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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5786_Библиотеки_им_академика_М_И_Перельмана.pdf
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uterine sarcoma. The differences between the two studies highlight the difficulties
in obtaining a correct preoperative ultrasound diagnosis of uterine sarcomata.
ADENOMYOSIS
Adenomyosis is a common condition, which is associated with a range of symptoms
including pelvic pain, dysmenorrhoea and menorrhagia. As these symptoms are also
commonly encountered in other gynaecological conditions, the reported accuracy
of clinical diagnosis of adenomyosis ranges from 2.6% to 26%.
be found in up to 20% of hysterectomy specimens; however, it is asymptomatic in
around 30% of these cases. It is more common in older multiparous women and
those who have had previous uterine surgery, especially curettage and caesarean
section. Advances in endometrial ablation have reduced the need for hysterectomy
in many women; however, if adenomyosis is present then the risk of subsequent
hyste rectomy is increased. Preoperative screening for adenomyosis may play a role in
the improved triage of women who are likely to benefit from endometrial ablation.
On clinical examination, there may be diffuse uterine enlargement, although the
posterior uterine wall may be disproportionately larger, which is usually more pronounced in the premenstrual phase. Diagnosis with ultrasound is difficult as there
are no characteristic features. Early studies used transabdominal ultrasound and
described the myometrium as having a ‘focal honeycomb’ appearance with irregular
5–7 mm cystic spaces; these findings confirmed adenomyosis in four out of nine subjects (Fig. 17.5).20 Subsequently, Bohlman et al diagnosed adenomyosis on the basis of
19
Adenomyosis may
Gynaecological pathology: the uterus
Fig. 17.5 A logitudinal view of the uterus showing a thick and hyperechoic posterior uterine
wall, which is typical of adenomyosis.
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hypoechogenicity of the myometrium, posterior uterine wall thickening and anterior
displacement of the endometrial cavity.21 However, these findings were confirmed at
histology in only 50% of cases. Siedler et al used similar criteria and reported a sensitivity of only 63% but a specificity of 97% with a positive predictive value of 71%.
Transvaginal ultrasound with its improved resolution enables evaluation of more
subtle features that may be suggestive of adenomyosis. Several features have been
reported that would be suggestive of adenomyosis, including uterine enlargement
not explained by leiomyomas, asymmetrical thickening of the anterior or posterior
uterine walls, lack of contour or abnormality effect, heterogeneous and poorly circumscribed areas in the myometrium, increased echotexture of the myometrium
and anechoic cysts or lacunae within the myometrium.
none of these features is either sensitive nor specific.
23,24
In isolation, however,
25
Diagnostic difficulties may arise in differentiating adenomyosis from fibroids,
which may also co-exist in up to 60% of women. Several features have been proposed that would be more suggestive of adenomyosis, including poorly defined
hypoechogenic area, minimal mass effect on the serosa or endometrium relative to
the size of the lesion, lack of edge shadowing, echogenic nodules and linear stria-
Ultrasound in obstetrics and gynaecology
tions radiating out from the myometrium and into the endometrium, and absence
of circular blood flow in the periphery on colour Doppler examination.
22
26
308
ENDOMETRIAL POLYPS
The ultrasound features of endometrial polyps are well recognized, being focal
hyperechoic lesions within the endometrium; this appearance remains constant
throughout the menstrual cycle as benign endometrial polyps are not responsive to
ovarian steroid hormones. Detailed inspection of the polyp may also reveal small
hypoechoic spaces within it, these being small pockets of glandular endometrial
secretions. They are best visualized in the proliferative phase of the menstrual
cycle as at this time they contrast against the relatively hypoechoic endometrium.
Endometrial polyps should be differentiated from fibroid polyps as the latter are
hypoechoic and cast acoustic shadows as a characteristic of being fibroids.
Endometrial polyps usually present in women after the age of 35. However, their
significance differs according to age group as in younger women, they are more
likely to be benign and present with intermenstrual bleeding, dysmenorrhoea or
subfertility. In the older, perimenopausal woman, they are usually detected during
screening for endometrial pathology due to irregular or postmenopausal bleeding. In
these women, polyps may be either seen as focal lesions or be detected as thickened
endometrium. Detection is important as, although only a minority of polyps are
malignant or hyperplastic, the standard management is hysteroscopic removal rather
than endometrial biopsy. Detection may be improved by the addition of saline into
the endometrial cavity – saline infusion sonohysterography. However, this technique,
although being comparable to diagnostic hysteroscopy, is associated with pain, infection and the risks of intraperitoneal spillage of malignant endometrial cells.
Timmerman et al have recently described the ‘pedicle sign’ which refers to
the colour Doppler detection of a feeding vessel that enters the body of a polyp
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Fig. 17.6 An image of a large endometrial polyp with a prominent vascular pedicle.
through its stalk (Fig. 17.6).27 They prospectively assessed 3099 women and
found that the pedicle sign had a sensitivity of 76.4% and specificity of 95.3% for
detection of endometrial polyps. The positive predictive and negative predictive
values were 81.3% and 93.8% respectively. The positive predictive value for any
intracavitary pathology was 94.2%. Given the high positive predictive value for
the detection of intracavitary pathology, the authors conclude that the pedicle
sign has the potential to replace second-line diagnostic tests such as saline infusion sonohysterography and hysteroscopy.
Gynaecological pathology: the uterus
ENDOMETRIAL HYPERPLASIA AND MALIGNANCY
Ultrasound measurement of endometrial thickness has become the fundamental step
in screening for pathology in women presenting with abnormal bleeding during the
peri- and postmenopausal decades. In these women, 10% will have significant endometrial pathology. The aim of ultrasound, therefore, is to screen out the 90% who do
not require further intervention and allow selection of appropriate intervention in the
remainder. The meta-analysis of Smith-Bindman et al, of 6000 women, forms the basis
for most strategies, namely that an endometrial thickness less than 4 mm, including
both leaves of endometrium, is highly unlikely to harbour any significant pathology
and the chances of malignancy are <1%.28 In the remainder of women, i.e. those with
an endometrial thickness greater than 5 mm, the next step is usually either endometrial
biopsy or hysteroscopy. Both are invasive to varying degrees.
In an attempt to obviate the need for further tests and proceed directly to treatment, several refinements on ultrasound endometrial assessment have been proposed.
Saline contrast sonohysterography allows not only detection of focal pathology but
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Ultrasound in obstetrics and gynaecology
Fig. 17.7 An example of a large malignant polyp with an irregular surface.
also an assessment of the morphological features. Benign endometrial polyps are
likely to have smooth surfaces whereas malignant polyps are likely to have irregular surfaces and may have necrotic cores and are associated with a haematometra
(Fig. 17.7). Doppler examination of the endometrium has been suggested to help
differentiate between benign and malignant endometrial lesions; however, authors
have reported a significant overlap and the usefulness of this modality has been
questioned. Power Doppler, on the other hand, with its ability to sensitively detect
small irregular vessels and with less interference from background noise, may have
potential in this context. In a study by Epstein et al, endometrial vascularization was
assessed subjectively by the operator and objectively using various Doppler vascularization indices.29 Both were reasonably accurate in detecting endometrial cancer
with sensitivities of 75% and 88% and specificities of 96% and 81% respectively.
Although the Doppler tests performed well in women with endometrial thickness
between 5 and 15 mm, subjective assessment of endometrial morphology was a better diagnostic test in women with endometrial thickness >15 mm.
310
CONCLUSION
Transvaginal ultrasound has been accepted as the most effective method for the
diagnosis of various uterine abnormalities. In recent years it has also been playing
an increasingly important role in the selection of women for different conservative and surgical management options. The introduction of 3D ultrasound has
significantly improved the accuracy of ultrasound diagnosis of congenital uterine
anomalies and submucous fibroids, which may help to improve our understanding of the clinical significance of these conditions and facilitate the development
of more effective strategies for their management.
References
1. Jurkovic D, Geipel A, Gruboeck K et al.
Three-dimensional ultrasound for the
assessment of uterine anatomy and
detection of congenital anomalies:
a comparison with hysterosalpingography
and two-dimensional sonography. Ultrasound Obstet Gynecol 1995;5:233–237
2. Raga F, Bonilla-Musoles F, Blanes J, Osborne
NG. Congenital Mullerian anomalies:
diagnostic accuracy of three-dimensional
ultrasound. Fertil Steril 1996;65:523–528
3. Buttram VC, Gibbons WE. Mullerian
anomalies: a proposed classification
(an analysis of 144 cases). Fertil Steril
1979;32:40–46
4. Salim R, Woelfer B, Backos M, Regan L,
Jurkovic D. Reproducibility of threedimensional ultrasound diagnosis of
congenital uterine anomalies. Ultrasound
Obstet Gynecol 2003;21:578–582
5. Jurkovic D, Gruboeck K, Tailor A,
Nicolaides KH. Ultrasound screening for
congenital uterine anomalies. Br J Obstet
Gynaecol 1997;104:1320–1321
6. Simon C, Martinez L, Prado F. Mullerian
defects in women with normal reproductive
outcome. Fertil Steril 1991;56:1192–1193
7. Woelfer B, Salim R, Banerjee S et al.
Reproductive outcomes in women with
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three-dimensional ultrasound screening.
Obstet Gynecol 2001;98:1099–1103
8. Salim R, Regan L, Woelfer B et al.
A comparative study of the morphology
of congenital uterine anomalies in women
with and without a history of recurrent
first trimester miscarriage. Hum Reprod
2003;1:162–166
9. Mueller GC, Gemmete JJ, Carlos RC.
Diagnostic imaging and vascular
embolization for uterine leiomyomas. Semin
Reprod Med 2004;22:131–142
10. Wamsteker K, Emanuel MH, de Kruif JH.
Transcervical hysteroscopic resection of
submucous fibroids for abnormal uterine
bleeding: results regarding the degree of
intramural extension. Obstet Gynecol
1993;82:736–740
11. Vercellini P, Cortesi I, Oldani S, Moschetta M,
De Giorgi O, Giorgio Crosignani P. The
role of transvaginal ultrasonography and
outpatient diagnostic hysteroscopy in the
evaluation of patients with menorrhagia.
Hum Reprod 1997;12:1768–1771
12. Farquhar C, Ekeroma A, Furness S, Arroll B.
A systematic review of transvaginal
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ultrasonography, sonohysterography
and hysteroscopy for the investigation
of abnormal uterine bleeding in
premenopausal women. Acta Obstet
Gynecol Scand 2003;82:493–504
13. Salim R, Lee C, Davies A, Jolaoso B, Ofuasia
E, Jurkovic D. A comparative study of threedimensional saline infusion sonohysterography
and diagnostic hysteroscopy for the
classification of submucous fibroids. Hum
Reprod 2005;20:253–257
14. Eldar-Geva T, Meagher S, Healy DL,
MacLachlan V, Breheny S, Wood C. Effect
of intramural, subserosal, and submucosal
uterine fibroids on the outcome of assisted
reproductive technology treatment. Fertil
Steril 1998;70:687–691
15. Bernard G, Darai E, Poncelet C, Benifla JL,
Madelenat P. Fertility after hysteroscopic
myomectomy: effect of intramural myomas
associated. Eur J Obstet Gynecol Reprod
Biol 2000;88:85–90
16. Hart R, Khalaf Y, Yeong CT, Seed P, Taylor A,
Braude P. A prospective controlled study of
the effect of intramural uterine fibroids on
the outcome of assisted conception. Hum
Reprod 2001:16:2411–2417
17. Hata K, Hata T, Maruyama R, Hirai M.
Uterine sarcoma: can it be differentiated
from uterine leiomyoma with Doppler
ultrsonography? A preliminary report.
Ultrasound Obstet Gynecol 1997;9:101–104
18. Szabo I, Szantho A, Papp Z. Uterine
sarcoma: diagnosis with multiparameter
sonographic analysis. Ultrasound Obstet
Gynecol 1997;10:220–225
19. Reinhold C, Tafazoli F, Wang L. Imaging
features of adenomyosis. Hum Reprod
Update 1998;4:337–349
20. Walsh JW, Taylor KJ, Rosenfield AT. Gray
scale ultrasonography in the diagnosis of
endometriosis and adenomyosis. Am J
Roentgenol 1979;132:87–90
21. Bohlman ME, Ensor RE, Sanders RC.
Sonographic findings in adenomyosis of the
uterus. Am J Roentgenol 1987;148:
765–766
22. Siedler D, Laing FC, Jeffrey RB Jr, Wing
VW. Uterine adenomyosis. A difficult
sonographic diagnosis. J Ultrasound Med
1987;6:345–349
23. Reinhold C, Atri M, Mehio A, Zakarian R,
Aldis AE, Bret PM. Diffuse uterine
adenomyosis: morphologic criteria and
diagnostic accuracy of endovaginal
sonography. Radiology 1995;197:609–614
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24. Hirai M, Shibata K, Sagai H, Sekiya S,
Goldberg BB. Transvaginal pulsed and color
Doppler sonography for the evaluation
of adenomyosis. J Ultrasound Med
1995;14:529–532
25. Brosens JJ, Barker FG. The role of
myometrial needle biopsies in the diagnosis
of adenomyosis. Fertil Steril 1995;63:
1347–1349
26. Devlieger R, D'Hooghe T, Timmerman D.
Uterine adenomyosis in the infertility clinic.
Hum Reprod Update 2003;9:139–147
27. Timmerman D, Verguts J, Konstantinovic
ML et al. The pedicle artery sign based on
sonography with color Doppler imaging
Ultrasound in obstetrics and gynaecology
can replace second-stage tests in women
with abnormal vaginal bleeding. Ultrasound
Obstet Gynecol 2003;22:166–171
28. Smith-Bindman R, Kerlikowaske K,
Feldstein VA et al. Endovaginal ultrasound
to exclude endometrial cancer and
other endometrial abnormalities. JAMA
1998;280:1510–1517
29. Epstein E, Skoog L, Isberg PE et al.
An algorithm including results
of gray-scale and power Doppler
ultrasound examination to predict
endometrial malignancy in women with
postmenopausal bleeding. Ultrasound
Obstet Gynecol 2002;20:370–376
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Gynaecological pathology: tubes and ovaries
Rüdiger Osmers
ABSTRACT
Size and structure of adnexal tumours are presented, with emphasis on twodimensional ultrasound. Benign tumours include dysfunctional ovarian cysts and
endometriosis. Malignant tumours include epithelial ovarian tumours. Other
tumours discussed in this chapter are fibromas, fibrothecomas and ovarian germ
cell tumours. In a separate section, the sonographic features of adnexal torsion
are presented. Tubal pathology includes tubal pregnancy, tubal carcinoma,
hydrosalpinx and pyosalpinx.
KEYWORDS
Adnexal torsion, cyst, endometriosis, fallopian tubes, hydrosalpinx, ovaries,
pyosalpinx, tubal pregnancy, tumour.
OVARIES
BENIGN AND MALIGNANT OVARIAN CYSTS: GENERAL CONSIDERATIONS
Refinements in ultrasound technology have been dramatic during the last few decades
and since the introduction of transvaginal ultrasound, assessment of the female lower
pelvis has been improved. High-resolution images contribute to a better understanding of ovarian function. On the other hand, the diagnosis of ovarian cysts has become
an increasingly more common phenomenon. This is true especially for hitherto clinically undetected ovarian cysts. However, the enormous histological diversity of
adnexal masses as well as physiological changes of the normal ovary co-exist with
a variety of sonographic findings. Therefore a particular challenge, especially in premenopausal women, is avoiding unnecessary operations on functional tumours and,
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on the other hand, correctly identifying true neoplasms and applying suitable therapy. The importance of sonography in the differential diagnosis of adnexal masses is
unquestionable and the main indications can be highlighted as follows:
screening for adnexal tumours in asymptomatic women
•
diagnostic clarification of women with clinical symptoms of disease
•
morphological description and differential diagnosis of adnexal tumours
•
diagnostic exploration of the abdomen in cases of suspected malignancy
•
(liver, omentum, kidney, ascites).
The significance of sonography as a screening method in the detection of ovarian
tumours has been subject to controversy. As the prognosis of advanced carcinoma is
poor, the aim of every screening programme must be the detection of early stages of
disease, including tumours of low malignant potential. It has been questioned, however, whether these early stages as a whole really contribute to the rapidly growing
group of ovarian carcinomas, which develop widespread peritoneal metastasis. In a
survey of 1601 women with family risk of ovarian cancer, Bourne et al2 found one
ovarian carcinoma stage Ia, one stage III and three tumours of low malignant poten-
Ultrasound in obstetrics and gynaecology
tial. However, out of those women with an inconspicuous scan, five developed
advanced stages of carcinoma within a time period of 24–44 months.
The incidence of malignant ovarian tumours increases with patient age and the
menopausal status has to be considered.
21
In a literature review of 8000 asymptomatic women, who had been scanned
by means of abdominal or vaginal sonography, an ovarian carcinoma was detected
in 10 cases.
14
Due to these limitations it has been recommended to further evaluate the
significance of screening programmes. In order to increase the predictive value,
screening should be restricted to specific risk groups such as women with a family history of ovarian cancer, postmenopausal status, nulliparae and women who
have never taken oral contraceptives (low ovulatory age).
The assessment and management of ovarian cysts are largely influenced by
patient age but the size of the ovary itself varies due to the alterations in the endocrine environment. Between the second and fourth decade benign ovarian tumours
occur 10 times more often than malignant neoplasms. Dermoid cysts predominate
before the age of 40; later these are mucinous and serous cystomas.
In the postmenopause there is a marked increase in the incidence of malignant tumours. As functional and inflammatory aspects change and endometriosis
ceases to be of importance, the likelihood of malignancy is higher in every sonographically detected tumour.
Different sonographic scoring systems have been introduced in an attempt
to identify criteria to differentiate benign from malignant adnexal tumours.
These tumour scoring systems are all based on descriptive sonomorphological
findings and most of them include the following items:
22–24
314
tumour size
•
tumour structure
•
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number of cysts and locules
•
inner and outer surface of the cyst: smooth surface or existence of
•
papillary projections
presence or absence of solid parts within the tumour
•
thickness of cyst wall and septal wall
•
echo-dense foci and acoustic shadowing
•
echogenicity of the lesion: hyperechoic, hypoechoic, anechoic
•
colour Doppler sonography: identification of blood vessels within the
•
cyst wall and septa, within solid components and papillary projections.
Assessment of the flow profile including flow velocity, resistance and
pulsatility indices, identification of arteriovenous shunting.
TUMOUR SIZE
The size of cystic ovarian lesions is one of the most important characteristics. The
risk of malignancy rises with increasing tumour size and this is true in both pre- and
postmenopausal women.5 Although the prevalence of malignancy related to the
tumour size varies in different studies, there is general agreement that tumours over
10 cm in diameter should be removed.
vaginal probes makes a reliable ultrasound evaluation of the entire cyst questionable
and the probability of malignancy is too high to justify conservative management.
4,18
The limited depth of penetration of the
Gynaecological pathology: tubes and ovaries
TUMOUR STRUCTURE
Complexity is a major feature of ovarian tumours in estimating the risk of malignancy.10 So-called ‘simple’ ovarian cysts are unilocular with no irregularities. As long
as these simple cysts are small (less than 3 cm) the risk of being malignant is low.6
In contrast, the term ‘complex’ cyst has been introduced to describe multiloculated
or multicystic tumours with or without papillary projections and solid components.
A loculated cyst is characterized by septa, which create compartments within a single cyst, whereas in multicystic tumours separate cysts exist apart from each other.
Papillary projections originating from cyst wall or septa must be interpreted
as localized epithelial overgrowth and strongly correlate with an increased risk of
malignancy.
ties and solid tumour components but the absence of detectable blood flow in a
small papillary projection should not influence clinical decisions unless the differential diagnosis of adherent fibrin or blood clots has to be excluded.
As a rule, the likelihood of malignancy increases with increasing complexity of an
ovarian tumour and this is true especially for the finding of papillary projections.
5
Colour Doppler can identify blood vessels within papillary irregulari-
CYST WALL AND SEPTAL WALL THICKNESS
The significance of cyst wall and septal wall thickness in evaluating ovarian tumours
has been subject to debate. Thin and smooth cyst walls more likely correlate with
benign conditions whereas thick and irregular walls are preferentially found in
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malignant neoplasms.12 However, there are inherent methodological difficulties as
to how to standardize the measurement and how to define a cut-off value when a
marked overlap of false-positive and false-negative results can be expected. Certain
benign cysts such as endometriomas and benign teratomas frequently accompany
thick walls or septa whereas on the other hand, early stages of ovarian cancer may
have rather thin walls. Therefore, this criterion should not be overestimated and
should be interpreted in correlation with other ultrasound findings.
ECHO-DENSE FOCI AND ACOUSTIC SHADOWING
Echo-dense foci are defined as highly reflective areas that appear almost white on greyscale ultrasound. Such foci represent calcified structures within the tissue, but also
the characteristic finding of teeth within dermoid cysts. Behind these highly reflective
areas, acoustic shadowing can usually be described. However, gas-filled bowel also is
highly reflective on ultrasound and misinterpretation may occur. Although the presence of echo-dense foci and acoustic shadowing within an ovarian tumour is highly
indicative of cystic teratomas, these phenomena do not exclude malignancy.
Ultrasound in obstetrics and gynaecology
ECHOGENICITY
The echogenicity of an ovarian tumour depends on the density of a lesion. Serous fluid
with water-like density is virtually anechoic. On grey-scale ultrasound this anechoic
fluid appears black whereas the increased density of mucinous fluid is described
as hypoechoic with a homogeneous grey appearance on ultrasound. Diluted cells
within the cyst fluid also enhance density and the sonographic image of tumours
containing blood or pus is therefore hypoechoic as well. Endometriomas typically
are homogeneously hypoechoic tumours and the echogenicity of these cysts is often
compared with a ‘ground-glass’ appearance (Fig. 18.1). Solid components within an
ovarian tumour tend to be rather hyperechoic and appear inhomogeneous.
The significance of the relative echogenicity of adnexal masses has been investigated and the risk of malignancy was estimated as low in anechoic lesions and vice
versa in hyperechoic tumours.13 However, according to our own results, echogenicity alone does not predict malignancy.16 Differences in echogenicity may facilitate differential diagnosis, but far more important is the differentiation between
fluid and solid components. The description of a complex tumour with solid elements that appear inhomogeneous and hyperechoic on grey-scale ultrasound is
highly suspicious of malignancy. This is true not because of the hyperechoic areas
per se but because these hyperechoic areas are solid. In contrast, differentiation
of anechoic versus hypoechoic cyst fluid alone does not alter clinical decisions
unless additional information is available.
9
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MORPHOLOGY SCORING SYSTEMS
Since the introduction of ultrasound, different scoring systems have been created in an attempt to estimate the risk of malignancy of a lesion. The first scoring