Figure-28-10 A 6-cm parovarian cyst(C)is seenmedial to therightovary(calipers) Multiple lesions within the pelvis can masquerade as an ovarian cyst(Table 28-9 ).The etiology of extraova rian cysts is suggested by visualization of a separate ipsilateral ovary(g 28-10 )and in some cases by connection with the organ of origin, such as in the case of a bladder diverticulum(13)or a Tarlov cyst (14) Bowel loops frequently mimic ovarian cysts. Therefore, watch for peristalsis when a questiona ble lesion is visua lized Nonvisualization of a Palpable Pelvic Mass Dermoid cysts have a variety of appea rances because of their aomplex nature. Frequently, the dermoid cyst mimics bowel gas and is seen only as an echogenic area with shadowing In a patient with a pa lpa ble pelvic mass in whom no abnorma lity is visual ized, consideran echogenic dermoid( Fig. 28-11Aand Fig 28-11B) and carefully scan in the region of the palpa ble mass. 28-11a. Dermoid Transabdominal view of the uterus(UT) demonstrates a questionable right mass (RT) Figure -28-11b Endovag inal scan demonstrates extremely echogenic nature of this mass, which was not recognized ontwo pnor sonograms. Don't stop After One Lesion Is Found Many benign ovarian tumors ocaurbilaterally(demoids, serous cystade nomas, and metastases). In addition, women with one gyn ecologic mal ignancy are at ncreased risk for a second mal ignancy ( Fig. 28-12Aand Fig 28-12B) Some ovarian tumors, such as endometria id tumors and estrogen-producing thecoma and granulosa cell tumors, are associated with endometrial hyperplasia and endometrial cancer(Fig. 28-13Aand Fig 28-13B). There also are rare syndromesin which gynecologic ma lignandes are grouped such as the Lynd cancer family syndrome, in which there is an assodation between ovarian cancer, colon cancer, and endometrial cancers (15)
Figure - 28-10. A 6-cm parovarian cyst (C) is seen medial to the right ovary (calipers). Multiple lesions within the pelvis can masquerade as an ovarian cyst (Table 28-9 ).The etiology of extraovarian cysts is suggested by visualization of a separate ipsilateral ovary (Fig. 28-10 ) and in some cases by connection with the organ of origin, such as in the case of a bladder diverticulum (13) or a Tarlov cyst. (14) Bowel loops frequently mimic ovarian cysts. Therefore, watch for peristalsis when a questionable lesion is visualized Nonvisualization of a Palpable Pelvic Mass Dermoid cysts have a variety of appearances because of their complex nature. Frequently, the dermoid cyst mimics bowel gas and is seen only as an echogenic area with shadowing. In a patient with a palpable pelvic mass in whom no abnormality is visualized, consider an echogenic dermoid (Fig. 28-11A and Fig. 28-11B ) and carefully scan in the region of the palpable mass. Figure - 28-11a. Dermoid. Transabdominal view of the uterus (UT) demonstrates a questionable right adnexal mass (RT). Figure - 28-11b. Endovaginal scan demonstrates extremely echogenic nature of this mass, which was not recognized on two prior sonograms. Don't Stop After One Lesion Is Found Many benign ovarian tumors occur bilaterally (dermoids, serous cystadenomas, and metastases). In addition, women with one gyn ecologic malignancy are at increased risk for a second malignancy (Fig. 28-12A and Fig. 28-12B ) . Some ovarian tumors, such as endometrioid tumors and estrogen-producing thecoma and granulosa cell tumors, are associated with endometrial hyperplasia and endometrial cancer (Fig. 28-13A and Fig. 28-13B ) . There also are rare syndromes in which gynecologic malignancies are grouped such as the Lynch cancer family syndrome, in which there is an association between ovarian cancer, colon cancer, and endometrial cancers. (15)
Figure-28-12a. Concurrentlesions: a 90-year-old woman with endometrial cancer and ovarian cancer. transabdominal viewof the uterus demonstrates ill-definition ofthe endometrium with invasion ofthe endometrium into the Figure-28-12b A 6-cm left adnexal cystwith multiple septations and solid nodules from ovarian cancer. Concurrentlesions: granulosa cell tumor with endometrialhyperplasia. Thickened endometrium(15 mm) with a small cyst. Fiqure-28-13b he histologictype was endometrial hyperplasia, pro bably secondary to the estrogenic effect of the granulosa celltumor (Levine D. Sonography of the postmenopausal pelvis. In: Anderson J, ed Gynaecologicalimaging. London, Churchill Livingstone [in press)) SONOGRAPHIC ABNORMALITIES OF THE PELVIS Abnormal Uterus Uterine Enlargement Causes of uterine enlargement are listed in(Table 28-10). These indude fibro ids, pregna ncy and pregnancy-related conditions, uterine sarcoma, endometrial
Figure - 28-12a. Concurrent lesions: a 90-year-old woman with endometrial cancer and ovarian cancer. transabdominal view of the uterus demonstrates ill-definition of the endometrium with invasion of the endometrium into the myometrium. Figure - 28-12b. A 6-cm left adnexal cyst with multiple septations and solid nodules from ovarian cancer. Figure - 28-13a. Concurrent lesions: granulosa cell tumor with endometrial hyperplasia. Thickened endometrium (15 mm) with a small cyst. Figure - 28-13b. The histologic type was endometrial hyperplasia, probably secondary to the estrogenic effect of the granulosa cell tumor. (Levine D. Sonography of the postmenopausal pelvis. In: Anderson J, ed. Gynaecological imaging. London, Churchill Livingstone [in press]) SONOGRAPHIC ABNORMALITIES OF THE PELVIS Abnormal Uterus Uterine Enlargement Causes of uterine enlargement are listed in (Table 28-10). These include fibroids, pregnancy and pregnancy-related conditions, uterine sarcoma, endometrial
carcinoma, and obstruction with a fluid-filled uterus. braids oocur in approximately 25% of women of reproductive age( Fig. 28-14A, Fig. 28-14B, and Fig. 28-14C). They consist of nodules of myometrium and typically cause an enlarged uterus with multiple masses thata re echo -attenuating. Theyare sensitive to estrogen stimulation and there fore ingrease in size during pregnancy. (16) Cystic areas are secondary to degeneration. Clumps of calcification cause echogenic fodi with shad ing. Fibroids are described by their location: they can be submucosal, intramural, subserosal, or pedunculated(see Fig. 28-8Aand Fig. 28-8B)Cervical and broad ligament fibroids are rare. Findings in patients with fibroids are summarized in(Table 28-11) Fibroids. Transabdominal view ofa fibroid uterus. The uterus is enlarged with a heterogeneous echotexture and a lumpy contour caused by fibroids. 28-14b Submucosal fibroids surrounded by fluid during a 28-14 Subserosal fibroid with broad attachment to the myometrium and a exophytic component. Figure-28 -8a Subserosal fibroid with broad attachment to the myometrium and a exophytic component
carcinoma, and obstruction with a fluid-filled uterus. Fibroids Fibroids occur in approximately 25% of women of reproductive age ( Fig. 28-14A , Fig. 28-14B , and Fig. 28-14C ). They consist of nodules of myometrium and typically cause an enlarged uterus with multiple masses that are echo-attenuating. They are sensitive to estrogen stimulation and therefore increase in size during pregnancy. (16) Cystic areas are secondary to degeneration. Clumps of calcification cause echogenic foci with shading. Fibroids are described by their location: they can be submucosal, intramural, subserosal, or pedunculated (see Fig. 28-8A and Fig. 28-8B ). Cervical and broad ligament fibroids are rare. Findings in patients with fibroids are summarized in (Table 28-11). Figure - 28-14a. Fibroids. Transabdominal view of a fibroid uterus. The uterus is enlarged with a heterogeneous echotexture and a lumpy contour caused by fibroids. Figure - 28-14b. Submucosal fibroids surrounded by fluid during a sonohysterogram. Figure - 28-14c. Subserosal fibroid with broad attachment to the myometrium and a exophytic component. Figure - 28-8a. Subserosal fibroid with broad attachment to the myometrium and a exophytic component
Transvaginal examination demonstrates a tissue plane between the uterusand the mass Small fibroids can be difficult to detect sonogra phically They ca use a hete rogeneous echotexture of the myometrium without sonog raphically visible focal lesions. At times, only a contourdistortion a long theinterface between the uterus and bladders seen. Sarcomas comprise less than 5% of uterine malignancies. They resemble fibroids or endometrial caranoma (17) When a rapid change in the size of fibroids is noticed, a uterine sarcoma should be considered as the etiology(Fig. 28-15A and Fig. 28-15B) Figure -28-15a. Uterine sarcoma Transa bdominal view of the uterus in a woman with a recent myomectomy demonstrates an enlarged uterus with a bizarre a ppearance to the myometrium with multiple cystic spaces Fiqure-28-15b CT has a similar appearan Adenomyosis isa cause of heavy painful menses. The condition is produced when nests ofendometrial tissue are located within the myometrium. The sonographic diagnosis is diffcult to make. In general, the uterus is enlarged without focal mass(18, 19)(Fig. 28-16). A times, small blood-conta ining spaces in the uterus can be seen ca used by dilated glands filled with menstrual products gure-28-16 Enlarged uterusin a 53-year-old woman with abnormal bleeding. The uterusis enlarged slightly and heterogeneous in echotexture but has no focal masses. Histologic examination re vealed adenomyosis
Figure - 28-8b. Transvaginal examination demonstrates a tissue plane between the uterus and the mass Small fibroids can be difficult to detect sonographically. They cause a heterogeneous echotexture of the myometrium without sonographically visible focal lesions. At times, only a contour distortion along the interface between the uterus and bladder is seen. Uterine Sarcoma Sarcomas comprise less than 5% of uterine malignancies. They resemble fibroids or endometrial carcinoma. (17) When a rapid change in the size of fibroids is noticed, a uterine sarcoma should be considered as the etiology (Fig. 28-15A and Fig. 28-15B ) . Figure - 28-15a. Uterine sarcoma. Transabdominal view of the uterus in a woman with a recent myomectomy demonstrates an enlarged uterus with a bizarre appearance to the myometrium with multiple cystic spaces. Figure - 28-15b. CT has a similar appearance. Adenomyosis Adenomyosis is a cause of heavy painful menses. The condition is produced when nests of endometrial tissue are located within the myometrium. The sonographic diagnosis is difficult to make. In general, the uterus is enlarged without focal mass (18,19) (Fig. 28-16 ) . At times, small blood-containing spaces in the uterus can be seen caused by dilated glands filled with menstrual products. Figure - 28-16. Enlarged uterus in a 53-year-old woman with abnormal bleeding. The uterus is enlarged slightly and heterogeneous in echotexture but has no focal masses. Histologic examination revealed adenomyosis
Focal adenomyomas also occur. These are difficult to distinguish from fibroids. Fibroids tend to be well arcumscni bed. In contrast, focal adenomyomas are ill defined and may have lacunae The preop rative distinction between fibroids and adenomyosis is important in women who are being treated for inferti lityor abnormal bleed ing since myomas can be removed; however, a denomyos is typically requires a hysterectomy. Magneticresonance is helpful in this dist inction (20) obstruction tients with hydrocolpos(fluid in the vagina) and hydrometrocolpos(fluid in the vagina and uterus)usually are studied soon after birth or at puberty when secretions ca obstruction because of an intact hymen or vaginalatresia Hematometra is seen in patients with cervical cancer or cervical stenosis(Fig. 28-17) Figure-28-17 Hematometra. Sagittal view of the uterus in a 63-year-old asymptomatic woman placed on cydic hormonal replacement therapy demonstrates a large endometrial fluid col lection with a thin suround ing ndometrium. she subsequently underwentsurgical dilation for cervical stenosis (Levine D. The postmenopausal pelvis. In: Nyberg DA, ed Transvaginal ultrasound. St Louis, MO, Mosby Year Book, 1992:228) Endometrial Cancer llargement of the uterus is a late finding in endometrial cancer. This disease is discussed in more detailin Chapter 29 Bright Reflectors In The Uterus Causes of brightechoes in the uterusand endometrium are listed in(Table 28-12 Uterine calcifications The most common cause of dense echoes in the ute rs ations resulting from fibroids. These appears dumps of cal dification( Fig. 28-18A)or as rim caldficationa Figure-28-18a. Uterine calcifications. Transvaginal transverse view of the uterus in a postmenopausal woman with abnormal bleeding demonstrates a well-defined echogenic focus with shadowing secondary to a calcified fibroid. Adjacent to this area is a fluid collection in a region of thickened endometrium(arrows). This was Aless common cause of calcificaton within the uterus is that of the arcuate artery. Arcuate artery calcifications are seen around the periphery of the uterus, usually in older w with severe medical problems suchas diabetes, chronicrenal failure, or hypertension. (21) actate calcifications occasiona lly are seenat the endometrial myometrial interface(see Fig. 28-18B) These are probably secondary to a prior infection or procedure
Focal adenomyomas also occur. These are difficult to distinguish from fibroids. Fibroids tend to be well circumscribed. In contrast, focal adenomyomas are ill defined and may have lacunae. The preoperative distinction between fibroids and adenomyosis is important in women who are being treated for infertility or abnormal bleed ing since myomas can be removed; however, adenomyosis typically requires a hysterectomy. Magnetic resonance is helpful in this distinction. (20) Obstruction Patients with hydrocolpos (fluid in the vagina) and hydrometrocolpos (fluid in the vagina and uterus) usually are studied soon after birth or at puberty when secretions cause obstruction because of an intact hymen or vaginal atresia. Hematometra is seen in patients with cervical cancer or cervical s tenosis (Fig. 28-17) . Figure - 28-17. Hematometra. Sagittal view of the uterus in a 63-year-old asymptomatic woman placed on cyclic hormonal replacement therapy demonstrates a large endometrial fluid collection with a thin surrounding endometrium. She subsequently underwent surgical dilation for cervical stenosi s. (Levine D. The postmenopausal pelvis. In: Nyberg DA, ed. Transvaginal ultrasound. St. Louis, MO, Mosby Year Book, 1992:228) Endometrial Cancer Enlargement of the uterus is a late finding in endometrial cancer. This disease is discussed in more detail in Chapter 29. Bright Reflectors In The Uterus Causes of bright echoes in the uterus and endometrium are listed in (Table 28-12 ) . Uterine calcifications The most common cause of dense echoes in the uterus are calcifications resulting from fibroids. These appear as clumps of cal cification (Fig. 28-18A ) or as rim calcification around a mass. Figure - 28-18a. Uterine calcifications. Transvaginal transverse view of the uterus in a postmenopausal woman with abnormal bleeding demonstrates a well-defined echogenic focus with shadowing secondary to a calcified fibroid. Adjacent to this area is a fluid collection in a region of thickened endometrium (arrows). This was endometrial hyperplasia. A less common cause of calcification within the uterus is that of the arcuate artery. Arcuate artery calcifications are seen around the periphery ofthe uterus, usually in older women with severe medical problems such as diabetes, chronic renal failure, or hypertension. (21) Punctate calcifications occasionally are seen at the endometrial myometrial interface (see Fig. 28-18B ). These are probably secondary to a prior infection or procedure. (22)