Ultrasound gyne oncology warda


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This simple presentation was designed as a part of the basic ultrasound knowledge for junior clinicians held half annually in the Department of Obstetrics and Gynecology - Mansoura University- Egypt, as a component of continuous medical education offered by the department.

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Ultrasound gyne oncology warda

  1. 1. ULTRASOUND AND GYNECOLOGICAL ONCOLOGY Osama M Warda MD Professor of Obstetrics & gynecology Mansoura University-EGYPT
  2. 2. NORMAL GYNECOLOGICAL ANATOMY- introduction Ultrasound exam of the uterus & ovaries is best performed trans-vaginally The ultrasound morphology & size of the uterus & ovaries change during the menstrual cycle. In menopausal transition the ovaries are smaller & contain fewer follicles than during reproductive years. They continue to shrink after the menopause, when the uterus also becomes smaller. Warda12 May 2014
  3. 3. NORMAL GYNECOLOGICAL ANATOMY- introduction A small amount of fluid in the pouch of Douglas is normal in women of fertile age but abnormal after the menopause. Normal tubes can only be seen if they float freely in fluid in the pouch of Douglas . On saline infusion sonography a normal uterine cavity is regular and outlined by smooth endometrium. hystero-contrast salingosonography is used to assess tubal patency. If one can observe moving contrast in the interstitial part of the tube for 10 seconds, and if no hydrosalpinx is seen, the tube is probably patent, even if free spill of contrast around the ovary is not clearly seen. - Warda12 May 2014
  4. 4. Ultrasound of Normal uterus The myometrium is homogeneous Morphology of endometrium changes during menstrual cycle At beginning of cycle the uterus is small and endometrium thin In follicular phase, uterus increases in size and endometrium becomes thicker and manifests ‘triple-layer’ appearance After ovulation the ‘triple-layer’ appearance disappears and the endometrium becomes homogeneously hyperechoic. Warda12 May 2014
  5. 5. Early follicular endometrium Trtriple –layer appearance Luteal phase Warda12 May 2014
  6. 6. Ultrasound of Normal cervix Ultrasound examination of the uterus should always start with examination of the cervix. The cervical canal should be identified & followed towards the corpus uteri so that it can be seen to join the endometrium . This examination technique ensures that it is indeed the uterus & the endometrium that have been identified. The myometrium of a normal cervix is homogeneous. In late proliferative phase of MC, clear fluid, corresponding to ovulatory cervical mucus, can be seen in cervix. The finding of many & even large retention cysts in the cervix is normal. Warda12 May 2014
  7. 7. Warda12 May 2014
  8. 8. cervix Nabothian follicle Nabothian f Warda12 May 2014
  9. 9. Ultrasound of Normal ovary Ovarian us morphology changes with the MC. In the beginning of the MC both ovaries usually contain 6- 7 follicles of <10mm diameter. The non-dominant ovary retains this appearance throughout the MC . In early FP, it is not possible to determine which ovary is going to become the dominant one. It can be identified 6- 9d before the LH surge, i.e. between D5-D12 of the MC (mean D8). The DF displays a linear growth of ±1.7mm/day. At the time of LH surge the DF = 18-22mm Warda12 May 2014
  10. 10. Ultrasound of Normal ovary(contd.,) After ovulation the follicle becomes a CL. The CL is usually smaller than the DF, its wall is thicker, and with high resolution US it is possible to see the crenellated appearance of its wall. Bleeding into CL explains presence of internal echoes in the CL at US. The CL is well vascularized & therefore it is surrounded by a ‘color ring’ or ‘fire ring’ on CD or PD ultrasound. On the 3rd of MC the CL of the previous cycle is no longer distinguishable even by CD ultrasound. Ovarian size changes during MC , vol. of non-dominant ovary 7-8ml remains unchanged, while DO increases from 7-8ml in FP to 20ml on day befor ovulation Warda12 May 2014
  11. 11. Natural cycle-dominant F Stimulated ovary Warda12 May 2014
  12. 12. Normal US of uterus & ovary in post-menopause The uterus & ovaries are smaller in postmenopausal women than in CBP. A normal uterus in a woman 5 years postmenopause = 5-6 length x2.5 AP x3 cm width. Normal ovary volume=1-4ml & with no follicles The endometrium is thin (<5mm), uniform (no cyclic changes, and hyperechoic. Calcified BV in the periphery of the myometrium are common & seen as bright echoes. Warda12 May 2014
  13. 13. Warda12 May 2014
  14. 14. Post-menopausal ovary Post menopausal uterus and ovary Warda12 May 2014
  15. 15. GYNECOLOGICAL MALIGNANCY-OVERVIEW Gynecologic cancers represent 14% of all solid tumors in women and 11% of deaths from them. Cervical, uterine and ovarian cancer represent 95% of gynecologic cancers and collectively rank the fourth in both incidence and mortality among cancers that affect women in developed countries. Worldwide, these tumors account for even larger share of cancer mortality in women Warda12 May 2014
  16. 16. Number of Cases of Cancer Cervix in Egypt, Jordan, USA EGYPT (1999-2001) JORDAN (1996-2001) USA (1999-2001) TOTAL per 100,000 96 194 5284 Age distribution (Years) 30-49 38.5% 45.3% 48.4% 50-69 52.1% 42.8% 36.2% 70+ 9.4% 11.9% 15.4% Warda12 May 2014
  17. 17. Endometrial carcinoma Worldwide it represents 3.9% of female cancers It is more common in developed countries : 18/100,000 in USA & Canada compared to 6/100,000 in Africa and is related to: - Prolonged high estrogen levels - Few number of children - Use of HRT Warda12 May 2014
  18. 18. Number of cases of Endometrial Carcinoma in Egypt, Jordan, USA Egypt (1999-2001) Jordan (1996-2001) USA (1999-2001) Total per 100,000 124 405 14129 Age distribution % <50 33.1 26 15.5 50-69 56.4 50.5 49.9 70+ 10.5 13.1 34.6 Warda12 May 2014
  19. 19. Ovarian cancer Epithelial ovarian carcinoma account for 90% of cases and is the leading cause of death in women with pelvic malignancies The incidence is higher in industrial countries of the world Women who are single and have low parity and a history of breast cancer are at risk. Warda12 May 2014
  20. 20. Age-standard incidence rate of Ovarian Carcinoma in Egypt, Jordan , USA TOTAL per 100,000 Egypt 1999-2001 Jordan 1996-2001 USA 1999-2001 All ages 5.4 4.6 10 <50 2.5 2.1 3.2 50-69 17.7 14.1 33.5 70+ 14.9 17.3 52.7 Warda12 May 2014
  21. 21. Ovarian Pathology Warda Haemorragic cyst. Small unilocular cyst, with some internal echoes, irregularly distributed. Thick, but smooth wall, absence of papillary projections. Normal ovarian tissue is visible medially. The picture is typical for haemorragic cyst/corpus luteum. 12 May 2014
  22. 22. Ovarian Pathology Warda Unilocular ovarian cyst. Thin, smooth margins, absence of papillary projections, virtually anecoic, suggestive a follicular cyst.12 May 2014
  23. 23. Ovarian Pathology Warda Slightly enlarged "solid" ovary in a woman of 63 years of age. The texture is moderately inhomogeneous. Marigin irregular but well defined. Histology confirmed the presence of a benign ovarian fibroma.12 May 2014
  24. 24. Ovarian Pathology Warda Unilocular ovarian cyst. "Ground glass" hypoecoic texture, slightly thickened but regular margins, some normal ovarian tissue is visible cranially, around the cyst. The picture is very suggestive for an ovarian endometrioma. 12 May 2014
  25. 25. Ovarian Pathology Warda Small dermoid in an otherwise normal sized ovary. Note the homogeneous, hyperechoic texture typical of a dermoid cyst. In this case shadowing was not detectable. 12 May 2014
  26. 26. Ovarian Pathology Warda Power Doppler well depict blood vessels around a normal sized corpus luteum, with the typical aspect of a "ring of fire". 12 May 2014
  27. 27. Ovarian Pathology Warda Unilocular ovarian cyst, few small papillary intracavitarian projections deform the caudal portion of the cyctic wall, otherwise smooth. Internal echoes are regularly distributed, with a "ground glass" texture. Histology confirmed the presence of a border-line ovarian cystadenoma of endometrioic type. 12 May 2014
  28. 28. Ovarian Pathology Warda Unilocular ovarian cyst, with "ground glass" internal texture, suggestive of endometrioma. A small "papillary-like" projection, deforms the lateral wall of the cyst. This an example of socolled "atypical endometrioma". In such cases, Power Doppler analysis is very useful to differentiate it from a true neoplasm. 12 May 2014
  29. 29. Ovarian Pathology Warda Small multilocular solid ovarian cyst, with few small septa and papillary projections. As such the picture would appear highly suspicious for malignancy. Subsequent evaluation with power and pulsed Doppler showed however, scanty vascularity and high impedance to blood flow. Histology demonstrated a benign cystic ovarian adenofibroma. 12 May 2014
  30. 30. Ovarian Pathology Warda Multilocular ovarian cyst. Several septa of different length and thickness, but no papillary projections or solid areas are present. Margins are well defined. Internal echoes are scanty. Histology diagnosed a benign ovarian cystadenoma of serous type. 12 May 2014
  31. 31. Ovarian Pathology Warda A small, round shape unilocular cyst, close but external to the ovary, suggestive to be a paraovary cyst. 12 May 2014
  32. 32. Ovarian Pathology Warda The ovary is enlarged, solid, with undefined margin, slightly unhomogeneous texture. Normal ovarian texture is not visible. The picture is suggestive of a primary malignant ovarian neoplasm or of an ovarian metastasis. 12 May 2014
  33. 33. Ovarian Pathology Warda Unilocular solid ovarian cyst, with 2 large intracavitarian solid, papillary areas, occupying almost 1/3 of the lumen of the cyst. Internal echoes are visible. Histology diagnosed a malignant cystadenocarcinoma of serious type. 12 May 2014
  34. 34. Ovarian Pathology Warda Very large (>22 cm) multilocular solid ovarian cyst. There are many septations forming a thick "web" and solid intra-cavitarian areas. Internal echoes are abundant. The picture is suggestive of a malignant cystadenocarcinoma of mucinous type. 12 May 2014
  35. 35. Ovarian Pathology Warda Enlarged, "solid" ovarian mass. Power Doppler show intense vascularisation. At histology an ovarian metastasis of breast cancer was diagnosed. 12 May 2014
  36. 36. Ovarian Pathology Warda Large ovarian solid tumor. Texture is homogeneous, margins are well defined. At histology a granulosa cell tumor was diagnosed. 12 May 2014
  37. 37. Ovarian Pathology Warda Superimposed power Doppler examination of a solid ovarian mass proved to be a granulosa cell tumor. Showing abundant and irregularly distributed vascularisation. 12 May 2014
  38. 38. Ovarian Pathology Warda Pulsed Doppler examination of blood flow impedance in an ovarian solid mass, proved to be a granulosa cell tumor. Maximum velocity is high and impedance to flow low. 12 May 2014
  39. 39. Ovarian Pathology Warda Neoplastic ovarian cyst with internal papillae 12 May 2014
  40. 40. Ovarian Pathology Warda Ovarian fibroma 12 May 2014
  41. 41. Ovarian Pathology Warda Mucinous cystadenocarcinoma 12 May 2014
  42. 42. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CD 12 May 2014
  43. 43. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CDUTERINE FIBROID 12 May 2014
  44. 44. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CD 12 May 2014
  45. 45. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CD ENDOMETRIAL CANCER 12 May 2014
  46. 46. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CD UTERINE LEIOMYOSARCOMA 12 May 2014
  47. 47. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CD Enlarged uterus in a 53-year-old woman with abnormal bleeding. The uterus is enlarged slightly and heterogeneous in echotexture but has no focal masses. Histologic examination revealed adenomyosis. 12 May 2014
  48. 48. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CDFOCAL adenomyosis- no line of demarcation+ presence of hypoechoic dots 12 May 2014
  49. 49. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CDCervical masses. (A) Sagittal view of the cervix demonstrates a large cervical fibroid which deviates the lower uterine segment anteriorly. fibroid Uterus 12 May 2014
  50. 50. Uterine Pathology Warda Submucous fibroid polyp/ sonohysterography+ CDMultiple endometrial polypi (sono hysterography 12 May 2014
  51. 51. Thank You Warda12 May 2014