Gynae/Breast Flashcards
What is first line investigation for endometriosis?
TV ultrasound
then
MRI
What is most common type of fibroid degeneration?
Fibroids are complicated by degeneration which occurs when the mass outgrows its own blood supply. This takes place in one of four ways:
Hyaline degeneration – this is the most common form, accounting for over half of cases. Proteinaceous material collects in the extracellular space. Calcification (typically described as popcorn calcification) can occur and is sometimes visible on plain films. Appearances on MRI are similar to non-degenerate fibroids with low signal on T2.
Myxoid degeneration – These fibroids are easily confused with cystic degeneration owing to their high T2 signal. The focal areas of very high T2 signal are set against a backdrop of low T2 signal where the gelatinous material has not reached. Where they appear cystic, the complex nature of the cysts suggests myxoid degeneration over cystic degeneration.
Cystic degeneration – Although this type of degeneration is uncommon it gives classical MRI appearances of high T2 signal.
Red degeneration (aka carneous degeneration) – This entity is related to pregnancy or use of the oral contraceptive pill, but can occur without either. It is essentially haemorrhagic necrosis and can present acutely as abdominal pain. MRI characteristics vary depending on the degradation of blood within the fibroid. Peripheral high T2 signal is often described.
How does Actinomycosis present?
Can present after IUCD insertion
Can appear as inflammatory mass that invades adjacent structures. Will have adjacent fat stranding and possible abscess formation
Thus pelvic actinomycosis tends to be consequent from events such as IUCD placement, surgery or trauma.
Can mimic a locally invasive malignancy
Uterine Anomalies
Renal agenesis, ectopia and fusion present in 33% of patients
Aplastic uterus + normal fallopian tubes and ovaries = MRKH syndrome (Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is an extreme subtype where there is complete aplasia of the upper third of the vagina and uterus. The fallopian tubes and ovaries will be seen normally. Primary amenorrhoea is the usual presentation.)
Widely divergent horns + fundal cleft = fusion anomaly (didelphys or bicornuate)
Didelphys: Non-fusion, two separate uterine horns, two separate cervices. All of the walls contain all of the layers of the normal uterus. The uterine cavities do not communicate with one another owing to the presence of a vaginal septum.
Two cervices also known as owl eyes on MRI = either didelphys or bicollis bicornuate (difficult to tell them apart)
No communication between two uterine horns = didelphys
Domed fundus = reabsorption anomaly (Septate or arcuate)
Recurrent midterm miscarriages can be due to septate uterus and can be surgically resected to improve fertility.
What is a molar pregnancy?
Due to abnormal fertilisation
2 types: Complete and Partial
- complete moles are associated with the absence of a fetus
- partial moles usually occur with an abnormal fetus or may even be associated with fetal demise
Complete: large polycystic uterine mass with uterus enlargement and elevated HCG. ‘Snowstorm’ apperance on US. No fetus
Partial Mole: fetus will be present along with polycystic placenta. Multiple congenital abnormalities
How to followup ovarian cysts?
What size needs followup in pre menopausal?
Haemorrhagic >5cm
or
>7cm normal
Advise MRI
What are the appearances on US and MRI of ovarian thecomas?
Oestrogen secreting fibrous tumours
-can result in endometrial hyperplasia and bleeding due to oestrogen
Ultrasound: hypoechoic solid masses
MRI: low on T1 and T2
Can develop into a carcinoma
What are features of mature teratomas?
Otherwise known as Dermoid cysts
Presence of fat is highly suggestive of MATURE teratoma
Fat, fluid and calcification even more specific
Mature teratomas can TORT or RUPTURE
Immature teratomas are malignant
Where do endometriomas occur?
What do they look like on imaging?
Can occur anywhere
Also known as ‘Chocolate cysts’
Ultrasound: appear as a single cyst with posterior acoustic enhancement and low level internal echoes
MRI: signal varies according to age of haemorrhage
T1: usually high signifying old blood products. will be low if acute haemorrhage
T2: usually hypointense. T2 shading sign. Low T2 signal may only involve parts of the cyst. Due to high concentration of protein and iron from repeated haemorrhage
- May have wall enhancement post contrast
- The presence of an enhancing nodule is suggestive of malignant transformation
What are Krukenberg tumours?
Krukenberg tumours are metastatic tumours to the ovary that contain well defined histological characteristics - mucin-secreting “signet ring” cells and usually originate in the gastrointestinal tract 4.
The time from diagnosis of the primary neoplasm to the development of ovarian metastasis is variable and can range from several months to >10 years.
Cytologic examination often reveals mucoid degeneration and many large cells shaped like signet rings.
Often bilateral and can be mistaken for primary malignancies
Appear as part cystic, part solid appearance
What is Asherman syndrome?
Intrauterine adhesions that form due to damage to endometrium
Associated with infertility
Cervical cancer take homes
Summary
Cervical cancer is hyperintense on T2 and isointense on T1. The cervical stroma is seen as a black line on T2.
Stage IB2 cancers are not amenable to trachelectomy – this includes tumours larger than 4cm or with extension into the vagina or parametrium
Stage IIB cancers are not amenable to a hysterectomy – this includes invasion into the parametrium
Inguinal lymph nodes are considered metastatic (para-aortic are considered regional)
Most cervical cancer is squamous cell carcinoma
Peutz-Jegher syndrome is associated with minimal deviation adenocarcinoma
What is a Phyllodes tumour of breast?
Basically looks like a fibroadenoma in an older patient
- Lobulated round hypoechoic mass
- Posterior acoustic shadowing
- Often have a halo of low attenuation
What is a contraindication to wide local excision?
Separate lesions in separate quadrants of the breasts contraindicate WLE
(mastectomy would then be performed instead)
HSG - multiple diverticular of fallopian tubes with no spill of contrast distally
What is diagnosis?
Salpingitis isthmica nodosa
-strong associated with infertility
-thought to be related to previous PID
Breast mass that is seen only on MRI but no mammo or ultrasound
What is it?
Locular carcinoma
BRCA 1 - assc with ductal carcinomas
BRCA 2 - assc with ductal and lobular carcinoma
Corpus luteal cyst
Corpus luteal cyst
The corpus luteum comprises the remnant of an ovarian follicle post ovulation. Without fertilisation the normal corpus luteum will involute spontaneously within 2 weeks but occasionally they can persist even in the absence of fertilisation and be seen as a corpus luteum cyst.
Ultrasound characteristics depend slightly on the age of the cyst and the presence or absence of haemorrhage within it but a small (<3 cm) thick walled, rounded, cystic structure with peripheral vascularity (the so-called ‘ring of fire’) would be classical.
A repeat ultrasound scan after 6 weeks (to ensure a different part of the menstrual cycle) is usually recommended.
Fluid filled tubular structure with
- thick enhancing walls
- thin enhancing walls
What are differentials?
Thick - pyosalpinx (high T1 and high T2)
Thin: Hydrosalpinx (low T1, high T2)
Female urogenital cytst?
Where is bartholin cyst located?
Where are Nabothian cysts located?
Gartner duct cyst
These are usually found incidentally on MRI scans but can cause dyspareunia. They do not communicate with the urethra and would be unlikely to cause post-void dribbling. They are remnants of the Wolffian ducts and occur superiorly in the anterolateral wall of the vagina.
Skene duct cyst
These are retention cysts of the paraurethral ducts and usually they are asymptomatic. On MRI they are seen inferior to the pubic symphysis but lateral to the external urethral meatus. Signal characteristics reflect their cystic nature with high T2 signal but fluid-fluid levels may also be present if there has been intracystic haemorrhage.
What are some benign features in IOTA (international ovarian tumour analysis)?
The IOTA rules were designed to standardise ultrasound findings in ovarian lesions.
Two sets of rules were drawn up; M-rules and B-rules (indicating malignant and benign characteristics respectively). The rules have been designed to be as simple as possible, for general use by anyone capable of performing transabdominal or transvaginal imaging of the ovaries.
Malignant = One or more M-rule, no B-rules
Benign = One or more B-rules, no M-rules
Indeterminate = everything else
What is Fitz-Hugh-Curtis syndrome?
It is a complication of PID where patient develops:
-RUQ due to liver capsule inflammation and adhesions
-due to chlamydia or gonorrhoea
Choriocarcinoma
What is it?
Can occur in the placenta in context of partum or post partum or uterus (and can be unrelated to pregnancy)
Placenta
Aggressive malignancy
Over half of cases assc with molar pregnancy, others assc with spontaneous abortion or even normal pregnancy
Uterus
Highly vascular aggressive tumour - a mass distending the uterus with central cystic necrosis
Can outgrow its blood supply leading to necrosis and haemorrhage
- Significantly elevated HCG levels are typical*
- Cannonball mets are common*
What imaging used to stage endometrial cancer?
What is normal endometrial thickness in post menopausal woman?
MRI pelvis with gaodlinium
Normal thickness in pre-menopausal woman is up to 16mm during secretory phase
Normal endometrial thickness in post menopausal woman is <5mm (100% negative predictive value for endometrial carcinoma)
Suspicious signs for endometrial ca:
- >5mm endometrial thickness
- poorly defined interface between endometrium and myometrium
What consititutes Stage II endometrial cancer?
Spread to the body of uterus and cervix - Stage 2
Spread to serosa/perioneal cavity or lymph nodes - Stage 3
Lymph nodes can be para-aortic or pelvic nodes (EXCEPT inguinal nodes - these would be NON regional)
Invasion into the myometrium is characterised by breach of dark junctional zone (this would be Stage 1B)
What are contraindications to fibroid embolisation?
Uterine artery arises from internal iliac artery
What is Adenomyosis?
This is the presence of ectopic endometrial tissue in the myometrium
Can be diffuse or limited to a focal area
Causes smooth muscle enlargement
- Classic MRI finding is: widening of the transitional(junctional) zone to >12mm*
- -small areas of high T1 and T2 signal can be seen representing small areas of hamorrhage and cystic change*
HSG will show small diverticula
