Genital Tract Diseases

WOMEN’S IMAGING

Genital Tract Diseases

Maria Theresa M. Navarro, MD Fourth Year Radiology Resident Department of Medical Imaging Quirino Memorial Medical Center

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

ULTRASOUND OF THE UTERUS

ANATOMY OF THE UTERUS

UTERUS  uterus is located in the true pelvis between the urinary bladder anteriorly and rectosigmoid posteriorly  anterior surface is covered with peritoneum to the level of the junction between the uterine corpus and cervix  vesicouterine pouch or anterior cul-de-sac – peritoneal space anterior to the uterus  posterior cul-de-sac – peritoneal reflection extends to the posterior fornix of the vagina 

UTERUS  lateral peritoneal reflection forms the broad ligament  uterus has two major body parts : 

 body

or fundus  cervix – lower cylindrical portion that projects into the vagina 

isthmus – narrow portion of the uterus that corresponds to the approximate position of the internal os and is the separation between

Size Of The Uterus Length (cm)

Width (cm)

AP Diameter (cm)

Nulliparo 6.0 – 8.5 us

3- 5

2- 4

Multiparo 8 – 10.5 us

4-5

3- 5

Menopau 3.5 – 7.0 se

2-4

1.7 – 3.3

UTERUS  Uterine Position 

 anteversion

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– cervix and vagina form a 90 deg

angle  retroversion, retroflexion, and tilting of the uterus to the right or the left  normal variants Zonal Anatomy of the Body of the Uterus (MRI)  centrally  endometrium demonstrates high signal intensity  junctional zone  inner myometrial layer shows low signal intensity  outer myometrium  intermediate signal intensity

Zonal Anatomy

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Endometrium (UTZ) thin echogenic stripe thickness and sonographic appearance of the endometrium change cyclically with the menstrual cycle

Ultrasound of the Uterus 

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Transabdominal and transvaginal ultrasound Hysterosonography – endometrial imaging  may confidently diagnose submucosal fibroids and may distinguish between a hyperplastic endometrium and a polyp.

Uterus

Hysterosonography

A. Hysterosalpingogaphy catheter is inserted into the lower uterine segment with a distended occluding balloon. B. Coronal hysterosongoram obtained after instillation of saline shows air within the occluding balloon of the catheter, with a resultant artifact along the left uterine wall

Sonohysterography

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

Hysterosalpingogram

Congenital Malformations 

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diagnosed during work-up for infertility, frequent miscarriages, or menstrual disorders Three different causes: 1. arrested development of mullerian ducts 2. failure of fusion of the mullerian ducts 3. failure of resorption of the median septum

CONGENITAL MALFORMATIONS

Unicornuate Uterus  agenesis of a unilateral mullerian duct  poorest fetal survival  most difficult to diagnose (confused as

CONGENITAL MALFORMATIONS Didelphic Uterus  complete failure of fusion of the mullerian duct 

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has two complete uteri, including endometria, myometria and serosal surfaces on each side may extend down to the cervix and may also involve a

CONGENITAL MALFORMATIONS Bicornuate Uterus  partial fusion of the mullerian ducts 

has some fusion of the lower uterine segment, but there are two uteri in the superior segment complete with endometrial cavities, myometria, and covering

Bicornuate Uterus

Bicornuate Uterus

Bicornuate uterus with pregnancy in one horn

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CONGENITAL MALFORMATIONS

Septate Uterus  failure of resorption of the septum after complete fusion of the mullerian ducts  may have thick or thin fibrous septation, including a significant myometrial component Arcuate Uterus  characterized by a small dimple or concave superior surface of the fundus.  variant than a deviant of normal

BENIGN UTERINE CONDITIONS  ADENOMYOSIS  migration of endometrial glands from the stratum basale into the myometrium  ectopic glands tend to be 2 – 3 mm below the endometrial-myometrial junction  Sonography and MRI  round appearance of the uterus without a discrete mass or contour deformity 

BENIGN UTERINE CONDITIONS  ADENOMYOSIS  TVS : abnormal heterogenous myometrium with areas of increased or decreased echogenicity  Color Doppler Imaging : hypervascularity throughout the lesion (vs. fibroids – peripheral flow) 

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

BENIGN TUMORS  LEIOMYOMAS  most common neoplasm of the uterus (20% to 30% of women older than 30 yo)  misnamed fibromyomas or fibroids  interleaved bundles of smooth muscle with varying amounts of fibrous connective tissue 

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BENIGN TUMORS

LEIOMYOMAS  Submucosal (5%- 10%) most symptomatic may cause menorrhagia, metrorrhagia, or postmenopausal bleeding  Intramural (most common) and Subserous (10% - 20%) if large may cause pressure effects on the adjacent pelvic organs or ligaments

Leiomyoma

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

BENIGN TUMORS  LEIOMYOMAS  acute symptoms are seen if the leiomyomas undergo torsion or necrosis  Broad-ligament myomas can simulate adnexal masses  estrogen dependent 

BENIGN TUMORS  LEIOMYOMAS  Ultrasound appearance depends on size, site, and age of tumor  sole manifestation of fibroids may simply be uterine enlargement or nodularity of the contour.  may also displace or distort the endometrial echo or alter the homogeneous midecho of the myometrium  great “mimickers” and may masquerade as endometrial 

polyp, ovarian masses or even stool-filled large bowel

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BENIGN TUMORS

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

Leiomyomas

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

Leiomyoma

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BENIGN TUMORS

Leiomyomas  Definitive diagnosis can be made by showing the “claw sign”, analogous to renal masses, of stretching of myometrium around the base of the lesion

BENIGN TUMORS  ENDOMETRIAL HYPERPLASIA  MOST COMMON cause of vaginal bleeding in both pre- and postmenopausal women  results from unopposed estrogen stimulation  On ultrasound 

 pronounced

endometrial stripe  may be indistinguishable from an endometrial polyp or carcinoma, even on TVS

BENIGN TUMORS  ENDOMETRIAL HYPERPLASIA  HSG can be definitive, but the diagnosis is usually confirmed by endometrial biopsy  Pipelle biopsy is often used as an office procedure at first referral for vaginal bleeding;  D & C and hysteroscopy are reserved more for therapeutic procedures 

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BENIGN TUMORS

POLYPS  represent areas of overgrowth of endometrial glands and stroma covered by endometrial epithelium  lesions may be pedunculated or sessile  fundus and multiple in 20%  at autopsy, seen up to 10% of women  vaginal bleeding or mucous discharge 

BENIGN TUMORS  POLYPS  appear as focal areas of increased endometrial thickening  confident ultrasound diagnosis may sometimes require HSG  TAS may be normal, whereas TVS images show focal irregularity of the endometrial stripe 

BENIGN TUMORS  POLYPS  HSG permits more accurate TVS identification of the lesion and more accurate distinction among hyperplasia, polyp, fibroid, or carcinoma  MRI can be used to confirm a lesion suspected to be a polyp, which has a moderately high signal on T2, versus fibroids, which, is especially when small, have a low signal. 

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BENIGN TUMORS

ARTERIOVENOUS MALFORMATION  multiple

communications between the arterial and venous system without an intervening capillary network.  congenital or more often iatrogenic due to intrauterine instrumentation.

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BENIGN TUMORS

ARTERIOVENOUS MALFORMATION  Color

and duplex Doppler sonography shows serpiginous cystic areas and a vascular tangle of blood vessels  demonstrate high velocity, lowresistance flow on duplex Doppler.

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BENIGN TUMORS

Arteriovenous Malformation  On

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

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MISCELLANEOUS BENIGN PROCESS PELVIC INFLAMMATORY DISEASE rarely confined to the uterus endometrium shows histologic changes of inflammation in more than 70% of women with acute PID 40% with mucopurulent cervicitis nonspecific on ultrasound, correlated with clinical picture thickening and irregularity of the endometrium and fluid, debris, or even gas within the endometrial cavity

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MISCELLANEOUS BENIGN PROCESS

Pyometra (pus in the uterine cavity) may complicate cervical stenosis acquired causes : infection, neoplasia, and iatrogenic factors clinical findings : more pronounced in premenopausal than postmenopausal women ultrasound appearance :  dilated, fluid-filled endometrial cavity  echogenicity of the cavity varies with the degree of debris or clot  distinction from endometrial polyp or even carcinoma is occasionally impossible when the fluid becomes uniformly echogenic.

Pyometra

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MISCELLANEOUS BENIGN PROCESS

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Hydrometocolpos when the hymen is imperforate, allowing the accumulation of secretions within the uterus and vagina Asherman Syndrome intrauterine fibrous adhesions cross the endometrial cavity. the synechiae form a mesh or spider’s web within the uterine lumen may cause infertility or hypo- or amenorrhea the fibrous strands can calcify, with a characteristic sonographic appearance.

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MISCELLANEOUS BENIGN PROCESS  Nabothian Cysts  obstructed and hence dilated inclusion cysts, of no clinical relevance, located within the cervix  routinely seen on TAS and especially TVS  Monckeberg’s Medial Sclerosis  manifesting as peripheral punctate echoes, is due to calcification in the smaller uterine artery branches 

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MALIGNANT DISEASE OF THE UTERUS Cervix  Ultrasound : not especially useful in the diagnosis of cervical disease, including neoplastic conditions  Papanicolaou-stained cervical smears incidence of cervical dysplasia and carcinoma in situ has risen sharply  whereas, that of invasive carcinoma has plummeted reciprocally.  women at risk : multiple sexual partners and precocious onset of coitus

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MALIGNANT DISEASE OF THE UTERUS Cervix

90% of invasive cervical carcinomas – originate from squamous cells in the ectocervix. 10% - arise as adenocarcinoma, usually from the more deeply situated columnar epithelium Imaging : chief role is staging of cervical carcinomas MRI – most impact on preoperative staging  squamous

cell carcinoma usually spread by local and lymphatic invasion  Gadoliniuim contrast enhancement at MRI is important in assessing patients with suspected recurrence after radiotherapy or surgery for the initial disease.

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MALIGNANT DISEASE OF THE UTERUS

Cervix  Sonography : to document the complications of advanced cervical disease and its treatment example : cervical stenosis, intrauterine fluid collection, or hydronephrosis

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MALIGNANT DISEASE OF THE UTERUS

ENDOMETRIAL CARCINOMA  MOST COMMON form of gynecologic malignancy  Incidence : 33,000 new case per year in the US  mostly confined to postmenopausal women  present early with postmenopausal bleeding  Ultrasound : either diffusely or partially echogenic  although 10% - 15% maybe isoechoic  when these features are seen, warrants HSG and biopsy

Staging of Endometrial Carcinoma  Prognostic Factors:  histologic grading of the tumor  extent of myometrial invasion  documentation of lymph node metastases

Endometrial Carcinoma (TVS)

The endometrium is thickened and irregular in this postmenopausal patient. Near the fundus, the endometrial– myometrial junction is indistinct, indicating myometrial invasion (arrow).

Endometrial Carcinoma (MRI)

Sagittal gadolinium-enhanced T1-weighted fat-suppressed MR image shows an endometrial cancer (T) with deep myometrial invasion. Note the thin rim of normal myometrium (black arrows). The disease extends to the upper third of the vagina (white arrow).

Staging of Endometrial Carcinoma  Stage IA - depth of myometrial invasion is none  Stage IB – depth is superficial  less than half of the myometrium  Stage IC – deep  more than half of the myometrium  Stage II - invasion of the cervix  worse prognosis  TVS is not as accurate as MRI in monitoring cervical involvement

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Endometrial Carcinoma  Incidence of regional and distant lymph node involvement is linked to the degree of myometrial invasion.  Role of imaging is negligible once a suspicious lesion has been identified  After biopsy diagnosis  hysterectomy  Ultrasonography: more accurate than serum CA125 levels in predicting myometrial invasion of endometrial carcinoma.  distant spread, beyond the serosa, is not reliably documented by ultrasound

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DIFFERENTIATION OF BENIGN FROM MALIGNANT CONDITIONS OF THE ENDOMETRIUM

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Benign Conditions  cystic atrophy, cystic and adenomatous hyperplasia, endometrial polyps  76% of benign conditions show cystic changes

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Malignant uterine tumors  thickened echogenic endometrium  enlarged  retroverted  lack subendometial halo  24% of endometrial malignancies show cystic changes

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DIFFERENTIATION OF BENIGN FROM MALIGNANT CONDITIONS OF THE ENDOMETRIUM

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No difference in Doppler parameters has been found between malignant and benign uterine diseases calculated sensitivity of increased color flow in predicting malignancy is low, approx. 40% Neither TVS nor color Doppler imaging can distinguish benign lesions from their malignant counterparts Differentiation is made by D & C, by hysteroscopy, and biopsy, or by ultrasound-guided suction biopsy.

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CLINICAL PERSPECTIVE 

ABNORMAL UTERINE BLEEDING     

MOST COMMON indication for gynecologic intervention Endometrial carcinoma is only seen in less than 1% of postmenopausal patients with abnormal vaginal bleeding D & C is insensitive for small polyps or foci of endometrial carcinoma Suction endometrial biopsies obtained with a Pipelle de Cornier device are renowned for sampling inaccuracies. Hysteroscopy is the most accurate method for excluding, or confirming, uterine disease as a cause for abnormal uterine bleeding 

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most invasive procedure and the most costly

TVS and HSG – preliminary screening Normal endometrial appearances on HSG correlate strongly with negative histology

CLINICAL PERSPECTIVE 

Abnormal Uterine Bleeding TVS and HSG – preliminary screening  Normal endometrial appearances on HSG correlate strongly with negative histology  In several large studies in perimenopausal women with uterine bleeding, HSG recorded 90% - 99% sensitivity, and 75% - 83% specificity in differentiating women with intrauterine lesions and those with normal or atrophic endometrium 

CLINICAL PERSPECTIVE  

INFERTILITY Causes of acquired infertility: endometrial adhesions (Asherman syndrome)  endometritis  PID  endometriosis 

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Septate uterus Radiographic hysterosalpingography – superior technique

CLINICAL PERSPECTIVE 

Menopause and Hormone Replacement Therapy

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endometrial regression  halted or reversed by administration of exogenous estrogen unopposed estrogen can induce endometrial carcinoma HRT regimens include progesterone supplements to counteract the effect of estrogen alone on endometrial proliferation Continuous HRT significantly influences the thickness of the postmenopausal endometrium but not of the myometrium endometrial thickness of 8 mm - cutoff normal range

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CLINICAL PERSPECTIVE 

Tamoxifen menopausal patients with breast cancer receive tamoxifen therapy (partial estrogen receptor agonist)  Effects on uterus : 

epithelial metaplasia  hyperplasia  carcinoma 

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TVS may show thickened, irregular cystic endometrium  cystic changes in the subendometrial zone without epithelial disease have also been documented. 

CLINICAL PERSPECTIVE 

Peurperium postpartum uterus should return to near normal size within 6 to 8 weeks after delivery.  increasing maternal parity is associated with slightly but significantly larger uterine dimensions up to 4 weeks postpartum. 

Pathologies in the Cervix

Morphology of Uterine Cervix  

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cylindrical portion of the uterus enters the vagina and lies at right angles to it 2-4 cm long isthmus –point of juncture with the uterus, marked by constriction of the lumen separated anteriorly from the bladder by a layer of fatty tissue posteriorly, covered by peritoneum

Morphology of Uterine Cervix   

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laterally, cervix is connected to the parametria and broad ligament ureters descend about 2cm lateral to the cervix and curve under the uterine arteries cervical canal – extends from the internal os, where it joins the uterine cavity, to the external os, which projects into the vaginal vault. internal os – where histologic transition from endometrial to endocervical glands is seen. upper third of the cervical canal or isthmus – undergo menstrual changes although less pronounced than the endometrial lining

CERVICAL ANATOMY  1.

2.

3.

DIVIDED INTO THREE ZONES (MRI): endocervical mucosa – increased signal intensity due to mucus glands cervical stroma – low signal intensity owing to the presence of fibrous connective tissue peripherally located smooth muscle, which demonstrates intermediate signal intensity

Benign Gynecologic Conditions 

CERVICITIS  chronic inflammation of the cervix stimulates reparative upward growth of the squamous epithelium, causing obstruction of some of the ducts of the endocervical glands NABOTHIAN CYSTS  results from retention of mucus within the glands

Nabothian Cysts

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

Benign Gynecologic Conditions 

CERVICAL POLYP 

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pedunculated, soft, smooth , red or purple and vary in size from a few millimeters to 3 cm. microscopically, hyperplastic condition of the endocervical epithelium and contains a large number of blood vessels at the surface edematous and inflamed can cause leukorrhea and intermentrual spotting

Cervical Polyp

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

Benign Gynecologic Conditions 

CERVICAL STENOSIS  usually asymptomatic, but may cause abnormal vaginal bleeding, dysmenorrhea, and infertility  if stenosis is severe, accumulation of uterine secretions (hydrometra or pyometra) or blood (hematometra) results  intracavitary fluid – indirect indicator of cervical stenosis

Malignant Gynecologic Conditions 

SQUAMOUS CELL CARCINOMA  MOST COMMON TYPE OF CERVICAL CANCER  precursors are the cervical dysplasias classified as mild (CIN-1), moderate (CIN-2), or severe (CIN-3).  screening with Papanicolaou smears  average transit time to carcinoma in situ for

Malignant Gynecologic Conditions 

ADENOCARCINOMA OF THE CERVIX  10% -15% of cervical cancer  arises from the columnar epithelium of the endocervical canal and glands  behavior, staging, and treatment of squamous cell and adenocarcinoma of cervix are similar.

Staging 

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Stage I  carcinoma confined to the cervix  minimally invasive disease  disease with invasion of > 5 mm depth from the base of the surface or gland\  > 7 mm horizontal spread Stage IIA  extension to the upper vagina Stage IIB  to the cardinal ligaments but not the lateral walls

Stage I B Cervcal Carcinoma

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

Stage IIB Cervical Carcinoma

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

CERVICAL CARCINOMA

Cervical carcinoma with endophytic growth in a 59year-old woman. The preoperative imaging diagnosis was stage IIb carcinoma. Sagittal T2-weighted MR image shows a slightly hyperintense mass that replaces the cervix (white arrows). The lesion is located almost within the cervical canal. The patient also has a

Staging 

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Stage IIIA  extension to the lower third of the vagina, without extending to the pelvic wall Stage IIIB  to the pelvic side wall, including cases of hydronephrosis Stage IV  carcinoma extending beyond the true pelvis and involving the mucosa of the bladder and rectum

Stage IIIA Cervical Carcinoma

a) Sagittal T2-weighted MR image shows a slightly hyperintense, exophytic, solid mass that extends along the anterior vaginal wall and reaches the lower one-third of the vagina (arrow). (b) Axial T2weighted MR image shows that the low signal intensity of the anterior vaginal wall is partly disrupted (arrowheads) and the fatty tissue between the mass and the posterior bladder wall has disappeared. However, the mass does not infiltrate the vesical

Stage IIIB Cervical Carcinoma

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

Stage IV Cervical Carcinoma

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

Stage IV Cervical Carcinoma

Stage IVb cervical carcinoma. (a) Sagittal T2weighted MR image shows a large mass in the uterine cervix. (b, c) CT scans show metastases of paraaortic lymph nodes (arrows in b) and

Cervical  CERVICAL CARCINOMA carcinoma with exophytic growth in a 44year-old woman. The pathologic stage was Ib-1. Sagittal T2weighted MR image shows a slightly hyperintense, cauliflower-like tumor in the posterior lip of

Staging 

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Lymphatic spread occurs by direct extension or tumor emboli Lymphatic node metastases occurs in: 15% of Stage I  30% of Stage II  50%of Stage III  >60% of Stage IV 

Imaging  

Transvaginal Ultrasound Transrectal Sonography tumor is seen as a hypo- or isoechoic area poorly distinct from normal cervical stroma  when endocervical canal is involved, its linear echoes are disrupted or appear as hyperreflecting areas (gaseous necrosis) 

Imaging  sonography

can evaluate gross invasion of the parametrium, pelvic side walls, and bladder.  parametrial invasion – irregular lateral tumor margins or vascular encasement  invasion of lateral side walls – parametrial thickening or a soft tissue mass extending to the side walls.  bladder invasion – include direct tumor invasion or immobility

Imaging  Sonography

is limited in its ability to evaluate lymph nodes and to differentiate benign pelvic disease such as endometriosis from tumor invasion.  Thus, sonography is not recommended as the sole imaging technique for evaluation of invasive disease.

Imaging  CT

scanning cannot reliably evaluate tumor size and parametrial invasion

 CT

scan is useful in :  detecting invasion of the pelvic side wall  evaluation of obstruction of the urinary tract  detection of nodal disease

Imaging  Soft

Tissue Contrast Resolution of MRI  allows accurate determination of tumor size  positive predictive value for detecting parametrial disease is 67%  high negative predictive value of 95%, making it useful for selecting candidates for surgery  detect lymph node metastases (similar to CT)

Imaging  Soft

Tissue Contrast Resolution of MRI  For extended clinical staging, MRI surpasses other modalities and is indicated for :  clinical stage I disease,  when the tumor is greater than 2 cm,  when tumor size is difficult to determine clinically,  and when the lesion is endocervical

DIAGNOSIS AND FOLLOW-UP OF GESTATIONAL TROPHOBLASTIC DISORDERS

Introduction 

GESTATIONAL TROPHOBLASTIC DISORDER (GTD)  term commonly applied to a spectrum of interrelated diseases, originating from the placental trophoblast that includes:  complete  partial  invasive moles  placental site trophoblastic tumors  choriocarcinoma  Incidence of Molar Pregnancies : 1:41 miscarriages

COMPLETE HYDATIDIFORM MOLE generalized swellling of the villous tissue  diffuse trophoblastic hyperplasia  no embryonic or fetal tissue  diploid, with chromosomes totally derived from the paternal genome probably resulting from the fertilization of an “empty oocyte”, devoid of maternal 23,X by a single spermatozoon 

PARTIAL HYDATIDIFORM MOLE (PHM) 

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refers to the combination of a fetus with localized placental molar degenerations Histologically:  focal swelling of the villous tissue  focal trophoblastic hyperplasia  embryonic or fetal tissue  abnormal villi are scattered within macroscopically normal placental tissue, which tends to retain its shape.

PARTIAL HYDATIDIFORM MOLE (PHM) 90% triploid, having inherited two sets of chromosomes from the father and one from the mother  Ultrasound :  enlarged placenta (thickness > 4 cm at 18 to 22 weeks)  containing multicystic, avascular, sonolucent spaces 

 Gold

standard for the definitive diagnosis, and subtyping of Hydatidiform Moles is histopathologic examination  Diagnostic pathologic features of molar pregnancies are essentially characterized by abnormal proliferation of villus trophoblast

INVASIVE HYDATIDIFORM MOLE  defined as the penetration of molar villi from a CHM or

defined as the penetration of molar villi from a CHM or PHM into the myometrium or the uterine vasculature  contains villous structures with a variable degree of trophoblastic proliferation  produces lower levels of hCG.  SSx: heavy vaginal bleeding  Ultrasonography : focal areas of increased echogenicity within the myometrium.  nodules

appear several weeks after evacuation  similar to lesions of placental site trophoblastic tumors

PLACENTAL SITE TROPHOBLASTIC TUMOR  

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RAREST FORM of GTD composed of intermediate trophoblastic cells from the extravillous trophoblast of the placental bed invade the myometrium by separating muscle bundle and fibers 15% - 20% behave in a malignant fashion, with metastasis to the lungs, liver, abdominal cavity, and brain. 90% of cases develops after a normal pregnancy SSx:amenorrhea of up to 1 year and irregular vagina bleeding of varying duration

CHORIOCARCINOMA    

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highly malignant tumor arises from the trophoblastic epithelium metastasize readily to the lungs, liver, and brain SSx: dyspnea, neurologic symptoms, abdominal pain a few weeks or months and sometimes up to 10-15 years after their last pregnancy Necrosis and hemorrhage are often present inside chorocarcinomas, and corresponding metastasis produces a sonographic picture of a semisolid echogenic mass. Better evaluated by computed tomography or MRI

CHORIOCARCINOMA serum hCG level must be measured a  appropriate histologic examination performed in any woman of reproductive age presenting with widespread lesions, metastasis of unknown origin, cerebral, or intra-abdominal bleeding  50% follow molar pregnancy  30% occur after miscarriage  20% occur after an apparently normal pregnancy 

PERSISTENT TROPHOBLASTIC TUMOR

after uterine evacuation, persistent trophoblastic tumor will develop in:  18% - 29% of patients with CHM  1 % - 11% of patients with PHM  serial hCG levels – gold standard  TVS is more accurate than TAS  TAS is only capable of detecting massive uterine involvement  TVS is more accurate in assessing the depth of myometrial invasion 

PERSISTENT TROPHOBLASTIC TUMOR

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

 nodules

of residual GTD are surrounded by newly formed vessels with frequent AV anastomoses  hypoechoic areas (blood lacunae) surrounded by irregular echogenic areas (trophoblastic nodules) and numerous intramyometrial signals (vascular shunts)

Ultrasound in the Detection of Hydatidiform Mole uterine cavity filled with central heterogenous mass with anechoic spaces of varying size and shape  snowstorm like appearance  Doppler : high velocities and low resistance flow from trophoblastic tissue 

Ultrasound in the Detection of Hydatidiform Mole In Invasive Mole: in addition to the central uterine lesion, myometrial invasion is present  Choriocarcinoma appearing as a mass enlarging the uterus, with a heterogeneity corresponding to areas of necrosis and hemorrhage 

Gestational Trophoblastic Disease

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

ULTRASOUND EVALUATION OF THE ADNEXA ( OVARY AND FALLOPIAN TUBES) Callen 5th

MATURE CYSTIC TERATOMAS

DERMOID CYSTS  Ovarian teratomas are the most common germ cell tumor and are derived from several histologic types, all of which contain mature or immature tissues of germ cell origin 

MATURE CYSTIC TERATOMAS  or ovarian cystic teratoma  most

common of the ovarian teratomas  contain mature tissues of ectodermal (skin , brain), mesodermal (muscle, fat), endodermal (mucinous or ciliated eptihelium)  younger age group (mean 30 years old)  most common in children

MATURE CYSTIC TERATOMAS  1. 2.

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Characteristic Ultrasound Features: white ball (hair and sebum) long, echogenic (white) lines and prominent dots in cyst fluid (hair floating freely in nonfatty fluid) shadowing

ENDOMETRIOMAS Endometriosis – presence of endometrial tissue outside of the endometrium and myometrium  locations : ovaries, uterine ligaments, rectovaginal septum, culde-sac, pelvic peritoneum  Symptoms: aquired dysmenorrhea, lower abdominal, pelvic and back pain, dyspareunia, irregular bleeding and infertility 

ENDOMETRIOMAS  Ultrasound

findings:  anechoic cyst to a cyst containing diffuse low level echoes with or without solid components to a solid- appearing mass  unilateral or bilateral  confused teratomas, abscesses, ovarian adenofibromas

BENIGN CYSTIC LESIONS OF OVARIAN AND PAROVARIAN STRUCTURES 

FUNCTIONAL CYSTS  most common during reproductive years  result from abnormalities in the release of anterior pituitary gonadotropins  maybe multiple, recurrent, and accompanied by corpora lutea

HEMORRHAGIC CORPUS LUTEUM CYSTS  Ultrasound

Findings:  typically contains spiderweblike material  bizarre blood clots may also be seen

PELVIC INFLAMMATORY DISEASE result of ascending spread of microorganisms from the vagina and cervix through the endometrial cavity, through the endometrium into the fallopian tubes.  Clinical Presentation: fever, pelvic pain and purulent vaginal discharge  commonest causative agents are: 

 Chlamydia

trachomatis  Neisseria gonorrhoeae

PELVIC INFLAMMATORY DISEASE   1. 2.

3.

Imaging Modality of Choice : Ultrasound Characteristic Ultrasound Features: fluid-filled sausage-shaped cystic structure presence of incomplete septa, that is, septa that are not seen to reach the opposite wall of the cystic structure on transverse section of a fluid-filled tube, mucosal folds are seen to protrude into the lumen, resulting in cogwheel appearance ( swollen), beads-on-a-string appearance (if not)

PARAOVARIAN CYSTS 

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may arise from embryonic ducts and are usually located between the tube and the ovary. mesothelial, mesonephric, paramesonephric origin On ultrasound : cyst clearly separate from the a normal ovary papillary projections and septa may develop malignancy may develop

PERITONEAL PSEUDOCYSTS 

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fluid collections among adhesions occuring after an inflammatory process in the peritoneal cavity or after an operation typical ultrasound morphology : cystic mass following the contours of the pelvis, with a deformed ovary suspended amongst adhesions centrally or peripherally echoic the cyst contain both septa and

BENIGN CYSTIC LESIONS OF OVARIAN AND PAROVARIAN STRUCTURES 

OVARIAN HYPERSTIMULATION SYNDROME  women undergoing ovulation induction  presentation similar to HL,except in timing  ovarian expansion with concomittant fluid shifts typically more rapid in OHS than HL

BENIGN CYSTIC LESIONS OF OVARIAN AND PAROVARIAN STRUCTURES 

POLYCYSTIC OVARIAN SYNDROME (PCOS)  complex endocrinologic disorder associated with chronic anovulation  hyperandrogenism - most consistent feature  manifestations of unopposed estrogenic stimulation, including menometorrhagia, endometrial hyperplasia, and endometrial carcinoma  higher risk of OHS

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POLYCYSTIC OVARIAN SYNDROME (PCOS)  more common in women with recurrent early pregnancy loss  TWO DIAGNOSTIC APPROACHES:  ultrasound appearance of a PCO  unexplained symptoms of menstrual disturbance, hyperandrogenism, or anovulation.  detection of hyperandrogenic chronic anovulation regardless of ovarian ultrasound appearance

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

of 10 or more cysts measuring 2 to 18 mm in diameter in a single plane arranged peripherally around an increased amount of central stroma  or less commonly, multiple small cysts 2 to 4 mm diameter distributed throughout the abundant stroma

Polycystic Ovarian Disease

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

OVARIAN VASCULAR LESIONS 

OVARIAN TORSION

5th most common gynecologic emergency (2.7% of all gynecologic emergencies)  1st three decades of life  50% to 81% of patients, unilateral ovarian tumors as cause of torsion  ovarian and para-ovarian cysts most common cause 

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OVARIAN TORSION

Ultrasound Findings:  twisted adnexal masses are often midline, positioned cranial to the uterine fundus  early diagnosis : enlarged ovary with absent markedly decreased ovarian blood flow  twisted vascular pedicle ( broad ligament, fallopian tube, adnexal and ovarian branches of the uterine arteries and veins) 

 “Whirpool

sign” – Color Doppler demonstrates flow within the pedicle circular or coiled twisted vessels

Ovarian Carcinoma

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

Practice Points 

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Benign Tumors : absence of solid components and no irregularity Malignant Tumors : presence of solid components and irregularity Mature Cystic Teratoma : white ball, long echogenic lines, prominent echogenic dots in cyst fluid, shadowing Endometrioma : ground glass appearance of cyst contents, wall nodularities

Practice Points 

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Hemorrhagic Corpus Luteum Cyst : spiderweb-like contents, bizarre blood clots Hydro-pyo-hematosalpinx : fluid-filled sausage-shaped cystic structure, incomplete septa, cogwheel appearance, beads-on-a- string appearance Paraovarian cyst: cyst clearly separate from a normal ovary

Practice Points 

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Peritoneal Pseudocyst : cystic mass following contours of the pelvis and with an ovary, often deformed, suspended amongst adhesions centrally or peripherally in the cyst Fibroma, Fibrothecoma : echopattern indistinguishable from that of a pedunculated myoma, that is, a solid, round, lobular, or oval tumor with a smooth outline and a regular stripy echogenicity.

Practice Points 

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Tubo-ovarian Abscess : unilocular cystic structure, or complex multicystic structure with thick walls and thick septae, filled with homogenous echogenic material (ground-glass appearance) Adnexal Torsion : the walls and any septa of the twisted lesion may look swollen at ultrasound examinantion; there maybe fluid in the pouch of Douglas; presence of color and spectral Doppler signals in the lesion does not exclude torsion

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