Prof Soha Talaat Cairo university Imaging in gynecology final

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Prof Soha Talaat Cairo university Imaging in gynecology final

  1. 1. Prof Soha Talaat
  2. 2. Prof Soha Talaat
  3. 3. Imaging in gynecology Prof Soha Talaat
  4. 4. Imaging modalities I.Plain film : Soft ovoid density seprated by fat planes Abnormality:  Soft tissue tumefaction : distended bladder , ovarian cyst, fibroid uterus .  Obliteration of normal fat planes>>infection.  Calcifications: fibroid, ovarian(dermoid).  Ascites ,hemo/pnemo-peritonium. Prof Soha Talaat
  5. 5. Missed IUD. Prof Soha Talaat
  6. 6. US first Prof Soha Talaat
  7. 7. Missed IUD Prof Soha Talaat
  8. 8. Imaging modalities II. Contrast Studies : 1. HSG . 2. Vaginography . 3. GIT studies . 4. IVU . 5. Arteriography (AVM , fibroid embolization). Prof Soha Talaat
  9. 9. Vaginography • Technique • Indications: 1. Fistula . 2. Congenital or acquired abnormalities of vagina . 3. To localize by reflux an ectopic ureter opening into vagina. Prof Soha Talaat
  10. 10. Vaginagraphy Prof Soha Talaat
  11. 11. Gynecologic US I. Scanning technique: A. TAS: • Uses transducers 3-5MHZ range. • Requires filling of the urinary bladder (ideal 1- 2 cm above the uterine fundus). • Obtained in sagittal and transverse planes (oblique image may be needed) • To view adnexa move transducer from side to side. • Main advantage providing an overview of the pelvis. Prof Soha Talaat
  12. 12. B.TVS • Performed with 5-9 MHZ transducers . • Empty bladder:  To minimize discomfort  Brings uterus and ovaries into focal zone. • Probe should be disinfected , Us gel applied to transducer head ,use condom . • AP& transverse pelvic planes. Prof Soha Talaat
  13. 13. TVS • Indications : 1. Early and second trimester pregnancy. 2. Lower uterine segment in late pregnancy. 3. Ectopic pregnancy. 4. Retroverted or retroflexed uterus. 5. Obese and gaseous patients. 6. Emergency cases where bladder is empty. 7. Follicular monitoring in ovulation induction. 8. Pulsed and colour Doppler. Prof Soha Talaat
  14. 14. TVS • Advantages: 1. Can be performed quickly without full bladder. 2. Determine source of pain more accurately. 3. Facilitates use of Doppler. 4. Biopsy guides :follicular aspiration ,cyst& abscess drainage , tumour biopsy. Prof Soha Talaat
  15. 15. TVS • Disadvantage : 1. Occasional confusion with anatomic orientation due to unfamiliar scan planes. 2. Limited field of view which allow only visualization of true pelvis . 3. Probe caliber may be painful to patients with narrow interoitus such as nullipara ,postmenopausal women. Prof Soha Talaat
  16. 16. TVS Prof Soha Talaat
  17. 17. TVS Transverse pelvic plane Prof Soha Talaat
  18. 18. Transperineal (translabial) US Dietz. Pelvic floor ultrasound: a review. Am J Obstet Gynecol 2010.Prof Soha Talaat
  19. 19. Transperineal (translabial) US 1.Pelvic floor disorders Recurrent urinary tract infections Urgency, frequency, nocturia, and/or • urge urinary incontinence Stress urinary incontinence Insensible urine loss Bladder-related pain Persistent dysuria Symptoms of voiding dysfunction • Symptoms of prolapse, ie, sensation of lump or dragging sensation Symptoms of obstructed defecation, eg, • straining at stool, chronic constipation, • vaginal or perineal digitation, and • sensation of incomplete bowel emptying • Fecal incontinence • Pelvic or vaginal pain ,Vaginal discharge or bleeding after Anti incontinence or prolapse surgery Prof Soha Talaat
  20. 20. Gross Anatomy Sagittal Section Prof Soha Talaat
  21. 21. Stress incontinence Prof Soha Talaat
  22. 22. Prof Soha Talaat
  23. 23. Transperineal (translabial) US TRUS • In virgins • In suspected lower uterine anomalies Prof Soha Talaat
  24. 24. Sonographic anatomy • The uterus : 1. Size . 2. Position . 3. Endometrial lining . 4. Myometrium 5. Cervix and endocervical canal Prof Soha Talaat
  25. 25. Uterus • Size: • Varies with age and parity . • Average: o Length=6– 8 cm . o Ap = 3-4 cm . o Transverse= 5cm Prof Soha Talaat
  26. 26. Post menopausal Prof Soha Talaat
  27. 27. Pre-pubertal uterus • Tubular in shape . • Cervix to corpus ratio 1/1 . • Thin endometrial stripe Prof Soha Talaat
  28. 28. Infantile uterus • 17ys female with primary amenorrhea Prof Soha Talaat
  29. 29. Uterus Position Mid line anteverted structure Prof Soha Talaat
  30. 30. Positions of the uterus Prof Soha Talaat
  31. 31. Prof Soha Talaat
  32. 32. Retroverted uterus Prof Soha Talaat
  33. 33. Embryology • The female reproductive system develops from the müllerian ducts , two ducts that originate in embryonic mesoderm lateral to each wolffian duct . • The paired müllerian ducts grow in medial and caudal directions .The most cephalad parts of the ducts remain separate and form the fallopian tubes .The lower parts of the ducts fuse (lateral fusion ) .The midline septum disappears ,leaving a single canal :the uterus and upper two -thirds of the vagina Prof Soha Talaat
  34. 34. Embryology • The lower third of the vagina develop from the bilateral sinovaginal bulbs which arise from the urogenital sinus .The sinovaginal bulbs fuse into solid mass called the vaginal plate ,which undergoes canalization in the second trimester ,the sinovaginal bulb fuses with the lower müllerian system (vertical fusion) . • The close developmental relationship of the müllerian and wolffian ducts explains the frequent association of anomalies of the female genital system and urinary tract Prof Soha Talaat
  35. 35. Müllerian duct anomalies are categorized most commonly into 7 classes according to (AFS) Classification Scheme (1988) : • Class I (hypoplasia/agenesis) • Class II (unicornuate uterus) • Class III (didelphys uterus) • Class IV (bicornuate uterus) • Class V (septate uterus) • Class VI (arcuate uterus) • Class VII (diethylstilbestrol-related anomaly) Prof Soha Talaat
  36. 36. The modified American Fertility Society (AFS) by Rock and Adam • Class 1: Dysgenesis of müllerian ducts. This class includes agenesis or hypoplasia of the müllerian duct derivatives: the uterus and upper two-thirds of the vagina. The most common form is the Mayer- Rokitansky-Kuster-Hauser syndrome (MRKH syndome), which is combined agenesis of the uterus, cervix, and upper portion of the vagina. • Class 2: Disorders of vertical fusion. These anomalies are due to failure of fusion of the müllerian system with the sinovaginal bulb. They include cervical dysgenesis and obstructive and non obstructive transverse vaginal septa. Prof Soha Talaat
  37. 37. The modified American Fertility Society (AFS) by Rock and Adam • Class 3: Disorders of lateral fusion : result in a duplicated or partially duplicated reproductive tract. The disorders are due to impaired fusion and/or septal resorption of fusing müllerian ducts attempting to form the uterus, cervix, and upper vagina. Failure of fusion of the paired müllerian ducts (as in didelphic and bicornuate uteri) and failure of midline septum resorption after fusion (as in septate uterus). Disorders due to lateral fusion defects are further subclassified into (a) the symmetric non obstructive form seen in five types: unicornuate, bicornuate, didelphic, septate, and DES-related uteri and (b) the asymmetric obstructive form seen in three types: unicornuate uterus with obstructed horn, double uterus with unilaterally obstructed horn, and double uterus with unilaterally obstructed vagina. • Class 4: Unusual configurations and combinations of defects [14]. Prof Soha Talaat
  38. 38. Uterine agenesis Prof Soha Talaat
  39. 39. In uterine agenesis Don’t forget to look in inguinal region Androgen insensitivity syndrome Prof Soha Talaat
  40. 40. Uterine shape Prof Soha Talaat
  41. 41. Septate uterus Prof Soha Talaat
  42. 42. Subseptate Prof Soha Talaat
  43. 43. Pregnancy in septate Prof Soha Talaat
  44. 44. Bicornuate uterus Prof Soha Talaat
  45. 45. Dideliphes Prof Soha Talaat
  46. 46. Differentiation between bicornuate and septate uterus • US may demonstrate two uterine cavities with normal endometrium. • A reliable means of distinguishing bicornuate from septate uteri is a concave fundus with a fundal cleft greater than 1 cm. • An increased intercornual distance (>4 cm) in bicornute uterus • 3D US may play a useful role in making this diagnosis.. Prof Soha Talaat
  47. 47. unicornuate One normally developed mullerian duct while the contralateral duct is either hypoplastic or absent Prof Soha Talaat
  48. 48. Arcuate Prof Soha Talaat
  49. 49. Obstructive anomalies hematocolpos Prof Soha Talaat
  50. 50. Hematometria &heamatocolpos Prof Soha Talaat
  51. 51. Haematometra , vaginal atresia Prof Soha Talaat
  52. 52. Uterus endometrium phase AP diameter Proliferative 4-8 mm Periovulatory 6-10mm Secretory 7-14mm Prof Soha Talaat
  53. 53. Endometrium :how to measure Prof Soha Talaat
  54. 54. Prof Soha Talaat
  55. 55. Prof Soha Talaat
  56. 56. Causes of endometrial thickening • Polyp. • Hyperplasia . • Tamoxifen. • Incomplete abortion • Hydatiform mole Prof Soha Talaat
  57. 57. Endometrial polyp • An endometrial polyp or uterine polyp is a polyp or lesion in the endometrium that takes up space within the uterine cavity. • Commonly occurring, they are experienced by up to 10% of women. • They may have a large flat base (sessile) or (pedunculated).[5][6] • Pedunculated polyps are more common than sessile ones.[7] • They range in size from a few millimeters to several centimeters.[6] • If pedunculated, they can protrude through the cervix into the vagina.[5][8] Small blood vessels may be present in polyps, particularly large ones.[5] Prof Soha Talaat
  58. 58. Prof Soha Talaat
  59. 59. Large polyp Prof Soha Talaat
  60. 60. Is this the same Prof Soha Talaat
  61. 61. Prof Soha Talaat
  62. 62. Causes of Postmenopausal Bleeding • Atrophic endometritis/vaginitis • Endometrial or cervical polyps • Exogenous estrogens • Endometrial hyperplasia • Endometrial cancer • Miscellaneous (e.g., cervical cancer, uterine sarcoma, urethral caruncle, trauma) Prof Soha Talaat
  63. 63. Endometrial hyperplasia Prof Soha Talaat
  64. 64. Take care of Doppler findings Prof Soha Talaat
  65. 65. Endometrial carcinoma • is the most common gynecological malignancy in many countries with the reported incidence of about 10% in postmenopausal patients presenting uterine bleeding . Prof Soha Talaat
  66. 66. ENDOMETRIAL CARCINOMA •The post menopausal endometrium usually atrophies measuring less than 3mm. •A double layer thickness >5mm is abnor. •Grade I carcinoma presents as widening of the endometrial stripe on U/S examination •A thickness of 7mm is accepted in women under hormonal therapy Prof Soha Talaat
  67. 67. ENDOMETRIAL CARCINOMA STAGING STAGE I: Confined to corpus STAGE II: Spread to cervix STAGE III: Vaginal ext, spread to adnexa, periton. iliac or paraortic LN metastases STAGE IV: Distant metastases or bowel or bladder invasion Prof Soha Talaat
  68. 68. Endometrial mass Prof Soha Talaat
  69. 69. Prof Soha Talaat
  70. 70. Prof Soha Talaat
  71. 71. ??Endometrial cancer Prof Soha Talaat
  72. 72. Molar pregnancy Prof Soha Talaat
  73. 73. Prof Soha Talaat
  74. 74. Choriocarcinoma Prof Soha Talaat
  75. 75. Sonohysterography Normal uterine cavity Prof Soha Talaat
  76. 76. Sonohysterography Prof Soha Talaat
  77. 77. Cervix • Barrel shaped , homogenous moderately echoic, smooth walled structure . • Central echogenic stripe >endocervical canal . Prof Soha Talaat
  78. 78. Nabothian cysts Prof Soha Talaat
  79. 79. Cervicitis Prof Soha Talaat
  80. 80. Cervical polyp • A cervical polyp is a common benign polyp or tumor on the surface of the cervical canal. • They can cause irregular menstrual bleeding or increased pain but often show no symptoms.[ • Treatment consists of simple removal of the polyp and prognosis is generally good. • About 1% of cervical polyps will show neoplastic change which may lead to cancer. MedlinePlus Encyclopedia Cervical polyps Prof Soha Talaat
  81. 81. Cervical polyp Prof Soha Talaat
  82. 82. Prof Soha Talaat
  83. 83. Prof Soha Talaat
  84. 84. 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
  85. 85. Cervical mass Prof Soha Talaat
  86. 86. Revised FIGO stagingStage Carcinoma in situ, intraepithelial carcinomaStage o Carcinoma strictly confined to cervixStage I: Ia Ia1 Ia2 Ib Ib1 Ib2 Preclinical carcinoma of cervix (microinvasive) Invasion of stroma < 3 mm in depth and < 7 mm in width Invasion 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 Carcinoma extending beyond the cervix but not to the pelvic wall; carcinoma involves the upper two third of the vagina Stage II: IIa IIb No obvious parametrial involvement Obvious parametrial involvement Carcinoma extending to pelvic wall; and nvolves lower third of vaginaStage III: IIIa IIIb Involvement of lower third of vagina Carcinoma extending beyond true pelvis or involving bladder or rectumStage IV: IVa IVb Spread to adjacent organs Spread to distant organs Prof Soha Talaat
  87. 87. Prof Soha Talaat
  88. 88. UTERINE PERFUSION • The main blood supply of the uterus is the uterine artery. • The uterine arteries give rise to the arcuate arteries, which give rise to the radial arteries, which give rise to the basal and the spiral arteries Prof Soha Talaat
  89. 89. Uterine artery flow Proliferative phase of the menstrual Cycle. a small amount of enddiastolic flow and a characteristic notch (RI=0.92) secretory phase :sharp increase of an enddiastolic blood flow leading to decrease of the resistance index (Rl=0.81) Prof Soha Talaat
  90. 90. Myometrium • Fibroids are very common. They occur in 2 or 3 out of every 10 women over age 35. • It is common to have more than one fibroid. Some women may have as many as a hundred. • Fibroids occur most often in women between ages 30 and 50, although women in their 20s sometimes have them. • Three out of every 10 hysterectomies in the United States are performed because of fibroids. Prof Soha Talaat
  91. 91. Fibroids Prof Soha Talaat
  92. 92. Pedunculated fibroid Prof Soha Talaat
  93. 93. Fibroid (interstitial) Prof Soha Talaat
  94. 94. Interstitial fibroid Prof Soha Talaat
  95. 95. Sub-mucous fibroid Prof Soha Talaat
  96. 96. Prof Soha Talaat
  97. 97. Intracavitary fibroid Prof Soha Talaat
  98. 98. Interstitial fibroid Prof Soha Talaat
  99. 99. Degenerated fibroid Prof Soha Talaat
  100. 100. Fibroid with pregnancy Prof Soha Talaat
  101. 101. The Ideal Patient for uterine fibroid embolization • Pre-menopausal pt not desiring fertility • Post-menopausal pt with failure of spontaneous regression • Pt has failed medical management • Fibroid is of moderate size (3-7cm) • Absolute contraindication to surgery (including pt preference) Prof Soha Talaat
  102. 102. Post-embolization pelvic angiography should be performed to document arterial occlusion Pre-embolization Post - embolization Prof Soha Talaat
  103. 103. Pathological subtypesIncidence  Leiomyosarcoma 25-30%  Endometrial stromal tumors 10-15% Endometrial stromal nodule Endometrial stromal sarcoma-low grade Undifferentiated sarcoma  Mixed epithelial-mesenchymal tumors Adenosarcoma 5% Carcinosarcoma (Mixed Mullerian Tumor) 45- 50% Homologous Heterologous  Undifferentiated 5% Uterine Sarcomas Prof Soha Talaat
  104. 104. ADENOMYOSIS • ADENOMYOSIS IS IMPLANTATION OF ENDOMETRIUM IN THE UTERINE WALL • DURING MENSTRUATION BLOOD IS ENTRAPPED INSIDE THE MYOMETRIUM •THE MYOMETRIUM IS HYPERTOPHIED •AND THE UTERUS IS ENLARGED Prof Soha Talaat
  105. 105. ADENOMYOSIS ON U/S Prof Soha Talaat
  106. 106. Adenomyosis Prof Soha Talaat
  107. 107. Adenomyosis Prof Soha Talaat
  108. 108.  A pyometra is a collection of pus distending the uterine cavity. It occurs principally when there is a stenosed cervical os, usually due to uterine or cervical malignancy and treatment with radiotherapy. However other causes include:  Fibroid degeneration  Cervical occlusion following surgery (e.g. prolapse surgery,1 endometrial ablation2)  Senile cervicitis  Puerperal infections  Congenital cervical anomalies3  Forgotten intra-uterine device4  Genital tuberculosis  Following egg retrieval in IVF5 Pyometra Prof Soha Talaat
  109. 109.  is a serious medical condition, because of both its association with malignant disease and the danger of spontaneous perforation, which carries significant morbidity and mortality  Although rare, ruptured pyometra should be considered in the differential diagnosis of acute abdomen in elderly women, especially those with malignant disorders of the genital tract.  The treatment of pyometra rupture is immediate laparotomy, peritoneal lavage and drainage, or simple hysterectomy Pyometra Prof Soha Talaat
  110. 110. Pelvic US Prof Soha Talaat
  111. 111. Pelvic US & Doppler Prof Soha Talaat
  112. 112. Prof Soha Talaat
  113. 113. Ovaries • Identified by:  Internal iliac artery  Elliptic shape  Multiple small cysts representing follicles. • Size; 4x3x2 cm ,mean volume=10cc. » Dominant follicle : (2- 2.5 cm) Prof Soha Talaat
  114. 114. Prof Soha Talaat
  115. 115. Dominant follicle Prof Soha Talaat
  116. 116. Post menopausal ovary Prof Soha Talaat
  117. 117. PCO Prof Soha Talaat
  118. 118. PCO Prof Soha Talaat
  119. 119. Ovarian cysts Prof Soha Talaat
  120. 120. Corpus leuteum cyst Prof Soha Talaat
  121. 121. 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
  122. 122. Simple cyst Prof Soha Talaat
  123. 123. Paraovarian Cyst • Wolfian duct remnant in the mesovarium • Detection on routine US • Size : 2-5 cm or more • Clues : – Cyst besides a normal ovary – Thin wall, anechoic content – Beak sign with the ovary Prof Soha Talaat
  124. 124. 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
  125. 125.  Pelvic adhesions( due to previous surgery and PID) surround the ovary and create complex cystic masses.  US depicts a normal- appearing ovary that is surrounded by loculated fluid, in a pattern resembling a spider web. Ovary Prof Soha Talaat
  126. 126. Follicular development Prof Soha Talaat
  127. 127. Follicular monitoring multi-planer 3D Prof Soha Talaat
  128. 128. Hyperstimulation Prof Soha Talaat
  129. 129. 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
  130. 130. Non ruptured follicle Prof Soha Talaat
  131. 131. Prof Soha Talaat
  132. 132. Complex cyst Echogenic non vascular parts Follow up post menstrual Prof Soha Talaat
  133. 133. Complex cyst Prof Soha Talaat
  134. 134. Large Functional Cyst •Trick : harmonic imaging is useful to ascertain that the lesion is fluid-filled Prof Soha Talaat
  135. 135. Color Döppler? • Color Döppler is not accurate : – In 30 % of functional ovarian cyst walls, arteries are detected – Presenting with a low resistive index • Do not take it for malignancy !!! Prof Soha Talaat
  136. 136. Endometriosis Prof Soha Talaat
  137. 137. Prof Soha Talaat
  138. 138. Endometriosis &pelvic adhesions Prof Soha Talaat
  139. 139. 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
  140. 140. 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
  141. 141. Endometrioma • Various sonographic appearance from anechoic to echogenic depending on the amount and coagulation of blood components • 88% shows posterior acoustic enhancement . • Borders may be irregular due to adhesions Rarely, sediment or clots Prof Soha Talaat
  142. 142. Endometrioma Prof Soha Talaat
  143. 143. •Neovascularization detected in the cyst wall •Absence of color flow in some echogenic portions like blood clots in hemorrhagic cysts and endomertiomas suggest their benign cystic nature Role of colour Doppler Prof Soha Talaat
  144. 144. Endometrioma Prof Soha Talaat
  145. 145. Prof Soha Talaat
  146. 146. Pelvic endometriosis Prof Soha Talaat
  147. 147. Dermoid cyst • Echogenic focus within a predominantly cystic mass .(tip of ice berg sign ). • Echogenic focus with posterior shadowing . • Fat or hair fluid level. Prof Soha Talaat
  148. 148. Dermoid Prof Soha Talaat
  149. 149. Dermoid Prof Soha Talaat
  150. 150. Prof Soha Talaat
  151. 151. Immature teratoma vascularized solid part Prof Soha Talaat
  152. 152. Immature teratoma vascularized solid part Prof Soha Talaat
  153. 153. Scoring system for cystic teratoma based on TVS& Doppler Score 2Reproductive age 2 2 B MODE: Unilateral Serial sonography positive 2 2 2 Thick walls . Thin echogenic band like echoes Echogenic tubericle within the ovary 2Colour Doppler :no vascularity Prof Soha Talaat
  154. 154. Prof Soha Talaat
  155. 155. 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 echoic Parts, papillae & border line thick Septation & other, masses signs of malignancy. ↓ ↓ ↓ Malignant lesion. Benign lesion pelvic MRI is recommended Prof Soha Talaat
  156. 156. Prof Soha Talaat
  157. 157. Prof Soha Talaat
  158. 158. Doppler findings of benign and maliqnant adnexal masses Benign ovarian tumors • Regular distribution of blood vessels • Blood vessels are equally calibrated • Blood vessels have muscle fibers with moderate-to-high resistance index values (RI=0.42) Malignant ovarian tumors • Irregular distribution of blood vessels • Blood vessels have irregular diameter • Low resistance index values (RI<0.42) • Display of tumoral lakes and arterio-venous shunts Prof Soha Talaat
  159. 159. Ovarian tumours Classification: Histogenetic classification: As the ovary is composed of surface epithelium, germ cell apparatus and stroma, ovarian tumours are classified into: 1- Epithelial tumours 2- Germ cell tumours 3- Stromal tumours Clinical classification: As ovarian tumours may be cystic or solid or complex and either of them may be benign or malignant, Prof Soha Talaat
  160. 160. Serous / Mucinous cystadenoma – Thin wall – Pure cystic content Serous : unilocular Mucinous : multilocular Prof Soha Talaat
  161. 161. Cystadenocarcinoma: Typical malignant features • US provides orientation tips • Malignant features : – Solid-cystic lesion – Multiple papillary projections – Thick, irregular wall > 3 mm – Vascularized septations Prof Soha Talaat
  162. 162. Prof Soha Talaat
  163. 163. Cystadenocarcinoma Color doppler : Vascularized vegetationsProf Soha Talaat
  164. 164. Clear cell carcinoma : Uniloculated cyst with solid parietal nodules Undifferenciated carcinoma : solid tumors with necrosis Prof Soha Talaat
  165. 165. Solid ovarian mass Prof Soha Talaat
  166. 166. Ovarian Fibroma •US features : –Solid enlarged ovary –Homogenous content –Arterial signal •US is equivocal in case of “old” fibroma : –Heterogeneous –Shadowing –Vessel paucity Prof Soha Talaat
  167. 167. Ovarian Fibroma Prof Soha Talaat
  168. 168. Borderline ovarian tumors • These tumors are benign, but have the potential for malignancy • Cyst with papillary vegetations – US is not able to differentiate a Borderline tumour from a cystadenocarcinoma – MRI might be useful to detect subtle vegetations • Recurrence is common : – The recommendation is to perform ovariectomy and and a close follow-up of the controlateral ovary Prof Soha Talaat
  169. 169. Prof Soha Talaat
  170. 170. Border line ov mass Prof Soha Talaat
  171. 171. Complex adnexal mass • Haemorrhagic cyst-contains diffuse internal echoes or an irregular clump of echoes due to clot. Repeat scans helpful to show change. • Ruptured cyst-typical history, irregularly-shaped cyst with surrounding fluid. • Torsion of cyst or ovary-heterogeneous enlarged ovary with or without a thick-walled cyst with internal echoes. • Endometriosis:a clump of solid echoes within the cyst due to clot. Follow-up • Acute / chronic tubo-ovarian abscess. • Dermoid cyst-complex mass with cystic and solid areas, fat change in the appearance of the internal echoes confirming its and/or calcification. Prof Soha Talaat
  172. 172. Complex adnexal mass • Neoplastic ovarian tumours, benign and malignant. • Pedunculated fibroid differentiation from an ovarian mass • Ectopic pregnancy-should always be considered in a patient of child-bearing age. Pregnancy test important. • Other inflammatory masses-e.g. appendix or diverticular mass. • Other neoplastic masses-e.g. arising from the bowel or peritoneum (benign peritoneal mesothelioma). Prof Soha Talaat
  173. 173. Masses Mimicking an Ovarian Origin • Pedunculated sub-serous fibroma • Chronic Hydrosalpinx • Peritoneal cyst • Pelvic abscess of intestinal origin Prof Soha Talaat
  174. 174. Prof Soha Talaat
  175. 175. Adnexal mass Prof Soha Talaat
  176. 176. Chronic ectopic Prof Soha Talaat
  177. 177. may reflect benign or malignant processes of the ovary. Bilateral Diffuse ovarian enlargement Prof Soha Talaat
  178. 178. Diffuse ovarian enlargment Benign causes of ovarian enlargement • Luteomas. • Tumors such as mature cystic teratomas, fibrothecomas, cystadenomas . • rare conditions including capillary hemangioma and massive edema of the ovaries. Prof Soha Talaat
  179. 179. Benign diffuse enlargment Torsion( edema) • Ovarian torsion (adnexal torsion) is an infrequent but significant cause of acute lower abdominal pain in women. • This condition is usually associated with reduced venous return from the ovary as a result of stromal edema, internal hemorrhage, hyperstimulation, or a mass. Prof Soha Talaat
  180. 180. •An enlarged ovary (>5 cm) • Prominent peripheral nonovulatory follicles . •Small amount of free fluid •May depict the cyst (or, less commonly, the mass) that predisposed the ovary to torsion. US Prof Soha Talaat
  181. 181. •Imaging modality of choice •An absence of arterial waveforms or high resistance to arterial flow with absent venous flow are highly suggestive. • Particularly when those findings are accompanied by ovarian enlargement. •However normal arterial waveforms do not rule out torsion. Doppler Prof Soha Talaat
  182. 182. Diffuse ovarian enlargment Ovarian malignancies include epithelial, stromal and germ-cell tumors. Primary malignancies that may exhibit metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma Prof Soha Talaat
  183. 183. Malignant diffuse enlargement Krukenberg •Metastatic signet ring cell adenocarcinoma of the ovary. •uncommon, 1% to 2% of all ovarian tumors •80% bilateral Prof Soha Talaat
  184. 184. Ovarian lymphoma • Primary female reproductive system lymphomas are distinctly uncommon. • genital involvement is more likely a component of widely disseminated disease. NHL of the ovary may be a source of pelvic retroperitoneal masses completely engulfing the internal female genitalia. Prof Soha Talaat
  185. 185. Ovarian lymphoma • lymphoma of the ovary may appear as a discrete hypoechoic mass or a large confluent aggregate mass that may fill the pelvis. Hyperemia is often observed • CT may reveal low-attenuation solid masses involving the uterus or confluent masses displacing or engulfing the pelvic organs Prof Soha Talaat
  186. 186. Lymphoma Prof Soha Talaat
  187. 187. Sonographic anatomy • The fallopian tubes:  Normal tubes could not be detected by US.  Test for tubal patency(sonohysterography) • The cul de sac;  Most dependent part of peritoneal cavity.  Normal findings a small amount of peritoneal fluid . • Urinary bladder : anechoic , normal wall thickness . Prof Soha Talaat
  188. 188. Normal tube delineated by fluid Prof Soha Talaat
  189. 189. 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
  190. 190. Prof Soha Talaat
  191. 191. Pyosalpinx • Color Doppler US image shows a hypoechoic tubular structure(arrow) containing echogenic debris. There is no internal blood flow; however, there is increased surrounding vascularity. Prof Soha Talaat
  192. 192. TOA Prof Soha Talaat
  193. 193. What about fallopian cancer Fallopian tube cancer is the least common of gynecological malignancies (0.3%) . It was first described by Renaud in 1847.1 Since then, there have been over 1500 cases Prof Soha Talaat
  194. 194. Histopathology 1-Benign tumors 2-malignant tumors a- 1ry fallopian tumors b- 2ry fallopian tumors Prof Soha Talaat
  195. 195. Benign tumor: 1- Adenomatoid tumor a-Most common benign tumor of fallopian tube Prof Soha Talaat
  196. 196. Malignant tumors: 1-1ry tumors : has a papillary features, it is the mostPrimary adenocarcinoma-a common 1ry tumor of the tubes represent 90% of the cases b-gross: Prof Soha Talaat
  197. 197. other types:-b 1-clear cell carcinoma 2-squamous cell carcinoma 3-mixed carcinoma 4-endometrioid carcinoma 5-sarcoma but 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 epithelial ovarian carcinoma Prof Soha Talaat
  198. 198. 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 *transcelomic Prof Soha Talaat
  199. 199. l picture :Clinica Triad: (latzko triad) 1-vaginal bleeding &serosangenous bleeding 2-hydrops lubae profluence 3-adenxal mass Prof Soha Talaat
  200. 200. Diagnosis : Ultrasound MRI pelvis Serum CA-125 Prof Soha Talaat
  201. 201. u/s images Prof Soha Talaat
  202. 202. Pelvic adhesions (PID) Prof Soha Talaat
  203. 203. PELVIC VARICES • Transvaginal Ultrasound: • Identification of multiple dilated structures around the uterus and ovaries with venous blood Doppler signal • Dilated pelvic vein with a diameter greater than 4 mm • Slow blood flow (about 3 cm/sec) • Dilated arcuate vein in the myometrium communicating between bilateral pelvic varicose veins • More than 50% of women have associated cystic ovaries Prof Soha Talaat
  204. 204. Prof Soha Talaat
  205. 205. Prof Soha Talaat
  206. 206. Prof Soha Talaat
  207. 207. Prof Soha Talaat
  208. 208. Prof Soha Talaat

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