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Core > Reproductive: Masses of the Uterus and Vagina > Flashcards

Reproductive: Masses of the Uterus and Vagina Flashcards

1
Q

What are the major subtypes of uterine fibroids?

A
  • Hyaline (most common)
  • Hypercellular (more dense)
  • Lipoleiomyoma (fat containing)
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2
Q

Are fibroids estrogen dependent?

A

Yes, they grow during pregnancy and involute with menopause

Note: This is also why they are rare before puberty.

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3
Q

MRI appearance of hyaline uterine fibroids

A

T1 dark and T2 dark with homogenous enhancement

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4
Q

MRI appearance of hypercellular uterine fibroids

A

T1 dark and T2 bright with homogenous enhancement

Note: These respond well to IR embolization.

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5
Q

MRI appearance of lipoleiomyoma

A

T1 bright (dark if fat sat) and T2 bright with possible rim enhancement

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6
Q

What are the 4 major types of uterine fibroid degeneration?

A
  • Hyaline degeneration (most common)
  • Red/carneous degeneration
  • Myxoid degeneration (rare)
  • Cystic degeneration (rare)
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7
Q

What is the most common type of fibroid degeneration?

A

Hyaline

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8
Q

Hyaline degeneration of a uterine fibroid

A

When the fibroid outgrows its blood supply, resulting in the accumulation of proteinaceous tissue

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9
Q

Carneous degeneration of a uterine fibroid

A

When venous thrombosis causes fibroid degeneration

Note: This usually occurs during pregnancy.

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10
Q

Which type of fibroid degeneration is classically T2 dark on MRI?

A

Hyaline degeneration

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11
Q

Which type of fibroid degeneration classically has a T1 bright peripheral rim?

A

Red (carneous) degeneration

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12
Q

What type of fibroid degeneration?

A

Red (carneous) degeneration

Note: T1 bright peripheral rim in the subacute phase.

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13
Q

What type of fibroid degeneration?

A

Myxoid degeneration

Note: T2 bright with minimal enhancement (hyaline degeneration is usually T2 dark).

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14
Q

What type of fibroid degeneration (no enhancement)?

A

Cystic degeneration

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15
Q

How can you tell whether a uterine fibroid has degenerated?

A

Absence or paucity of enhancement (normally uterine fibroids enhance avidly)

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16
Q

How can you differentiate a normal uterine fibroid from a uterine leiomyosarcoma

A

You can’t, but a rapidly enlarging fibroid with areas of necrosis should make you more suspicious of a leiomyosarcoma

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17
Q

Adenomyosis

A

When endometrial tissue is found within the myometrium

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18
Q

Risk factors for adenomyosis

A
  • Multiple prior pregnancies
  • Uterine procedures (e.g. c section, dilatation and curettage, etc.)
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19
Q

What portion of the uterus is most commonly affected by adenomyosis?

A

The posterior wall

Note: The cervix is usually spared.

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20
Q

Imaging findings of adenomyosis

A
  • Thickening of the junctional zone on MRI (best imaging test)
  • Enlarged uterus with normal contour
  • Heterogeneous myometrium on ultrasound
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21
Q

Classic imaging finding for adenomyosis

A

Thickening of the junctional zone >12 mm on MRI (either focal or diffuse)

Note: You may also see T2 bright foci in the myometrium (endometrial cystic tissue).

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22
Q
A

Adenoomyosis

Note: Thickening of the junctional zone along the posterior uterine wall with T2 bright foci.

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23
Q
A

Adenomyosis

Note: Heterogeneous thickening of the junctional zone with cystic changes.

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24
Q

e

A

Junctional zone

Note: d is the endometrium and f is the myometrium.

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25
Q

A

A

Myometrium

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26
Q

B

A

Junctional zone

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27
Q

C

A

Endometrium

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28
Q

Imaging absence of the junctional zone is normal in what pts?

A
  • Pre-puberty
  • Postmenopausal
  • During pregnancy and postpartum for 6 months (appears similar to myometrium)
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29
Q

How long does it take the junction zone to return to its normal MRI appearance after a pregnancy?

A

6 months after delivery

Note: Before this and during pregnancy the junctional zone appears too similar to myometrium to tell apart.

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30
Q

How thick is the endometrium allowed to be?

A
  • Up to 12 mm (if proliferative trilaminar appearance)
  • Up to 16 mm (if secretory homogeneously hyperechoic appearance)
  • Up to 4 mm (if postmenopausal)
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31
Q

When should you recommend endometrial sampling in a postmenopausal pt?

A

Anytime the endometrium is 5 mm or thicker (especially if there is abnormal uterine bleeding)

32
Q

What is the classic ovarian tumor that causes endometrial thickening?

A

Granulosa cell tumor of the ovary

33
Q

Which genetic syndrome is associated with a 30-50x increased risk of endometrial cancer?

A

Hereditary Non-Polyposis Colon Cancer (HNPCC)

34
Q

What is the most common type of endometrial cancer?

A

Adenocarcinoma (>90%)

35
Q

What imaging study is used to stage endometrial cancer?

A

MRI (to determine myometrial invasion depth and cervical involvement)

Note: PET/CT is also used if there is concern for possible distant metastases. Most often, ultrasound/biopsy demonstrate stage 1 disease and additional imaging is not needed.

36
Q

Which MRI sequence is best for finding enometrial cancer drop metastases in the vagina?

A

Diffusion imaging and ADC (mets will have restricted diffusion)

37
Q

MRI appearance of endometrial cancer

A
  • Restricted diffusion
  • T1 hypoenhancing (relative to myometrium)
  • T2 intermediate (T2 bright relative to junctional zone)
38
Q

What are the key MRI findings when staging endometrial cancer?

A
  • Myometrial invasion (less than or more than half)
  • Cervical stromal invasion
39
Q

At what point does stage 1a endometrial cancer become stage 1b?

A

Deep myometrial invasion (when the tumor invades more than half the myometrial thickness)

40
Q

At what point does stage 1 endometrial cancer become stage 2?

A

Cervical stroma invasion

Note: Normal cervical mucosa enhancement on 2-3 min post contrast imaging excludes cervical stromal invasion.

41
Q

What is the best study to look for nodal metastases in endometrial cancer?

42
Q

How does management change from stage 1 to stage 2 endometrial cancer?

A

Stage 1 (usually total abdominal hysterectomy)
Stage 2 (usually preoperative radiation and radical hysterectomy)

43
Q

What uterus changes are common in pts taking tamoxifen?

A
  • Endometrial thickening
  • Subendometrial cysts
  • Endometrial polyps (30%)
44
Q

Post menopausal pt

A

Think tamoxifen changes

Note: Multicystic endometrial thickening.

45
Q

This pt most likely has a history of…

A

Breast cancer (and is taking tamoxifen)

Note: Cystic thickening of the endometrium, think tamoxifen changes.

46
Q

Postmenopausal pts with tamoxifen changes to the endometrium can normally have endometrial thickening >10 mm. When should you biopsy?

A

If the pt is symptomatic (abnormal uterine bleeding)

Note: If asymptomatic, you shouldn’t do an endometrial biopsy in pts on tamoxifen (even if the endometrium is thickened).

47
Q
A

Hyperechoic structure within the endometrium with vascularity, possible endometrial polyp. Recommend sonohysterogram.

48
Q

When should sonohysterography be performed?

A

During the early proliferative phase (~days 4-6 of the menstrual cycle)

49
Q

What is the most common type of cervical cancer?

A

Squamous cell carcinoma (90%)

Note: Usually related to HPV infection.

50
Q

At what point does the management of cervical cancer change from surgery alone to chemotherapy/radiation?

A

From stage 2A (spread beyond the cervix, but no parametrial invasion)

to

Stage 2B (Parametrial invasion, but no extension to the pelvic sidewall)

Note: Invasion of the pelvic sidewall or lower 1/3 of the vagina will upgrade to stage 3a and also require chemo/radiation.

51
Q

Parametrium

A

A fibrous band that separates the supravaginal cervix from the bladder (it extends between the layers of the broad ligament)

Note: The uterine artery runs inside the parametric, which is why parametrial invasion in cervical cancer requires chemotherapy.

52
Q

What is the imaging sign of parametrial invasion in the setting of cervical cancer?

A

Disruption of the T2 dark cervical ring

53
Q

Endometrial fluid (more than trace amount) in a postmenopausal pt with cervical cancer…

A

Think endometrial cavity outlet obstruction due to cervical stenosis secondary to the cervical cancer

54
Q

Differential for solid vaginal mass

A
  • Squamous cell carcinoma
  • Cervical/uterine cancer prolapsing into the vagina
  • Metastases
  • Vaginal rhabdomyosarcoma (common in children)
  • Clear cell adenocarcinoma (associated with maternal DES exposure)
  • Leiomyoma
55
Q

What is the most common type of vaginal cancer?

A

Squamous cell carcinoma (85%)

Note: Usually associated with HPV.

56
Q

Maternal diethylstilbestrol (DES) exposure is a risk factor for what type of cancer?

A

Clear cell adenocarcinoma of the vagina

57
Q

Vaginal rhabdomyosarcoma is most common in what pt population?

A

Bimodal distribution in young females:

  • Ages 2-6
  • Ages 14-18
58
Q

Pediatric

A

Think vaginal rhabdomyosarcoma

Note: It can occur in the uterus, but more commonly starts in the vagina and invades the uterus secondarily.

59
Q

What is the most likely primary cancer if you identify metastasis in the anterior wall of the upper 1/3 of the vagina?

A

Upper genital tract cancer, such as uterine (90%)

60
Q

What is the most likely primary cancer if you identify a metastasis in the posterior wall of the lower 1/3 of the vagina?

A

GI tract (90%)

61
Q

What are the major cystic lesions in the region of the cervix/vagina?

A
  • Nabothian cyst
  • Gartner duct cyst
  • Skene gland cyst
  • Bartholin gland cyst
62
Q
A

Nabothian cyst

63
Q
A

Gartner duct cyst

Note: Cyst in the mid vagina.

64
Q
A

Gartner duct cyst

Note: Cyst in the mid vagina.

65
Q

Pathophysiology of nabothian cysts

A

Cystic dilatation of mucous glands due to epithelial plugging in the setting of inflammation

66
Q

Pathophysiology of Garner duct cysts

A

Incomplete regression of the Wolffian ducts

67
Q

What is the most common location for a Gartner duct cyst?

A

Anterolateral wall of the upper vagina

68
Q

Clinical manifestations of Gartner duct cysts

A

Urinary dysfunction (if there is mass effect on the urethra)

69
Q

Pathophysiology of bartholin cysts

A

Cystic dilatation of the mucin-secreting Bartholin glands due to obstruction

70
Q

Treatment for Bartholin cysts

A
  • Nothing (if asymptomatic)
  • Marsupialization (if symptomatic or infected)
71
Q

How can you distinguish a Baththolin cyst from a Gartner duct cyst?

A

Batholin cysts happen below the pubic symphysis (Garner duct cysts are above)

72
Q

Clinical manifestations of Skene gland cysts

A
  • Asymptomatic (most common)
  • Recurrent UTIs
  • Urethral obstruction

Note: The Skene glands are periurethral.

73
Q
A

Bartholin or Skene cyst

Note: Below the pubic symphysis.

74
Q
A

Bartholin or Skene cyst

75
Q

What are the most common cysts at each colored location?

A

Red (Gartner duct cyst)
Green (Skene gland cyst)
Blue (Bartholin gland cyst)

76
Q
A

Skene or Barhtolin cyst

77
Q

How can you differentiate a Skene cyst from a Bartholin cyst?

A

Skene cysts are periurethral (tend to be centered more anteriorly)

Bathrolin cysts are associated with the labia majora (and tend to be centered more posteriorly)

Note: Bartholin cysts are near the Butthole.

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