Книги по МРТ КТ на английском языке / Advanced Imaging of the Abdomen - Jovitas Skucas

FEMALE REPRODUCTIVE ORGANS

small and capillary-like in appearance. Most of these malformations are believed to be congenital in origin. Most develop in the myometrium.

Metrorrhagia is a common presentation. It is more common in premenopausal women. Uncontrolled bleeding after dilation and curettage should suggest an arteriovenous malformation, a (pseudo)aneurysm, an arteriovenous fistula, or a large vessel trauma.

Gray-scale US in women with uterine arteriovenous malformations is nonspecific, revealing subtle inhomogeneous myometrial tubular structures. Doppler US detects low-resistence flow and signals with flow reversals, suggesting arteriovenous shunting (Fig. 12.33).

Magnetic resonance imaging detects an arteriovenous malformation as a focal uterine tumor containing disrupted junctional zones and, if the tumor is large enough, prominent parametrial blood vessels. Flowing blood in these malformations presents as a serpiginous signal void on both T1and T2-weighted MRI, while stasis results in a hyperintense signal on T2-weighted images. A malformation enhances on postcontrast images, similar to blood vessels. Magnetic resonance angiography shows tortuous, coiled vessels in the pelvis.

Only a few vaginal arteriovenous malformations have been described. These lesions can be suspected with Doppler US, CT, and MRI. They are hypointense on T1and hyperintense on T2-weighted images; contrast-enhanced T1weighted images reveal paradoxical flow-related enhancement in some, possibly caused by turbulent blood flow.

Traditional therapy of massive uncontrolled bleeding was uterine artery ligation or hysterectomy. Pelvic arteriography is diagnostic and also provides access for transcatheter embolization for these often surgically difficult to resect tumors. Selective transcatheter arterial embolization of uterine arteriovenous malformations and other similar vascular abnormalities tends to preserve reproductive capacity.

Uterine Artery Aneurysms

Uterine true aneurysms are rare. (Pseudo)- aneurysms are more common and are a cause of massive bleeding (Fig. 12.34).

Gray-scale US reveals a pulsating, hypoor anechoic structure. True fusiform aneurysms contain an arterial flow pattern. Color and duplex Doppler US identify (pseudo)aneurysms

FEMALE REPRODUCTIVE ORGANS

Posttherapy

Post–Hormone Therapy

Postmenopausal women are placed on estrogen therapy to lessen the osteoporosis or control ovarian atrophy. Because of an increased risk of endometrial hyperplasia and carcinoma with estrogen therapy alone, various regimens of progesterone are often added.

Endovaginal US in asymptomatic postmenopausal women after the initiation of hormone replacement therapy reveals an increased endometrial thickness after the start of therapy. Sequential hormone therapy leads to changes similar to a premenopausal endometrium. Endometrial thickness measured with endovaginal US in healthy women in physiologic menopause was 3.5mm, increasing to 5.7mm after estrogen therapy alone (117); after adding progestin, endometrial thickness measured 6.0mm. Endovaginal color Doppler US reveals that uterine artery PI and RI decrease during the first month of therapy.

Uterine artery pulsatility index in postmenopausal women receiving hormone replacement treatment tends to decrease, presumably due to increased uterine vascularity.

Some women develop vaginal bleeding while on hormonal therapy. Ultrasonography measurement of endometrial thickness does not select those who will bleed.

Postchemotherapy Changes

Tamoxifen citrate is a nonsteroidal antiestrogen agent binding to estrogen receptors and is used in breast cancer therapy. One of the side effects of tamoxifen is endometrial and myometrial stimulation and its use is associated with endometrial hyperplasia, polyps, and carcinomas. Fibromyomas also grow.

Endovaginal US found 69% of postmenopausal women treated with adjuvant tamoxifen to have an endometrial thickness >2.5mm (118). One recommendation is that an endometrial thickness of 6mm be considered a cutoff for endovaginal US in asymptomatic postmenopausal women receiving tamoxifen. A thickened, irregular, and hyperechoic endometrium containing small cysts or a homogeneous appearance is typical. Endovagi-

nal US using intrauterine saline as a contrast agent (hysterosonography) is more specific but not significantly more sensitive than endovaginal US in detecting endometrial abnormalities (119,120). Tamoxifen polyps tend to be larger than typical polyps and are composed of cystic glandular dilation, epithelial metaplasia, and periglandular stromal condensation (121). These polyps range from sessile to pedunculated and appear as a hyperechoic, smoothly marginated tumor. Some contain cysts. An irregular polyp outline or endometrial thickening should raise suspicion for a carcinoma.

Magnetic resonance imaging identifies two patterns in postmenopausal women with breast cancer receiving tamoxifen therapy (122):

1.A homogeneous hyperintense endometrium on T2-weighted images, postcontrast enhancement of the endometrialmyometrial junction, and a lumen signal void. Histopathology in two thirds of these women revealed either atrophic or proliferative endometria.

2.A heterogeneous endometrium on T2weighted images, postcontrast enhancement of the endometrial-myometrial junction, and lattice-like lumen enhancement, with most of these women having polyps.

Chemotherapy for breast cancer results in a loss of uterine volume, measurable with serial imaging.

Some investigators advocate routine US and endometrial biopsy even in asymptomatic women receiving tamoxifen. Hysteroscopy is used to resect any visualized polyps, and endometrial curettage evaluates abnormal endometrial thickening. An American College of Obstetricians and Gynecologists recommendation for women with breast cancer being treated with tamoxifen is to discontinue therapy if atypical hyperplasia is detected (121); a hysterectomy should be considered if further tamoxifen therapy is deemed necessary.

Postoperative Changes

One of the complications encountered with gynecologic surgery is ureteral damage. If damage is suspected, postoperative color Doppler US detection of ureteral jets is worth-

while, keeping in mind that it takes longer to visualize bilateral ureteral jets immediately after surgery.

Postlaparoscopy

The most common complication after laparoscopic gynecologic surgery is an incisional hernia. Omental herniation can occur through a trocar incision site.

Postoophorectomy

Occasionally ovarian remnants are left behind unintentionally after an oophorectomy. Some of these remnants are functional and lead to symptoms. Ultrasonography in women with ovarian remnants reveals a range from simple cysts, multiple septations, and presumed residual ovarian tissue with arterial and venous flow; aspiration of ovarian remnants provides symptomatic relief. Thus a US finding of a cystic or multiseptated pelvic mass containing a rim of vascular solid tissue, detected postoophorectomy, should raise the possibility of an ovarian remnant.

ADVANCED IMAGING OF THE ABDOMEN

Thus even complex fluid collections in a woman after hysterectomy do not necessitate antibiotic therapy or surgical drainage.

Imaging of the vaginal cuff shows a symmetric or slightly asymmetric soft tissue tumor, usually surrounded by fat. Sagittal US reveals the vaginal cuff as a hypoechoic linear structure with a thin central echogenic line. Unfortunately, a postoperative hematoma, seroma, abscess, or lymphocele also has a similar appearance, thus making detection of complications difficult. The presence of gas bubbles raises suspicion of an abscess.

Postoperative fibrosis is common. In general, MRI is superior to CT in detecting tumor recurrence, because MRI allows a distinction between fibrosis and tumor; fibrosis has a low signal intensity on T2-weighted images, while tumor has a high signal intensity.

Post-Laser Ablation of Endometrium

Laser endometrial ablation is performed to control symptomatic heavy, painful menses. Magnetic resonance imaging immediately after therapy reveals an increase in uterine volume due to endometrial swelling.

Poststerilization

Tubal sterilization is performed by ligation, occlusion with a clip or band, or by partial fallopian tube resection. Most of these obstructions are in the tube midportion and a postprocedure hysterosalpingogram reveals partial fallopian tube visualization.

Transcervical fallopian tube recanalization is achievable in most women. A successful pregnancy following recanalization, on the other hand, occurs in less than half. One complication of tubal recanalization is tubal perforation, usually associated with few, if any, sequelae.

Posthysterectomy

Hysterectomy-associated complications include pelvic abscess and injury to adjacent structures.

Endovaginal US commonly reveals pelvic fluid collections during the first postoperative week; these fluid collections gradually resolve and do not imply a postoperative complication.

Intrauterine Device Complications

An occasional intrauterine device migrates into the peritoneal cavity. Imaging or laparoscopy should localize it. One, inserted 4 years previously, migrated into the bladder and led to recurrent urinary tract infections (123); it was detected by US, conventional radiographs, and cystoscopy. These migrating devices tend to become surrounded by adhesions and thus are difficult to remove.

An intrauterine device was inserted through the urethra into the bladder (124); it could not be removed by transurethral endoscopy and required surgery.

Postradiation Therapy

Interstitial edema and inflammation of involved tissues develop shortly after radiation therapy. Magnetic resonance imaging during this phase reveals a hyperintense signal on T2-weighted

FEMALE REPRODUCTIVE ORGANS

images. Once fibrosis develops, after about 1 year, a hypointense signal predominates from the involved tissue and little postcontrast enhancement is evident.

Girls with Wilms’ tumors who underwent whole abdomen radiotherapy were later found to have primary ovarian failure (125); US revealed their ovaries to be undetected or small and their uteri to be abnormally small in spite of hormone replacement therapy. Ultrasonography in those who underwent hemiabdomen radiotherapy identified normal gonadotropin levels and a normal-sized uterus, but the ovary on the radiotherapy side was not seen or was small in half of the patients (125).

Chronic radiation changes consist primarily of fibrosis. Magnetic resonance imaging shows a low signal intensity on T2-weighted images. Postcontrast MR reveals tissue enhancement even during the chronic phase.

Examination and Surgical

Complications

Hysterosalpingography

Intravasation and subsequent embolization into the lungs are known complications of hysterosalpingography. The previously used oilbased media probably were less painful, but a number of embolization-associated deaths were reported. Therefore, most radiologists currently use water-soluble agents.

Tumor Seeding

Pelviscopic excision of malignant gynecologic tumors potentially disseminates malignant cells to surrounding structures. Localized tumor seeding or tumor dissemination develops intraperitoneally and at trocar sites after laparoscopic tumor resection. Most of these metastases are in patients with FIGO stages IIIC to IV, although even an ovarian mature cystic teratoma containing a focus of carcinoma poses a risk. Seeding occurs not only from malignant tumors; thus during laparoscopic myomectomy fragments of uterine leiomyomas were inadvertently implanted and grew in abdominal-wall incisions.

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Technique

Ultrasonography

Ultrasonography (US) has become the modality of choice for scrotal imaging. It can differentiate intrafrom extratesticular tumors with a sensitivity of over 95%. The specificity, however, is considerably lower. Transducers using 10-MHz provide detailed resolution, although with scrotal swelling a lower frequency is necessary for full coverage.

Seminal vesicles and surrounding structures are readily studied with endorectal US. Threedimensional (3D) endorectal US outlines the prostate in three planes and aids the study of transition zone hyperplasia; the central zone and enlarged transition zones are best identified using a coronal plane.

Transabdominal gray-scale US has a limited role in evaluating the prostate; the gland is located too far posteriorly and is too small for detailed study. An endorectal US approach is preferred.

Variability in interpreting endorectal US prostate images is a concern. Even well-trained physicians differ both in describing findings of random videotaped images of the prostate and in deciding whether to biopsy.

Transperineal US during contrast enhanced voiding urosonography has been proposed in children (1). Posterior urethral valves can be detected with this technique but further work is necessary to establish its clinical relevance.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) of the scrotum is still evolving. Especially in children, with an equivocal US study MRI may obviate the need for exploratory surgery. In addition, new applications being reported suggest that MRI will evolve into the primary imaging modality of the testes.

Endorectal surface coils allow prostate zonal study. The prostatic capsule, neurovascular bundles, vas deferens, and seminal vesicles are readily studied.

T1-weighted magnetic resonance (MR) images outline the prostatic margin with surrounding fat, although the internal prostate zonal architecture is not defined. T2-weighted images show a hyperintense peripheral zone and a heterogeneous more hypointense central and transition zones. An endorectal coil improves spatial resolution. Postgadolinium T1weighted images reveal less peripheral zone enhancement than central zone.

Magnetic resonance voiding cystourethrography is feasible after gadolinium-enhanced excretory MR urography. Magnetic resonance fluoroscopy using a T1-weighted gradient echo sequence provides real-time urethral imaging during voiding. Both sonourethrography and MR imaging of the anterior urethra are feasible, with the urethral lumen distended with saline. Both modalities provide information about periurethral tissues.