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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5775_Библиотеки_им_академика_М_И_Перельмана
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A.Normalendometrium
B.Endometrialhyperplasia
C.Submucosalfibroid
D.Endometrialpolyp
14.A20-year-oldfemalepresentswithaleftadnexalmass.Basedontheimagesprovided,whichofthe
followingismostconcerningformalignancy?
A.Largelesionsize
B.Presenceofbloodflow
C.Absenceofpapillaryexcrescences
D.Presenceofsolidcomponents
AnswersandExplanations
1a. AnswerC. Images of theleft ovary show a rounded mass with low-level homogeneousinternal
echoes,increased through transmission, and lack of vascular flow. Thesefindingsare characteristic of
endometrioma.Endometriomas occur in females of menstrualageas a result of growthof endometrial
tissuewithintheovaries. The tissueundergoes repeated cyclical hemorrhage and forms cystic lesions
containingdegeneratedbloodproducts.Thesonographicappearanceofendometriomascanbevariable,
althoughapproximately50% ofendometriomas appearas unilocular cystscontaininglow-levelinternal
echoes. Other variations include multiloculated, mixed solid cystic, and, rarely, anechoic cystic
morphologies. Although a cystic lesion containing homogeneous low-level echoes is the classic
appearanceofanendometrioma,thisappearancecanoverlapwiththatofahemorrhagiccyst.Therefore,a
6-to12-weekfollow-upultrasoundissuggestedwhenencounteringalesionwiththesecharacteristicsfor
thefirsttimeinapatientofmenstrualagetoallowfortheexpectedevolutionofahemorrhagiccyst.
Ahemorrhagiccyst(choiceA)isusuallyacomplexcysticmasswithalace-likeorreticularpatternof
internalechoesduetointerdigitatingfibrinstrandsorasolid-appearingareawithconcavemarginsandno
internal flow on Doppler ultrasound due to a retracting clot within the cyst.A mature cystic teratoma
(dermoid) (choice B) usually contains hyperechoic components, lines and dots, and area of acoustic
shadowing, with no internal flow at color Doppler sonography. Tuboovarian abscess (choice D) is
commonlyseenasamultilocularcomplexadnexalmasswithinternalechoesandseptations.
1b. Answer D. Although the diagnosis of endometriosis is suspected based on the history, signs,
symptoms,physicalexamfindings,andimagingtests,laparoscopyisconsideredthegoldstandardforthe
diagnosisofendometriosis.
1c. Answer C. Endometrioid carcinoma is the most common malignant neoplasm arising from
endometriosisfollowedbyclearcellcarcinoma.
1d.AnswerD.Gastrointestinaltractinvolvementisseenin5%to37%ofpatientswithendometriosis.
Therectosigmoidcolonisthemostcommonlyinvolvedsitefollowedbythesmallbowel,thececum,and
theappendix,inorderofdecreasingfrequency.
References: GoreRM, SzucsRA,WolfEL, et al. Miscellaneous abnormalities of thecolon. In: Gore RM, Levine MS (eds). Textbook of
gastrointestinalradiology,3rded.Philadelphia,PA:SaundersElsevier,2008:1213.
HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:578–579.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:579–580.
WoodwardPJ,SohaeyR,MezzettiTP.Endometriosis:radiologic-pathologiccorrelation.RadioGraphics2001;21(1):193–216.
2a.AnswerC.Theimagesshowtwoendometrialcavitieswith separation,whichextendsthroughthe
lower uterinesegment andcervix.Themain differential is between septate, bicornuate, anddidelphys
uterine anomalies. The 3D coronal image shows a single fundal contour, which extends above the
interostial line.This key imaging feature excludesboth bicornuateand didelphys anomalies, which are
associatedwith a fundal cleft>1 cm. Arcuateuterus would be associatedwith a singleuterine cavity.
DES(in utero diethylstilbestrol exposure)uterineanomalies are associatedwith anatrophic, T-shaped
uterinecavity.
2b. Answer C. In certain cases, surgical resection of the fibrous septation can improve obstetrical
outcomes. Unicornuate, didelphys, and bicornuate uterus are associated withrenal anomalies. Arcuate
uterine configuration is considered a normal anatomic variant that has no effect on fertility and is not
associatedwithrenal anomalies. Patients with DES uterus are at increased riskfor vaginal clear cell
carcinoma.
References:BehrSC,CourtierJL,QayyumA.ImagingofMüllerianductanomalies.RadioGraphics2012;32(6):E233–E250.
Chandler TM, Machan LS, Cooperberg PL, et al. Müllerian duct anomalies: from diagnosis to intervention. Br J Radiol
2009;82(984):1034–1042.
3.AnswerC.Bothovariescontainmultiplesmallfolliclesthatlineupalongtheperipheryoftheovary,
theso-calledstringofpearlssign.Also,theovarianstromaisprominentandechogenic.Thisappearance,
along with the provided clinical history, is most consistent with polycystic ovary syndrome (PCOS).
PCOSisanendocrinedisordercharacterizedbyhyperandrogenismandanovulation/oligoovulationdueto
highlevelsofluteinizinghormone(LH)andlowlevelsoffollicle-stimulatinghormone(FSH).Clinically,
womenpresentwithinfertility,hirsutism,obesity,acne,andinsulinresistance.
Ovarian torsion (choice A) is not the best choice because although there are multiple peripheral
folliclesasisoftenseenintorsionbothovarieslookfairlysymmetric.Patientswithtorsionpresentwith
painandanenlargedovaryontheaffectedside.Intorsion,theovarianechotextureisoftenheterogeneous,
differentfromthiscasewheretheechotextureishomogeneous.
Hyperstimulated ovaries (choice B) are usually markedly enlarged with multiple cysts, often with
intracystic hemorrhage, ascites, and pleural effusions. Most often, this occurs in the setting of firsttrimester pregnancy following ovulation induction for assisted fertility. The ovaries in this patient are
onlymildlyenlarged,andthequestionstatedthatsheisnotpregnant.
Althoughendometriosis (choiceD)canbeacauseofinfertility,itis notthebestchoicebecauseno
endometrioma is shown. Endometriomas usually have the appearance of complex ovarian cysts, often
containinguniformlow-levelechoes.Othersonographicfeatures includepunctateechogenicmuralfoci,
fluid–fluid levels,internalseptations,multilocularity,andsolid-appearingnodules duetoclottedblood.
Theovariesinthiscasehavenoneofthesesonographicfeatures.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:580–589.
LeeTT,RauschME.Polycysticovariansyndrome:roleofimagingindiagnosis.RadioGraphics2012;32(6):1643–1657.
4.AnswerD.Thefirstimageshowstheleftovary,whichisnormalbothinsizeandinmorphology.The
nextimageshowstherightovary,whichisenlargedrelativetotheasymptomaticleftside.Inaddition,the
ovarianstroma isenlargedandheterogeneous,and thefolliclesaredisplacedperipherally. Theimaging
findings,alongwiththeclinicalpresentationandlaboratoryvalues,arecompatiblewithovariantorsion
(choiceD).Clinically, patientswithovariantorsionpresent withacuteonsetofpain, oftenwithnausea
andvomiting.Intermittentpainmayprecedetheacuteepisodebyweeks.Ovariantorsionmaypresentat
any time in life, although relatively uncommon following menopause. The risk is increased during
pregnancy.Themostconstantfindinginovariantorsionisunilateralenlargementofthetorsedovary.This
istrueevenwhentheovaryshowsDopplerflow,whichisthoughttobetheresultofdualbloodsupplyto
theovary.Thetorsedovarycan,infact,showarterialflow,venousflow,both,orneither.Therefore,in
theappropriateclinicalsetting,anenlargedovaryshouldsuggesttorsioneveninthepresenceofDoppler
flow. Additional findings include heterogenous echotexture (from hemorrhage, edema, and necrosis),
relative paucity of follicles, small peripheral follicles, echogenic rings around thefollicles (follicular
ringsign),twistedpedicle,whirlpoolsign,andovariancyst.
Oophoritis (choice A) is not correct because of the clinical presentation. Although there can be
relative asymmetric ovarian enlargement, oophoritis typically presents in the context of pelvic
inflammatory disease, which has a different presentation of fever, cervical motion tenderness, and
leukocytosis,whichthispatientdoesnothave.Ovarianhyperstimulation(choiceB)isincorrectbecause
it typically involves both ovaries in a patient in the setting of first-trimester pregnancy following
ovulation induction. This patient is not pregnant, and only one ovary is enlarged. Polycystic ovarian
syndrome(choiceC)isincorrectbecauseoftheacutepresentation,whichisnotafeatureofPCOS.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:580–582.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:584.
5.AnswerB.Thefirstimageshowsanabnormallythickenedendometriumwithasolidmasscontaining
cysticspaces.The secondimageshowsDopplerflowwithinthemass.Basedontheimagesshown and
theclinicalinformationprovided,thebestanswerisB.
Thepatientispostmenopausalandpresentswithvaginalbleeding.Accordingtoaconsensusstatement
by the Society of Radiologists in Ultrasound, an endometrial thickness of >5 mm in a woman with
postmenopausal bleeding is abnormal. In a woman of this age group, the most likely causes are
hyperplasia,polyps,submucosalfibroid,andcarcinoma.Theendometriuminthispatientisclearlymuch
thickerthan5mm.Inapostmenopausalpatient,theendometriumisnormallythin,homogeneous,and<5
mm. If the endometrium is thicker than 5 mm in a woman with postmenopausal bleeding, further
evaluationwithtissuesamplingshouldbeobtained.Inapostmenopausalwomanwhoisnotbleeding,the
upperlimitofendometrial thicknessiscontroversial,but athresholdof8mm(some suggest 11mm) is
advocated.
ChoiceAisnotcorrectbecausetheendometriumisclearlytoothicktocallnormalinawomanofany
age.Also,thereisclearlyamassintheendometrialcanal.Althoughsubmucosalfibroids(choiceC)can
causebleeding,theyareusuallybroadbased,solid,hypoechoicmasseswithanouterlayerofechogenic
endometrium.Thislesionisnotcompletelysolidandisisoechoictothemyometrium.Althoughthecystic
componentsaremorecommonlypresentwithinpolyps,theycanalsobeidentifiedwithinhyperplasiaand
carcinoma.Therefore,atissuediagnosisisneeded.ChoiceDisnotthecorrectanswerbecauseimaging
cannotreliablyexcludecarcinoma.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:541–546.
6. Answer B. The first image shows an enlarged uterus with a bulbous configuration, with marked
myometrial heterogeneity, especiallyalongtheanterior aspect.Thesecond image(transvaginal) shows
similar findings with multiple echogenic andhypoechoic linear striations, the so-called venetianblind
appearance. Also note the indistinct interface between the endometrium and the myometrium. These
findingsaretheresultofadenomyosis.Adenomyosisisacommonconditioncharacterizedbythepresence
of endometrial glands and stroma in the myometrium. These patients present with abnormally heavy
vaginalbleeding, particularlyatmenses, dyspareunia, and an enlarged uterus. Verycommonly, thereis
greaterinvolvementintheposteriorwall.Adenomyosiscomesintwoforms:diffuse,whichiscomposed
ofwidelyscatteredfoci within themyometrium,andnodular, whichconsistsof circumscribed nodules
called adenomyomas. Ultrasound findings include an enlarged, globular uterus, disproportionate
thickening of the posterior myometrium, myometrial cysts, heterogeneous echotexture, linear shadows
(“venetianblind”)pattern,andindistinctmyometrial–endometrialinterface.MRIishighlyaccurateinthe
diagnosis of adenomyosis, which shows thickening of the junctional zone (>12 mm) on T2-weighted
images,aswellaspoorlydefinedareasofdecreasedT2signalinthemyometrium.
Lipoleiomyoma (choice A) are rare, fat-containing, benign neoplasms that are well-defined, solid
echogenic masses. Intramural leiomyoma (choice C) is incorrect because of the indistinct borders.
Althoughtheycanhaveavarietyofappearancesandcanalsohavethe“venetianblind”appearance,they
arewell-circumscribedmasses.Endometrialpolyp(choiceD)isincorrectbecausetheimagesshowthat
the abnormality is in the myometrium, not the endometrium.Also, polyps do not cause dyspareunia or
globularuterineenlargement.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:550–553.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:559–560.
7.AnswerB.Thefirsttwoimageslabeled“rtovary”showahomogeneouslyechogenicmasswithinthe
right ovary. Attenuation of the ultrasound beam resultsinpoor visualization of the deepportionofthe
mass, the“tipoftheiceberg”sign.Thesecondimageshowsshadowingdeep tothemass.Thenexttwo
imagesarelabeled“ltovary”andshowacysticlesioncontainingmultipleechogenic,linearstrands,the
“dermoidmesh”sign.Thesecondimageoftheleftovaryalsoshowsanechogenicmasswithattenuation
oftheultrasoundbeamdeeptothemass.Therefore,thecorrectanswerisbilateraldermoidcysts,choice
B.Dermoidsarebenignovariangermcelltumorscomposedofmatureepithelialstructuresincludingskin,
desquamated epithelium,hair,teeth, sebum,lipid, andcalcification.Theyare present from birth, grow
slowly,andareoftendetectedincidentallyduringimagingperformedforotherreasons.Tentotwenty-five
percentarebilateral.Dermoidsexhibitavarietyofappearances.ThedermoidplugorRokitanskynodule
isan echogenicmasscomposedofamixtureofhair andsebaceousmaterial.Often,onlythesuperficial
portionof this lesionis well visualized because ofattenuationoftheultrasound beam,the“tip of the
icebergsign.”Somedermoidshavemultiplefloatinglinearechoes,whicharehair,the“dermoidmesh”
sign.Thefluidcomponentissebumandcanbeanechoicorcontainlow-levelechoes.Afat–fluidlevelis
veryuncommonly seen but is a very characteristic finding, as are multiple echogenic floating spheres,
whichare fat globules. Some dermoids can show multiple components. Most dermoids are surgically
removed becauseof risk of torsionormalignant transformation, which occurs in approximately2% of
dermoids.
Endometriomas(choiceA)haveavarietyofappearancesincludinghomogeneous,low-levelechoes
in a ground-glass pattern, punctate echogenic foci in the wall, and fluid–fluid levels. They are often
multipleandbilateral.Themarkedly hyperechoictissues shown on thiscase arenottypicalofthelowlevelechoeswithin endometriomas.Also,hair would not be a feature of endometriomas. Tuboovarian
abscesses(choiceC)arecysticmassesandareoftenbilateralbutalsowouldnotexhibitthedistinctive
features alreadydescribedfordermoids.Hemorrhagic cysts(choice D) canshowreticular fineechoes
thattendtobelacyinappearance,notthestraightlinearechoesseeninthiscase.Theycanalsoappearto
besolidandbemistakenforthedermoidplug,butthedermoidplugisusuallymoreechogenicandwill
attenuate the ultrasound beam, whereas a hemorrhagic cyst will show posterior enhancement. Also,
hemorrhagiccystsarenottypicallybilateral.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:586–592.
8.AnswerB.Thestandardforpeerreviewispeerconsensus,not pathologicorsurgicalproofofthe
final diagnosis. Peer review data is immune to legal action and discovery. It is a safe form of selfregulationamongqualifiedradiologists.Thepeerreviewdataarenotavailableforpublicreportingnor
cantheybeusedbyTheJointCommissiontomakeaccreditationdecisions.
Reference:AmericanBoardofRadiology.Quality&SafetyDomainSpecification&ResourceGuide,2016.
9.AnswerC.Thefirstimageshowsahomogeneouslyechogenicintramuralmassintheposterioruterus.
The second image shows no Doppler flow within this lesion. A highly echogenic mass within the
myometrium is virtuallydiagnostic of a lipomatousuterinetumor. These are uncommon benigntumors
consisting of variable portions of mature adipocytes, smooth muscle, or fibrous tissue. These tumors
histologically include pure lipomas, lipoleiomyoma, and fibrolipomyomas. The typical ultrasound
appearance is that of an echogenic solid mass with no Doppler flow. These tumors are typically
asymptomaticandrequirenotreatment.Itisimportanttolocalizethesemassestotheuterusastheimaging
appearanceoverlapswiththemorecommonovariandermoid.
ChoiceAisincorrectbecauseacalcifiedfibroidwouldshowposteriorshadowing,whichthisdoes
not. The typical appearance of an adenomyoma (choice B) is that of a heterogeneous nodule with
indistinctmarginsandcysticspaces,whichisverydifferentfromtheappearanceofthis.AuterineAVM
(choiceD)isalesioncomposed ofmultipletubularorserpiginouscysticstructuresin themyometrium,
sometimes extending into the endometrium on gray-scale imaging corresponding to vessels shown on
colorDopplerimaging.Theymostoftenfollowtraumasecondarytopregnancy,dilatationandcurettage,
orabortion.
References:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:548–550,559–561.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:558–559.
10.AnswerC.Transvaginalultrasoundimagesoftheleftadnexashowadilatedtubularstructurefilled
withlow-levelinternalechoes(debris).Theincompleteinternalseptations suggestthatthisstructureis
the fallopiantube and nota cystic ovarian mass. The transverse imageshows small nodules along the
wallofthetube,whichrepresentthickenedendosalpingealfolds(“cogwheelsign”).
The imagingappearanceisconsistent with pyosalpinx inthe settingofpelvicinflammatorydisease
(PID).Pyosalpinx occurs when adhesionsobstruct the fimbriatedendof the fallopiantuberesultingin
accumulation of pus within the tube. The infection may progress and involve the ovary resulting in a
tuboovarian complex (TOC) or a tuboovarian abscess (TOA). In a TOC, the ovary and tube can be
identifiedas separatestructureswithinthe inflammatorymass.However,tuboovarian abscesses(TOA)
appear as complex multiloculated cystic and solid adnexal masses in which the fallopian tubes and
ovariescannotbeidentifiedasdiscreteentities.
Absenceof the “gut signature”in thetubular structure shownexcludesenterocolitis. Moreover,the
clinicalhistoryalsoindicatesapelvicpathology(choiceA).Ovariantorsion isnotcommonin patients
with PID because of formation of adhesions in the pelvis from the inflammatory process (choice B).
PyosalpinxisamanifestationofPIDandisnotassociatedwithmalignantdegeneration(choiceD).
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:580.
11.AnswerD.Imagesoftherightovaryshowasimplecystwithimperceptiblewall,increasedthrough
transmissionandno internalseptations or muralnodularity. According totheSocietyofRadiologistsin
Ultrasound (SRU) consensus statement for Management of Asymptomatic Ovarian and Other Adnexal
CystsImagedatUS:
Inpostmenopausalwomen,
Simplecysts≤1cm:areclinicallyinconsequential;donotneedfollow-up.
Cysts >1and ≤7 cm:arealmost certainly benign;yearlyfollow-upwith US is recommended.(The
cystinthisquestionfallsintothiscategory,sochoiceDiscorrect.)
Cysts >7 cm: may be difficultto assess completely with US;further imaging with MR or surgical
evaluationshouldbeconsidered.
Reference:LevineD,BrownDL,AndreottiRF,etal.Managementofasymptomatic ovarianandotherAdnexalcystsimagedatUS:Society
ofRadiologistsinultrasoundconsensusconferencestatement.Radiology2010;256(3):943–954.
12. AnswerB. Theimageprovided shows low-level echoes inthe superficial aspect of the urinary
bladder. This is an example of reverberation artifact, which occurs when sound reflects off of strong
acousticinterfacesinthenearfield,andthereturningpulseisstrongenoughtoreflectoffofthetransducer
itselfandbackintothebody sothat itcaninteractwiththesame near-fieldinterfacesasecond timeor
multiple times. This produces an additional set of echoes that are interpreted as arising deep to the
originalreflector.Thereverberationartifactisusuallynotobviousinsofttissues.However,theanechoic
backgroundofcysticstructuresallowsthereverberationstobeseen.
Reverberationartifactcanbedecreasedoreliminatedbydecreasingpoweroutputandgain(choiceA
isincorrect).Theycanalsobeminimizedby positioningthetransducersothatthecystic structureisno
longer inthe nearfield.Usingmoreultrasoundgel(choiceC)willdisplaceairbetween the transducer
andskinsurfacetoeliminatereflectioncausedby air,butwillhavenoimpactonreverberationartifact.
Evenifthebladderismoredistended(choiceD),itwillstillbeinthenearfieldifallotherparameters
remainthesameand,therefore,willhavenoimpactonthereverberationartifact.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:22.
13.AnswerD.Thefirstimageshowsasmoothechogenicmassexpandingtheendometrialcavityatthe
fundus.Thesecondimageshowsafeedingvesselextendingtothemass.Thisappearanceischaracteristic
ofendometrialpolyp. Endometrialpolypsarecommonbenignhyperplastic overgrowthsofendometrial
glandsandstromathatformaprojectionfrom thesurfaceoftheendometrium.Theyareoneofthemost
common etiologies of abnormal vaginal bleeding in both premenopausal and postmenopausal women.
However, they may also be asymptomatic. Although the majority of endometrial polyps are benign, a
smallpercentage(0.5%to3%)maybepremalignantormalignant.Thetypicalsonographicappearanceof
endometrialpolypisafocal,roundechogenicmasswithintheendometrialcavity.Thevisualizationofa
feeding artery in the pedicle is characteristic of endometrial polyp. If a feeding artery is not readily
visualized,sonohysterogrammayberequiredtoconfirmthediagnosis.
The ultrasound images here show the typical appearance of an endometrial polyp. A normal
endometrium (choice A) would not be expected to have such appearance. Generally, endometrial
hyperplasia (choice B) is characterized bydiffuse thickening of the endometrium as opposed to focal
natureofanendometrialpolyp.Sonohysterographyishelpfulindifferentiatingbetweenthetwoentities.A
vascular pedicle will not be expected to be seen in endometrial hyperplasia. A submucosal fibroid
(choiceC)isusuallyhypoechoicwithposteriorshadowingandhasanoverlyingechogenicendometrium.
References:JorizzoJR,ChenMYM,RiccioGJ.Endometrialpolyps.AJRAmJRoentgenol2001;176(3):617–621.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:564.
14. AnswerB. The first image shows a largemixed solid and cystic leftovarian mass. The second
imageshowslow-resistancearterialflowinthesolidcomponentofthelesion.
When evaluating a mixed solid and cystic ovarian lesion, the features that raise concern for
malignancy are thick irregular septa (>3 mm), wall thickening, andpapillaryexcrescences, which are
solid nodules along the septationsoralong the wall.Incystic ovarian neoplasms,a solid nodule with
internalblood flowhasthegreatestchanceofbeingassociatedwithmalignancy.Presence ofvery-lowresistance arterial flow in the solid component raises the level of suspicion but is not specific for
malignancy.Low-resistanceflowcanalsobeseenincorpuslutealcystsandhigh-resistancearterialflow
canalsobeseeninportionsofovariancancer.
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