of vaginal bleeding in both pre- and postmenopausal bleeding in both pre- and postmenopausal womenwomen

results from unopposed estrogen results from unopposed estrogen stimulationstimulation

On ultrasoundOn ultrasoundpronounced endometrial stripe pronounced endometrial stripe may be indistinguishable from an endometrial may be indistinguishable from an endometrial polyp or carcinoma, even on TVSpolyp or carcinoma, even on TVS

BENIGN TUMORSBENIGN TUMORS ENDOMETRIAL HYPERPLASIAENDOMETRIAL HYPERPLASIA

HSG can be definitive, but the HSG can be definitive, but the diagnosis is usually confirmed by diagnosis is usually confirmed by endometrial biopsyendometrial biopsy

Pipelle biopsy is often used as an Pipelle biopsy is often used as an office procedure at first referral office procedure at first referral for vaginal bleeding;for vaginal bleeding;

D & C and hysteroscopy are D & C and hysteroscopy are reserved more for therapeutic reserved more for therapeutic proceduresprocedures

BENIGN TUMORSBENIGN TUMORS POLYPSPOLYPS represent areas of overgrowth of represent areas of overgrowth of

endometrial glands and stroma endometrial glands and stroma covered by endometrial epitheliumcovered by endometrial epithelium

lesions may be pedunculated or lesions may be pedunculated or sessilesessile

fundus and multiple in 20%fundus and multiple in 20% at autopsy, seen up to 10% of womenat autopsy, seen up to 10% of women vaginal bleeding or mucous dischargevaginal bleeding or mucous discharge

BENIGN TUMORSBENIGN TUMORS POLYPSPOLYPS

appear as focal areas of increased appear as focal areas of increased endometrial thickeningendometrial thickening

confident ultrasound diagnosis confident ultrasound diagnosis may sometimes require HSGmay sometimes require HSG

TAS may be normal, whereas TVS TAS may be normal, whereas TVS images show focal irregularity of images show focal irregularity of the endometrial stripethe endometrial stripe

BENIGN TUMORSBENIGN TUMORS POLYPSPOLYPS

HSG permits more accurate TVS HSG permits more accurate TVS identification of the lesion and more identification of the lesion and more accurate distinction among accurate distinction among hyperplasia, polyp, fibroid, or hyperplasia, polyp, fibroid, or carcinomacarcinoma

MRI can be used to confirm a lesion MRI can be used to confirm a lesion suspected to be a polyp, which has suspected to be a polyp, which has a moderately high signal on T2, a moderately high signal on T2, versus fibroids, which, is especially versus fibroids, which, is especially when small, have a low signal.when small, have a low signal.

BENIGN TUMORSBENIGN TUMORS ARTERIOVENOUS ARTERIOVENOUS

MALFORMATIONMALFORMATION

multiple communications between multiple communications between the arterial and venous system the arterial and venous system without an intervening capillary without an intervening capillary network.network.

congenital or more often iatrogenic congenital or more often iatrogenic due to intrauterine instrumentation.due to intrauterine instrumentation.

BENIGN TUMORSBENIGN TUMORS ARTERIOVENOUS ARTERIOVENOUS

MALFORMATIONMALFORMATION

Color and duplex Doppler Color and duplex Doppler sonography shows serpiginous sonography shows serpiginous cystic areas and a vascular tangle cystic areas and a vascular tangle of blood vessels of blood vessels

demonstrate high velocity, low-demonstrate high velocity, low-resistance flow on duplex Doppler.resistance flow on duplex Doppler.

BENIGN TUMORSBENIGN TUMORS Arteriovenous MalformationArteriovenous Malformation

On MRI, AVMs appear as a focal On MRI, AVMs appear as a focal uterine mass or a disruption of uterine mass or a disruption of the junctional zones, with the junctional zones, with serpiginous flow-related signal serpiginous flow-related signal voids and prominent voids and prominent parametrial vessels.parametrial vessels.

MISCELLANEOUS BENIGN PROCESSMISCELLANEOUS BENIGN PROCESS PELVIC INFLAMMATORY DISEASEPELVIC INFLAMMATORY DISEASE rarely confined to the uterusrarely confined to the uterus endometrium shows histologic changes endometrium shows histologic changes

of inflammation in more than 70% of of inflammation in more than 70% of women with acute PIDwomen with acute PID

40% with mucopurulent cervicitis40% with mucopurulent cervicitis nonspecific on ultrasound, correlated nonspecific on ultrasound, correlated

with clinical picturewith clinical picture thickening and irregularity of the thickening and irregularity of the

endometrium and fluid, debris, or even endometrium and fluid, debris, or even gas within the endometrial cavitygas within the endometrial cavity

MISCELLANEOUS BENIGN PROCESSMISCELLANEOUS BENIGN PROCESS

Pyometra (pus in the uterine cavity)Pyometra (pus in the uterine cavity) may complicate cervical stenosismay complicate cervical stenosis acquired causes : infection, neoplasia, and acquired causes : infection, neoplasia, and

iatrogenic factorsiatrogenic factors clinical findings : more pronounced in clinical findings : more pronounced in

premenopausal than postmenopausal womenpremenopausal than postmenopausal women ultrasound appearance : ultrasound appearance :

dilated, fluid-filled endometrial cavitydilated, fluid-filled endometrial cavity echogenicity of the cavity varies with the echogenicity of the cavity varies with the

degree of debris or clotdegree of debris or clot distinction from endometrial polyp or even distinction from endometrial polyp or even

carcinoma is occasionally impossible when carcinoma is occasionally impossible when the fluid becomes uniformly echogenic.the fluid becomes uniformly echogenic.

PyometraPyometra

MISCELLANEOUS BENIGN PROCESSMISCELLANEOUS BENIGN PROCESS

HydrometocolposHydrometocolpos when the hymen is imperforate, allowing when the hymen is imperforate, allowing

the accumulation of secretions within the the accumulation of secretions within the uterus and vaginauterus and vagina

Asherman SyndromeAsherman Syndrome intrauterine fibrous adhesions cross the intrauterine fibrous adhesions cross the

endometrial cavity.endometrial cavity. the synechiae form a mesh or spider’s the synechiae form a mesh or spider’s

web within the uterine lumenweb within the uterine lumen may cause infertility or hypo- or may cause infertility or hypo- or

amenorrheaamenorrhea the fibrous strands can calcify, with a the fibrous strands can calcify, with a

characteristic sonographic appearance.characteristic sonographic appearance.

MISCELLANEOUS BENIGN PROCESSMISCELLANEOUS BENIGN PROCESS Nabothian CystsNabothian Cysts

obstructed and hence dilated obstructed and hence dilated inclusion cysts, of no clinical inclusion cysts, of no clinical relevance, located within the cervix relevance, located within the cervix

routinely seen on TAS and especially routinely seen on TAS and especially TVSTVS

Monckeberg’s Medial SclerosisMonckeberg’s Medial Sclerosismanifesting as peripheral punctate manifesting as peripheral punctate

echoes, is due to calcification in the echoes, is due to calcification in the smaller uterine artery branchessmaller uterine artery branches

MALIGNANT DISEASE OF THE MALIGNANT DISEASE OF THE UTERUSUTERUS

CervixCervix Ultrasound : not especially useful in Ultrasound : not especially useful in

the diagnosis of cervical disease, the diagnosis of cervical disease, including neoplastic conditionsincluding neoplastic conditions

Papanicolaou-stained cervical smears - Papanicolaou-stained cervical smears - incidence of cervical dysplasia and incidence of cervical dysplasia and carcinoma in situ has risen sharplycarcinoma in situ has risen sharply

whereas, that of invasive carcinoma whereas, that of invasive carcinoma has plummeted reciprocally.has plummeted reciprocally.

women at risk : multiple sexual women at risk : multiple sexual partners and precocious onset of partners and precocious onset of coituscoitus

MALIGNANT DISEASE OF THE UTERUSMALIGNANT DISEASE OF THE UTERUS CervixCervix 90% of invasive cervical carcinomas – originate 90% of invasive cervical carcinomas – originate

from from squamous cells in the ectocervix.squamous cells in the ectocervix. 10% - arise as adenocarcinoma, usually from 10% - arise as adenocarcinoma, usually from

the more deeply situated columnar epitheliumthe more deeply situated columnar epithelium Imaging : chief role is staging of cervical Imaging : chief role is staging of cervical

carcinomascarcinomas MRI – MRI – most impactmost impact on preoperative stagingon preoperative staging

squamous cell carcinoma usually spread by local squamous cell carcinoma usually spread by local and lymphatic invasionand lymphatic invasion

Gadoliniuim contrast enhancement at MRI is Gadoliniuim contrast enhancement at MRI is important in assessing patients with suspected important in assessing patients with suspected recurrence after radiotherapy or surgery for the recurrence after radiotherapy or surgery for the initial disease.initial disease.

MALIGNANT DISEASE OF THE MALIGNANT DISEASE OF THE UTERUSUTERUS

CervixCervixSonography :Sonography :

to document the to document the complications of advanced complications of advanced cervical disease and its cervical disease and its treatmenttreatment

example : cervical stenosis, example : cervical stenosis, intrauterine fluid collection, intrauterine fluid collection, or hydronephrosisor hydronephrosis

MALIGNANT DISEASE OF THE UTERUSMALIGNANT DISEASE OF THE UTERUS ENDOMETRIAL CARCINOMAENDOMETRIAL CARCINOMA

MOST COMMONMOST COMMON form of gynecologic form of gynecologic malignancymalignancy

Incidence : 33,000 new case per year in Incidence : 33,000 new case per year in the USthe US

mostly confined to postmenopausal womenmostly confined to postmenopausal women present early with postmenopausal present early with postmenopausal

bleedingbleeding Ultrasound : either diffusely or partially Ultrasound : either diffusely or partially

echogenicechogenicalthough 10% - 15% maybe isoechoicalthough 10% - 15% maybe isoechoicwhen these features are seen, warrants when these features are seen, warrants HSG and biopsyHSG and biopsy

Staging of Endometrial Staging of Endometrial CarcinomaCarcinoma

Prognostic Factors:Prognostic Factors:histologic grading of the tumorhistologic grading of the tumorextent of myometrial invasionextent of myometrial invasiondocumentation of lymph node documentation of lymph node

metastasesmetastases

Endometrial Carcinoma (TVS)Endometrial Carcinoma (TVS)

The endometrium is thickened and irregular in this postmenopausal patient. Near the fundus, the endometrial–

myometrial junction is indistinct, indicating myometrial invasion (arrow).

Endometrial Carcinoma (MRI)Endometrial Carcinoma (MRI)

Sagittal gadolinium-enhanced T1-weighted fat-suppressed MR image shows an endometrial cancer (T) with deep myometrial invasion.

Note the thin rim of normal myometrium (black arrows). The disease extends to the upper third of the vagina (white arrow).

Staging of Endometrial CarcinomaStaging of Endometrial Carcinoma Stage IA - depth of myometrial invasion Stage IA - depth of myometrial invasion

is noneis none Stage IB – depth is superficialStage IB – depth is superficial

less than half of the myometriumless than half of the myometrium Stage IC – deepStage IC – deep

more than half of the myometriummore than half of the myometrium Stage II - invasion of the cervix Stage II - invasion of the cervix

worse prognosisworse prognosis TVS is not as accurate as MRI in TVS is not as accurate as MRI in

monitoring cervical involvementmonitoring cervical involvement

Endometrial CarcinomaEndometrial Carcinoma Incidence of regional and distant Incidence of regional and distant

lymph node involvement is linked to lymph node involvement is linked to the degree of myometrial invasion.the degree of myometrial invasion.

Role of imaging is negligible once a Role of imaging is negligible once a suspicious lesion has been identifiedsuspicious lesion has been identified

After biopsy diagnosis After biopsy diagnosis hysterectomy hysterectomy Ultrasonography: more accurate than Ultrasonography: more accurate than

serum CA125 levels in predicting serum CA125 levels in predicting myometrial invasion of endometrial myometrial invasion of endometrial carcinoma.carcinoma.distant spread, beyond the serosa, is distant spread, beyond the serosa, is not reliably documented by not reliably documented by ultrasoundultrasound

DIFFERENTIATION OF BENIGN FROM MALIGNANT CONDITIONS OF THE DIFFERENTIATION OF BENIGN FROM MALIGNANT CONDITIONS OF THE ENDOMETRIUMENDOMETRIUM

Benign ConditionsBenign Conditions cystic atrophy, cystic and adenomatous cystic atrophy, cystic and adenomatous

hyperplasia, endometrial polypshyperplasia, endometrial polyps 76% of benign conditions show cystic 76% of benign conditions show cystic

changeschanges

Malignant uterine tumors Malignant uterine tumors thickened echogenic endometriumthickened echogenic endometrium enlarged enlarged retrovertedretroverted lack subendometial halolack subendometial halo 24% of endometrial malignancies show 24% of endometrial malignancies show

cystic changescystic changes

DIFFERENTIATION OF BENIGN FROM DIFFERENTIATION OF BENIGN FROM MALIGNANT CONDITIONS OF THE MALIGNANT CONDITIONS OF THE ENDOMETRIUMENDOMETRIUM

No difference in Doppler parameters No difference in Doppler parameters has been found between malignant has been found between malignant and benign uterine diseasesand benign uterine diseases

calculated sensitivity of increased calculated sensitivity of increased color flow in predicting malignancy is color flow in predicting malignancy is low, approx. 40%low, approx. 40%

Neither TVS nor color Doppler Neither TVS nor color Doppler imaging can distinguish benign imaging can distinguish benign lesions from their malignant lesions from their malignant counterpartscounterparts

Differentiation is made by D & C, by Differentiation is made by D & C, by hysteroscopy, and biopsy, or by hysteroscopy, and biopsy, or by ultrasound-guided suction biopsy.ultrasound-guided suction biopsy.

CLINICAL PERSPECTIVE CLINICAL PERSPECTIVE ABNORMAL UTERINE BLEEDINGABNORMAL UTERINE BLEEDING

MOST COMMONMOST COMMON indication for gynecologic indication for gynecologic interventionintervention

Endometrial carcinoma is only seen in less than 1% of Endometrial carcinoma is only seen in less than 1% of postmenopausal patients with abnormal vaginal postmenopausal patients with abnormal vaginal bleedingbleeding

D & C is insensitive for small polyps or foci of D & C is insensitive for small polyps or foci of endometrial carcinomaendometrial carcinoma

Suction endometrial biopsies obtained with a Pipelle Suction endometrial biopsies obtained with a Pipelle de Cornier device are renowned for sampling de Cornier device are renowned for sampling inaccuracies.inaccuracies.

Hysteroscopy is the Hysteroscopy is the most accuratemost accurate method for method for excluding, or confirming, uterine disease as a cause excluding, or confirming, uterine disease as a cause for abnormal uterine bleedingfor abnormal uterine bleeding

most invasive proceduremost invasive procedure and the most costlyand the most costly TVS and HSG – preliminary screeningTVS and HSG – preliminary screening Normal endometrial appearances on HSG correlate Normal endometrial appearances on HSG correlate

strongly with negative histologystrongly with negative histology

CLINICAL PERSPECTIVE CLINICAL PERSPECTIVE

Abnormal Uterine BleedingAbnormal Uterine Bleeding TVS and HSG – preliminary screeningTVS and HSG – preliminary screening Normal endometrial appearances on Normal endometrial appearances on

HSG correlate strongly with negative HSG correlate strongly with negative histologyhistology

In several large studies in In several large studies in perimenopausal women with uterine perimenopausal women with uterine bleeding, HSG recorded 90% - 99% bleeding, HSG recorded 90% - 99% sensitivity, and 75% - 83% specificity in sensitivity, and 75% - 83% specificity in differentiating women with intrauterine differentiating women with intrauterine lesions and those with normal or lesions and those with normal or atrophic endometriumatrophic endometrium


INFERTILITYINFERTILITY Causes of acquired infertility:Causes of acquired infertility:

endometrial adhesions (Asherman endometrial adhesions (Asherman syndrome)syndrome)

endometritisendometritis PIDPID endometriosisendometriosis

Septate uterusSeptate uterus Radiographic hysterosalpingography Radiographic hysterosalpingography

– superior technique– superior technique

CLINICAL PERSPECTIVE CLINICAL PERSPECTIVE Menopause and Hormone Menopause and Hormone

Replacement TherapyReplacement Therapy endometrial regression endometrial regression halted or reversed halted or reversed

by administration of exogenous estrogenby administration of exogenous estrogen unopposed estrogen can induce endometrial unopposed estrogen can induce endometrial

carcinomacarcinoma HRT regimens include progesterone HRT regimens include progesterone

supplements to counteract the effect of supplements to counteract the effect of estrogen alone on endometrial proliferationestrogen alone on endometrial proliferation

Continuous HRT significantly influences the Continuous HRT significantly influences the thickness of the postmenopausal thickness of the postmenopausal endometrium but not of the myometriumendometrium but not of the myometrium

endometrial thickness of 8 mm - endometrial thickness of 8 mm - cutoff normal range


TamoxifenTamoxifen menopausal patients with breast cancer menopausal patients with breast cancer

receive tamoxifen therapy (partial estrogen receive tamoxifen therapy (partial estrogen receptor agonist)receptor agonist)

Effects on uterus : Effects on uterus : epithelial metaplasiaepithelial metaplasia hyperplasiahyperplasia carcinomacarcinoma

TVS TVS may show thickened, irregular cystic may show thickened, irregular cystic

endometriumendometrium cystic changes in the subendometrial zone cystic changes in the subendometrial zone

without epithelial disease have also been without epithelial disease have also been documented.documented.


PeurperiumPeurperium postpartum uterus should return to postpartum uterus should return to

near normal size within 6 to 8 weeks near normal size within 6 to 8 weeks after delivery.after delivery.

increasing maternal parity is associated increasing maternal parity is associated with slightly but significantly larger with slightly but significantly larger uterine dimensions up to 4 weeks uterine dimensions up to 4 weeks postpartum.postpartum.

Pathologies in Pathologies in the Cervixthe Cervix

Morphology of Uterine Morphology of Uterine CervixCervix

cylindrical portion of the uteruscylindrical portion of the uterus enters the vagina and lies at right angles to enters the vagina and lies at right angles to

itit 2-4 cm long2-4 cm long isthmus –point of juncture with the uterus, isthmus –point of juncture with the uterus,

marked by constriction of the lumenmarked by constriction of the lumen separated anteriorly from the bladder by a separated anteriorly from the bladder by a

layer of fatty tissuelayer of fatty tissue posteriorly, covered by peritoneumposteriorly, covered by peritoneum

Morphology of Uterine Morphology of Uterine CervixCervix

laterally, cervix is connected to the parametria laterally, cervix is connected to the parametria and broad ligamentand broad ligament

ureters descend about 2cm lateral to the cervix ureters descend about 2cm lateral to the cervix and curve under the uterine arteriesand curve under the uterine arteries

cervical canal cervical canal – extends from the internal os, – extends from the internal os, where it joins the uterine cavity, to the external where it joins the uterine cavity, to the external os, which projects into the vaginal vault.os, which projects into the vaginal vault.

internal os – internal os – where histologic transition from where histologic transition from endometrial to endocervical glands is seen.endometrial to endocervical glands is seen.

upper third of the cervical canal or isthmus – upper third of the cervical canal or isthmus – undergo menstrual changes although less undergo menstrual changes although less pronounced than the endometrial liningpronounced than the endometrial lining

CERVICAL ANATOMYCERVICAL ANATOMY DIVIDED INTO THREE ZONES DIVIDED INTO THREE ZONES

(MRI):(MRI):

1.1. endocervical mucosa – increased endocervical mucosa – increased signal intensity due to mucus glandssignal intensity due to mucus glands

2.2. cervical stroma – low signal cervical stroma – low signal intensity owing to the presence of intensity owing to the presence of fibrous connective tissuefibrous connective tissue

3.3. peripherally located smooth muscle, peripherally located smooth muscle, which demonstrates intermediate which demonstrates intermediate signal intensitysignal intensity

Benign Gynecologic Benign Gynecologic ConditionsConditions

CERVICITIS CERVICITIS chronic inflammation of the cervixchronic inflammation of the cervix

stimulates reparative upward stimulates reparative upward growth of the squamous growth of the squamous epithelium, causing obstruction of epithelium, causing obstruction of some of the ducts of the some of the ducts of the endocervical glandsendocervical glands

NABOTHIAN CYSTSNABOTHIAN CYSTS results from retention of mucus results from retention of mucus

within the glandswithin the glands

Nabothian CystsNabothian Cysts

(a) Sagittal T2-weighted MR image shows multiple small cysts in the deep stroma of the anterior cervix (arrows). (b) Sagittal T1-weighted MR image shows that the lesions have slightly high signal intensity (arrows).


CERVICAL POLYPCERVICAL POLYP pedunculated, soft, smooth , red or purple pedunculated, soft, smooth , red or purple

and vary in size from a few millimeters to 3 and vary in size from a few millimeters to 3 cm.cm.

microscopically, hyperplastic condition of microscopically, hyperplastic condition of the endocervical epithelium and contains a the endocervical epithelium and contains a large number of blood vessels at the large number of blood vessels at the surfacesurface

edematous and inflamededematous and inflamed can cause leukorrhea and intermentrual can cause leukorrhea and intermentrual

spottingspotting

Cervical PolypCervical Polyp

(a) Sagittal T2-weighted MR image shows a large multicystic mass filling the endocervical canal (arrows). (b) Sagittal T1-weighted MR image shows hypointense fluid filling the cysts (arrows). At histologic analysis, the lesion was proved to represent cystically dilated endometrial glands and was diagnosed as a cystic polyp.


CERVICAL STENOSIS CERVICAL STENOSIS usually asymptomatic, but may cause usually asymptomatic, but may cause

abnormal vaginal bleeding, abnormal vaginal bleeding, dysmenorrhea, and infertilitydysmenorrhea, and infertility

if stenosis is severe, accumulation of if stenosis is severe, accumulation of uterine secretions (hydrometra or uterine secretions (hydrometra or pyometra) or blood (hematometra) pyometra) or blood (hematometra) resultsresults

intracavitary fluid – indirect indicator intracavitary fluid – indirect indicator ofof

cervical stenosis cervical stenosis

Malignant Gynecologic Malignant Gynecologic ConditionsConditions

SQUAMOUS CELL CARCINOMASQUAMOUS CELL CARCINOMA MOST COMMONMOST COMMON TYPE OF TYPE OF

CERVICAL CANCERCERVICAL CANCER precursors are the precursors are the cervical dysplasiascervical dysplasias

classified as mild (CIN-1), moderate classified as mild (CIN-1), moderate (CIN-2), or severe (CIN-3).(CIN-2), or severe (CIN-3).

screening withscreening with Papanicolaou smearsPapanicolaou smears average transit time to carcinoma in average transit time to carcinoma in

situ for situ for

Malignant Gynecologic Malignant Gynecologic ConditionsConditions

ADENOCARCINOMA OF THE ADENOCARCINOMA OF THE CERVIXCERVIX

10% -15% of cervical cancer10% -15% of cervical cancer arises from the columnar epithelium arises from the columnar epithelium

of the endocervical canal and glandsof the endocervical canal and glands behavior, staging, and treatment of behavior, staging, and treatment of

squamous cell and adenocarcinoma squamous cell and adenocarcinoma of cervix are similar.of cervix are similar.

StagingStaging Stage IStage I

carcinoma confined to the cervixcarcinoma confined to the cervixminimally invasive diseaseminimally invasive diseasedisease with invasion of > 5 mm disease with invasion of > 5 mm depth from the base of the surface or depth from the base of the surface or gland\gland\

> 7 mm horizontal spread Stage IIA> 7 mm horizontal spread Stage IIA extension to the upper vaginaextension to the upper vagina

Stage IIBStage IIB to the cardinal ligaments but not the to the cardinal ligaments but not the

lateral wallslateral walls

Stage I B Cervcal CarcinomaStage I B Cervcal Carcinoma

Sagittal (a) and axial (b) T2-weighted MR images show a slightly hyperintense mass in the uterine cervix. The mass protrudes into the posterior vaginal fornix; however, the vaginal mucosa attached to the tumor is intact (arrows in a). The tumor is completely surrounded by hypointense cervical stroma on the axial image (arrowheads in b).

Stage IIB Cervical CarcinomaStage IIB Cervical Carcinoma

Sagittal (a) and axial (b) T2-weighted MR images show that the cervix is almost entirely replaced by a slightly hyperintense mass. The tumor protrudes into the parametrium bilaterally (arrowheads in b); however, it does not reach the pelvic wall. Hydrometra, which is caused by the obstructed internal cervical os, is also noted (arrow in a).

CERVICAL CARCINOMACERVICAL CARCINOMACervical carcinoma with endophytic growth in a 59-year-old woman.

The preoperative imaging diagnosis was stage IIb carcinoma.

Sagittal T2-weighted MR image shows a slightly hyperintense mass that replaces the cervix (white arrows).

The lesion is located almost within the cervical canal. The patient also has a mature cystic teratoma of the right ovary, which is seen as a cystic mass (black arrow) behind the uterus.

StagingStaging Stage IIIAStage IIIA

extension to the lower third of the extension to the lower third of the vagina, without extending to the vagina, without extending to the pelvic wallpelvic wall

Stage IIIBStage IIIB to the pelvic side wall, including to the pelvic side wall, including

cases of hydronephrosiscases of hydronephrosis Stage IVStage IV

carcinoma extending beyond the true carcinoma extending beyond the true pelvis and involving the mucosa of pelvis and involving the mucosa of the bladder and rectumthe bladder and rectum

Stage IIIA Cervical CarcinomaStage IIIA Cervical Carcinoma

a) Sagittal T2-weighted MR image shows a slightly hyperintense, exophytic, solid mass that extends along the anterior vaginal wall and reaches the lower one-third of the vagina (arrow). (b) Axial T2-weighted MR image shows that the low signal intensity of the anterior vaginal wall is partly disrupted (arrowheads) and the fatty tissue between the mass and the posterior bladder wall has disappeared. However, the mass does not infiltrate the vesical mucosa.

Stage IIIB Cervical CarcinomaStage IIIB Cervical Carcinoma

(a) Sagittal T2-weighted MR image shows a slightly hyperintense, large, solid mass that extends from the uterine cervix to the lower part of the uterine body. It also extends to the lower one-third of the anterior vaginal wall (arrow). (b) Axial T2-weighted MR image shows that the tumor also reaches the left posterior wall of the bladder, although the thinned vesical muscular layer remains (arrowheads). (c) MR urogram clearly shows left hydronephrosis caused by tumor invasion.

Stage IV Cervical CarcinomaStage IV Cervical Carcinoma

Stage IVA. Sagittal T2-weighted MR image shows a hypointense mass that occupies the uterine cervix and invades the vaginal wall anteriorly. At the level of the vaginal extension, the tumor reaches the mucosa of the posterior vesical wall (arrows).

Stage IV Cervical CarcinomaStage IV Cervical Carcinoma

Stage IVb cervical carcinoma. (a) Sagittal T2-weighted MR image shows a large mass in the uterine cervix. (b, c) CT scans show metastases of paraaortic lymph nodes (arrows in b) and hematogenous hepatic metastases

CERVICAL CARCINOMACERVICAL CARCINOMA

Cervical carcinoma with exophytic growth in a 44-year-old woman. The pathologic stage was Ib-1. Sagittal T2-weighted MR image shows a slightly hyperintense, cauliflower-like tumor in the posterior lip of the portio (arrows). The tumor markedly expands the posterior vaginal fornix.

StagingStaging Lymphatic spread occurs by Lymphatic spread occurs by

direct extension or tumor embolidirect extension or tumor emboli Lymphatic node metastases Lymphatic node metastases

occurs in:occurs in: 15% of Stage I15% of Stage I 30% of Stage II30% of Stage II 50%of Stage III50%of Stage III >60% of Stage IV>60% of Stage IV

ImagingImaging

Transvaginal UltrasoundTransvaginal Ultrasound Transrectal SonographyTransrectal Sonography

tumor is seen as a hypo- or isoechoic tumor is seen as a hypo- or isoechoic area poorly distinct from normal area poorly distinct from normal cervical stromacervical stroma

when endocervical canal is involved, its when endocervical canal is involved, its linear echoes are disrupted or appear as linear echoes are disrupted or appear as hyperreflecting areas (gaseous necrosis)hyperreflecting areas (gaseous necrosis)

ImagingImaging

sonography can evaluate gross invasion sonography can evaluate gross invasion of the parametrium, pelvic side walls, of the parametrium, pelvic side walls, and bladder.and bladder.parametrial invasionparametrial invasion – irregular – irregular lateral tumor margins or vascular lateral tumor margins or vascular encasementencasement

invasion of lateral side wallsinvasion of lateral side walls – – parametrial thickening or a soft tissue parametrial thickening or a soft tissue mass extending to the side walls.mass extending to the side walls.

bladder invasionbladder invasion – – include direct include direct tumor invasion or immobilitytumor invasion or immobility

ImagingImaging

Sonography is limited in its Sonography is limited in its ability to evaluate lymph nodes ability to evaluate lymph nodes and to differentiate benign and to differentiate benign pelvic disease such as pelvic disease such as endometriosis from tumor endometriosis from tumor invasion.invasion.

Thus, sonography is Thus, sonography is not not recommendedrecommended as the sole as the sole imaging technique for imaging technique for evaluation of invasive disease.evaluation of invasive disease.

ImagingImaging CT scanning CT scanning cannot reliablycannot reliably evaluate evaluate

tumor size and parametrial invasiontumor size and parametrial invasion

CT scan is CT scan is usefuluseful in : in :detecting invasion of the pelvic detecting invasion of the pelvic side wallside wall

evaluation of obstruction of the evaluation of obstruction of the urinary tracturinary tract

detection of nodal diseasedetection of nodal disease

ImagingImaging

Soft Tissue Contrast Resolution of Soft Tissue Contrast Resolution of MRIMRIallows accurate determination of tumor allows accurate determination of tumor sizesize

positive predictive value for detecting positive predictive value for detecting parametrial disease is 67%parametrial disease is 67%

high negative predictive value of 95%, high negative predictive value of 95%, making it useful for selecting making it useful for selecting candidates for surgerycandidates for surgery

detect lymph node metastases detect lymph node metastases (similar to CT) (similar to CT)

ImagingImaging

Soft Tissue Contrast Resolution of MRISoft Tissue Contrast Resolution of MRIFor extended clinical staging, MRI For extended clinical staging, MRI surpasses other modalities and is surpasses other modalities and is indicated for :indicated for :

clinical stage I disease,clinical stage I disease,when the tumor is greater than 2 cm,when the tumor is greater than 2 cm,when tumor size is difficult to when tumor size is difficult to determine clinically,determine clinically,

and when the lesion is endocervicaland when the lesion is endocervical

DIAGNOSIS AND DIAGNOSIS AND FOLLOW-UP OF FOLLOW-UP OF GESTATIONAL GESTATIONAL

TROPHOBLASTITROPHOBLASTIC DISORDERSC DISORDERS

IntroductionIntroduction GESTATIONAL TROPHOBLASTIC DISORDER (GTD)GESTATIONAL TROPHOBLASTIC DISORDER (GTD)

term commonly applied to a spectrum of interrelated term commonly applied to a spectrum of interrelated diseases, originating from the placental trophoblast diseases, originating from the placental trophoblast that includes:that includes: completecomplete partialpartial invasive molesinvasive moles placental site trophoblastic tumorsplacental site trophoblastic tumors choriocarcinomachoriocarcinoma

Incidence of Molar Pregnancies : 1:41 miscarriagesIncidence of Molar Pregnancies : 1:41 miscarriages

COMPLETE HYDATIDIFORM COMPLETE HYDATIDIFORM MOLEMOLE

generalized swellling of the villous generalized swellling of the villous tissuetissue

diffuse trophoblastic hyperplasiadiffuse trophoblastic hyperplasia no embryonic or fetal tissueno embryonic or fetal tissue diploid, with chromosomes totally diploid, with chromosomes totally

derived from the paternal genome derived from the paternal genome probably resulting from the fertilization probably resulting from the fertilization of an “empty oocyte”, devoid of of an “empty oocyte”, devoid of maternal 23,X by a single spermatozoonmaternal 23,X by a single spermatozoon

PARTIAL HYDATIDIFORM PARTIAL HYDATIDIFORM MOLE (PHM)MOLE (PHM)

refers to the combination of a fetus with refers to the combination of a fetus with localized placental molar degenerationslocalized placental molar degenerations

Histologically:Histologically: focal swelling of the villous tissuefocal swelling of the villous tissue focal trophoblastic hyperplasiafocal trophoblastic hyperplasia embryonic or fetal tissueembryonic or fetal tissue abnormal villi are scattered within abnormal villi are scattered within

macroscopically normal placental macroscopically normal placental tissue, which tends to retain its shape.tissue, which tends to retain its shape.

PARTIAL HYDATIDIFORM PARTIAL HYDATIDIFORM MOLE (PHM)MOLE (PHM)

90% triploid, having inherited two 90% triploid, having inherited two sets of chromosomes from the sets of chromosomes from the father and one from the motherfather and one from the mother

Ultrasound :Ultrasound : enlarged placenta (thickness > 4 enlarged placenta (thickness > 4

cm at 18 to 22 weeks)cm at 18 to 22 weeks) containing multicystic, avascular, containing multicystic, avascular,

sonolucent spaces sonolucent spaces

Gold standard for the definitive Gold standard for the definitive diagnosis, and subtyping of diagnosis, and subtyping of Hydatidiform Moles is Hydatidiform Moles is histopathologic examinationhistopathologic examination

Diagnostic pathologic features Diagnostic pathologic features of molar pregnancies are of molar pregnancies are essentially characterized by essentially characterized by abnormal proliferation of villus abnormal proliferation of villus trophoblasttrophoblast

INVASIVE HYDATIDIFORM INVASIVE HYDATIDIFORM MOLEMOLE

defined as the penetration of molar villi from defined as the penetration of molar villi from a CHM or PHM into the myometrium or the a CHM or PHM into the myometrium or the uterine vasculatureuterine vasculature

contains villous structures with a variable contains villous structures with a variable degree of trophoblastic proliferationdegree of trophoblastic proliferation

produces lower levels of hCG.produces lower levels of hCG. SSx: heavy vaginal bleedingSSx: heavy vaginal bleeding Ultrasonography : focal areas of increased Ultrasonography : focal areas of increased

echogenicity within the myometrium.echogenicity within the myometrium. nodules appear several weeks after evacuationnodules appear several weeks after evacuation similar to lesions of placental site trophoblastic similar to lesions of placental site trophoblastic

tumorstumors

PLACENTAL SITE TROPHOBLASTIC PLACENTAL SITE TROPHOBLASTIC TUMORTUMOR

RAREST FORMRAREST FORM of GTDof GTD composed of intermediate trophoblastic cells composed of intermediate trophoblastic cells

from the extravillous trophoblast of the from the extravillous trophoblast of the placental bed invade the myometrium by placental bed invade the myometrium by separating muscle bundle and fibersseparating muscle bundle and fibers

15% - 20% behave in a malignant fashion, with 15% - 20% behave in a malignant fashion, with metastasis to the lungs, liver, abdominal cavity, metastasis to the lungs, liver, abdominal cavity, and brain.and brain.

90% of cases develops after a normal pregnancy90% of cases develops after a normal pregnancy SSx:amenorrhea of up to 1 year and SSx:amenorrhea of up to 1 year and irregular irregular

vagina bleeding of varying durationvagina bleeding of varying duration

CHORIOCARCINOMACHORIOCARCINOMA highly malignant tumorhighly malignant tumor arises from the trophoblastic epitheliumarises from the trophoblastic epithelium metastasize readily to the lungs, liver, and brainmetastasize readily to the lungs, liver, and brain SSx: dyspnea, neurologic symptoms, abdominal SSx: dyspnea, neurologic symptoms, abdominal

pain a few weeks or months and sometimes pain a few weeks or months and sometimes up to 10-15 years after their last pregnancyup to 10-15 years after their last pregnancy

Necrosis and hemorrhage are often present Necrosis and hemorrhage are often present inside chorocarcinomas, and corresponding inside chorocarcinomas, and corresponding metastasis produces a sonographic picture of a metastasis produces a sonographic picture of a semisolid echogenic mass.semisolid echogenic mass.

Better evaluated by computed tomography or Better evaluated by computed tomography or MRIMRI

CHORIOCARCINOMACHORIOCARCINOMA serum hCG level must be measured aserum hCG level must be measured a appropriate histologic examination performed appropriate histologic examination performed

in any woman of reproductive age presenting in any woman of reproductive age presenting with widespread lesions, metastasis of unknown with widespread lesions, metastasis of unknown origin, cerebral, or intra-abdominal bleedingorigin, cerebral, or intra-abdominal bleeding

50% follow molar pregnancy50% follow molar pregnancy 30% occur after miscarriage30% occur after miscarriage 20% occur after an apparently normal 20% occur after an apparently normal

pregnancypregnancy

PERSISTENT TROPHOBLASTIC PERSISTENT TROPHOBLASTIC TUMORTUMOR

after uterine evacuation, persistent after uterine evacuation, persistent trophoblastic tumor will develop in: trophoblastic tumor will develop in: 18% - 29% of patients with CHM18% - 29% of patients with CHM1 % - 11% of patients with PHM1 % - 11% of patients with PHM

serial hCG levels – serial hCG levels – gold standard gold standard TVS is more accurate than TASTVS is more accurate than TAS

TAS is only capable of detecting TAS is only capable of detecting massive uterine involvementmassive uterine involvement

TVS is more accurate in assessing the TVS is more accurate in assessing the depth of myometrial invasiondepth of myometrial invasion

PERSISTENT TROPHOBLASTIC PERSISTENT TROPHOBLASTIC TUMORTUMOR

color Doppler imaging (CDI) – with its added color Doppler imaging (CDI) – with its added capability of displaying blood flow data capability of displaying blood flow data throughout area of interest, has improved the throughout area of interest, has improved the accuracy of TVSaccuracy of TVS

Ultrasonography :Ultrasonography : nodules of residual GTD are surrounded by newly nodules of residual GTD are surrounded by newly

formed vessels with frequent AV anastomosesformed vessels with frequent AV anastomoses hypoechoic areas (blood lacunae) surrounded by hypoechoic areas (blood lacunae) surrounded by

irregular echogenic areas (trophoblastic nodules) irregular echogenic areas (trophoblastic nodules) and numerous intramyometrial signals (vascular and numerous intramyometrial signals (vascular shunts)shunts)

Ultrasound in the Detection Ultrasound in the Detection of Hydatidiform Moleof Hydatidiform Mole

uterine cavity filled with central uterine cavity filled with central heterogenous mass with anechoic heterogenous mass with anechoic spaces of varying size and shapespaces of varying size and shape

snowstorm like appearancesnowstorm like appearance Doppler : high velocities and low Doppler : high velocities and low

resistance flow from trophoblastic resistance flow from trophoblastic tissuetissue

Ultrasound in the Detection Ultrasound in the Detection of Hydatidiform Moleof Hydatidiform Mole

In Invasive Mole: in addition to the In Invasive Mole: in addition to the central uterine lesion, myometrial central uterine lesion, myometrial invasion is presentinvasion is present

Choriocarcinoma appearing as a Choriocarcinoma appearing as a mass enlarging the uterus, with a mass enlarging the uterus, with a heterogeneity corresponding to heterogeneity corresponding to areas of necrosis and hemorrhageareas of necrosis and hemorrhage

Gestational Trophoblastic Gestational Trophoblastic DiseaseDisease

Transverse transvaginal US (A) shows an echogenic mass with multiple cystic spaces within the endometrial cavity in a woman with a hydatidiform mole. The small cystic spaces (*, A) are felt to represent hydropic villi. Sagittal transvaginal US with colour flow (arrows, B) documents flow to the mole. Hydatidiform mole is a subtype of gestational trophoblastic disease.

ULTRASOUND ULTRASOUND EVALUATION OF THE EVALUATION OF THE

ADNEXA ADNEXA ( OVARY AND ( OVARY AND

FALLOPIAN TUBES)FALLOPIAN TUBES)

Callen 5th edition

MATURE CYSTIC MATURE CYSTIC TERATOMASTERATOMAS

DERMOID CYSTSDERMOID CYSTS Ovarian teratomas are the Ovarian teratomas are the most most

common common germ cell tumor and germ cell tumor and are derived from several are derived from several histologic types, all of which histologic types, all of which contain mature or immature contain mature or immature tissues of germ cell origintissues of germ cell origin


or or ovarian cystic teratomaovarian cystic teratoma most common most common of the ovarian of the ovarian

teratomasteratomas contain mature tissues of ectodermal contain mature tissues of ectodermal

(skin , brain), mesodermal (muscle, (skin , brain), mesodermal (muscle, fat), endodermal (mucinous or ciliated fat), endodermal (mucinous or ciliated eptihelium)eptihelium)

younger age group (mean 30 years old)younger age group (mean 30 years old) most common most common inin childrenchildren


CCharacteristic Ultrasound haracteristic Ultrasound Features:Features:

1.1. white ball (hair and sebum)white ball (hair and sebum)2.2. long, echogenic (white) lines long, echogenic (white) lines

and prominent dots in cyst and prominent dots in cyst fluid (hair floating freely in fluid (hair floating freely in nonfatty fluid)nonfatty fluid)

3.3. shadowingshadowing

ENDOMETRIOMASENDOMETRIOMAS Endometriosis – presence of Endometriosis – presence of

endometrial tissue outside of the endometrial tissue outside of the endometrium and myometriumendometrium and myometrium

locations : ovaries, uterine locations : ovaries, uterine ligaments, rectovaginal septum, ligaments, rectovaginal septum, cul-de-sac, pelvic peritoneumcul-de-sac, pelvic peritoneum

Symptoms: Symptoms: aquired aquired dysmenorrhea, lower abdominal, dysmenorrhea, lower abdominal, pelvic and back pain, pelvic and back pain, dyspareunia, irregular bleeding dyspareunia, irregular bleeding and infertilityand infertility

ENDOMETRIOMASENDOMETRIOMAS Ultrasound findings:Ultrasound findings: anechoic cyst to a cyst anechoic cyst to a cyst

containing diffuse low level containing diffuse low level echoes with or without solid echoes with or without solid components to a solid- components to a solid- appearing massappearing mass

unilateral or bilateral unilateral or bilateral confused teratomas, abscesses, confused teratomas, abscesses,

ovarian adenofibromasovarian adenofibromas

BENIGN CYSTIC LESIONS OF BENIGN CYSTIC LESIONS OF OVARIAN AND PAROVARIAN OVARIAN AND PAROVARIAN

STRUCTURESSTRUCTURES FUNCTIONAL CYSTSFUNCTIONAL CYSTS

most common during most common during reproductive yearsreproductive years

result from abnormalities in the result from abnormalities in the release of anterior pituitary release of anterior pituitary gonadotropinsgonadotropins

maybe multiple, recurrent, and maybe multiple, recurrent, and accompanied by corpora luteaaccompanied by corpora lutea

HEMORRHAGIC CORPUS LUTEUM HEMORRHAGIC CORPUS LUTEUM CYSTSCYSTS

Ultrasound Findings:Ultrasound Findings: typically contains spiderweb-typically contains spiderweb-

like materiallike material bizarre blood clots may also bizarre blood clots may also

be seenbe seen

PELVIC INFLAMMATORY DISEASEPELVIC INFLAMMATORY DISEASE

result of ascending spread of result of ascending spread of microorganisms from the vagina and microorganisms from the vagina and cervix through the endometrial cervix through the endometrial cavity, through the endometrium cavity, through the endometrium into the fallopian tubes.into the fallopian tubes.

Clinical Presentation: fever, pelvic Clinical Presentation: fever, pelvic pain and purulent vaginal dischargepain and purulent vaginal discharge

commonest commonest causative agents are:causative agents are: Chlamydia trachomatisChlamydia trachomatis Neisseria gonorrhoeaeNeisseria gonorrhoeae

PELVIC INFLAMMATORY DISEASEPELVIC INFLAMMATORY DISEASE Imaging Modality of ChoiceImaging Modality of Choice : :

UltrasoundUltrasound Characteristic Ultrasound Features:Characteristic Ultrasound Features:1.1. fluid-filled sausage-shaped cystic fluid-filled sausage-shaped cystic

structurestructure2.2. presence of incomplete septa, that is, presence of incomplete septa, that is,

septa that are not seen to reach the septa that are not seen to reach the opposite wall of the cystic structureopposite wall of the cystic structure

3.3. on transverse section of a fluid-filled on transverse section of a fluid-filled tube, mucosal folds are seen to tube, mucosal folds are seen to protrude into the lumen, resulting in protrude into the lumen, resulting in cogwheel appearance (cogwheel appearance ( swollen), swollen), beads-on-a-stringbeads-on-a-string appearance (if not) appearance (if not)

PARAOVARIAN CYSTSPARAOVARIAN CYSTS

may arise from embryonic ducts may arise from embryonic ducts and are usually located between and are usually located between the tube and the ovary.the tube and the ovary.

mesothelial, mesonephric, mesothelial, mesonephric, paramesonephric originparamesonephric origin

On ultrasoundOn ultrasound : : cyst clearly cyst clearly separate from the a normal ovaryseparate from the a normal ovary

papillary projections and septa papillary projections and septa may developmay develop

malignancy may developmalignancy may develop

PERITONEAL PSEUDOCYSTSPERITONEAL PSEUDOCYSTS

fluid collections among adhesions fluid collections among adhesions occuring after an inflammatory occuring after an inflammatory process in the peritoneal cavity or process in the peritoneal cavity or after an operationafter an operation

typical ultrasound morphologytypical ultrasound morphology : : cystic mass following the contours cystic mass following the contours of the pelvis, with a deformed ovary of the pelvis, with a deformed ovary suspended amongst adhesions suspended amongst adhesions centrally or peripherally echoiccentrally or peripherally echoic

the cyst contain both septa and the cyst contain both septa and papillary projectionspapillary projections


STRUCTURESSTRUCTURES OVARIAN HYPERSTIMULATION OVARIAN HYPERSTIMULATION

SYNDROMESYNDROME women undergoing ovulation women undergoing ovulation

inductioninduction presentation similar to HL,except in presentation similar to HL,except in

timingtiming ovarian expansion with concomittant ovarian expansion with concomittant

fluid shifts typically more rapid in fluid shifts typically more rapid in OHS than HLOHS than HL


STRUCTURESSTRUCTURES POLYCYSTIC OVARIAN SYNDROME POLYCYSTIC OVARIAN SYNDROME

(PCOS)(PCOS) complex endocrinologic disorder complex endocrinologic disorder

associated with chronic anovulationassociated with chronic anovulation hyperandrogenism - hyperandrogenism - most consistent most consistent featurefeature

manifestations of unopposed estrogenic manifestations of unopposed estrogenic stimulation, including menometorrhagia, stimulation, including menometorrhagia, endometrial hyperplasia, and endometrial endometrial hyperplasia, and endometrial carcinomacarcinoma

higher risk of OHShigher risk of OHS

POLYCYSTIC OVARIAN SYNDROME POLYCYSTIC OVARIAN SYNDROME (PCOS)(PCOS) more common in women with recurrent more common in women with recurrent

early pregnancy lossearly pregnancy loss TWO DIAGNOSTIC APPROACHES:TWO DIAGNOSTIC APPROACHES:

ultrasound appearance of a PCOultrasound appearance of a PCOunexplained symptoms of menstrual unexplained symptoms of menstrual disturbance, hyperandrogenism, or disturbance, hyperandrogenism, or anovulation.anovulation.

detection of hyperandrogenic chronic detection of hyperandrogenic chronic anovulation regardless of ovarian anovulation regardless of ovarian ultrasound appearanceultrasound appearance

POLYCYSTIC OVARIAN SYNDROME (PCOS)POLYCYSTIC OVARIAN SYNDROME (PCOS) ULTRASONOGRAPHIC APPEARANCEULTRASONOGRAPHIC APPEARANCE (Transabdominal Technique by Adams et al)(Transabdominal Technique by Adams et al)

presence of 10 or more cysts measuring presence of 10 or more cysts measuring 2 to 18 mm in diameter in a single 2 to 18 mm in diameter in a single plane arranged peripherally around an plane arranged peripherally around an increased amount of central stromaincreased amount of central stroma

or less commonly, multiple small cysts 2 or less commonly, multiple small cysts 2 to 4 mm diameter distributed to 4 mm diameter distributed throughout the abundant stromathroughout the abundant stroma

Polycystic Ovarian Polycystic Ovarian DiseaseDisease

Sagittal (A) and transverse (B) transvaginal ultrasound of the left ovary depicting multiple subcentimetre peripherally placed follicles in enlarged ovaries with echogenic central stroma.

OVARIAN VASCULAR LESIONSOVARIAN VASCULAR LESIONS

OVARIAN TORSIONOVARIAN TORSION 5th most common gynecologic 5th most common gynecologic

emergency (2.7% of all gynecologic emergency (2.7% of all gynecologic emergencies)emergencies)

11stst three decades of life three decades of life 50% to 81% of patients, unilateral 50% to 81% of patients, unilateral

ovarian tumors as cause of torsionovarian tumors as cause of torsion ovarian and para-ovarian cysts most ovarian and para-ovarian cysts most

common causecommon cause

OVARIAN TORSIONOVARIAN TORSION Ultrasound Findings: Ultrasound Findings: twisted adnexal masses are often midline, positioned twisted adnexal masses are often midline, positioned

cranial to the uterine funduscranial to the uterine fundus early diagnosis : enlarged ovary with absent early diagnosis : enlarged ovary with absent

markedly decreased ovarian blood flowmarkedly decreased ovarian blood flow twisted vascular pedicle ( broad ligament, fallopian twisted vascular pedicle ( broad ligament, fallopian

tube, adnexal and ovarian branches of the uterine tube, adnexal and ovarian branches of the uterine arteries and veins)arteries and veins) ““Whirpool sign” Whirpool sign” – – Color Doppler demonstrates flow Color Doppler demonstrates flow

within the pedicle circular or coiled twisted vesselswithin the pedicle circular or coiled twisted vessels

Ovarian CarcinomaOvarian Carcinoma

Sagittal transvaginal US image demonstrates a large complex cystic mass arising from the left adnexa. The presence of flow within the solid nodule suggests malignant aetiology.

Practice PointsPractice Points

Benign Tumors : absence of solid Benign Tumors : absence of solid components and no irregularitycomponents and no irregularity

Malignant Tumors : presence of solid Malignant Tumors : presence of solid components and irregularitycomponents and irregularity

Mature Cystic Teratoma : white ball, Mature Cystic Teratoma : white ball, long echogenic lines, prominent long echogenic lines, prominent echogenic dots in cyst fluid, shadowingechogenic dots in cyst fluid, shadowing

Endometrioma : ground glass Endometrioma : ground glass appearance of cyst contents, wall appearance of cyst contents, wall nodularitiesnodularities


Hemorrhagic Corpus Luteum Cyst : Hemorrhagic Corpus Luteum Cyst : spiderweb-like contents, bizarre spiderweb-like contents, bizarre blood clotsblood clots

Hydro-pyo-hematosalpinx : fluid-filled Hydro-pyo-hematosalpinx : fluid-filled sausage-shaped cystic structure, sausage-shaped cystic structure, incomplete septa, cogwheel incomplete septa, cogwheel appearance, beads-on-a- string appearance, beads-on-a- string appearanceappearance

Paraovarian cyst: cyst clearly Paraovarian cyst: cyst clearly separate from a normal ovaryseparate from a normal ovary


Peritoneal Pseudocyst : cystic mass Peritoneal Pseudocyst : cystic mass following contours of the pelvis and with following contours of the pelvis and with an ovary, often deformed, suspended an ovary, often deformed, suspended amongst adhesions centrally or amongst adhesions centrally or peripherally in the cystperipherally in the cyst

Fibroma, Fibrothecoma : echopattern Fibroma, Fibrothecoma : echopattern indistinguishable from that of a indistinguishable from that of a pedunculated myoma, that is, a solid, pedunculated myoma, that is, a solid, round, lobular, or oval tumor with a round, lobular, or oval tumor with a smooth outline and a regular stripy smooth outline and a regular stripy echogenicity.echogenicity.


Tubo-ovarian Abscess : unilocular cystic Tubo-ovarian Abscess : unilocular cystic structure, or complex multicystic structure, or complex multicystic structure with thick walls and thick structure with thick walls and thick septae, filled with homogenous septae, filled with homogenous echogenic material (ground-glass echogenic material (ground-glass appearance)appearance)

Adnexal Torsion : the walls and any septa Adnexal Torsion : the walls and any septa of the twisted lesion may look swollen at of the twisted lesion may look swollen at ultrasound examinantion; there maybe ultrasound examinantion; there maybe fluid in the pouch of Douglas; presence fluid in the pouch of Douglas; presence of color and spectral Doppler signals in of color and spectral Doppler signals in the lesion does not exclude torsionthe lesion does not exclude torsion

Thank You !Thank You !

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