ULTRASOUND AND GYNECOLOGICAL ONCOLOGY

Osama M Warda MD Professor of Obstetrics & gynecology

Mansoura University-EGYPT

NORMAL GYNECOLOGICAL ANATOMY- introduction

� Ultrasound exam of the uterus & ovaries is best performed trans-vaginally

� The ultrasound morphology & size of the uterus & ovaries change during the menstrual cycle.

� In menopausal transition the ovaries are smaller & contain fewer follicles than during reproductive years. They continue to shrink after the menopause, when the uterus also becomes smaller.

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NORMAL GYNECOLOGICAL ANATOMY- introduction

� A small amount of fluid in the pouch of Douglas is normal in women of fertile age but abnormal after the menopause.

� Normal tubes can only be seen if they float freely in fluid in the pouch of Douglas .

� On saline infusion sonography a normal uterine cavity is regular and outlined by smooth endometrium.

� hystero-contrast salingosonography is used to assess tubal patency. If one can observe moving contrast in the interstitial part of the tube for 10 seconds, and if no hydrosalpinx is seen, the tube is probably patent, even if free spill of contrast around the ovary is not clearly seen.

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Ultrasound of Normal uterus

� The myometrium is homogeneous

� Morphology of endometrium changes during menstrual cycle

� At beginning of cycle the uterus is small and endometrium thin

� In follicular phase, uterus increases in size and endometrium becomes thicker and manifests ‘triple-layer’ appearance

� After ovulation the ‘triple-layer’ appearance disappears and the endometrium becomes homogeneously hyperechoic.

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Early follicular endometrium

Trtriple –layer appearance

Luteal phase

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Ultrasound of Normal cervix

� Ultrasound examination of the uterus should always start with examination of the cervix.

� The cervical canal should be identified & followed towards the corpus uteri so that it can be seen to join the endometrium .

� This examination technique ensures that it is indeed the uterus & the endometrium that have been identified.

� The myometrium of a normal cervix is homogeneous. In late proliferative phase of MC, clear fluid, corresponding to ovulatory cervical mucus, can be seen in cervix.

� The finding of many & even large retention cysts in the cervix is normal.

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Warda 12 May 2014

cervix

Nabothian follicle

Nabothian f Warda 12 May 2014

Ultrasound of Normal ovary � Ovarian us morphology changes with the MC.

� In the beginning of the MC both ovaries usually contain 6-7 follicles of <10mm diameter.

� The non-dominant ovary retains this appearance throughout the MC .

� In early FP, it is not possible to determine which ovary is going to become the dominant one. It can be identified 6-9d before the LH surge, i.e. between D5-D12 of the MC (mean D8).

� The DF displays a linear growth of ±1.7mm/day. At the time of LH surge the DF = 18-22mm

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Ultrasound of Normal ovary(contd.,)

� After ovulation the follicle becomes a CL.

� The CL is usually smaller than the DF, its wall is thicker, and with high resolution US it is possible to see the crenellated appearance of its wall. Bleeding into CL explains presence of internal echoes in the CL at US.

� The CL is well vascularized & therefore it is surrounded by a ‘color ring’ or ‘fire ring’ on CD or PD ultrasound.

� On the 3rd of MC the CL of the previous cycle is no longer distinguishable even by CD ultrasound.

� Ovarian size changes during MC , vol. of non-dominant ovary 7-8ml remains unchanged, while DO increases from 7-8ml in FP to 20ml on day befor ovulation

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Natural cycle-dominant F Stimulated ovary

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Normal US of uterus & ovary in post-menopause

� The uterus & ovaries are smaller in postmenopausal women than in CBP.

� A normal uterus in a woman 5 years postmenopause = 5-6 length x2.5 AP x3 cm width. Normal ovary volume=1-4ml & with no follicles

� The endometrium is thin (<5mm), uniform (no cyclic changes, and hyperechoic.

� Calcified BV in the periphery of the myometrium are common & seen as bright echoes.

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Warda 12 May 2014

Post-menopausal ovary

Post menopausal uterus and ovary

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GYNECOLOGICAL MALIGNANCY-OVERVIEW

� Gynecologic cancers represent 14% of all solid tumors in women and 11% of deaths from them.

� Cervical, uterine and ovarian cancer represent 95% of gynecologic cancers and collectively rank the fourth in both incidence and mortality among cancers that affect women in developed countries.

� Worldwide, these tumors account for even larger share of cancer mortality in women

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Number of Cases of Cancer Cervix in Egypt, Jordan, USA

EGYPT (1999-2001)

JORDAN (1996-2001)

USA (1999-2001)

TOTAL per 100,000

96 194 5284

Age distribution (Years)

30-49 38.5% 45.3% 48.4%

50-69 52.1% 42.8% 36.2%

70+ 9.4% 11.9% 15.4%

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Endometrial carcinoma

� Worldwide it represents 3.9% of female cancers

� It is more common in developed countries : 18/100,000 in USA & Canada compared to 6/100,000 in Africa and is related to:

- Prolonged high estrogen levels

- Few number of children

- Use of HRT

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Number of cases of Endometrial Carcinoma in Egypt, Jordan, USA

Egypt (1999-2001)

Jordan (1996-2001)

USA (1999-2001)

Total per 100,000

124 405 14129

Age distribution %

<50 33.1 26 15.5

50-69 56.4 50.5 49.9

70+ 10.5 13.1 34.6

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Ovarian cancer

� Epithelial ovarian carcinoma account for 90% of cases and is the leading cause of death in women with pelvic malignancies

� The incidence is higher in industrial

countries of the world � Women who are single and have low

parity and a history of breast cancer are at risk.

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Age-standard incidence rate of Ovarian Carcinoma in Egypt, Jordan , USA

TOTAL per 100,000

Egypt 1999-2001

Jordan 1996-2001

USA 1999-2001

All ages 5.4 4.6 10

<50 2.5 2.1 3.2

50-69 17.7 14.1 33.5

70+ 14.9 17.3 52.7

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Ovarian Pathology

Warda

Haemorragic cyst. Small unilocular cyst, with some internal echoes, irregularly distributed. Thick, but smooth wall, absence of papillary projections. Normal ovarian tissue is visible medially. The picture is typical for haemorragic cyst/corpus luteum.

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Ovarian Pathology

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Unilocular ovarian cyst. Thin, smooth margins, absence of papillary projections, virtually anecoic, suggestive a follicular cyst. 12 May 2014

Ovarian Pathology

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Slightly enlarged "solid" ovary in a woman of 63 years of age. The texture is moderately inhomogeneous. Marigin irregular but well defined. Histology confirmed the presence of a benign ovarian fibroma. 12 May 2014

Ovarian Pathology

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Unilocular ovarian cyst. "Ground glass" hypoecoic texture, slightly thickened but regular margins, some normal ovarian tissue is visible cranially, around the cyst. The picture is very suggestive for an ovarian endometrioma.

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Ovarian Pathology

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Small dermoid in an otherwise normal sized ovary. Note the homogeneous, hyperechoic texture typical of a dermoid cyst. In this case shadowing was not detectable.

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Ovarian Pathology

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Power Doppler well depict blood vessels around a normal sized corpus luteum, with the typical aspect of a "ring of fire".

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Ovarian Pathology

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Unilocular ovarian cyst, few small papillary intracavitarian projections deform the caudal portion of the cyctic wall, otherwise smooth. Internal echoes are regularly distributed, with a "ground glass" texture. Histology confirmed the presence of a border-line ovarian cystadenoma of endometrioic type.

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Ovarian Pathology

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Unilocular ovarian cyst, with "ground glass" internal texture, suggestive of endometrioma. A

small "papillary-like" projection, deforms the lateral wall of the cyst. This an example of

socolled "atypical endometrioma". In such cases, Power Doppler analysis is very useful to

differentiate it from a true neoplasm.

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Ovarian Pathology

Warda

Small multilocular solid ovarian cyst, with few small septa and papillary projections. As such

the picture would appear highly suspicious for malignancy. Subsequent evaluation with

power and pulsed Doppler showed however, scanty vascularity and high impedance to

blood flow. Histology demonstrated a benign cystic ovarian adenofibroma. 12 May 2014

Ovarian Pathology

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Multilocular ovarian cyst. Several septa of different length and thickness, but no papillary projections or solid areas are present. Margins are well defined. Internal echoes are scanty. Histology diagnosed a benign ovarian cystadenoma of serous type.

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Ovarian Pathology

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A small, round shape unilocular cyst, close but external to the ovary, suggestive to be a paraovary cyst.

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Ovarian Pathology

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The ovary is enlarged, solid, with undefined margin, slightly unhomogeneous texture. Normal ovarian texture is not visible. The picture is suggestive of a primary malignant ovarian neoplasm or of an ovarian metastasis.

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Ovarian Pathology

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Unilocular solid ovarian cyst, with 2 large intracavitarian solid, papillary areas, occupying almost 1/3 of the lumen of the cyst. Internal echoes are visible. Histology diagnosed a malignant cystadenocarcinoma of serious type.

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Ovarian Pathology

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Very large (>22 cm) multilocular solid ovarian cyst. There are many septations forming a thick "web" and solid intra-cavitarian areas. Internal echoes are abundant. The picture is suggestive of a malignant cystadenocarcinoma of mucinous type.

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Ovarian Pathology

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Enlarged, "solid" ovarian mass. Power Doppler show intense vascularisation. At histology an ovarian metastasis of breast cancer was diagnosed.

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Ovarian Pathology

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Large ovarian solid tumor. Texture is homogeneous, margins are well defined. At histology a granulosa cell tumor was diagnosed.

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Ovarian Pathology

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Superimposed power Doppler examination of a solid ovarian mass proved to be a granulosa cell tumor. Showing abundant and irregularly distributed vascularisation.

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Ovarian Pathology

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Pulsed Doppler examination of blood flow impedance in an ovarian solid mass, proved to be a granulosa cell tumor. Maximum velocity is high and impedance to flow low.

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Ovarian Pathology

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Neoplastic ovarian cyst with internal papillae

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Ovarian Pathology

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Ovarian fibroma

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Ovarian Pathology

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Mucinous cystadenocarcinoma

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Uterine Pathology

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Submucous fibroid polyp/ sonohysterography+ CD

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Uterine Pathology

Warda

Submucous fibroid polyp/ sonohysterography+ CD UTERINE FIBROID

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Uterine Pathology

Warda

Submucous fibroid polyp/ sonohysterography+ CD

12 May 2014

Uterine Pathology

Warda

Submucous fibroid polyp/ sonohysterography+ CD

ENDOMETRIAL CANCER

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Uterine Pathology

Warda

Submucous fibroid polyp/ sonohysterography+ CD

UTERINE LEIOMYOSARCOMA

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Uterine Pathology

Warda

Submucous fibroid polyp/ sonohysterography+ CD

Enlarged uterus in a 53-year-old woman with abnormal bleeding. The uterus is enlarged slightly and heterogeneous in echotexture but has no focal masses. Histologic examination revealed adenomyosis.

12 May 2014

Uterine Pathology

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Submucous fibroid polyp/ sonohysterography+ CD FOCAL adenomyosis- no line of demarcation+ presence of hypoechoic dots

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Uterine Pathology

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Submucous fibroid polyp/ sonohysterography+ CD Cervical masses. (A) Sagittal view of the cervix demonstrates a large cervical fibroid which deviates the lower uterine segment anteriorly.

fibroid

Uterus

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Uterine Pathology

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Submucous fibroid polyp/ sonohysterography+ CD Multiple endometrial polypi (sono hysterography

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Thank You

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