الرحيم الرحمن الله بسمأوتوا يرفع” والذين منكم آمنوا الذين الله

درجات “العلمالله صدق

العظيم: وسلم عليه اله صلى الله رسول قال

الله ” سهل علما فيه يلتمس طريقا سلك منلتضع المالئكة وإن الجنة إلى طريقا له

وإن يصنع بما رضا العلم لطالب أجنحتهاومن السماوات فى من له يستغفر العالموفضل الماء فى الحيتان حتى األرض فى

سائر على القمر كفضل العابد على العالم“ االنبياء ورثة العلماء وإن الكواكب

الله رسول صدق

الرحيم الرحمن الله الرحيم بسم الرحمن الله بسمدرجات ”” العلم أوتوا والذين منكم آمنوا الذين الله درجات يرفع العلم أوتوا والذين منكم آمنوا الذين الله ““يرفع

العظيم الله العظيم صدق الله صدق

Prof Soha Talaat

بسم الله الرحمن للرحيم

Prof Soha Talaat

Imaging in gynecology

Prof Soha Talaat

Imaging modalitiesI.Plain film :

Soft ovoid density seprated by fat planes

Abnormality: Soft tissue tumefaction : distended

bladder , ovarian cyst, fibroid uterus .

Obliteration of normal fat planes>>infection.

Calcifications: fibroid, ovarian(dermoid).

Ascites ,hemo/pnemo-peritonium.

Prof Soha Talaat

Missed IUD.

Prof Soha Talaat

US first

Prof Soha Talaat

Missed IUD

Prof Soha Talaat

Imaging modalities

II. Contrast Studies :1. HSG .2. Vaginography .3. GIT studies .4. IVU .5. Arteriography (AVM , fibroid

embolization).

Prof Soha Talaat

Vaginography

• Technique

• Indications:

1. Fistula .

2. Congenital or acquired abnormalities of vagina .

3. To localize by reflux an ectopic ureter opening into vagina.

Prof Soha Talaat

Vaginagraphy

Prof Soha Talaat

Gynecologic US

I. Scanning technique:A. TAS:• Uses transducers 3-5MHZ range.• Requires filling of the urinary bladder (ideal 1-

2 cm above the uterine fundus).• Obtained in sagittal and transverse planes

(oblique image may be needed)• To view adnexa move transducer from side to

side.• Main advantage providing an overview of the

pelvis.

Prof Soha Talaat

B.TVS• Performed with 5-9

MHZ transducers .• Empty bladder: To minimize discomfort Brings uterus and

ovaries into focal zone.• Probe should be

disinfected , Us gel applied to transducer head ,use condom .

• AP& transverse pelvic planes.

Prof Soha Talaat

TVS

• Indications :1. Early and second trimester pregnancy.2. Lower uterine segment in late pregnancy.3. Ectopic pregnancy.4. Retroverted or retroflexed uterus.5. Obese and gaseous patients.6. Emergency cases where bladder is empty.7. Follicular monitoring in ovulation induction.8. Pulsed and colour Doppler.

Prof Soha Talaat

TVS

• Advantages:

1. Can be performed quickly without full bladder.

2. Determine source of pain more accurately.

3. Facilitates use of Doppler.

4. Biopsy guides :follicular aspiration ,cyst& abscess drainage , tumour biopsy.

Prof Soha Talaat

TVS

• Disadvantage :

1. Occasional confusion with anatomic orientation due to unfamiliar scan planes.

2. Limited field of view which allow only visualization of true pelvis .

3. Probe caliber may be painful to patients with narrow interoitus such as nullipara ,postmenopausal women.

Prof Soha Talaat

TVS

Prof Soha Talaat

TVS Transverse pelvic plane

Prof Soha Talaat

Transperineal (translabial) US

Dietz. Pelvic floor ultrasound: a review. Am J Obstet Gynecol 2010. Prof Soha Talaat

Transperineal (translabial) US 1.Pelvic floor disorders

Recurrent urinary tract infections

● Urgency, frequency, nocturia, and/or

• urge urinary incontinence

● Stress urinary incontinence

● Insensible urine loss

● Bladder-related pain

● Persistent dysuria

● Symptoms of voiding dysfunction

• Symptoms of prolapse, ie, sensation of lump or dragging sensation

● Symptoms of obstructed defecation, eg,

• straining at stool, chronic constipation,

• vaginal or perineal digitation, and

• sensation of incomplete bowel emptying

• Fecal incontinence• Pelvic or vaginal pain ,Vaginal

discharge or bleeding after

Anti incontinence or prolapse surgery

Prof Soha Talaat

Gross AnatomyGross AnatomySagittal SectionSagittal Section

Prof Soha Talaat

Stress incontinence

Prof Soha Talaat

Prof Soha Talaat

Transperineal (translabial) USTRUS

• In virgins

• In suspected lower uterine anomalies

Prof Soha Talaat

Sonographic anatomy

• The uterus :1. Size .

2. Position .

3. Endometrial lining .

4. Myometrium

5. Cervix and endocervical canal

Prof Soha Talaat

Uterus• Size:• Varies with age and

parity .• Average:o Length=6– 8 cm .o Ap = 3-4 cm .o Transverse= 5cm

Prof Soha Talaat

Post menopausal

Prof Soha Talaat

Pre-pubertal uterus

• Tubular in shape .• Cervix to corpus ratio

1/1 .• Thin endometrial

stripe

Prof Soha Talaat

Infantile uterus

• 17ys female with primary amenorrhea

Prof Soha Talaat

Uterus Position

Mid line anteverted structure

Prof Soha Talaat

Positions of the uterus

Prof Soha Talaat

Prof Soha Talaat

Retroverted uterus

Prof Soha Talaat

Embryology

• The female reproductive system develops from the müllerian ducts , two ducts that originate in embryonic mesoderm lateral to each wolffian duct .

• The paired müllerian ducts grow in medial and caudal directions .The most cephalad parts of the ducts remain separate and form the fallopian tubes .The lower parts of the ducts fuse (lateral fusion ) .The midline septum disappears ,leaving a single canal :the uterus and upper two -thirds of the vagina

Prof Soha Talaat

Embryology • The lower third of the vagina develop from the bilateral sinovaginal

bulbs which arise from the urogenital sinus .The sinovaginal bulbs fuse into solid mass called the vaginal plate ,which undergoes canalization in the second trimester ,the sinovaginal bulb fuses with the lower müllerian system (vertical fusion) .

• The close developmental relationship of the müllerian and wolffian ducts explains the frequent association of anomalies of the female genital system and urinary tract

Prof Soha Talaat

Müllerian duct anomalies are categorized most commonly into 7 classes

according to (AFS) Classification Scheme (1988) :

• Class I (hypoplasia/agenesis)• Class II (unicornuate uterus) • Class III (didelphys uterus) • Class IV (bicornuate uterus) • Class V (septate uterus)• Class VI (arcuate uterus) • Class VII (diethylstilbestrol-related anomaly)

Prof Soha Talaat

The modified American Fertility Society (AFS) by Rock and Adam

• Class 1: Dysgenesis of müllerian ducts. This class includes agenesis or hypoplasia of the müllerian duct derivatives: the uterus and upper two-thirds of the vagina. The most common form is the Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH syndome), which is combined agenesis of the uterus, cervix, and upper portion of the vagina.

• Class 2: Disorders of vertical fusion. These anomalies are due to failure of fusion of the müllerian system with the sinovaginal bulb. They include cervical dysgenesis and obstructive and non obstructive transverse vaginal septa.

Prof Soha Talaat

The modified American Fertility Society (AFS) by Rock and Adam

• Class 3: Disorders of lateral fusion : result in a duplicated or partially duplicated reproductive tract. The disorders are due to impaired fusion and/or septal resorption of fusing müllerian ducts attempting to form the uterus, cervix, and upper vagina. Failure of fusion of the paired müllerian ducts (as in didelphic and bicornuate uteri) and failure of midline septum resorption after fusion (as in septate uterus). Disorders due to lateral fusion defects are further subclassified into (a) the symmetric non obstructive form seen in five types: unicornuate, bicornuate, didelphic, septate, and DES-related uteri and (b) the asymmetric obstructive form seen in three types: unicornuate uterus with obstructed horn, double uterus with unilaterally obstructed horn, and double uterus with unilaterally obstructed vagina.

• Class 4: Unusual configurations and combinations of defects [14].

Prof Soha Talaat

Uterine agenesis

Prof Soha Talaat

In uterine agenesisDon’t forget to look in inguinal region

Androgen insensitivity syndrome

Prof Soha Talaat

Uterine shape

Prof Soha Talaat

Septate uterus

Prof Soha Talaat

Subseptate

Prof Soha Talaat

Pregnancy in septate

Prof Soha Talaat

Bicornuate uterus

Prof Soha Talaat

Dideliphes

Prof Soha Talaat

Differentiation between bicornuate and septate uterus

• US may demonstrate two uterine cavities with normal endometrium.

• A reliable means of distinguishing bicornuate from septate uteri is a concave fundus with a fundal cleft greater than 1 cm.

• An increased intercornual distance (>4 cm) in bicornute uterus

• 3D US may play a useful role in making this diagnosis..

Prof Soha Talaat

unicornuateOne normally

developed mullerian duct while the

contralateral duct is either hypoplastic or

absent

Prof Soha Talaat

Arcuate

Prof Soha Talaat

Obstructive anomalies hematocolpos

Prof Soha Talaat

Hematometria &heamatocolpos

Prof Soha Talaat

Haematometra , vaginal atresia

Prof Soha Talaat

Uterusendometrium

phase AP diameter

Proliferative 4-8 mm

Periovulatory 6-10mm

Secretory 7-14mm

Prof Soha Talaat

Endometrium :how to measure

Prof Soha Talaat

Prof Soha Talaat

Prof Soha Talaat

Causes of endometrial thickening

• Polyp.

• Hyperplasia .

• Tamoxifen.

• Incomplete abortion

• Hydatiform mole

Prof Soha Talaat

Endometrial polyp • An endometrial polyp or uterine polyp is a

polyp or lesion in the endometrium that takes up space within the uterine cavity.

• Commonly occurring, they are experienced by up to 10% of women.

• They may have a large flat base (sessile) or (pedunculated).[5][6]

• Pedunculated polyps are more common than sessile ones.[7]

• They range in size from a few millimeters to several centimeters.[6]

• If pedunculated, they can protrude through the cervix into the vagina.[5][8] Small blood vessels may be present in polyps, particularly large ones.[5]

Prof Soha Talaat

Prof Soha Talaat

Large polyp

Prof Soha Talaat

Is this the same

Prof Soha Talaat

Prof Soha Talaat

Causes of Postmenopausal Bleeding

• Atrophic endometritis/vaginitis

• Endometrial or cervical polyps

• Exogenous estrogens

• Endometrial hyperplasia

• Endometrial cancer

• Miscellaneous (e.g., cervical cancer, uterine sarcoma, urethral caruncle, trauma)

Prof Soha Talaat

Endometrial hyperplasia

Prof Soha Talaat

Take care of Doppler findings

Prof Soha Talaat

Endometrial carcinoma

• is the most common gynecological malignancy in many countries with the reported incidence of about 10% in postmenopausal patients presenting uterine bleeding .

Prof Soha Talaat

ENDOMETRIAL CARCINOMAENDOMETRIAL CARCINOMA

•The post menopausal endometrium usuallyThe post menopausal endometrium usually atrophies measuring less than 3mm.atrophies measuring less than 3mm.•A double layer thickness >5mm is abnor.A double layer thickness >5mm is abnor.

•Grade I carcinoma presents as widening of the Grade I carcinoma presents as widening of the endometrial stripe on U/S examinationendometrial stripe on U/S examination

•A thickness of 7mm is accepted in women underA thickness of 7mm is accepted in women under hormonal therapyhormonal therapy

Prof Soha Talaat

ENDOMETRIAL CARCINOMAENDOMETRIAL CARCINOMA

STAGINGSTAGING

STAGE I: STAGE I: Confined to corpusConfined to corpus

STAGE II: STAGE II: Spread to cervixSpread to cervix

STAGE III: STAGE III: Vaginal ext, spread to adnexa, periton.Vaginal ext, spread to adnexa, periton. iliac or paraortic LN metastasesiliac or paraortic LN metastases

STAGE IV: STAGE IV: Distant metastases or bowel or bladderDistant metastases or bowel or bladder invasioninvasion

Prof Soha Talaat

Endometrial mass

Prof Soha Talaat

Prof Soha Talaat

Prof Soha Talaat

?? Endometrial cancer

Prof Soha Talaat

Molar pregnancy

Prof Soha Talaat

Prof Soha Talaat

Choriocarcinoma

Prof Soha Talaat

Sonohysterography

Normal uterine cavityProf Soha Talaat

Sonohysterography

Prof Soha Talaat

Cervix

• Barrel shaped , homogenous moderately echoic, smooth walled structure .

• Central echogenic stripe >endocervical canal .

Prof Soha Talaat

Nabothian cysts

Prof Soha Talaat

Cervicitis

Prof Soha Talaat

Cervical polyp• A cervical polyp is a common

benign polyp or tumor on the surface of the cervical canal.

• They can cause irregular menstrual bleeding or increased pain but often show no symptoms.[

• Treatment consists of simple removal of the polyp and prognosis is generally good.

• About 1% of cervical polyps will show neoplastic change which may lead to cancer.

MedlinePlus Encyclopedia Cervical polyps

Prof Soha Talaat

Cervical polyp

Prof Soha Talaat

Prof Soha Talaat

Prof Soha Talaat

Cervical carcinoma• The most frequent gynecologic

carcinoma in women under 50 years of age and the third most common

gynecologic malignancy in postmenopausal women following endometrial and ovarian cancer .

• In Egypt , WHO estimates indicate that every year, 2713 women are

diagnosed with cervical cancer and 2178 die from the disease. About 10.3 % of women in the general population

are estimated to harbor cervical human papilloma virus (HPV) infection

at a given time .Prof Soha Talaat

Cervical mass

Prof Soha Talaat

Stage Revised FIGO staging

Stage o Carcinoma in situ, intraepithelial carcinoma

Stage I:

Ia

Ia1

Ia2

Ib

Ib1

Ib2

Carcinoma strictly confined to cervix

Preclinical carcinoma of cervix (microinvasive)

Invasion of stroma < 3 mm in depth and < 7 mm in widthInvasion of stroma > 3 mm but < 5 mm in depth and no wider than 7 mm

Lesions confined to cervix or preclinical lesions greater than stage IA

Clinical lesions 4 cm or smaller

Clinical lesions larger than 4 cm

Stage II:

IIa

IIb

Carcinoma extending beyond the cervix but not to the pelvic wall; carcinoma involves the upper two third of

the vagina

No obvious parametrial involvement

Obvious parametrial involvement

Stage III:

IIIa

IIIb

Carcinoma extending to pelvic wall; and nvolves lower third of vagina

Involvement of lower third of vagina

Stage IV:

IVa

IVb

Carcinoma extending beyond true pelvis or involving bladder or rectum

Spread to adjacent organs

Spread to distant organs

Prof Soha Talaat

Prof Soha Talaat

UTERINE PERFUSION

• The main blood supply of the uterus is the uterine artery.

• The uterine arteries give rise to the arcuate arteries, which give rise to the radial arteries, which give rise to the basal and the spiral arteries

Prof Soha Talaat

Uterine artery flow

Proliferative phase of the menstrual

Cycle. a small amount of enddiastolic flow and a characteristic

notch (RI=0.92)

secretory phase :sharp increase of an enddiastolic blood flow leading to decrease of the resistance index (Rl=0.81)

Prof Soha Talaat

Myometrium

• Fibroids are very common. They occur in 2 or 3 out of every 10 women over age 35.

• It is common to have more than one fibroid. Some women may have as many as a hundred.

• Fibroids occur most often in women between ages 30 and 50, although women in their 20s sometimes have them.

• Three out of every 10 hysterectomies in the United States are performed because of fibroids.

Prof Soha Talaat

Fibroids

Prof Soha Talaat

Pedunculated fibroid

Prof Soha Talaat

Fibroid (interstitial)

Prof Soha Talaat

Interstitial fibroid

Prof Soha Talaat

Sub-mucous fibroid

Prof Soha Talaat

Prof Soha Talaat

Intracavitary fibroid

Prof Soha Talaat

Interstitial fibroid

Prof Soha Talaat

Degenerated fibroid

Prof Soha Talaat

Fibroid with pregnancy

Prof Soha Talaat

The Ideal Patient for uterine fibroid embolization

• Pre-menopausal pt not desiring fertility

• Post-menopausal pt with failure of spontaneous regression

• Pt has failed medical management

• Fibroid is of moderate size (3-7cm)

• Absolute contraindication to surgery (including pt preference)

Prof Soha Talaat

Post-embolization pelvic angiography should be performed to document arterial occlusion

Pre-embolization Post - embolization

Prof Soha Talaat

Pathological subtypes Incidence

Leiomyosarcoma 25-30% Endometrial stromal tumors 10-15%

Endometrial stromal noduleEndometrial stromal sarcoma-low gradeUndifferentiated sarcoma

Mixed epithelial-mesenchymal tumorsAdenosarcoma 5%Carcinosarcoma (Mixed Mullerian Tumor) 45-

50%HomologousHeterologous

Undifferentiated 5%

Uterine Sarcomas

Prof Soha Talaat

ADENOMYOSISADENOMYOSIS

• ADENOMYOSIS IS IMPLANTATION ADENOMYOSIS IS IMPLANTATION OF ENDOMETRIUM IN THE UTERINE OF ENDOMETRIUM IN THE UTERINE WALLWALL

• DURING MENSTRUATION BLOOD IS DURING MENSTRUATION BLOOD IS ENTRAPPED INSIDE THE MYOMETRIUMENTRAPPED INSIDE THE MYOMETRIUM•THE MYOMETRIUM IS HYPERTOPHIEDTHE MYOMETRIUM IS HYPERTOPHIED•AND THE UTERUS IS ENLARGEDAND THE UTERUS IS ENLARGED

Prof Soha Talaat

ADENOMYOSIS ON U/S

Prof Soha Talaat

Adenomyosis

Prof Soha Talaat

Adenomyosis

Prof Soha Talaat

A pyometra is a collection of pus distending the uterine cavity. It occurs principally when there is a stenosed cervical os, usually due to uterine or cervical malignancy and treatment with radiotherapy. However other causes include:

Fibroid degeneration Cervical occlusion following surgery (e.g. prolapse

surgery,1 endometrial ablation2) Senile cervicitis Puerperal infections Congenital cervical anomalies3 Forgotten intra-uterine device4 Genital tuberculosis Following egg retrieval in IVF5

Pyometra

Prof Soha Talaat

is a serious medical condition, because of both its association with malignant disease and the danger of spontaneous perforation, which carries significant morbidity and mortality

Although rare, ruptured pyometra should be considered in the differential diagnosis of acute abdomen in elderly women, especially those with malignant disorders of the genital tract.

The treatment of pyometra rupture is immediate laparotomy, peritoneal lavage and drainage, or simple hysterectomy

Pyometra

Prof Soha Talaat

Pelvic US

Prof Soha Talaat

Pelvic US & Doppler

Prof Soha Talaat

Prof Soha Talaat

Ovaries

Prof Soha Talaat

Prof Soha Talaat

Dominant follicle

Prof Soha Talaat

Post menopausal ovary

Prof Soha Talaat

PCO

Prof Soha Talaat

PCO

Prof Soha Talaat

Ovarian cysts

Prof Soha Talaat

Corpus leuteum cyst

Prof Soha Talaat

Functional Ovarian Cyst

• Extremely common• Failure of a follicle to

rupture• Size > 30 mm• US features :

– Anechoic– Posterior

enhancement– Thin, smooth wall < 3

mm

• Strategy :– Next cycle US

follow-up (Day 5-7)– Disappearance of

the cyst, although…

– A functional cyst can be present during several months

– Give time…..Prof Soha Talaat

Simple cyst

Prof Soha Talaat

Paraovarian Cyst

• Wolfian duct remnant in the mesovarium

• Detection on routine US• Size : 2-5 cm or more

• Clues :– Cyst besides a normal

ovary– Thin wall, anechoic

content– Beak sign with the ovary

Prof Soha Talaat

PERITONEAL INCLUSION CYSTS

• Nonneoplastic reactive mesothelial proliferations. Abnormal functioning ovaries and peritoneal adhesions are usually present.

• These cysts occur exclusively in premenopausal women with a history of previous abdominal surgery, trauma, PID, or endometriosis.

• Patients usually present with pelvic pain or mass.

• Radiographic features

• Extraovarian location• e Spider web pattern

(entrapped ovary): peritoneal adhesions extend to surface of ovary distorting ovarian contour

• Oblong loculated collection simulating hydro- or pyosalpinx

• * Complex cystic appearance simulating paraovarian cyst

• Irregular thick septations accompanied by complex cystic mass, simulating

• ovarian neoplasmProf Soha Talaat

Pelvic adhesions( due to previous surgery and PID) surround the ovary and create complex cystic masses.

US depicts a normal-appearing ovary that is surrounded by loculated fluid, in a pattern resembling a spider web. Ovary

Prof Soha Talaat

Follicular development

Prof Soha Talaat

Follicular monitoringmulti-planer 3D

Prof Soha Talaat

Hyperstimulation

Prof Soha Talaat

Luteal Cyst• Detected during the secretory phase

(D 15-28) of the menstrual cycle• Size : 2-7 cm• Polymorphism :

– Heterogeneous content with fibrin septa: « fish net »

– Clot simulating vegetation– Pseudo-solid cyst

• Color Döppler :– Non vascular septa– Vascularized thick wall– May be misdiagnosed as a

cystadenocarcinoma US Follow-up 2 months later (1 month is

too early !!!)Prof Soha Talaat

Non ruptured follicle

Prof Soha Talaat

Prof Soha Talaat

Complex cyst

Echogenic non vascular parts Follow up post menstrual

Prof Soha Talaat

Complex cyst

Prof Soha Talaat

LargeFunctional

Cyst•Trick : harmonic

imaging is useful to ascertain that the

lesion is fluid-filled

Prof Soha Talaat

Color Döppler?• Color Döppler is not

accurate :– In 30 % of functional

ovarian cyst walls, arteries are detected

– Presenting with a low resistive index

• Do not take it for malignancy !!!

Prof Soha Talaat

Endometriosis

Prof Soha Talaat

Prof Soha Talaat

Endometriosis &pelvic adhesions

Prof Soha Talaat

Anatomic location of endometriosis• Endometrial glands +

stroma in ectopic location – Ovary: endometrioma– Peritoneum

• Bladder 6.4%• Intestine 9.9%

– Subperitoneal space (posterior endometriosis)

• Utero-sacral ligaments and torus uterinus 69%

• Vagina / rectovaginal pouch 14.5% (painful defecation)

Fauconnier A et al, Fertil Steril 2002; 78: 719Prof Soha Talaat

Imaging protocol• Ultrasound• transabd. + transvaginal + Color Doppler

• MRI • Fasting and IM injection of peristaltic

inhibitor• T2 in 3 orientations: TR/TE 4000/90

– 512x256 matrix, 30cm FOV, 3-4 mm, subcut anterior sat bands

– Check best orientation at T2 for three T1– Native T1– T1 with fat saturation– T1 fat sat with IV contrast (bladder, bowel,

vagina)Kinkel et al, Eur Radiol 2006; 16: 285Prof Soha Talaat

Endometrioma

• Various sonographic appearance from anechoic to echogenic depending on the amount and coagulation of blood components

• 88% shows posterior acoustic enhancement .

• Borders may be irregular due to adhesions

Rarely, sediment or clots

Prof Soha Talaat

Endometrioma

Prof Soha Talaat

•Neovascularization detected in the cyst wall •Absence of color flow in some echogenic portions like blood clots in hemorrhagic cysts and endomertiomas suggest their benign cystic nature .

Role of colour Doppler

Prof Soha Talaat

Endometrioma

Prof Soha Talaat

Prof Soha Talaat

Pelvic endometriosis

Prof Soha Talaat

Dermoid cyst

• Echogenic focus within a predominantly cystic mass .(tip of ice berg sign ).

• Echogenic focus with posterior shadowing .

• Fat or hair fluid level.

Prof Soha Talaat

Dermoid

Prof Soha Talaat

Dermoid

Prof Soha Talaat

Prof Soha Talaat

Immature teratoma vascularized solid part

Prof Soha Talaat

Immature teratoma vascularized solid part

Prof Soha Talaat

Scoring system for cystic teratoma based on TVS& Doppler

Score

Reproductive age 2

B MODE:

Unilateral

Serial sonography positive

2

2

Thick walls.

Thin echogenic band like echoes

Echogenic tubericle within the ovary

2

2

2

Colour Doppler :no vascularity 2Prof Soha Talaat

Prof Soha Talaat

using gray scale US, color Doppler and magnetic resonance imaging in

evaluating adnexal masses

TAS ↓

TVS with complementary C D(To assess internal echo pattern and exact site of origin)

↓ ↓ ↓ Non hyperechoic solid cystic anechoic cystic

echoicParts, papillae & border line thick Septation & other, masses signs of malignancy. ↓ ↓ ↓ Malignant lesion. Benign lesion pelvic MRI is recommended

Prof Soha Talaat

Prof Soha Talaat

Prof Soha Talaat

Doppler findings ofbenign and maliqnant adnexal masses

Benign ovarian tumors• Regular distribution of blood vessels• Blood vessels are equally calibrated• Blood vessels have muscle fibers with moderate-to-high

resistance index values (RI=0.42)

Malignant ovarian tumors• Irregular distribution of blood vessels• Blood vessels have irregular diameter• Low resistance index values (RI<0.42)• Display of tumoral lakes and arterio-venous shunts

Prof Soha Talaat

Ovarian tumoursClassification:Histogenetic classification: As the ovary is composed of surface epithelium, germ cell apparatus

and stroma, ovarian tumours are classified into:1- Epithelial tumours 2- Germ cell tumours 3- Stromal tumours

Clinical classification:As ovarian tumours may be cystic or solid or complex and either of

them may be benign or malignant,

Prof Soha Talaat

Serous / Mucinous cystadenoma

– Thin wall– Pure cystic content

Serous : unilocular Mucinous : multilocularProf Soha Talaat

Cystadenocarcinoma:Typical malignant features

• US provides orientation tips• Malignant features :

– Solid-cystic lesion– Multiple papillary projections– Thick, irregular wall > 3 mm– Vascularized septations

Prof Soha Talaat

Prof Soha Talaat

Cystadenocarcinoma

Color doppler : Vascularized vegetationsProf Soha Talaat

Clear cell carcinoma :Uniloculated cyst with solid parietal nodules

Undifferenciated carcinoma : solid tumors with necrosis

Prof Soha Talaat

Solid ovarian mass

Prof Soha Talaat

Ovarian Fibroma•US features:

–Solid enlarged ovary–Homogenous content

–Arterial signal

•US is equivocal in case of “old” fibroma: –Heterogeneous

–Shadowing–Vessel paucity

Prof Soha Talaat

Ovarian Fibroma

Prof Soha Talaat

Borderline ovarian tumors• These tumors are benign, but have the potential

for malignancy• Cyst with papillary vegetations

– US is not able to differentiate a Borderline tumour from a cystadenocarcinoma

– MRI might be useful to detect subtle vegetations

• Recurrence is common : – The recommendation is to perform ovariectomy and

and a close follow-up of the controlateral ovary

Prof Soha Talaat

Prof Soha Talaat

Border line ov mass

Prof Soha Talaat

Complex adnexal mass

• Haemorrhagic cyst-contains diffuse internal echoes or an irregular clump of echoes due to clot. Repeat scans helpful to show change.

• Ruptured cyst-typical history, irregularly-shaped cyst with surrounding fluid.

• Torsion of cyst or ovary-heterogeneous enlarged ovary with or without a thick-walled cyst with internal echoes.

• Endometriosis:a clump of solid echoes within the cyst due to clot. Follow-up

• Acute / chronic tubo-ovarian abscess.• Dermoid cyst-complex mass with cystic and solid areas,

fat change in the appearance of the internal echoes confirming its and/or calcification.

Prof Soha Talaat

Complex adnexal mass

• Neoplastic ovarian tumours, benign and malignant.• Pedunculated fibroid differentiation from an ovarian

mass• Ectopic pregnancy-should always be considered in a

patient of child-bearing age. Pregnancy test important.• Other inflammatory masses-e.g. appendix or diverticular

mass.• Other neoplastic masses-e.g. arising from the bowel or

peritoneum (benign peritoneal mesothelioma).

Prof Soha Talaat

Masses Mimicking an Ovarian Origin

• Pedunculated sub-serous fibroma

• Chronic Hydrosalpinx

• Peritoneal cyst

• Pelvic abscess of intestinal origin

Prof Soha Talaat

Prof Soha Talaat

Adnexal mass

Prof Soha Talaat

Chronic ectopic

Prof Soha Talaat

may reflect may reflect benign or benign or malignant malignant

processes of processes of the ovary.the ovary.

Bilateral Diffuse ovarian enlargement

Prof Soha Talaat

Diffuse ovarian enlargment Benign causes of ovarian enlargement

• Luteomas.

• Tumors such as mature cystic teratomas, fibrothecomas, cystadenomas .

• rare conditions including capillary hemangioma and massive edema of the ovaries.

Prof Soha Talaat

Benign diffuse enlargmentTorsion( edema)

• Ovarian torsion (adnexal torsion) is an infrequent but significant cause of acute lower abdominal pain in women.

• This condition is usually associated with reduced venous return from the ovary as a result of stromal edema, internal hemorrhage, hyperstimulation, or a mass.

Prof Soha Talaat

•An enlarged ovary (>5 cm)• Prominent peripheral nonovulatory follicles .•Small amount of free fluid•May depict the cyst (or, less commonly, the mass) that predisposed the ovary to torsion.

US

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•Imaging modality of choice •An absence of arterial waveforms or high resistance to arterial flow with absent venous flow are highly suggestive. • Particularly when those findings are accompanied by ovarian enlargement. •However normal arterial waveforms do not rule out torsion.

Doppler

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Diffuse ovarian enlargment Ovarian malignancies include epithelial, stromal and germ-cell

tumors. Primary malignancies that may exhibit

metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma

Prof Soha Talaat

Malignant diffuse enlargementKrukenberg

•Metastatic signet ring cell adenocarcinoma of the ovary. •uncommon, 1% to 2% of all ovarian tumors•80% bilateral

Prof Soha Talaat

Ovarian lymphoma

• Primary female reproductive system lymphomas are distinctly uncommon.

• genital involvement is more likely a component of widely disseminated disease. NHL of the ovary may be a source of pelvic retroperitoneal masses completely engulfing the internal female genitalia.

Prof Soha Talaat

Ovarian lymphoma

• lymphoma of the ovary may appear as a discrete hypoechoic mass or a large confluent aggregate mass that may fill the pelvis. Hyperemia is often observed

• CT may reveal low-attenuation solid masses involving the uterus or confluent masses displacing or engulfing the pelvic organs

Prof Soha Talaat

Lymphoma

Prof Soha Talaat

Sonographic anatomy

• The fallopian tubes: Normal tubes could not be detected by US. Test for tubal patency(sonohysterography)

• The cul de sac; Most dependent part of peritoneal cavity. Normal findings a small amount of peritoneal

fluid .

• Urinary bladder : anechoic , normal wall thickness .

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Normal tube delineated by fluid

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Hydrosalpinx• Hydrosalpinx, pyosalpinx,

and hematosalpinx are used to describe a dilated fallopian tube filled with fluid, pus, or blood, respectively.

• Blockage usually occurs at the fimbriated end of the fallopian tubes and is caused by adhesions from infectious or inflammatory processes.

• The most common causes of hydrosalpinx are pelvic inflammatory disease and endometriosisProf Soha Talaat

Prof Soha Talaat

Pyosalpinx

• Color Doppler US image shows a hypoechoic tubular structure(arrow) containing echogenic debris. There is no internal blood flow; however, there is increased surrounding vascularity.

Prof Soha Talaat

TOA

Prof Soha Talaat

What about

fallopian cancer

Fallopian tube cancer is the least common of gynecological malignancies (0.3%) . It was first described by Renaud in 1847.1 Since then, there have been over 1500 cases

Prof Soha Talaat

Histopathology

1-Benign tumors

2-malignant tumors

a- 1ry fallopian tumors

b- 2ry fallopian tumors

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Benign tumor:1- Adenomatoid tumor a-Most common benign tumor of fallopian tube

Prof Soha Talaat

Malignant tumors:1-1ry tumors a- Primary adenocarcinoma: has a papillary features, it is the most common 1ry tumor of the tubes represent 90% of the cases b-gross:

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b-other types: 1-clear cell carcinoma 2-squamous cell carcinoma 3-mixed carcinoma 4-endometrioid carcinoma 5-sarcomabut all these types are LESS common

N.B. The common mullerian origin of fallopian tube and ovarian cancer could explain the cytological and histological similarities between them. Difficulties in diagnosis exist due to the similarities shared between fallopian tube carcinoma and epithelialovarian carcinoma

Prof Soha Talaat

2-2ry tumors:• Tubal involvement often by ovarian borderline

tumors and carcinomas, cervical and endometrial carcinoma (invasive or in-situ) and pseudomyxoma peritonei

• Metastases from extra-genital site are rare

Mode of transmission

*direct

*lymphatic

*blood

*transcelomicProf Soha Talaat

Clinical picture:

Triad: (latzko triad)1-vaginal bleeding &serosangenous bleeding

2-hydrops lubae profluence

3-adenxal mass

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Diagnosis:

Ultrasound

MRI pelvis

Serum CA-125

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u/s images

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Pelvic adhesions (PID)

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PELVIC VARICES• Transvaginal Ultrasound:• Identification of multiple dilated

structures around the uterus and ovaries with venous blood Doppler signal

• Dilated pelvic vein with a diameter greater than 4 mm

• Slow blood flow (about 3 cm/sec)

• Dilated arcuate vein in the myometrium communicating between bilateral pelvic varicose veins

• More than 50% of women have associated cystic ovaries

Prof Soha Talaat

Prof Soha Talaat

Prof Soha Talaat

Prof Soha Talaat

Prof Soha Talaat

Prof Soha Talaat