docLa diagnostica ecografica delle masse ovariche
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La diagnostica ecografica delle masse ovariche
La diagnostica ecografica delle masse ovariche Francesco P.G. Leone Clinica Ostetrica e Ginecologica Direttore Prof. Irene Cetin Dipartimento di Scienze Cliniche L. Sacco Università degli Studi di Milano [email protected] Metodologia Definizione massa ovarica Screening Ca Ovaio Valutazione pre-operatoria Endometriosi Teratoma Ca Ovaio [email protected] Metodologia Definizione massa ovarica Screening Ca Ovaio Valutazione pre-operatoria Endometriosi Teratoma Ca Ovaio [email protected] anamnesi visita [email protected] [email protected] [email protected] [email protected] Semeiotica ginecologica Courtesy of P.Catapano [email protected] [email protected] EcoTV [email protected] TVS: L’alta frequenza … high resolution wideband (3-9 MHz) endocavitary probe high accuracy [email protected] Semeiotica ecografica ginecologica Courtesy of P. Catapano [email protected] Metodologia dello studio ecografico della pelvi femminile Il primo tempo di esecuzione dell’esame prevede una profondità e una focalizzazione utile a visualizzare tutta la pelvi [email protected] Metodologia dello studio ecografico della pelvi femminile Il secondo tempo è invece organ oriented e la esecuzione dell’esame prevede una profondità e una focalizzazione utile a visualizzare ogni singolo organo o lesione [email protected] Esame organ oriented: ovaio - mobilità e dolenzia ….possibilità di eseguire con enorme semplicità manovre di mobilizzazione degli organi e di identificazione dei punti di massima dolenzia…. [email protected] Metodologia dello studio ecografico della pelvi femminile Il secondo tempo è invece organ oriented e la esecuzione dell’esame prevede una profondità e una focalizzazione utile a visualizzare ogni singolo organo o lesione [email protected] Esame organ oriented: sigma-retto La valutazione del sigma-retto… [email protected] Esame organ oriented: peritoneo La valutazione del peritoneo viscerale… aderenze (“spider in a web”, “flapping sail”) dolorabilità “push&pull manoeuvres” [email protected] [email protected] [email protected] [email protected] Strumentazione e tecnologia: sonovaginografia evidenzia noduli endometriosici del setto retto-vaginale [email protected] [email protected] J Ultrasound Med Feasibility of performing a virtual patient examination using three-dimensional ultrasonographic data acquired at remote locations. NelsonTR et al, 2001 Telemedicine (US documentation, storage, networking) and tertiary consultation (second opinion). [email protected] 2mm slices [email protected] Metodologia Definizione massa ovarica Screening Ca Ovaio Valutazione pre-operatoria Endometriosi Teratoma Ca Ovaio [email protected] Analisi macroscopica [email protected] Analisi microscopica [email protected] [email protected] Morphologic Classification (n=300) Granberg 1989 (after modification in Leuven) Type of tumor N Malign. % 1.Unilocular cyst 85 0 0 2.Unilocular solid 34 16 47 3.Multilocular cyst 60 1 2 4.Multilocular solid 70 35 50 5.Solid tumor 51 31 61 (Ultrasound Obstet [email protected] Gynecol 2000; 16: 395-8) Subjective assessment (n=300) 100 A, B (= 5,00010,000 TVS) 90 80 Sensitivity 70 D, E, F (= 200300 TVS) 60 Accuracy D,E,F= 82-86% C = 89% A,B = 92% 50 C (= 1,000 TVS) 40 30 20 10 0 False positive rate 0 20 40 60 80 [email protected] 100 Timmerman „99 Logistic regression model Papillarities >3mm (0,1) Color score (1,2,3,4) ~Probability of cancer Menopause (0,1) CA 125 (1 - 31 090) [email protected] “Consensus opinion from the international ovarian tumor analysis (IOTA) group” Adnexal lesion Part of an ovary or an adnexal mass that is judged from an assessment of ultrasound images to be inconsistent with normal physiologic function Qualitative assessment of morphology Unilocular cyst Multilocular cyst Unilocular-solid cyst Multilocular-solid cyst Solid [email protected] Cystic contents Anechoic Low-level echogenicity Ground glassappearance Haemorrhagic Mixed [email protected] Measurement and quantitative assessment of morphology • Lesion The size of both ovaries and the lesions are measured as the largest three diameters in two perpendicular planes. • Septum The thickness is measured where it appears to be at its widest • Papillary projection The largest projection is measured in height and base. The number of separate papillary projections and whether blood flow can be detected. • 1 : no flow Color score • 2 : minimal flow • 3 : rather strong flow • 4 : very strong flow Color score 1 : no flow 2 : minimal flow 3 : rather strong flow 4 : very strong flow [email protected] Multicenter prospective studies IOTA (International ovarian tumor analysis) Prospective multicenter trial Pre-operative characterization of adnexal masses Based on artificial intelligence Aim: to collect 1,000 patients 1,275 completed patient data [email protected] [email protected] % of malignancy IOTA 2005 Unilocular cyst 0.5-1% Multilocular cyst 10% Unilocular-solid cyst 37% Multilocular-solid cyst 43% Solid 65% [email protected] Sensitivity 95%, specificity of 91%. LR+ = 10.45 LR− = 0.06. The rules were applicable in 76% of the tumors. [email protected] [email protected] [email protected] Nuove strategie? [email protected] Mezzi di contrasto endovascolari Endometrioma [email protected] Ecografia transvaginale 3-D Rendering [email protected] Ecografia transvaginale 3-D Color Rendering Branching of vessels [email protected] Ecografia transvaginale 3-D VOCAL [email protected] Metodologia Definizione massa ovarica Screening Ca Ovaio Valutazione pre-operatoria Endometriosi Teratoma Ca Ovaio [email protected] [email protected] http://www.pnlg.it/ [email protected] [email protected] [email protected] [email protected] Metodologia Definizione massa ovarica Screening Ca Ovaio Valutazione pre-operatoria Endometriosi Teratoma Ca Ovaio [email protected] “Il primo grande amore non dura tutta la vita ma la cambia per sempre.” Claudio Baglioni [email protected] Valutazione ombelicale [email protected] Valutazione pelvica [email protected] Metodologia Definizione massa ovarica Screening Ca Ovaio Valutazione pre-operatoria Endometriosi Teratoma Ca Ovaio [email protected] [email protected] Endometriosi ovarica [email protected] International Ovarian Tumour Analysis (IOTA) Sonographic assessment of morphology: qualitative classification typical [email protected] International Ovarian Tumour Analysis (IOTA) Sonographic assessment of morphology: cystic contents typical ::::::: ::::::: ::::::: ::::::: Anechoic Low level Ground glass Hemorrhagic Mixed [email protected] Typical endometrioma Unilocular cyst with regular internal wall Ground glass appearance (homogeneously dispersed echogenic) cystic [email protected] Typical endometrioma Blood flow score 1-2 (no or only minimal flow) [email protected] International Ovarian Tumour Analysis (IOTA) Sonographic assessment of morphology: cystic contents atypical ::::::: ::::::: ::::::: ::::::: Anechoic Low level Ground glass Hemorrhagic Mixed [email protected] Atypical endometrioma Unilocular or multilocular cyst with irregular internal wall (hyperechoic foci), with complete or incomplete septum Anechoic or low-level (homogeneous low level echogenic) or mixed cystic content Blood flow score 3-4 (moderate or high flow) [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Endometriosi posteriore [email protected] Endometriosi posteriore: legamenti utero-sacrali legamento utero-sacrale dx [email protected] legamento utero-sacrale dx sigma-retto Endometriosi posteriore: sigma-retto [email protected] Endometriosi posteriore: sigma-retto [email protected] [email protected] Intestinal endometriosis @ 3DTVS-VCI [email protected] Intestinal endometriosis @ LPS [email protected] Intestinal endometriosis @ 3DTVS-VCI [email protected] Intestinal endometriosis @ LPS [email protected] Intestinal endometriosis @ 3DTVS-VCI [email protected] Intestinal endometriosis @ 3DTVS-VCI “pulling-out sign” Courtesy of Valentino Remorgida & Simone Ferrero [email protected] [email protected] [email protected] Bromley B. et al., J Ultrasound Med 2000 a mottled inhomogeneous myometrial texture globular appearing uterus small cystic spaces within the myometrium a "shaggy" indistinct endometrial stripe [email protected] … diffuse adenomyosis Reinhold C. et al., Radiology 1995 … focal adenomyosis cystic spaces within the myometrium persistent, irregular, slightly dilated radial uterine vessels increased microvessel density in adenomyosis uteri Perrot N. et al., UOG 2001 Schindl M.et al., [email protected] Fertil Steril 2001 [email protected] ISUOG 2006 OP17.08 - Sonographic based triage for symptomatic deep infiltrating endometriosis treated with a levonorgestrel-releasing intrauterine system. F.P.G. Leone, C. Marciante, T. Bignardi, and E. Ferrazzi. Dept. Obstetrics and Gynecology, DSC L. Sacco, Via GB Grassi 74, University of Milan, Italy - [email protected] Objective: To report three cases of severely symptomatic deep infiltrating endometriosis managed by transvaginal sonography (TVS) and by a levonorgestrel-releasing intrauterine system (LNG-IUS). Design: CASE 1. A 34 years-old woman was admitted for severe dysmenorrhea and dyspareunia, menorrhagia and severe anemia. The patient was previously unsuccessfully treated with tranexamic acid, progestins, danazol, GnRH analogues and endometrial resection. TVS showed an enlarged uterus, with inhomogeneous and thickened posterior myometrium, with focal honeycomb lesions highly and irregularly vascularized, typical for deep adenomyosis (Figure 1). A LNG-IUS was inserted. At 48 months follow-up, the patient was free of symptoms. CASE 2. A 38-year-old woman presented with cyclic worsening dysmenorrhea, deep dyspareunia and dyschezia during the last year. TVS showed normal uterus and ovaries, and on the left, an inhomogeneous hypoechoic lesion which infiltrate the antimesenteric sigmoid wall, painful at push-and-pull manoeuvres, highly suspicious for sigmoid endometriosis (Figure 2). Barium enema confirmed the TVS image. By the imaging diagnosis of endometriosis, a LNG-IUS was placed. At 21 months follow-up, the patients referred dramatically improvement of symptoms with pain only evoked by deep pelvic exam. CASE 3. A 41 years-old woman was referred with a recent history of severe dysmenorrhea and dysuria. TVS showed an inhomogeneous polypoid 3cm lesion involving the vesical base and vesicouterine septum (Figure 3). Cystoscopy confirmed a polypoid extramucosal lesion close to ureterovesical junction. A LNG-IUS was inserted. At 8 months follow-up, the patient persisted free of symptoms. 8Fr 14Fr 1 a 2 b Conclusion: Accurate diagnosis by TVS of deep infiltrating endometriosis may permit a conservative medical treatment based on LNG-IUS. [email protected] 3 Metodologia Definizione massa ovarica Screening Ca Ovaio Valutazione pre-operatoria Endometriosi Teratoma Ca Ovaio [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Metodologia Definizione massa ovarica Screening Ca Ovaio Valutazione pre-operatoria Endometriosi Teratoma Ca Ovaio [email protected] [email protected] [email protected] [email protected] [email protected]
