Prof Soha Talaat Cairo university Imaging in gynecology final

Imaging in
gynecology
Prof Soha Talaat

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

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

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
Transverse pelvic plane
Prof Soha Talaat

Transperineal (translabial) US
Dietz. Pelvic floor ultrasound: a review. Am
J Obstet Gynecol 2010.Prof Soha Talaat

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 Anatomy
Sagittal Section
Prof Soha Talaat

Stress incontinence
Prof Soha Talaat

TRUS
• 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

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 agenesis
Don’t forget to look in inguinal region
Androgen
insensitivity
syndrome
Prof Soha Talaat

Uterine shape
Prof Soha Talaat

Septate uterus
Prof Soha Talaat

Pregnancy in septate
Prof Soha Talaat

Bicornuate uterus
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

unicornuate
One normally developed
mullerian duct while the
contralateral duct is
either hypoplastic or
absent
Prof Soha Talaat

Obstructive anomalies
hematocolpos
Prof Soha Talaat

Hematometria &heamatocolpos
Prof Soha Talaat

Haematometra , vaginal atresia
Prof Soha Talaat

Uterus
endometrium
phase AP
diameter
Proliferative 4-8 mm
Periovulatory 6-10mm
Secretory 7-14mm
Prof Soha Talaat

Endometrium :how to measure
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

Is this the same
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 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

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

Endometrial mass
Prof Soha Talaat

??Endometrial cancer
Prof Soha Talaat

Molar
pregnancy
Prof Soha Talaat

Choriocarcinoma
Prof Soha Talaat

Sonohysterography
Normal uterine cavity
Prof 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

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

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

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

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

Pedunculated fibroid
Prof Soha Talaat

Fibroid (interstitial)
Prof Soha Talaat

Interstitial fibroid
Prof Soha Talaat

Sub-mucous fibroid
Prof Soha Talaat

Intracavitary 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 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

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

ADENOMYOSIS ON U/S
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 & Doppler
Prof Soha Talaat

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

Dominant follicle
Prof Soha Talaat

Post menopausal ovary
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

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 monitoring
multi-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

Complex cyst
Echogenic non vascular
parts Follow up post menstrual
Prof Soha Talaat

Large
Functional
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

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

•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

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

Immature teratoma
vascularized solid part
Prof Soha Talaat

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

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

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

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

Serous / Mucinous cystadenoma
– Thin wall
– Pure cystic content
Serous : unilocular Mucinous : multilocular
Prof 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

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

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

Chronic ectopic
Prof Soha Talaat

may reflect
benign or
malignant
processes of
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 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

•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

•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

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 enlargement
Krukenberg
•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

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

Normal tube delineated by fluid
Prof Soha Talaat

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

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

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
Prof Soha Talaat

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

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

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

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

l picture :Clinica
Triad: (latzko triad)
1-vaginal bleeding &serosangenous bleeding
2-hydrops lubae profluence
3-adenxal mass
Prof Soha Talaat

Diagnosis :
Ultrasound
MRI pelvis
Serum CA-125
Prof Soha Talaat

Pelvic adhesions (PID)
Prof Soha Talaat

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 Cairo university Imaging in gynecology final

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