gynecology Flashcards
describe endometrioma on MRI
They contain blood
hyperT1, does not suppress on fat-sat
T2 shading sign: low signal affecting variable portions of the cyst, typically layering dependently
T2 dark spot sign present if chronic hemorrhage.
Pathology and mri appearance of adenomyosis of uterus
defined by the presence of ectopic endometrial tissue within the myometrium. Benign invasion of the myometrium by the endometrium also results in adjacent smooth muscle hyperplasia.
Pelvic MRI
MRI is the modality of choice to diagnose and characterise adenomyosis, and T2 weighted images (sagittal and axial) are most useful. MRI has a sensitivity of 78-88% and a specificity of 67-93%.
The most easily recognised feature is thickening of the junctional zone of the uterus to more than 12 mm, either diffusely or focally (normal junctional zone measures no more than 5 mm).
T2
typically a region of adenomyosis appears as an ill-defined ovoid/diffuse region of thickening, often with small high T2 signal regions representing small regions of cystic change
the region may also have a striated appearance.
T1
foci of high T1 signal are often seen, indicating menstrual haemorrhage into the ectopic endometrial tissues.
T1 C+ (Gd)
contrast enhanced MR evaluation is usually not indicated for evaluation of adenomyosis, however, if performed, it shows enhancement of the ectopic endometrial glands
Types of epithelial ovarian tumors (6)
Serous Mucinous Endometrioid Clear cell Brenner Undifferentiated
Types of germ cell ovarian tumors (5)
Teratoma (mature, immature) Dysgerminoma Endodermal sinus tumor Embryonal cell carcinoma Choriocarcinoma
Types of sex cord-stromal ovarian tumors (5)
Granulosa cell tumor Fibrothecoma Sclerosing stromal tumor Sertoli-Leydig tumor Steroid cell tumor
Are the majority of epithelial ovarian tumors benign or malignant?
Benign (60%)
malignant (35%)
low malignant potential (5%)
What features help differentiate serous from mucinous tumors (ovarian)?
Serous cystadenomas are smaller, contain thin walled cysts and are usually unilocular.
They have stable density/signal of the locules with papillary projections being common.
Calcifications (psammomatous bodies) are common. Frequently bilateral.
Peritoneal carcinomatosis more frequent.
Mucinous cystadenomas are often large with multilocular appearance.
Small cystic components with honeycomb-like locules of varying density/signal.
Papillary projections, calcifications and bilaterality are rare.
Which ovarian tumor is more frequently malignant: serous or mucinous tumor?
Serous (60% benign, 15% low malignant potential, 25% malignant)
Mucinous (80% benign, 10-15% low malignant potential, 5-10% malignant)
A ruptured mucinous adenocarcinoma is associated with what?
Pseudomyxoma peritonei
What is histologic definition of papillary projections (ovarian tumors) and MR appearance?
Papillary projections represent folds of
the proliferating neoplasmic epithelium growing over a stromal core.
T2-weighted MR images demonstrate the structure of a hypointense fibrous core that supports the hyperintense edematous
stroma.
In the case of an ovarian tumor that has the appearance of an epithelial tumor, what features suggest that it is benign? (6)
diameter less than 4cm
entirely cystic components
wall thickness less than 3mm
lack of internal structures (papillary projections)
absence of ascites
absense of invasive characteristics (peritoneal disease, adenopathy)
Papillary projections are most commonly present in benign, low-malignant-potential or malignant epithelial ovarian neoplasms?
low-malignant-potential (67%)
benign (13%), malignant (38%)
They are the single best predictor of an epithelial neoplasm.
What ovarian tumor is associated with synchronous endometrial carcinoma or endometrial hyperplasia (15-30% of cases)?
Endometrioid carcinoma
Most common malignant neoplasm arising from endometriosis?
Endometrioid carcinoma
second most common is clear cell carcinoma
True or false: Brenner tumors are rarely malignant
True
they are also associated with other ovarian tumors in 30% of cases.
What are the 2 typical presentations of a Brenner tumor
1- multilocular cystic mass with a solid component
2- small mostly solid tumor
solid component shows mild enhancement
they contain dense fibrous stroma which is T2 hypo.
extensive amorphous calcification often present within the solid component
What peritoneal complication can arising from rupture of a mature cystic teratoma?
Leakage of liquefied sebaceous contents into the peritoneum can result in granulomatous peritonitis
What is a rokitansky nodule
AKA dermoid plug
it is a solid protuberance arising from an ovarian cyst in the context of a mature cystic teratoma. It often contains calcific, dental, adipose, hair and/or sebaceous components.
What are the US findings of a mature cystic teratoma?
US findings in mature cystic teratomas vary from a cystic lesion with a densely echogenic tubercle (Rokitansky nodule) projecting into the cyst lumen, to a diffusely or partially echogenic mass with the echogenic area usually demonstrating sound attenuation owing to sebaceous material and hair within the cyst cavity, to multiple thin, echogenic bands caused by hair in the cyst cavity. The dermoid plug (rokitansky nodule) is echogenic, with shadowing due to adipose tissue or calcifications within the plug or to hair arising from it.
What serum marker is frequently elevated in immature cystic teratomas?
Serum AFP is elevated in 50% of cases (elevated in many different tumors)
The tumor usually does not produce beta-HCG
What features help differentiate an immature cystic teratoma from a mature cystic teratoma?
Larger size (>15cm)
Faster growth
Prominent solid components
internal necrosis or hemorrhage
Scattered calcifications; calcification in mature teratomas is localized to mural nodules
frequently demonstrate perforation of the capsule, which is not always well defined
metastases; peritoneum, liver, lung
What is the typical imaging appearance of an ovarian dysgerminoma?
Multilobulated solid mass with prominent fibrovascular septa.
The septa are hypo to isointense on T2
The septa often show marked enhancement
It contains areas of necrosis and hemorrhage
When a mature cystic teratoma undergoes malignant degeneration, what is the most common resulting neoplasm?
Squamous cell carcinoma (80%)
Others: Endodermal sinus tumors (pediatrics) adenocarcinoma thyroid carcinoma malignant melanoma TCC sarcoma carcinoid neuroectodermal tumor
What is the typical imaging appearance of an endodermal sinus tumor?
Typically manifests in the second decade of life
Large complex pelvic mass that extends into the abdomen and contains both solid and cystic components.
May have coexisting mature teratoma
rapid growth
elevated serum AFP is frequent
What ovarian tumors are associated with endometrial thickening?
endometroid carcinoma of the ovary
may have synchronous endometrial carcinoma or endometrial hyperplasia present in up to 1/3rd of cases
clear cell carcinoma of the ovary
granulosa cell tumours of the ovary
ovarian fibrothecoma
ovarian thecoma
Serous carcinoma can present in ovary and uterus at the same time but I cant find a source (berdugo)
What is typical MR appearance of ovarian fibroma?
Because of their abundant collagen contents, these tumors have low signal intensity on T1-weighted MR images and very low signal intensity on T2-weighted images. These findings are relatively diagnostic for fibroma.
Usually demonstrates heterogeneous enhancement
Dense calcifications are often seen. Scattered high signal intensity areas in the mass represent edema or cystic degeneration.
True or false: Granulosa cell tumors present with intracystic papillary projections
False.
What hormone is produced by granulosa cell tumors?
Estrogen
What are the effects on the uterus of the estrogen produced by granulosa cell tumors?
Estrogenic effects on the uterus may manifest as uterine enlargement
endometrial thickening/hyperplasia or hemorrhage
polyps
carcinoma
What feature can you use to differentiate a pedunculated/broad ligament leiomyoma from an ovarian fibroma?
Pedunculated uterine leiomyomas and broad ligament leiomyomas frequently appear as adnexal or ovarian masses, typically with very low signal intensity on T2-weighted MR images.
Subserosal myomas are supplied by the vessels from the uterine arteries that course through the adjacent myometrium and may appear as the vessels that intervene between a myoma and the adjacent uterus. In contrast, ovarian masses are most likely fed directly by the ovarian arteries or by the ovarian branches of the uterine arteries that course along the fallopian tubes. Observation of the interface vessels between the uterus and adnexal masses seems to be useful in differentiating leiomyoma from ovarian fibroma.
What is Meigs syndrome?
Triad of pleural effusion, ascites and benign ovarian tumor.
In 80-90% of cases the tumor is a fibroma.
5 most common tumors to metastasize to ovaries?
colon
stomach
breast
lung
contralateral ovary
Name this tumor:
Metastatic tumors to the ovary that contain mucin-secreting “signet ring” cells and usually originate in the gastrointestinal tract
Krukenberg tumor
What is the typical MR appearance of a krukenberg tumor
bilateral complex masses with hypointense solid components (dense stromal reaction) and internal hyperintensity (mucin) on T1- and T2-weighted MR images, respectively.
What features are suggestive of a malignant ovarian epithelial tumor?
thick, irregular wall
thick septa
papillary projections
large soft-tissue component with necrosis
What ovarian tumors are frequently associated with calcifications?
serous epithelial tumor
fibrothecoma
mature or immature teratoma
Brenner tumor
What ovarian tumors are associated with highly enhancing solid components?
sclerosing stromal tumor
Sertoli-Leydig cell tumor
struma ovarii (subtype of mature teratoma)
cystadenofibroma
What is the difference between bicornuate, septate and didelphis uterus?
Bicornuate: two endometriums with fundal dip
Septate: two endometriums without fundal dip
Didelphis: two uterus
When assessing for cervical incompetence in a pregnant patient what are the normal values for the length of the cervix and the width of the internal os of the cervix?
Length of cervixmust be at least 30mm
width of internal os must be no more than 5mm
Name the locations and frequency (%) of ectopic pregnancy
Tubal ectopic (93-97) Interstitial/cornual ectopic (3-4) Ovarian ectopic Cervical ectopic C-section scar Intra-abdominal
Describe the following mullerian duct anomalies:
1- uterus didelphys 2- bicornuate uterus 3- septate uterus 4- arcuate uterus 5- unicornuate uterus
1- two uterine horns and two cervices separate from each other.
2- two uterine horns that communicate with each other and is associated with an indented contour of the upper margin of the uterine fundus. Can have 1 or 2 cervices.
3- failure of resorption of all or part of the median septum. Midline septum that extends from the fundus caudally.
4- mild indentation of the superior portion of the endometrium secondary to near complete resorption of the septum (normal septum completely resolves). This is often considered a normal variant.
5- only 1 uterine horn is present due to arrest of development of one of the mullerian ducts. Frequently associated with rudimentary uterine horn.
Renal anomalies are more frequent with this type of anomaly.
How do you differentiate bicornuate from septate uterus? Why is it important?
The contour of the upper margin of the uterine fundus differs. This surface is concave with an indentation in a bicornuate uterus and convex or flattened in a septate uterus.
Differentiating between them is important because septate uterus is associated with high rate of recurrent spontaneous miscarriages and can be treated with hysteroscopic resection of the septum.
Name this condition: bloody fluid in the vaginal and endometrial canals
Hematometrocolpos
Name this lesion: most frequently identified cystic vaginal lesions.
Describe their imaging findings.
Gartner’s duct cysts
Typically located in the lateral or anterolateral vaginal wall, are simple in appearance, and can be simple it multiple.
True or false: fluid in the endometrial cavity is only normal during pregnancy.
False
Tiny amount normal during menstruation.
Small amount of fluid in endocervical canal normal during reproductive years.
In what situations can you have large amounts of fluid in the endometrial and endocervical canals during the reproductive years?
Pregnancy and its complications
Pelvic inflammatory disease
Cervical stenosis
Obstruction by fibroids
Cervical or endometrial mass, less likely
What is the most common etiology of simple fluid in the endometrial cavity of a postmenopausal woman?
Cervical stenosis
Cervical carcinoma
Endometrial carcinoma
What is the normal endometrial thickness in a postmenopausal woman?
What thickness is worrisome?
Less than 4-5mm
Thicker than 4-5mm in patient with vaginal bleeding.
If no vaginal bleeding, ideal measurement unclear, but above 8mm is a more reasonable threshold.
What is the most common cause of postmenopausal bleeding?
Endometrial atrophy
What are the ultrasound features of an endometrial polyp?
Round or oval echogenic focus (as opposed to fibroids which are hypoechoic)
Disruption of endometrial echotexture
Heterogeneous thickened endometrium (multiple polyps)
Diffuse endometrial thickening (large polyp)
An endometrial hypoechoic halo can be present, helps differentiate from diffuse endometrial thickening
Feeding vessel
Can have cysts
Can prolapse into cervix or vagina
What is a Venetian blinds appearance?
In pelvic imaging, it is a finding suggestive of a uterine fibroid.
Shadowing pattern characterized by multiple recurring shadows alternating with linear echogenic areas.
True or false:
Ultrasound cannot reliably distinguish a leiomyosarcoma from a leiomyoma
True, unless metastasis or invasion of adjacent structures
Cystic changes are common in benign leiomyomas
What are the ultrasound features of adenomyosis?
Enlarged uterus
Globular uterine shape
Disproportionate thickening of the posterior myometrium
Myometrial cysts
Heterogenous echotexture
Venetian blinds pattern
Moth eaten appearance
Border between endometrium and myometrium poorly defined
Increased prominence of hypoechoic central myometrium (junctional zone)
Focal adenomyomas
Diagnosis of a benign ovarian neoplasm should only be made if what features are present?
entirely cystic mass
wall thickness less than 3 mm
lack of internal structure
absence of both ascites and invasive characteristics, such as peritoneal nodules or lymphadenopathy
After contrast administration, only the cyst wall and septations enhance
accuracy of 84% (ct/mri abdo/pelvis teaching file)
In what percentage of ovarian torions is there an associated ovarian/paraovarian mass present?
80%
What are the diagnostic criteria for polycystic ovary morphology on ultrasound?
12 or more follicles measuring 2-9mm and/or
increased ovarian volume >10cc
in 30% of cases the varies appear normal
What are the follow up recommendations for a postmenopausal ovarian cyst?
Thin walled unilocular 1-7cm cyst: yearly FU
>7cm: MRI or surgery
What is the incomplete septum sign in hydrosalpinx?
The wall of the fallopian tube is folded as the tube turns, giving the appearance of a septum that does not cover the entire diameter of the tube.
At how many weeks of gestational age are the following structures first seen on endovaginal ultrasound:
1- gestational sac
2- yolk sac
3- embryo
1- 5 weeks
2- 5 1/2 weeks
3- 6 weeks
What are the findings diagnostic of intrauterine pregnancy failure on transvaginal ultrasound? (NEJM article)
Crown–rump length of ≥7 mm and no heartbeat
Mean sac diameter of ≥25 mm and no embryo
Absence of embryo with heartbeat ≥2 wk after a scan that showed a gestational sac without a yolk sac
Absence of embryo with heartbeat ≥11 days after a scan that showed a gestational sac with a yolk sac
What are the findings suspicious for but not diagnostic of intrauterine pregnancy failure on transvaginal ultrasound? (NEJM article)
Crown–rump length of <7 mm and no heartbeat
Mean sac diameter of 16–24 mm and no embryo
Absence of embryo with heartbeat 7–13 days after a scan that showed a gestational sac without a yolk sac
Absence of embryo with heartbeat 7–10 days after a scan that showed a gestational sac with a yolk sac
Absence of embryo ≥6 wk after last menstrual period
Empty amnion (amnion seen adjacent to yolk sac, with no visible embryo)
Enlarged yolk sac (>7 mm)
Small gestational sac in relation to the size of the embryo (<5 mm difference between mean sac diameter and crown–rump length)
How do you measure the mean gestational sac diameter?
Average of the sagittal, transverse and anteroposterior diameters of the sac
1- In a woman with a pregnancy of unknown location whose hCG level is more than 2000 mIU per milliliter, the most likely diagnosis is a ______________, occurring approximately ________ as often as ____________.
2- ___________ occurs approximately 19 times as often as a _____________ when the hCG level is 2000 to 3000 mIU per milliliter and the uterus is empty.
3- ___________ occurs approximately 70 times as often as a _______________ when the hCG level is more than 3000 mIU per milliliter with an empty uterus.
1- non-viable intra-uterine pregnancy, twice, ectopic pregnancy
2- Ectopic pregnancy, viable intra-uterine pregnancy
3- Ectopic pregnancy, viable intra-uterine pregnancy
TRUE OR FALSE
A b-hCG level of 1000 or more is required to diagnose ectopic pregnancy by endovaginal ultrasound
FALSE
The hCG levels in women with ectopic pregnancies are highly variable, often <1000 mIU/ml, and the hCG level does not predict the likelihood of ectopic pregnancy rupture. Thus, when the clinical findings are suspicious for ectopic pregnancy, transvaginal ultrasonography is indicated even when the hCG level is low.
What ovarian mass has this ultrasound appearance:
Homogeneous hypoechoic ovarian mass with posterior shadowing
Fibroma
What are the findings of uterine leiomyosarcoma?
Irregular contours
Rapidly growing in post menopausal women
Arise de novo - 0.2% arise from leiomyoma
The presence of necrosis does not differentiate a degenerating leiomyoma from a leiomyosarcoma
TRUE OR FALSE
Most uterine leiomyosarcomas arise from a leiomyoma
FALSE
0.2% of uterine leiomyosarcomas arise from leiomyomas. The majority arise DE NOVO
What is the normal endometrial thickness in the following scenarios:
1- asymptomatic premenopausal
2- asymptomatic postmenopausal
3- postmenopausal with vaginal bleeding
1- <15mm (can be thicker and still normal depending on cycle)
2- <8mm
3- 4mm or less (dx of atrophy)
What is the differential diagnosis for uterine bleeding?
Polyp
Atrophy
Carcinoma
Fibroid
What is the role of trophoblasts?
Help developing embryo invade the endometrium and implant in the myometrium
Establish maternal-fetal circulation
Form part of the placenta
Secretion of hCG and human placental lactogen (hPL)
What percentage of complete molar pregnancies develop into an invasive mole or choriocarcinoma?
15-25% invasive mole
5-8% choriocarcinoma
The hCG must be followed until complete resolution (0).
What are the imaging findings of a hydatidiform mole?
Enlarged uterus
Heterogeneous endometrial canal with multiple tiny cystic spaces (snow storm, swiss cheese)
Hypervascular
bilateral ovarian cysts 50%
If an embryo is also present, often abnormal, it is a partial mole. If there is no embryo, it is a complete mole.
What is the difference between a complete/partial mole and an invasive mole?
Invasive mole invades into the myometrium whereas complete/partial mole is limited to the endometrium.
Metastasis possible but rare.
What is a choriocarcinoma?
Malignant tumor that arises from trophoblasts
TRUE OR FALSE
Choriocarcinoma can arise from any pregnancy.
TRUE
Molar pregnancy, term, pre-term pregnancy and pregnancy termination are all risk factors for choriocarcinoma.
Non-gestational choriocarcinoma is possible but rare.
TRUE OR FALSE
Gadolinium does not cross the placenta and is therefore safe to use in pregnancy
FALSE
Gadolinium crosses the placenta. Although no adverse events have been documente, its use is not recommended in pregnancy due to lack of data.
What is cervical funneling?
Cervical funneling is a sign of cervical incompetence and represents the dilatation of the internal part of the cervical canal and reduction of the cervical length.
Greater than 50% funneling before 25 weeks is associated with approximately 80% risk of preterm delivery.
What is the normal ratio of amniotic fluid to fetus in the second trimister?
1:1. If less: oligohydramnios.
What is the Potter sequence and its common findings?
The Potter sequence is a constellation of findings demonstrated postnatally as a consequence of severe, prolonged oligohydramnios in utero.
P: pulmonary hypoplasia
O: oligohydramnios
T: twisted skin (wrinkly skin)
T: twisted face (Potter facies: low set ears, retrognathia, hypertelorism)
E: extremity deformities (limb deformities: club hands and feet, joint contractures)
R: renal agenesis (bilateral)
What are the findings of Potter facies?
Low set ears
Flattened nose
Wrinkled skin
Micrognathia
What is twin to twin transfusion syndrome?
There is an arterio-venous anastomosis in the placenta. The donor twin partially perfuses recipient twin with arterial blood flow (deoxygenated).
If untreated, fatal. The donor twin is small and the recipient twin develops heart failure from increased blood flow.
What is twin reversed arterial perfusion sequence?
Arterio-arterial anastomosis in placenta. The recipient twin is acardiac (has no heart) and is perfused by deoxygenated blood from the donor twin. The acardiac twin has no placental circulation.
It is fatal to the recipient twin and may be fatal to the donor twin.
How do you diagnose fetal ventriculomegaly?
Fetal ultrasound: Measure the lateral ventricles at the level of the choroid plexus, abnormal if over 10mm.
What are the MRI characteristics of endometrioma?
hyperT1 secondary to the presence of blood
HypoT2 secondary to deoxyhemoglobin/methemoglobin
Shading sign
T2 dark spot sign
May have wall enhancement. Enhancing nodule suggests malignant transformation.
What is the shading sign (gyne)?
MRI finding typically seen in endometrioma, be can present in some endometrioid tumours.
In lesions that are hyperT1, there is HypoT2 affecting variable portions of the cyst. It may involve only a small portion of the cysts, typically layering dependently, or the entire cyst. Secondary to high concentration of protein and iron within the endometrioma from recurrent haemorrhage. The degree of shading can vary from faint to complete signal loss.
It helps to distinguish endometriomas from other blood containing lesions (e.g. haemorrhagic corpus luteum cysts), with a sensitivity of 90-92%, a specificity of 91-98% and a diagnostic accuracy of 91-96%.
What is the T2 dark spot sign (gyne)?
T2 dark spot sign is an MRI appearance of endometriomas seen as a result of chronic haemorrhage. The sign is useful in differentiating a solitary endometrioma from a functional haemorrhagic ovarian cyst, as both might show high T1 signal with T2 shading.
The T2 dark spot is seen within the cyst, often against the cyst wall, but not within the cyst wall itself.
What are the 2 most common ovarian neoplasms that arise from endometriosis/endometrioma?
Endometrioid (most common)
Clear cell carcinoma
