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22 Cards in this Set
- Front
- Back
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Submucosal Fibroids
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Project into the endometrial can
Only 5% of fibroids Most commonly symptomatic – Dysmenorrhea, menorrhagia – Increased incidence of infertility Intracavitary myomas (acute an wall) may be safely resected Dx: endometrial polyp - high t2 will enhance |
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Subserosal Fibroids
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• Beneath the serosa
• Usually asymptomatic • May be pedunculated – If large, may resect laparoscopically • May undergo torsion, resulting in infarction and pain • Must be differentiated from adnexal lesions: MRI helpful - Bridging vessel sign DX: |
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Degenerated Fibroids: Types of Degeneration
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Hyaline (calcific) degeneration
– Common, heterogenous T2 signal, decreased enhancement Hemorrhagic degeneration – Uncommon, associated with pregnancy – Peripheral venous thrombosis or rupture of intratumoral arteries – High T1 signal (peripheral or central) – Minimal/no enhancement Cystic degeneration – Very high T2, no enhancement, 5% fibroids Myxoid (gelatinous) degeneration (?) Fatty degeneration – Leiomyoma to Lipoleiomyoma, <.5% DDX: Ovarian Fibroma -• Also T2-hypointense • Inseparable from ovary |
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Fibroid Expulsion: Risk Factors
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• Submucosal lesions
• Extensive contact with endometrial surface • Pedunculated lesions • Pretreatment with Lupron • Cervical prolapse – Sets stage for ascending infection and endometritis |
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Tubo ovarian abscess DDX
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- Simple Hydrosalpinx
- Bilateral Hydrosalpinges - Bilateral Hydrosalpinges |
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Criteria that favor malignancy in ovarian lesions:
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Size > 4cm
Solid mass or large solid component Wall thickness > 3mm Septal thickness >3mm, vegetations, nodularity Necrosis Ancillary criteria |
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Dermoid Cyst (Mature Cystic Teratoma)
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• Most common ovarian neoplasm
• 10% Bilateral • Between 26-44% of ovarian tumors • Peak incidence: 20-29 years • Typically unilocular, filled with keratin and sebum; may contain hair, teeth, skin, cartilage Mature Cystic Teratoma • 35% of ovarian neoplasms • 10% bilateral • Fat is present in 95% • Fluid/fluid levels & calcification is common • MRI exploits the presence of fat/sebum • They follow fat signal on all sequences • High signal on both T1 & T2 WI • Fat-Saturated sequences show signal drop – Dermoid becomes dark on Fat-Saturated GRE T1 sequences |
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Endometriosis
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• Ectopic, functional endometrial glands located
outside the uterus • Range: microscopic implants → large cysts • Very common; at least 5-10%; 31% of females undergoing laparoscopy • Often debilitating symptoms: pelvic pain, dysmenorrhea, dyspareunia, infertility • >50% have ovarian involvement Endometrioma • Most common manifestation • Characteristically low SI on T2 WI – “ T2 shading ” • Fat suppressed GRE-T1 sequences diagnostic: always bright • Advantage: can detect nearly all sites of deep pelvic endometriosis |
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Unicornuate Uterus
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• Single uterine horn and fallopian tube
– Complete, or almost complete, arrest of development of one of the paired mullerian ducts • Low fertility rate • High incidence of spontaneous abortion, premature birth, intrauterine growth retardation, abnormal fetal lie. • Other complications include dysmenorrhea, hematometra, increased incidence of endometriosis and ectopic pregnancy • Well visualized on HSG • MRI identifies the presence and degree of dilatation of a non-communicating rudimentary horn • 40% of patients have associated renal anomalies – Ipsilateral agenesis (2/3), horseshoe or ectopic kidneys, duplications and cystic renal dysplasias |
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Septate Uterus
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• Most common congenital uterine
anomaly – Due to partial or complete failure of resorption of the uterovaginal septum between following fusion of the Mullerian ducts. • Septa composed of myometrial or fibrous tissue • May be partial or complete – Complete Extending to the external cervical os – In 5% the septa may extend into the superior vagina • High rate of reproductive failure, SAB in up to 90% • May be successfully corrected hysteroscopically up to 86% delivery rates) • HSG and TVUS combined accuracy 90%; MRI 100% |
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Bicornuate Uterus
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• Two uterine horns; one cervix
• From partial non-fusion of the mullerian ducts – (Uterovaginal horns at the level of the fundus) • Fewer complications than septate • Treatment may require laparotomy Bicornuate Uterus: Two Types • Central bridging myometrium may extend to internal cervical os (uterus bicornuate unicollis) or to the external cervical os (uterus bicornuate bicollis) • Angle >105 degrees, uterus more likely to be bicornuate |
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Uterus Didelphys
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• Failure of fusion of Mullerian
ducts • Two entirely separate uterine horns and two cervices • Highest pregnancy rates of all Mullerian anomalies • MRI best demonstrates detailed uterine and cervical anatomy |
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Peritoneal Inclusion Cysts
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• Large collections of physiologic ovarian fluid that
accumulate between peritoneal adhesions • May have history of surgery, trauma, endometriosis and pelvic inflammatory disease • Also known as: – Benign cystic mesothelioma – Peritoneal pseudocysts – Inflammatory cysts of the peritoneum – Multilocular peritoneal inclusion cysts • Fluid-signal lesions • Thin septations • Loculate and conform to surrounding structures; not displacing them |
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Lower Pelvic Cystic Lesions
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• Most common: Nabothian cysts, Gartner duct
cyst, Bartholin gland cysts |
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Gartner’s Duct Cysts
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• Anterolateral aspect, proximal
vagina • Derived from vaginal remnants of mesonephric (wolffian) ducts • A secretory retention cyst • May be associated with developmental anomalies of the GU tract – Unilateral renal agenesis/ hypoplasia, – Ectopic ureter insertion |
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Bartholin Gland Cysts
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• Posterolateral aspect of distal vagina
• Develop as a complication of infection of the vestibular glands of the vagina • Often evident on physical exam • Rarely, malignant tumors may arise (squamous cell, adenoid cystic carcinoma) |
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Polycystic Ovaries
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• Decreased T2 signal of
ovarian stroma • 10+ cysts • Ovary > 4 cm |
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Cervical Cancer Treatment staging
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Stage I-A1 / I-A2: <5mm stromal invasion
Stage I-B1: <4cm (esp. “IB1A” <2cm) confined to cervix Brachytherapy / local ablation / fertility preserving surgery, simple/modified radical hysterectomy, trend for increasing use of chemoradiation Stage I-B2: >4cm Confined to cervix Stage II-A1 / II-A2: No parametrial invasion Radical hysterectomy & LND; trend for increasing use of chemoradiation Stage II-B: Parametrial invasion (and beyond) Radiation/chemotherapy, not hysterectomy candidates |
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Cervical Cancer: MR
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• Clinical staging correlates poorly with surgery or
pathology (40 – 70%) • MR can accurately stage cervical cancer – Accuracy: 94% for stage IB & II – 75-95% accurate for evaluating parametrial invasion • Better than CT and transrectal US • Imaging, including MR, now recommended by GCIG-Gynecologic Cancer Intergroup • T2-weighted images typically more useful • Tumor is hyperintense, compared to hypointense cervical stroma – Disruption of normal dark cervical stromal “ring” – Lower signal than endometrium • Contrast-enhanced images may show tumor margins more accurately • MR also useful for evaluating bladder/rectal invasion, lymph node metastases |
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cervical mass ddx
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leiomyoma
adenoma Malignum endocervical gland hyperplasia deep clustered nabothian cysts |
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Adenoma Malignum
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• Rare subtype of mucinous adenocarcinoma of the cervix
• 3% of cervical adenocarcinomas – 0.15-0.45% of all cervical cancer • Associated with Peutz Jeghers • Arise from the columnar epithelium of the endocervical canal • Composed of well-differentiated endocervical glands • Patients present with profuse watery vaginal discharge • Clinical course - early peritoneal dissemination and early metastases – -Respond poorly to radiation and chemotherapy – -Unfavorable prognosis • Diagnosis difficult to establish on PAP smear or even biopsy – -Well differentiated appearing glands, similar to Nabothian cysts Specific Image Findings • Cysts markedly hyperintense on T2-WI • Cervical stroma surrounding the cystic mass also T2- hyperintense – Due to presence of tiny cysts not fully depicted on MR or from edema within the cervical stroma • High signal mucin within the cervical and vaginal canals • Following gadolinium, solid enhancing portion is typically seen |
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Endometrial Carcinoma
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• Most common gynecologic malignancy
• Peak incidence: 55-65 • Risk factors: obesity, DM, PCO, nulliparity, unopposed ERT, endometrial hyperplasia • Most commonly presents with bleeding (75-90%) – 5% of PM bleeding is due to cancer • Important in differentiating between I-A, I-B – Stage I-A: Confined to endometrium or < 50% myometrial invasion • <3% risk of LN mets Should sample lymph nodes – Stage I-B: >50% myometrial invasion • Almost 50% risk of LN mets Extensive pelvic and para-aortic lymphadenectomy - MRI: sensitivity = 69-94%, specificity = 64-100% for myometrial invasion • Accuracy of MRI: 82-92% • T2-weighted images: tumor hyperintense relative to JZ • Used to assess for disruption of hypointense JZ; not as important anymore (stage remains IA) • Tumor enhances, but less than the endometrium and surrounding myometrium – Better sequence for post-menopausal women – Helpful in pts. with indistinct JZ on T2 – Helpful in pts. with adenomyosis • Post-gadolinium images may better define exact extent of tumor – May overestimate extent of tumor involvement |
