O+G Flashcards
Bartholin cysts are
Cystic dilatation of Bartholins glands.
Clinical: Most patients asx. Cyst formation in reproductive years. Secondary infection and abscess not uncommon. Rarely, malginancy can arise.
Bartholin cyst imaging characteristics:
Smooth marginated round vulvular cyst
Thin wall without significant inflammatory change
Thin septations may be present
Posterolateral aspect of the vaginal introitus, within superficial perineal pouch, below perineal membrane/PS
Typically solitary, can be multiple/bilateral
CT: Low density, non enhancing.
Uniformly thin wall, minimal enhancement
MRI
T1: Hypointense, but dependant on protein/haemorrhage
T2: Homogenous high signal, heterogenous if complicated
PCT1: no central enhancement. Thickened enhancing wall suggests infection. Nodular enhancement ?malignant transformation (rare)
US: thin walled anechoic vulvular cyst
no colour flow
Bartholin cyst embryology
Glands arise from urogenital sinus
Analogous to male Cowper (bulbourethral) glands
Bartholin cyst differentials
Bartholinitis: infection of the cyst, thickened enhancing wall with adjacent inflammatory change
Skene gland cyst: cystic dilatation of a Skene gland
Positioned anteriorly in vaginal introitus at the external urethral meatus
Gartner duct cyst: Simple cyst arising from anterolateral vaginal wall
Typically above the level of the pubic symphysis/perineal membrane
Epidermal inclusion cyst: SC lesion, most commonly from labia majora. often secondary to trauma or surgery
Urethral diverticulum: Cystic lesion margin of the mid urethra. May communicate with the lumen. Above the level of PS/perineal membrane
Adenocarcinoma of Bartholin’s gland: Significant enhancing soft tissue component
Periurethral collagen injection
Nabothian cyst: Endocervical canal
Urethral caruncle: Benign excrescences of urethral mucosa, postmenopausal
Prolapsed utererocoele: childhood mass eccentric to urethral meatus
Bartholin cyst clinical issues
Presentation: Asymptomatic, palpable vulvar mass, dyspareunia, pain/signs of infection
Demographics: Reproductive years, 20-30s. Glands involute post
2% of women in their lifetime
Prognosis: Resolve spontaneously, secondary infection
Malignant transformation: 40% adeno, 40% squamous cell. New cyst after 40 is suspicious
Treatment: Small asx; no treatment
If symptomatic; marsupialisation
other: resection, fistulisation, aspiration, ablation
Bartholinitis is
Infection of dilated/obstructed Bartholin gland, leads to abscess formation
located along the posterolateral vaginal introitus in superficial perineal pouch, below level of the pubic symphysis/perineal membrane
Can be bilateral, multilocular
Bartholinitis imaging characteristics
CT: Low density, rim enhancement
Peripheral enhancement may be slightly irregular
May see thin internal enhancing septation
Adjacent inflammatory fat stranding
MRI
T1: Well marginated, variable intensity
T2: High signal intensity uni or multilocular cyst
T1C+FS: thickened irregular enhancing wall with surrounding inflammation
US: introital cyst transperineal/translabial US
Increased peripheral Doppler flow
May have septations, internal debris
Nabothian cysts are
Mucinous endocervical gland cysts arising as a result of obstruction secondary to overgrowth of the squamous epithelium at their neck.
Tunnel clusters: complex multicystic dilation of endocervical glands
Nabothian cyst imaging characteristics
Circumscribed, unilocular, superficial cysts of the cervix
Typically simple and superficial but can be complex and invade cervical stroma
Most are few mm in diamter
Round or oval, single or multiple, can be numerous
CT: non-enhancing, hypodense to cervical lesion
MRI:
T1: Intermediate to hyperintense (mucinous)
T2: hyperintense, circumscribed, superficial
US: Anechoic, circumscribed lesion with posterior acoustic enhancement
Nabothian cyst differentials
Adenoma malignum: low-grade mucinous carcinoma affecting deep endocervical glands. Multilocular cystic masses. Enhancing solid components. Deeply penetrating. Copious watery vaginal discharge
Squamous cell carcinoma: Solid mass of cervix. Necrotic regions but solid elements predominate
Nabothian cysts clinical
usually asymptomatic
Tunnel clusters almost always occur in multigravid women >30
The majority require no treatment
Symptomatic; cyst drainage, cryosurgery, conization
Endocervical polyp imaging characteristics
Small pearl shaped mass
Feeding vessel in stalk on colour imaging
Originates from cervical canal, may protrude through external os and prolapse into canal
Usually between 2-30mm
Giant polyps are rare
CT
Soft tissue mass, similar attenuation to myometrium
MR
T1: low intensity within cystic spaces of polyp
T2: low intensity mass surrounded by high intensity fluid. large multicystic with high signal intensity fluid filling canal
DWI: no restriction
C+: Brisk enhancement, similar to myometrium
US
Echogenic mass within canal
Thickening of canal +/- cystic change
Central feeding vessel in stalk
Well defined echogenic structure in endocervix
Surrounding fluid may be present
May have cystic spaces
Sonohystogram: Smoothly marginated mass projecting off stalk
Endocervical polyp differentials
Cervical malignancy: Cannot differentiate from benign vs malignant containing polyp.
Cervical malignancy may invade underlying cervical tissue
Cervical leiomyoma: 10% of fibroid. Usually submucosally or subserosally but may be polypoid
Blood clot: no vascularity, will not enhance. Should pass over time.
Endometrial polyp or fibroid: Large enough to prolapse through external cervical os. tend to be polypoid with broad base.
Sarcoma botryoides: extremely rare, adolescents
Mullerian adenosarcoma: extremely rare
Uterine epithelioid endometrial stromal sarcoma: also rare
Endocervical polyp pathology
Etiology
Tamoxifen use
Other: multiparity, chronic cervicitis, foreign bodies, estrogen secretion
Focal hyperplastic protrusions of endocervical folds
Develop dysplasia and in situ or invasive carcinoma <1%
Gross
Usually pedunculated, may be sessile
Soft, smooth, red or purple
Few to 30mm
Microscopic
Classified according to the preponderance of tissue component: mucosal, fibrous, vascular, mixed endocervical/endometrial, mesodermal stromal
Cystically dilated endocervical glands
Large no. of blood vessels at surface
Inflammatory infiltrate 80%
Cervical carcinoma clinical
Third most common gynae malignancy
Typically presents in younger women with an average age of onset around 45 years
Risk factors:
HPV (not for clear cell or mesonephric)
Multiple sexual partners or male partner with multiple partners
Young age of first intercourse
High parity
Immunosuppression
HLA subtypes
Oral contraceptives
nicotine/smoking (not adeno)
Presentation:
Vaginal bleeding, discharge, abnormal screening
Cervical carcinoma pathology
Thought to arise from the transformation of cervical intraepithelial neoplasia
Histological types
Squamous: vast majority, HPV exposure
Adenocarcinoma: rarer. Subtypes: clear cell, endometrioid, mucinous, serous, mesonephric
Neuroendocrine: small cell, rare
Adenosquamous, rare
Squamous arise from the squamocolumnar junction. Situated at the ectocervix in younger patients and regresses into the endocervical canal with age
Adenocarcinomas arise from the endocervix
Prognosis
5 yr survival 92% stage 1 and 17% stage IV
Cervical carcinoma imaging characteristics
US
Hypoechoic, heterogeneous mass
May show increased vascularity on colour doppler
CT
Useful in assessing advanced disease, particularly adenopathy
also monitoring mets, planning of radiation port placement, guiding bx
Can be hypo or isoenhancing to normal stroma
MRI
Normal low signal cervical stroma provides intrinsic contrast for the high signal tumour
T1: usually isointense to pelvic muslces
T2: Hyperintense relative to stroma
C+: not routine, can be helpful for small tumours. high signal relative to stroma
Cervical carcinoma staging
FIGO or AJCC https://radiopaedia.org/articles/cervical-cancer-staging-1
FIGO 2018
1. confined to the cervix
- 1a1 0-3mm depth
- 1a2 3-5
- 1b1 5-20
- 1b2 20-40
- 1b3 >40
- beyond the uterus but not extended to lower third of the vagina or pelvic wall
- 2a1 upper 2/3 of vagina without parametrial <40
- 2a2 same >40
- 2b with parametrial but not wall - involves lower third of the vagina, +/- pelvic wall +/- hydronephhrosis +/- pelvic/paraaortic nodes
- 3a lower third no wall
- 3b pelvic wall and/or hydronephrosis
- 3c pelvic or paraaortic nodes - beyond true pelvis or mucosa of bladder or rectum
- 4a1 adjacent organs
- 4a2 distant organs
Mullerian duct anomalies are
Congenital abnormalities that occur when Mullerian/paramesonephric ducts dont develop correctrly.
Result may be complete agenesis, defective vertical or lateral fusion, or resorption failure
1-5% of women
majority asymptomatic, can present with miscarriages and infertility
Obstruction - abdominal mass and dysmenorrhoea
Delayed treatment - potentially infertility
Mullerian anomaly subtypes
Agenesis 10%
Arcuate 7%
Unicornuate 15%
Duplication
Didelphys 7.5%
Bicornuate 25%
Septate 45%
Mullerian anomaly associations
Renal anomalies; agenesis, crossed fused ectopic, duplex
Uterine agenesis is
Class 1 Mullerian duct anomaly where there is the complete absence of uterine tissue above the vagina
Agenesis-hypoplasia spectrum accounts for 10-15% of MDA
Uterine agenesis pathology
Clinical
Primary amenorrhea, normal hormonal levels with fully functional gonads
Path
Complete absence of the Mullerian ducts; Mayer Rokitansky Kuster Hauser MRKH syndrome
Associations
Renal tract anomalies
Vertebral anomalies
Unicornuate uterus is
Class 2 Mullerian duct anomaly characterised by a banana-shaped uterus usually draining into a single fallopian tube
Unicornuate uterus pathology
Failure of one of the ducts to elongate while the other develops naturally. Predominance on the right. May or may not have a rudimentary horn
Subclassification
A: Rudimentary horn
- A1: endometrium
- - A1a: communicating 10%
- - A1b: non communicating 22%
- A2: Controlateral horn has no endometrial cavity 33%
B: No horn 35%
Associations
Renal abnormalities; more common with unicornuate than the others, 40% of cases. Always ipsilateral to the rudimentary horn
Cryptomenorrhea
Primary infertility
Treatment and prognosis
Second worst obstetric outcome, with septate worst
Spontaneous abortion rates 41-62%
Unicornuate uterus imaging characteristics
HSG:
Fusiform banana shape
May have a small cavitation in type a
Drains to single fallopian tube
US
Difficult to detect on US, may be tapering
MRI
Curved and elongated uterus; banana shaped external contour
Reduced volume
Asymmetric configuration
Normal myometrial zonal anatomy
May be difficult to tell from bicorunate with only one side cannulated
Arcuate uterus is
Mild variant shape of the uterus, mild indentation of the endometrium at the uterine fundus. Least associated with reproductive failure.
Arcuate uterus pathology
Mild fundal indentation of the endometrium. Most common anomaly, 3.9% population. Exists on a spectrum with septate uterus, from least to most resorption of the uterovaginal septum
Arcuate uterus imaging characteristics
Normal fundal contour
No horn division
Smooth indentation of the fundal endometrial canal, <1cm
Increased transverse diameters
Fluoroscopy
Opacification of the cavity, single cavity, broad saddle shaped indentation of the uterine fundus
US
Normal external contour
Broad smooth indentation on the fundal endometrium
MRI
Normal external uterine contour. Myometrial fundal indentation is smooth and broad. Isointense to normal myometrium
Arcuate uterus differentials
Septate: Exist on a spectrum from most to least resorptive
Bicornuate: Arcuate has normal or slightly indented external fundal contour. Bicornuate has a more marked fundal indentation <5mm above the level of the uterine horns
Uterus didelphys is
Class III Mullerian duct anomaly where there is complete duplication of uterine horns as well as duplication of the cervix with no communication
Uterine didelphys pathology
Associations
Renal agenesis (helyn werner wunderlich)
Vaginal septum, including transverse septum
Along with unicornuate, greatest impact on reproductive performance
Pathology
Failed ductal fusion between 12-16th week of pregnancy
Characterised by two symmetric widely divergent uterine horns and two cervices
Uterine volume in each is reduced
Increased incidence of fertility issues; pregnancy to term 20%, third aborted, half premature. Only 40% result in living infants
Uterine didelphys imaging characteristics
Two widely spaced uterine corpora, each with a single Fallopian tube. Separate horns with large fundal cleft (distinct from septate)
HSG
Two separate endocervical canals that open into separate fusiform endometrial cavities with no communication between horns
If associated with longitudinal vaginal septum only one cervical os may be depicted and it may be cannulated with the endometrial configuration mimicking a unicornuate uterus
US
Separate divergent uterine horns identified with a large fundal cleft. Endometrial cavities are uniformly separate with no evidence of communication. Two separate cervices need to be documents.
MRI
Two separate uteri with widely divergent apices. Two separate cervices. Usually an upper vaginal longitudinal septum. Normal zonal anatomy is preserved.
Bicornuate uterus is
Class IV Mullerian duct anomaly, type of duplication anomaly. Concave or heart shaped external contour, fundal cleft >1cm deep. Caudally fused symmetric uterine cavities with some degree of communication.
Bicornuate uterus pathology
Clinical
Incidentally often
Early pregnancy loss and cervical incompetence
Associations
Longitudinal vaginal septum in 25%
Abnormalities of the renal tract
Pathology
Abnormal development of the paramesonephric ducts. Partial failure of fusion resulting in uterus divided into two horns
Subtypes; according to cervical canal
Bicollis: two cervical canals; central myometrium extends to the external cervical os
Unicollis: one cervical canal; central myometrium extends to the internal cervical os
Treatment and prognosis
In recurrent pregnancy loss; strassman metroplasty could be considered
In cervical incompetence; placement of cervical cerclage may increase fetal survival rates
Bicornuate uterus imaging characteristics
External contour is concave or heart-shaped, horns are divergent
Fundal cleft is typically more than 1cm deep and the intercornual distance is widened
Uterus seen as comprising caudally fused symmetric uterine cavities with some degree of communication, usually at the isthmus. Angle between the horns usually more than 105 degrees
HSG
Divided uterus, difficult to differentiate between septate and bicornuate since the uterine fundal contour is not visible
MRI
Helps confirm anatomy by showing a deep >1cm fundal cleft in the outer uterine contour and an intercornual distance of >4cm. Normal zonal anatomy
Septate uterus is
Class V Mullerian duct anomaly. Type of duplication anomaly resulting from partial or complete failure of resorption of the uterovaginal septum after fusion of the paramesonephric ducts.
Septate uterus pathology
Commonest. Type V.
Most common anomaly associated with subfertility, preterm labour, reproductive failure.
Partial or complete failure of resorption of the uterovaginal septum after fusion of the paramesonephric ducts. Septum is usually fibrous but can have some muscle
Associations: concurrent renal anomalies
Treatment
Metroplasty
Septate uterus subtypes
Partial: endometrial canal but not the cervix.
Complete: extends either to internal or external os
Septate uterus/vagina: extends into vagina
Septate uterus imaging characteristics
Variable external contour, convex, flat or mildly (<1cm) concave.
Acute angle between uterine cavities.
Endometrial canals are completely separated by tissue isoechoic to myometrium with extension to endocervical canal.
HSG:
Inaccurate for septate vs bicornuate. Angle of less than 75 between the uterine horns suggestive of septate, 105 suggestive of bicornuate
US
Endometrial stripe separated at the fundus by the intermediate echo septum. Extends to cervix in complete type. May show vascularity in septum.
MRI
Normal uterus size. Each endometrial cavity smaller than normal cavity. Variable septum signal
Septate uterus differentials
Bicornuate: shape of external contour
Arcuate: small myometrial indentation with normal contour
Thick adhesion
Haematometrocolpos is
Distension of the uterus and vagina with blood (metra uterus colpo ovary)
Haematometrocolpos imaging characteristics
Echgenic fluid within distended uterus +/- vagina
US
distended uterus/vaginal cavities. HM thick walled, HC thin walled.
Mixed echogenicity
No flow (if flow mass)
3D ?MDA
MR
T1 iso to hyper
T2 Hyper
Haematometrocolpos differentials
Pyometra: fever WCC. clinical dx
Endometritis: Post instrumentation/childbirth. Gas bubbles in endometrial cavity. Not associated with amenorrea, does not involve vagina
Muco/hydro metrocolpos
Gestational trophoblastic disease: Complete mole snowstorm appearance, not echogenic fluid. Invasive mole typically hypervascular and invading myometrium. Does not involve vagina
RPOC
Complex adnexal lesion
Haematometrocolpos causes
Imperforate hymen (most common)
MDA: vaginal septum (TV/Vert), vaginal agenesis, cervical agenesis, uterus didelphys with obstructed hemivagina
Cloacal malformation: confluence of rectum, vagina, urethra. Often septated/bilobed.
Cervical/vaginal stenosis: post radiation therapy, post recon surgery, chronc GVHD
Endometritis is
Ascending polymicrobial infection of the cervic and uterus
Endometritis imaging characteristics
Increasing fluid and gas in endometrial cavity in postpartum patient with fever and pelvic tenderness. Findings can be normal frequently
CT
Thickening, fluid gas
parametrial inflmmation/collection/pyosalpinx
MRI
Thickened endometrial cavity, fluid or gas
Contrast enhanced MR for collections
US
uterus may be enlarged, tender
thickened heterogenous endometrium. Endometrial fluid and echoes.
Adnexal collections
Increased flow
Endometritis pathology
Post partum usually polymicrobial
Not related to pancrea; chlamydia, gonorrhea, genital mycoplasms, aerobic/anaerobic vaginal flora
Clinical
Enlarged, tender post partum uterus. Fever WCC/
Non post partum: lower abd pain, dysparuenia, fever, back pain and vomiting. Adnexal tenderness on bimanual
Endometritis differentials
RPOC: Echogenic endometrial mass. High vel low resistance flow doppler.
Clot and debris
Normal gas in cavity
Gartner duct cyst is
Embryologic mesonephric duct remnant. Simple anterolateral upper vaginal wall cyst.
Gartner duct imaging characteristics
Simple appearing cyst. Anterolateral upper vaginal wall. Above PS/perineal membrane
US
Simple anechoic vaginal wall cyst.
May have internal echoes/debris
Peripheral Doppler flow with inflammation/infection
CT
Low attenuation non enhancing
MR
T1 hypo
T2 hyper
May be atypical if infected, haemorrhagic, proteinaceous
Nodular enhancement suggests rare malignant transformation
Urethral diverticulum are
Uni or multilocular lesions adjacent to and often surrounding urethra.
Majority are acquired arising from infected/inflamed periurethral skene glands
Usually asymptomatic and incidental. May cause UTI sx, dribblings, dyspareunia
Urethral diverticula imaging characteristics
MR
T2 hyperintense
T1 hypointense
Diverticular neck may be visualised
Irregular wall enhancement or mass like components may suggest infection/malignancy
US
Well marginated anechoic periurethral cystic lesions
peripheral doppler flow suggests infection
CT
hypointense periurethral cystic lesion
may opacify post void
may see complicating stones
Fluoro
Urethral diverticula differentials
Bartholin cyst - posterolateral vaginal introitus
Skene gland cyst - anterior vaginal introitus at external meatus
Gartner duct cyst - classically anterolateral vaginal wall above the pelvic diaphragm
Urethral tumour - solid, expands urethra
Vaginal fistula is
an epithelially lined communication between the vaginal lumen and adjacent pelvic organs
types; vesico, colo/entero, recto/ano
Simple (single tract) or complex (multiple tracts).
Vaginal fistula causes
Obstetric trauma
Gynae/urologic procedures
Inflammation (Crohns)/ infection
Pelvic malignancy (bladder, cervical, endometrial)
Radiation therapy, 20 years post
Vaginal fistula imaging characteristics
Fluoroscopy
communication between the vaginal lumen and other pelvic organ, specific to type
CECT
Enteric contrast in vagina with bowel associated
Vesico or ureterovaginal fistula confirmed with contrast in vagina on CT cystography or urography
MR
Superior modality owing to multiplanar capabilities and soft tissue contrast
Abnormal T2/STIR linear hyperintensity
Surrounding low T2 fibrous wall
Low signal intensity tract with enhancing wall on T1+C
Cervical stenosis is
Canal narrowing from benign or iatrogenic source.
When severe, results in hydrometra, pyometra or haematometra.
Cervical canal narrowing <2.5-3.5mm
Cervical stenosis pathology
Any process that results in inflammation, erosion, repair and regeneration of cervical mucosa
In post menopausal women usually age related atrophy
Recognised complication following D/C, radiation therapy, cone biopsy and cervical amputations, radical tracheloectomy
Cervical stenosis imaging
Thickened cervix, fluid within endometrial canal
May see ancillary signs to suggest etiology eg thickened bowel post radiotherapy
May see dilated blood filled fallopians
Loss of normal cervix zonal architecture if radiation or old
Cervical stenosis differentials
Obstructed uterus secondary to malignancy
Obstructed uterus secondary to mass effect - cervical or submucosal leiomyoma or other pelvic mass causing compression/obstruction
Congenital abnormalities - imperforate hymen, complete transverse vaginal septum, cervical atresia, vaginal atresia
May have associated haemtocolpos and haematometra
Kidneys should be evaluated
Mayer Rokitansky Kuster Hauser syndrome is
congenital anomaly characterised by vaginal agenesis associated with spectrum of other GU tract abnormalities.
Two forms
A: congenital absence of the uterus and upper 2/3 vagina with normal ovaries and fallopian tubes
B: includes associated abnormalities of the ovaries and fallopians rubes, as well as renal anomalies
Mayer Rokintansky Kuster Hauser syndrome pathology
Arrested development of the paramesonephric ducts at 7 weeks.
Normal external genitalia and absence or reduced development of the uterus and upper two thirds of the vagina
Upper vagina, uterus, cervix and fallopian tubes from Mullerian ducts from 8-12w.
KUB concomitantly at 6-12 w.
Assoc: vertebral anomalies, renal anomalies (agenesis, ectopic kidney, fused kidney, renal hypoplasia and horseshoe kidney
Adenoma malignum is
Subtype of mucinous adenocarcinoma of cervix , termed malignum due to virulent and fatal progression
Adenoma malignum pathology
Well-differentiated endocervical glands that extend from surface to deeper portion of the cervical wall.
Presents with cluster of cysts, deceptively benign on histo
Associated with
Peutz jeghers syndrome
Mucinous ovarian tumours
Ovarian sex cord tumours with annular tubules
Endometrial hyperplasia is
Excessive proliferation of endometrial glands with increased ratio of glands to stroma
Endometrial hyperplasia imaging
Endometrial thickening with well defined myometrial interface
Focal or diffuse
May have cystic change
MRI
T1: usually not seen
T2: diffuse thickening of striple, iso/hypo to normal endometrium. May hve cystic change
C+FS: hypo to myometrium early, iso to hyper to myometrium late
US
Diffusely thickened, homogenous
May show cystic swiss cheese change
If atypical hypoechoic/heteerogenous areas
Multiple vessels, sparse vasculairty
Endometrial hyperplasia cutoffs
Premenopausal
>8mm proliferative
>16mm secretory
Post menopausal with bleeding >5mm
Postmenopausal without bleeding >8-11mm
Endometrial hyperplasia differentials
Secretory endometrium
Endometrial carcinoma - may coexist. irregular thickening/mass. ill-defined margins. myometrial invasion.
Endometrial polyp - may coexist. sessile polyps may mimic focal. Separate endometrial lining. Single feeding vessel in pedunculated. Fibrous stalk MR.
endometritis - hypervascular, fluid in cavity, adnexal changes of PID
Submucosal leiomyoma - focal hypoechoic thickening of endometrial echo complex. MR can easily differentiate.
Endometrial hyperplasia pathology
Unopposed estrogen; chronic anovulatory, exogenous, tamoxifen, obesity, secreting tumours
Assoc; endometrial polyp, endometrial cancer
post menopausal bleeding
Divided into hyperplasia with and without atypia. 25% with have or will have carcinoma.
Endometrial cancer epidemiology
Most common gynae cancer. Peak incidence 6th decade.
Risk factors: estrogen exposure; replacement, PCOS, tamoxifen, obesity, early menarche/late menopause, nulliparity, secreting tumours, DM
Assoc: HNPCC, complex hyperplasia
Endometrial cancer pathology
Majority adenocarcinoma
Divided into type 1 and 2
Type 1: 80%. unopposed estrogen and endometrial hyperplasia. Obese mid 50s women. Well diff, slow progression. PTEN gene mutation 3-80%
- endometrioid carcinoma
Type 2: 20%. Endometrial atrophy. 70ish. p53 mutation 50%. Less differntiation and spreads early
- papillary serous carcinoma
- clear cell carcinoma
- adenosquamous carcinoma
- adenocarcinoma with squamous diff
= undifferentiated/small cell
Endometrial cancer imaging
US
Thickening or polypoid mass
premenopausal; varies with cycle. >16 secretory, >8 prolif
post menopausal >5, or 8 if HRT/tamox
Suggestive US features; heterogenous, irregular. polypoid mass. intrauterine fluid. frank myometrial invasion. Disruption of subendometrial halo
CT
Mets
MRI
T1: hypo to iso to normal endometrium
C+: hypoenhancing. delayed for stromal invasion.
t2: iso to hypo relative to normal. heterogenous. hypointense to myometrium
DWI: restricted
Endometrial cancer FIGO
stage 1: tumour confined to the uterus
stage 1a: an invasion of less than half of the myometrium
stage 1b: an invasion of the outer half of myometrium
stage 2: tumour extends to the cervical stroma
stage 3: tumour extends beyond the uterus
stage 3a: tumour invades the serosa or adnexa
stage 3b: tumour invades the vagina or parametrium
stage 3c: pelvic/para-aortic lymph node involvement
3c1: pelvic lymph node involvement
3c2: para-aortic lymph node involvement\
stage 4: bladder/rectal invasion or distant metastases
stage 4a: tumour extends into adjacent bladder or bowel
stage 4b: distant metastases
Endometrial cancer differentials
Benign proliferation
endometrial hyperplasia
endometrial polyp
Submucosal uterine leiomyoma
DDX advanced
Uterine sarcoma - endometrial sarcoma, leiomyosarcoma, malignant mixed Mullerian tumour
Uterine lymphoma
Cervical cancer with invasion
Mets
Fibroids are
Benign tumours of uterine smooth muscle cells
Fibroid types
Location
Intramural: most common, surrounded by myometrium
Subserosal: deep to and abutting serosa. sessile or pedunculated. May grow laterally through broad lig folds. Can tort and infarct.
Submucosal: deep to endometrium. Sessile or pedunculated. Stretches over endometrium or projects into cavity. Can pass through cervix. Odten symptomatic, irregular bleeding and infertility
Fibroid imaging
HSG
Mass effect on endometrium
CT
Hypo or homogenous enhancement
can calcify
MRI
T1 iso to myometrium
T2: homogenous, hypointense to myometrium. pseudocapsule. hyperintense rim, edema,lymph, veins
C+: solid enhancing, variable, enhancing halo
US
homogenous, hypoechoic, shadowing
peripheral flow, decreased central flow
have have stalk vessel in pedunculated or bridging vessel sign in subserosal
Fibroid differentials
Adenomyoma: poorly marginated and intermediate T2. Punctate hyperintense T1/T2 foci. Ill defined endometrial/myometrial junction and contiguous with junctional zone
Malignant uterine neoplasm; leimyosarcoma. irregular and indistinct. heterogeneous t2 and post con signal. rapid growth
Contraction
Ovarian fibroma
Fibroid degeneration
Hyaline; focal or generalized
Cystic
Myxoid
Red/carneous; due to haemorrhagic infarct
Not degenerative but other types
parasitic; subserosal torted off
broad lig and cervical
diffuse
lipoleiomyoma
pyomyoma - suppurative
Pyomyoma is
Suppurative leimyoma. Presents with sepsis, bactaraemia, leiomyoma.
Pyomyoma imaging
Gas and internal debris. Heterogenous in attenuation with regions of degeneration associated with parametrial inflammation
Intramural/submucosal/subserosal
MPR helps identify pyomyoma rupture with discontinuity of wall
Uterine AVM pathology (etiology and assoc)
Etiology:
Congenital (rare)
Acquired; post traumatic or infectious
Risk factors: D/C, IUD, pelvic surgery, infection, GTD, carcinoma, diethylstilbestrol exposure
Assoc:
pseudoaneurysm
Uterine AVM imaging
US
Small anechoic spaces distributed uniformly producing spongy myometrial echotexture
No mass effect
2 mosaic patterns of colour; flow reversal and colour aliasing
High flow low resistance arterial flow
Prominent parametrial vessels
MR
Bulky appearance, focal or diffuse disruption of the junctional zone
Multiple serpentine flow related signal voids
No well defined mass or margins
MRA: enlarged arteries, vascular network, early venous filling
Angiographic
Complex tangle of vessels
Hypertrophied feeding uterine arteries
Early venous drainage
Uterine AVM ddx
Gestational trophoblastic disease - positive bhcg, overlapping features, may coexist
Endometrial carcinoma - neovascularity, low volume, high velocity
RPOC - bhcg, endometrial based mass, overlapping doppler characteristics
Pelvic varicosities - normal venous waveforms
Uterine haemangiomas - phleboliths
Ovarian torsion is
Twisting of the vascular pedicle on axis of infundibulopelvic and uteroovarian ligaments. Leads to venous and lymphatic congestion, arterial obstruction and infarction.
Torsion imaging
Enlarged oedematous ovary displaced
>4cm in one dimension or >20cc premeno 10cc post meno
Heterogenously echogenic appearance of the ovary
US
enlarged, heterogenous, hyperechoic
peripherally displaced follicles
displaced to midline
cystic or solid lesion as lead point
twisted vascular pedicle
free fluid/haematoma
probe pain
Doppler
whirlpool along pedicle
pulsed doppler variable findings
CT
Enlarged cyst or mass may be present
Twisted vascular pedicle is specific
Free fluid
May have subacute haemorrhage
MRI
T1 hypointense. can be hyper if subacute haemorrhage, or haemorrhagic lesion
T2 increased due to oedema. hyperintense follicles
C+ variable
Torsion ddx
Haemorrhagic cyst; highly variable appearance. typicall avascular with reticular fishnet pattern. can have retractile clot, fluid level, debris
Ectopic pregnancy; positive bhcg. Tubal mass with thick echogenic ring
Isolated fallopian tube torsion; FT thickened walls,internal haemorrhage
PID; complex fluid collection with pseudo solid appearing components. hyperaemia.
Torsion pathology
Follicular cyst most common
Mature cystic teratoma most common tumour
Presentation
acute onset sharp pelvic pain, n/v
Demographics
reproductive years, 20% pregnant
2-3% gynae emergencies
increases with ovarian stimulation
Prognosis
If untreated, infarction
Spontaneous torsion detorsion leading to ovarian oedema
Treatment
surgery; detorse vs remove
Follicular cyst - definition, imaging, ddx, clinical
Hormone dependent functional ovarian cyst. Arrested follicular development with subsequent cyst formation.
Imaging
Well marginated round with thin wall
2-8cm solitary
Peripheral rim of compressed ovarian parenchyma, often with other smaller developing follicles
US: anechoic, avascular, simple apearing. varied if haemorrhagic
MR: T1 low T2 high. No central enhancement. Thin smooth enhancing wall without nodularity of papillary projections. Varied central signal if haemorrhagic.
CECT: fluid density, no central enhancement
DDX
endometrioma
CL cyst
Paraovarian cyst
Surface epithelial tumour
Clinical
Majority of simple cysts in premenopause are follicular and regress in 2 cycles
Corpus luteal cyst - definition, pathology, imaging, ddx, clinical
Cystic dilatation of normal physiological corpus luteum
Path
Round yellow with lobulated margins
Thickened and irregular
Serous or serosanguinous internally
Wall becomes luteinised; granulosa lutein, theca lutein and k cells
Menstrual cycle:
Follicular - FSH, dominant follicle, estradiol, LH surge, ovulation
Luteal - Ovulation, CL, progesterone, CL increases then involutes to corpus albicans
Imaging
Unilocular cyst wih irregular thick crenelated vascular wall
Mimic solid when collapsed
MR
thickened irregular enhancing wall
Variable signal due to haemorrhage
No internal enhancing papillary projections or mural nodularity
US
anechoic with thickened echogenic wall
posterior enhancement
variable due to haemorrhage
ring of fire vascularity
typically <3cm
DDX
Ectopic
Endometrioma
Primary ovarian neoplasia
Ovarian abscess
Clinical
Asx, can have rupture and haemorrhage
Majority regress in 2 months
Theca lutein cysts - defintion, imaging, ddx, clinical
Multiple theca lutein cysts in associated with increased levels of or abnormal ovarian respone to bhcg
Imaging
Bilaterally enlarged ovaries with multiple cysts of variable sizes
Hypervascular central uterine mass if molar
typically 6-12cm
preservation of underlying ovary
thin walled cysts
No nodules or solid components
Spoke wheel ovaries
DDX
ovarian epithelial neoplasm
PCOS
OHSS
Clinical
Usually asx, can rupture or tort
typically regress after causative factor
Haemorrhagic cyst - definition, imaging, ddx, clinical
Haemorrhage into cystic space in ovarian pathology
Imaging
Avascular hypoechoic ovarian mass with fine, lacy internal echoes
Most resolve 6-12 weeks
Mass like complex adnecal without vascularity
If ruptures, haemoperitoneum
DDX
Endometrioma - more uniform echoes
Solid ovarian mass - papillary projections more likely than angular fragments
Torsion - can be painful, haemorrhagic
Clinical
Most asx and resolve
Larger - pain, acute abdo
Surgery for severe - rupture or torsion
PCOS IS
Polycystic ovarian morphology with clinical and endocrine dysfunction. Must exclude other etiologies of hyperandrogenism and menstrual disturbance.
PCOS imaging
> 25 follicles, >10mL volume
Usually bilateral, may be unilateral
Other: >9follicles per section. String of pearls appearance.
MRI
T1 low follicles, stroma isointense to myometrium
T2 small subcapsular hyperintense follicles. low signal ovarian cortex and central tissue.
C+ follicle rim enhancement. enhancement of vascularised stroma.
US
FNPO >25, sesn 85 sp 94
volume 10cc
Increased stromal volume and echogenicitiy
Endometrial thickening - homogeneous or heterogenous, can have cystic change. due to unopposed estrogen.
Increased stromal blood flow and vessel calibre, decreased RI PI
PCOS ddx
Normal ovaries with multiple functional cysts
Polycystic ovaries. absent clinical and biochemical features
Multifolliclar ovaries - incomplete pulsatile gonadotropin stimulation. assoc w hyperprolactin, hypothalamic anovulation, weight related amenorrhea. Normal LH and T, decreased FSH. Mid to late normal puberty. Fewer follicles.
Pelvic congestion - prominent ovaries, polycystic pattern to clusters of 4-6. Enlarged uterus thick endometrium.
OHSS
Dermoid cysts are
Congenital cystic tumour composed of well differentiated derivations from at least 2/3 germ cell layers. Classified as benign ovarian germ cell tumour.
Dermoid cyst imaging
CT
Fat is diagnostic
Teeth or calc in half
May see floating mass of hair
Dermoid plug in wall
Enhancement of solid component may occur in benign
MRI
T1 - heterogenous. Bone low, fat high. Can have chemical shift artefact.
T1FS - suppression is diagnostic
T2 - variable
SWI - restricting, due to keratinoid substance
C+ - enhancement can occur in benign
US
Dependant on size of plug, calcific elements and histo
May be echogenic or cystic
3 most common;
- cystic with echogenic shadowing nodule projecting inward (Rokitansky)
- Tip of iceberg; Echogenic with sound attenuation owing to sebaceous material or hair within cavity
- Dermoid mesh; multiple thin dot dash caused by hair
Shadowing calcific structures
Fluid fluid level with sebaceous and serous
Floating nodules
Complications
- torsion
- rupture
- malignant transformation
- pseudomyxoma peritonei
- infection
- paraneoplastic encephalitis
Dermoid cyst differentials
Endometriomas
Bowel - gas/faeces may mimic rokitansky
Haemorrhagic cyst
Pedunculated lipoleiomyoma
Immature teratoma - predominantly solid that contain fatty elements, irregular calcifications and numberous cysts
Dermoid cyst pathology
Cavity filled with sebaceous material liquid/semisolid
Surrounding firm capsule
Usually unilocular
1 or more rokintansky nodule
Micro
Well differentiated derivatives of 3 germ layers
Orderly arrangement of tissues
Squamous epithelium lined walls of cyst
Compressed ovarian stoma
Hair, skin, muscle within wall
Strumi ovarii
Anembryonic pregnancy is
Form of failed early pregnancy with a gestational sac but the embryo does not form
Anembryonic pregnancy pathology
Blastocyst formed from fertilised ovum
Fetal pole never develops
bHCG formed due to syncytiotrophoblast invasion into endometrium
Anembryonic pregnancy imaging
No embryo in gestational sac MSD >25mm
OR
No embryo on follow up scan
- 11 days after showing sac with yolk sac but no embryo, or
- 2 weeks after scan showing gestational sac with no yolk sac or embryo
Ancillary
- Absent yolk sac MSD >8mm
- poor decidual reaction
- irregular sac shape
- low sac position
Anembryonic pregnancy differentials
Early pregnancy
Pseudogestational sac
Gestational trophoblastic disease
Ectopic pregnancy pathology
Epidemiology
- 1-2% pregnancies.
- 18% of 1st trimester w bleeding
- assoc with IVF
Locations
- tubal (ampullary, isthmal, fimbrial)
- Interstitial/cornual
- Ovarian
- Cervical
- Scar ectopic
- Abdominal ectopic
RF
- IVF
- Prior ectopic
- Tubal surgery/injury
- PID
- SIN
- endometrial injury
- IUD
- Endometriosis
- Previous placenta previa
- Congenital uterine anomalies
- smoking
- maternal age
bHCG increases at a slower rate, 50% or less in 48 hours
Ectopic pregnancy imaging
Empty uterus
pseudogestational sac
decidual cast
thick echogenic endometrium
Complex adnexal cystic mass 95% with empty uterus
Simple 10
Ring of fire
Live extrauterine
Free pelvic fluid or haemoperitoenum
- positive bhcg, fluid and empty uterus 70%
Special ectopic key features (interstitial, ovarian, cervical and c scar)
Interstitial
- 2-4%
- higher risk of rupture, massive haemorrhage, uterine rupture
- interstitial line sign (echogenic line from mass to endometrial echo complex
- eccentric gestational scar, <5mm myometrium in all planes
Ovarian
- <3%
- Wide echogenic outer ring
- on or in ovary
- Unable to separate on pressure
Cervical
- <1%
- sac within the distended cervix, hour glass appearance of the uterus
- abnormally low sac position
- hyperechoic reaction
- internal os usually closed
- consider miscarriage in progress; no HR, open internal os, sliding sac sign, loss on repeat us
C section
- empty uterus and cervical canal
- anterior lower part of uterine segment
- absence of myometrium between bladder wall and gestational sac
- methotrexate injections, high surgical morbidity
- uterine rupture and massive haemorrhage
- ddx; anterior cervical ectopic, prominent c scar tissue, miscarriage in progress
Pregnancy unknown location definition and differentials
Neither uterine or ectopic prengnancy identified on TVUS in setting of positive BHCG
DDX
- early
- non viable not detected
- complete miscarriage
- unidentified ectopic
Failed pregnancy criteria
Diagnostic:
MSD>25 - no embryo
CRL >7 - no FHR
Absence of embryo with HB >14 days after GS no YS
Absence of embryo with HB > 11 days after GS with YS
Sac, no embryo, MSD <12mm that fails to double >14 days
Sac no embryo and MSD >12mm with no FHR >7 days
Embryo no FHR and no FHR >7days
Cessation of previous FHR
Suspicious:
CRL <7mm no FHR
MSD 16-24 no embryo
Absent embryo with FHR 7-13 post GS wo YS
Absence of embryo with FHR 7-10 post GS w YS
No embryo >6weeks LMP
No embryo when amnion visible
Embryo present with amnion visible but no FHR
Small GS in relation to embryo <5mm
Enlarged YS >7mm
Complete miscarriage is
cessation of vaginal bleeding with no RPOC or GS in women with previous IUP
Inevitable miscarriage is
Open internal os, bleeding, 1st trimester. Most often intracervical contents. Migration on serial scans. Progression of a threatened miscarriage once cervix opens
Perigestational haemorrhage is
Haemorrhage around fetus during gestation. Spectum includes
- chorionic; separation of chorion from endometrium
- periplacental; subchorionic/preplacental, retroplacental
- placental
Epidemiology
2% pregnancies <10weeks
20% of those have vaginal bleeding <10 weeks
Prognosis
- 90% success rate if living and small
- large >50%, 25% loss rate
- haemorrhage with embryonic bradycardia 80% loss rate
Subchorionic haemorrhage
perigestation between uterine wall and chorionic membrane
US
crescentic collection and elevation of chorionic membrane
variable echotexture
extension toward placental margin
Small <30%, medium 20-50, large >50%
Prognosis
increased risk of abruption and preterm labour
poor prognosis if extension to internal os
ddx
retroplacental
marginal can mimic twin gestational sac
chorioamniotic separation
Physiological gut herniation
Natural phenomenom from 6-13 weeks
Intestine elongates and moves outside of embryonic abdomen into base of umbilical cord at 8 weeks
Midgut rotates 90 CC
10-11 weeks intestines return, then rotate additional 180 CC
Physiological gut herniation imaging
bowel outside anterior abdominal wall at base of umbilical cord
not seen after 12-13 weeks
no other organs
extent of hernia relatively small
DDX
gastroschisis - right side of umbilical cord
omphalocoele - midline, membrane, small AC, direct UC insertion
Nuchal translucency is
Normal fluid filled space at the back of the fetal neck 11 weeks to 13 weeks 6 days.
Increased NT thoguht to be related to dilated lymph channels. Non specific sign of generalised getal abnormality.
Thickened NT associations
Aneuploidy
- trisomies
- turners
Non aneuploidy structural defects and syndromes
- congenital heart disease
- Noonan syndrome
- CDH
- Omphalocoele
- skeletal dysplasias
- Smith lemli opitz syndrome
- VACTERL assoc
Miscarriage or fetal demise
Intrauterine infections; Parvo B19
NT technique
Midsag
- VC down
- tip of nose/nasal bone, hard palate, diencephalon
Magnificantion
- only head and upper chest
No extension or flexion
Free floating fetus
Calipers inside hyperechoic edges, widest part measured
NT assessment
CRL between 45 and 84, 11 weeks 3 days to 13 weeks 6 days
No septations
<2.2-2.8mm normal, needs to be age/CRL matched
Interpretation
<2mm <1% risk
3.4mm 7% risk
3.5-4.4mm 20% risk
5.5-6.4mm 50% risk
>8.5mm 75% risk
Correlate with
bhcg
afp
PAPP A
oestrriol
Further workup
Increased risk of less than 1/300, further on patients desrire after counselling
Amniocentesis and or chorionic villus sampling
fetal echo
Hydrops fetalis is
excessive extravasation of fluid into the third space of a getus which could be due to heart dailure, overload, decreased onc pressure or increased permeability.
At least two components of;
- pleural effusion
- pericardial effusion
- ascites
- generalised body oedema
- placental enlargement
- polyhydramnios
- hepatomegaly
Hydrops fetalis pathology
Immune or non immune cardiac failure
Immune
- 10%
- fetomaternal incompatibility, including rhesus
Non immune
- chromosomal anomalies
- cardiac causes (rate, congenital anomalies, tumours)
- twin related complications (transfusion syndrome, reversed arterial perfusion sequence)
- in utero infections (TORCH, PB19, coxsackie)
- fetal tumours (sacrococc teratoma, hepatic haemangioendothelioma, placental chorioangioma)
- in born errors of metabolism (gaucher, niemann pick)
- fetal hypoprotein states
- congenital anaemia
- skeletal dysplasia
- high output flow states (vein of galen aneurysmla malformation)
- thoracic/pulmonary (primary hydrothorax, CPAM, CDH, PS)
Placenta praevia is
abnormally low lying placenta to the internal cervical os. common cause of antenatal haemorrhage
Placenta praevia risk factors
Previous PP
Previous CS
Increased maternal age
Increased parity
Large placentas
Smoking
Assisted conception
Placenta praevia association
abnormal placental villous adherences
Placenta praevia classification
1: low lying - 20-5mm
2: marginal - reaches internal os, doesnt cover
3: partial - partially covers
4: complete - completely covers
Placental abruption is
premature separation of normally implanted placenta after 20 w and before 3rd stage of labour. Potentially fatal. Cause of 3rd trimester bleeding.
Placental abruption risk factors
Preeclampsia
Prior abruption
PROM
Maternal age
Maternal trauma
Smoking
Cocaine/amphetamine
Thrombophilia
Chorioamnionitis
Short cord
Multiparity
Placental abruption clinical
Board like abdo tone
Bleeding, can be concealed
Uterine contractions
lumbar pain
Maternal/fetal compromise
Placental abruption pathology
Likely rupture of a spiral artery with haemorrhage into the decidua basalis leading to separation.
Classification:
Marginal
Retroplacental
Preplacental
Placental abruption imaging
US:
Retroplacental haematoma
Interplacental anechoic areas
Separation and rounded edges
Placental thickening
Thickening of retroplacental myometrium
Disrupted placental circulation
Intra-amniotic echos
Blood in fetal stomach
Intermembranous clot (twins)
Placental abruption complications
IUGR
Fetal demise
Maternal exsanguination
Placental abruption ddx
Isoechoic:
Contraction
Placentomegaly
Hypoechoic:
leiomyoma
Subplacental space
Placental variations
Single lobe, bilobe, succenturiate, circumvallate, circummarginate, placenta membranacea, placenta fenestrata, zonary, annular, ring, shorse shoe
Bilobed placeta
Two near equal sized lobes. If smaller, succenturiate.
Assoc: velamentous cord insertion, increased risk vasa previa II, post partum haemorrhage
Succenturiate lobe
Smaller accessory lobe. Check for vascular connection over os (vasa previa)
Complications: type II vasa previa, post partum haemorrhage
Circumvallate placenta
Small chorionic plate, inward insertion of membranes from the edge to the centre (placental shelf)
Complications; increased risk abruption, IUGR
ddx: amniotic shelf, amniotic band close to placenta
Circummarginate placenta
Similar to circumvallate but not inward rolling. Chorionic membranes insert inward from margin of placental edge.
