Munasarjat ja sivuelinten poikkeavat löydökset

Munasarjat ja sivuelinten poikkeavat löydökset Maija-­‐Rii6a Ordén, LT, naistentau<en ja synnytysten sekä perinatologian erikoislääkäri, KYS SGY Presymposium 25.11.2015 Ovario -­‐ adnex •  Ovario ja tuba •  Verisuonet (aneurysmat/pseudoaneurysmat), ligamen<t (intraligamentäärinen myoma), sidekudos •  Suoli (diver<kuliiP, appendisiiP, tuumorit) •  Retroperitoneum (imusolmukkeet) •  Metastaasit (rinta, vatsalaukku, lymfooma) •  Lan<omunuainen Tutkimustekniikka •  SystemaaPnen (laidasta laitaan) –  Sagi6aalises<: rakko+uretra-­‐fossa Douglas-­‐kohtu Rektovaginaalinen septum, rectum –  Poiki6ain: kohtu ja adneksit •  Liikuta – paina anturilla forniksiin ja toisella kädellä liikuta suolia ja paina ovariot alas –  Kiinnikkeet (kohtu – suolet – ovario) –  Ovariotuumorin rajautuminen (dermoidi) •  Huomioi aristus (etu UÄ vs CT/MRI) Adnextuumori • 
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Sa6umalöydös vs oireisen tutkiminen Transvaginaalinen UÄ (transrektaalinen) Transabdominaalinen (kookas tuumori) Benigni – borderline – maligni Tarvitseeko leikata? Missä leikataan – kuka leikkaa – miten leikataan? MaligniteePriski – pitääkö leikata esim raskauden aikana Ovariokysta/tuumori
•  Tyttösikiöllä (istukan hormonit)
•  Ennen murrosikää neoplastisia
•  Fertiili-iässä
–  Toiminnalliset
–  Tulehdukselliset
–  Kasvaimet
–  Raskauteen liittyvät
•  Postmenopaussissa
–  Kasvaimet
–  Kysta 2,5-18%:lla
MaligniteePriski • 
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Ennen menarkea ja menopaussin jälkeen UÄ:ssä kompleksi tai solidi tuumori Syöpäsuku Aiempi sairaste6u syöpä (rinta, ventrikkeli) Ascites •  Premenopaussissa 6-­‐11% •  Postmenopaussissa 29-­‐35% Munasarjakasvaimet
•  ei-neoplastiset
–  follikkelikysta
–  keltarauhaskysta
–  parovariaalikysta
•  neoplastiset
–  epiteelikasvaimet
–  Stroomasolukasvaimet
–  itusolukasvaimet
Adnextuumori: benigni / maligni • 
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koko
lokeroisuus
papillit
solidit osat
molemminpuolisuus
ascites
verisuonitus
Doppler-tutkimukset
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suonia on / ei
suonten määrä / kulku
nekroottiset alueet
(virtausmittaukset
–  PI < 1.0
–  RI < 0.4
–  PSV > 20 cm/s
–  TAMXV > 10 cm/s)
0.94 (0.83)
1.0 (0.9)
0.062 (0.053)
24.8 (17.6)
103.6 (53.6)
14.4 (22.2)
45.6 (60.8)
2.75 (2.08)
2.8 (2.0)
0.19 (0.13)
76.6 (27.7)
190.4 (72.0)
103.8 (86.4)
193.7 (168.2)
1.35 (1.82)
1.4 (1.8)
0.07 (0.09)
78.1 (27.0)
185.9 (46.3)
45.6 (56.0)
116.5 (180.7)
R
tensity (dB)
ise in intensity (%)
(dB/sec)
ec)
ec)
B $ sec)
B $ sec)
".001
".001
.001
".001
".001
".001
".001
Figure 1. Scheme of a recorded time-i
DCE 1 and 2 and areas 1 and 2.
UÄ-­‐varjoainetutkimus Numbers are the means. Numbers in parentheses are the SDs.
es were calculated for benign versus malignant masses.
Figure 3. Representative time-intensity curves for one benign and
one malignant ovarian tumor.
nostic time-intensity curve with a
entifiable start and peak was oball participants (Fig 3). Mean val-
time-intensity curves, both the baseline
Figure 2. Serous cystadenocarcinoma of the
and maximum power Doppler intensities,
ovary. Transvaginal power Doppler US scans of
Ordén et al. Radiology 2003 as well as the absolute and relative
in- (A)
the tumor
before and (B) after administra-
ev
m
te
gr
C
w
an
pr
da
(R
of
tu
of
tis
ev
(ie
bl
be
co
la
ei
no
re
Ovario
Ovariotuumori
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Yksilokeroinen, ei solideja osia
Yksilokeroinen ja solideja osia
Monilokeroinen, ei solideja osia
Monilokeroinen ja solideja osia
Solidi tuumori
Granberg Gyn Oncol 1989
Timmerman (IOTA) UOG 2000
Interna<onal Ovarian Tumor Analysis IOTA 2000 IOTA 2000 IOTA 2000 Neste Fossa Douglasissa
Sagi6aalikuva, suurin AP-­‐mi6a Simple US-­‐based rules (IOTA) 2008 M-­‐rules (vii,aa maligniin) 1. epäsäännöllinen solidi 2. Ascites 3. Vähintään 4 papillia 4. Epäsäänn mul<lokulaarinen solidi tuumori ≥ 100 mm 5. Runsas verisuonitus (color score 4) B-­‐rules (vii,aa benigniin) 1.  Yksilokeroinen 2.  Solidi osa < 7mm 3.  Akus<nen katve 4.  Sileäseinäinen mul<lokulaarinen tuumori < 100mm 5.  Ei verisuonia (color score 1) Vielä epäselvä -­‐> •  UÄ exper<lle arvioon tai LR1 (12)/LR2 (6) analyysi – 
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Ikä (v) Ascites on/ei Suonia papillassa on/ei Suurin solidi osa (mm) Epäsäänn kystan seinät on/ei Akus<set katveet on/ei Suvussa munasarjasyöpää on/ei Hormonihoito on/ei Tuumorin max mi6a (mm) Kipu tutki6aessa on/ei Solidi tuumori on/ei Color score (1-­‐4) h6p://gin-­‐onc-­‐calculators.com/iota.php ADNEX Assessment of Different NEoplasias in the adneXa •  Benigni / borderline /stage I / stage II-­‐IV ca /
secondary metasta<c cancer •  Ikä + CA-­‐125 + sairaala (onkol vs muu) sekä 6 UÄ parametria (CA-­‐125 ei väl6ämätön) •  www.iotagroup.org/adnexmodel Van Calster et al 2015 IOTA - ADNEX model
1.
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9.
Age of the patient at examination (years)
Oncology center (referral center for gyn-oncol)?
Maximal diameter of the lesion (mm)
Maximal diameter of the largest solid part (mm)
More than 10 locules?
Number of papillations (papillary projections)
Acoustic shadows present?
Ascites (fluid outside pelvis) present?
Serum CA-125 (U/ml)
calculate
Clear
Additional information is given when moving the mouse pointer over the variable names.
Contact Ben Van Calster in case of problems ([email protected]).
Consult Timmerman et al (Ultrasound in Obstetrics and Gynecology 2000; 16:500-505) for information
on the terms and definitions used for standardized ultrasound examination and data collection.
Gynecologic Imaging Repor<ng and Data System (GI-­‐RADS) 1.  GI-­‐RADS 1: varmas< benigni – 
Normaali ovario 2.  GI-­‐RADS 2: hyvin todennäköises< benigni – 
Toiminnallinen (follikkeli, corpus luteum, hemorraginen kysta) 3.  GI-­‐RADS 3: todennäköises< benigni – 
Endometriooma, dermoidi, simplex cysta, hydrosalpinx, parov kysta, peritoneaal pseudokysta, varrellinen myoma, PID 4.  GI-­‐RADS 4: todennäköises< maligni –  1-­‐2 malignia piirre6ä 5.  GI-­‐RADS 5: hyvin todennäköises< maligni – 
Vähint 3 malignia piirre6ä Amor et al. J Ultrasound Med 2009 RMI (risk of malignancy index)
Tingulstad 1996
RMI = CA 125 x MP x UÄ
MP-pisteet: 1p = premenopaussi
4p = postmenopaussi
UÄ-pisteet: 1p = simplex kysta tai 1 seuraavista
4p = 2 seuraavista
monilokeroinen
kiinteät alueet, papillit
ascites
molemminpuolinen
RMI > 200 malignisuspekti
CA 125 koholla
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munasarjasyöpä
endometrioosi
raskaus
PID
myomat
Kystinen adnex tuumori
l toiminnallinen
l seroosi ovariokysta
l sactosalpinx
l endometriooma
l parovarielli kysta
l kystadenooma
l kystinen teratooma
Kompeksi adnex tuumori
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kystadenooma
pyosalpinx
tubo-ovarielli abskessi
endometrioosi
kystinen teratooma
ovariokarsinooma
kohdunulkoinen raskaus
Solidi adnextuumori
l kohdun myoma
l ovariofibrooma
l fibrotekooma, tekooma
l ovariokarsinooma
Cysta simplex
Cysta parovarialis
ovary
Cervix rauhaset
fundus
bladder
histologic diagnoses were obtained. In those
cation are shown in Table 2.
Endometriooma Figure 2. Transvaginal sonogram of an adnexal mass diagnosed
as an endometriotic cyst and classified as GI-RADS 3. Surgery
was performed, and the diagnosis was confirmed on
histopathologic analysis.
J Ultrasound Med 2009; 28:285–291
Figure 3. Transvaginal sonogram of an
as hydrosalpinx and classified as GI-RA
formed, and the diagnosis was confirm
analysis.
deciduaalinen reaktio
raskausaikana
Figure 13
Mikä ilmiö?
emorrhagic cyst in a 37oppler transvaginal US scan
Figure 13: Endometrioma in a 36-year-old
woman. Transvaginal US scan reveals a compl
Endometriooma, decidualisaa<o raskausaikana Figure 4 Gray-scale (a) and color Doppler (b) ultrasound images of a decidualized endometrioma incorrectly suggested by the original
ultrasound examiner to be a borderline ovarian tumor. It appeared as a unilocular-solid cyst with ground-glass echogenicity and several
large vascularized papillary projections. Note the rounded shape of the papillary projections (this case has been described in a report by
Fruscella et al.8 ).
Figure 5 Gray-scale (a) and power Doppler (b) ultrasound images of a decidualized endometrioma with rounded vascularized papillary
projections with smooth contour within an ovarian cyst with ground-glass echogenicity of the cyst fluid. Two experienced ultrasound
examiners found this pattern to be typical of decidualized endometriomas.
Hemorraginen kysta Hemorraginen kysta Figure 12
Fi
flow was detected within this solid area, and the mass was classified as GI-RADS 4. Surgery was performed, and histopathologic analysis revealed cystadenofibroma.
Cystadenofibroma Seroosi cystadenocarcinoma Figure 1
F
Figure 2
Dermoidi Figur
Hemorraginen kysta Figure 3
howing a
walls. No
was clastopatho-
a solid area with irregular contours and blood flow within it.
The mass was classified as GI-RADS 5. Surgery was performed,
and histopathologic analysis revealed primary serous ovarian
carcinoma.
Seroosi cystadenocarcinoma Dermoidi
Dermoidi kysta
Dermoidi
Struma ovari Fibroma/fibrotekooma Ovarian fibroma and fibrothecoma
194
193
Paladini et al.
Paladini et al. UOG 2009 Figure 3 Ultrasound imagesFigure
of fibroma/fibrothecoma.
Usingofpattern
recognition (Table Using
2, Patterns
2 and
3), these tumors
are2,described
as these tumors are described as round,
2 Ultrasound images
fibroma/fibrothecoma.
pattern
recognition
(Table
Pattern 1),
round, oval or lobulated solid
tumors,
without solid
stripy tumors
shadowswith
and regular
with regular
oror
irregular
internal
echogenicity
(a,b), or such
oval
or lobulated
(a–c)
irregular
(d) internal
echogenicity,
withdensity
stripythat
shadows (arrows) and with no cystic
evaluation of internal echogenicity is very difficult (c,d). These patterns were seen in 27% (12/44) of the fibromas/fibrothecomas in our series.
Seroosi kystadenoma Musiini kystadenooma
Cystadenooma
Kystadenooma
Ovariokarsinooma
Savelli ja Cacciatore Seroosi cystadenokarsinooma
Savelli ja Cacciatore Musiini kystadenokarsinooma Savelli & Cacciatore Gravidan o
variot Figure 22
tum
cau
mo
man
of o
to d
com
not
a te
only
sis
Hyperreactio luteinalis, theca
luteiinikystat
•  ei-neoplastinen thecaluteiinikystien
suureneminen
•  hCG
•  monisikiöraskaus, trofoblastitauti, OHSS,
sikiöhydrops
•  molemminpuoleinen, monilokeroinen
•  voi liittyä ascites, pleuraneste,
hemokonsentraatio
•  voi tuottaa androgeeneja
•  häviää raskauden jälkeen
Gravidan ovariot
dx (6cm)
sin (7cm)
Luteooma
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hCG à ovariostrooman hypertrofia
solidi
usein molemminpuolinen, multinodulaarinen
keskimäärin 6cm
enemmän mustaihoisilla
PCOS potilailla
25%:ssa tuottaa androgeeneja
häviää raskauden jälkeen
konservatiivinen linja
Gynandroblastoma Ren polycysticus
ovario
Varrellinen myoma
kanta
liikuta
etsi ovariot
Myoma degeneraatio
M
corpus
E
cervix
kalkki
nekroosi
Ovariotorsio
kiertynyt suonipedikkeli
”whirlpool sign”
ovarian
rsion.
examirsion13 :
e ovars in the
he ovarnt when
xal torr initial
iling of
ts with
having
al flow
of this
er findseverity
o were
ment of
95 and
spected
els was
Doppler
s were
ypically
on the
RF 400
al and
d flow
well as
Ovariotorsio 209
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Figure 1 Coiling of ovarian blood vessels in a case with preserved
arterial and venous blood flow.
Kliininen kuva Äkillinen kipu Suurentunut ovario Ovarion ödeema 1.  Kiertynyt suonipedikkeli 2.  Venavk ei näy 3.  Arteriavk ei näy Munatorvien tulehdusmuutokset
•  epätäydelliset väliseinät
•  ”cogwheel sign” (hammasratas)
akuutissa; paksut seinämät (>5mm)
•  ”beads-on-a-string sign” (helminauha)
kroonisessa; ohuet seinämät
•  tubo-ovarielli kompleksi / abskessi
•  peritoneaaliset inkluusiokystat
Munatorvi
normaali
sacto
Salpingitis
chronica
acuta
Sactosalpinx
S-o-itis acuta
Peritoneaaliset inkluusiokystat Figure 20
Figure 20: Peritoneal inclusion cyst in a 29-year-old woman. (a) Transverse transabdominal US scan
Suolisto
kaasu
RESULTS
A positive diagnosis of acute appendicitis by ultrasound
was made in 68 patients. Of these, only 38 patients
met all the inclusion criteria and they comprised the
AppendisiiP a
b
adenocarcinoma, mucocele and
appearing appendix on laparo
removed. In these four cases the
of acute appendicitis was suspect
TAS and TVS.
DISCUSSION
TAS has been widely used in
appendicitis, having a detecti
90%6,9,19,20 . The diagnosis of ac
has, however, been described on
reports14 – 16 . Our study demon
employment of TVS with TAS
diagnosis of acute appendicitis
quarter of patients. Our study
inclusion criteria, and it also r
for investigation amongst the sur
and the fact that each techn
for the examiner, since he perf
examinations. Our study did n
specificity and positive and neg
However, the results of our study
a contribution of TVS in addition
of acute appendicitis.
The most important informatio
strictly selected group (patients w
TVS combined with TAS can de
Table 1 Clinical data of the 38 patient
Range
Age (years)
Temperature (◦ C)
White blood cell count
14–61
36–39
4400–18
Appendicitis
Cacciatore & Molander Corpus luteum Figure 10
Figure 10: Corpus luteum in a 35-year-old woman. (a) Transvaginal US scan demonstrates a typical ap-
Granuloosasolutuumori
Semimaligni ovariotuumori
Ovariokarsinooma
Tuumori vai ei?
ei, vaan hematooma
Ovariokarsinooma
Savelli ja Cacciatore Ovario ca
maksametastaasi
Ovariokarsinooma
Peritoneaalikarsinoosi
Metastaasi ovariossa 510
Testa et al.
Figure 4 Color Doppler ultrasound images of (a) an ovarian metastasis derived from colon cancer with vessels within the septa (color score
2) and (b) an ovarian metastasis derived from gastric cancer (color score 3).
Colonca ovarian metastases from colorectal cancer were cystic on
computed
tomography, while
those derived
Mul<lokulaarinen suolisto-­‐ ja from stomach
cancer appeared to be mostly solid. Our results also
sappi<eca:ssa agree
fairly well with descriptions made of metastatic
tumors in the ovaries in pathology textbooks7 – 14 , except
Ventrikkelica cancer is associated with a favorable outcome3 . It has also
been suggested that surgical removal of pelvic metastases
Solidi lymfoomassa, rinta-­‐, kohtu-­‐ ja derived from breast cancer improves survival, provided
entr ca:ssa are detected more than 5 years after
that vthe
metastases
the primary tumor was diagnosed and provided that
ess-evident
n between the
Dysgerminooma Guerriero et al.
Tubo-­‐ovarielli abskessi Tutkiminen
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palpaatiolöydös/kipu/anamneesi
UÄ: transvag. / transabd.
aina kliininen tutkiminen + UÄ
Doppler, mikäli solideja osia
CA 125
–  syöpäriski
–  postmenopausaaliset
Kirjallisuu6a • 
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Granberg S et al. Macroscopic characteriza<on of ovarian tumors and the rela<on to the histological diagnosis: criteria to be used for ultrasound evalua<on. Gynecol Oncol 1989;35:139-­‐144 Timmerman D et al. Terms, defini<ons and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from thwe Interna<onal Ovarion Tumor Analysis (IOTA) group. Ultrasound Obstet Gynecol 2000;16:500-­‐505 Timmerman D et al. Simple ultrasound-­‐based rules for the diagnosis of ovarian cancer. UOG 2008;31:681-­‐690 Timmerman D et al. Simple ultrasound rules to dis<nguish between benign and malignant adnexal masses before surgery: prospec<ve valida<on by IOTA goup. BMJ 2010;341:c6839 Timmerman D et al. Ovarian cancer predic<on in adnexal masses using ultrasound-­‐based logis<uc regression models: a temporal and external valida<on study by the IOTA group. UOG 2010;36:226-­‐234 Ameye L et al. Clinically oriented three-­‐step strategy for assessment of adnexal pathology. UOG 2012;40:582-­‐591 Van Calster B et al. Prac<cal guidance for applying the ADNEX model from the IOTA group to discriminate between different subtypes of adnexal tumors. Facts Views Vis Obgyn 2015;7:32-­‐41 Levine D et al. Management of asymptoma<c ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 2010;256:943-­‐954 Il Jung S. Ultrasonography of ovarian masses using pa6ern recogni<on approach. Ultrasonography 2015;34:173-­‐182 Brown et al. Adnexal masses: US characteriza<on and repor<ng. Radiology 2010;254:342-­‐354 Amor F et al. Gynecologic imaging repor<ng and data system. A new proposal for classifying adnexal masses on the basis of sonographic findings. J Ultrasound Med 2009;28:285-­‐291. Kirjallisuu6a 2 • 
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Imaging og gynecolocigal disease (1): ultrasound features of metastases in the ovaries differ depending on the origin of the primary tumor. UOG 2007;29:505-­‐511 Imaging of gynecological disease (2): clinical and ultrasound characteris<cs of Sertoli call tumors, Sertoli-­‐
Leydic cell tumors and Leydic cell tumors. Demidov VN et al UOG 2008;31:85-­‐91 Imaging of gynecological disease (3): clinical and ultrasound characteris<cs of granulosa cell tumors of the ovary. Van Holsbeke et al. UOG 2008;31:450-­‐6 Imaging of gynecological disease (4): clinical and ultsasound characteris<cs of struma ovari. Savelli et al 2008;32:210-­‐9 Imaging of gynecological disease (5): clinical and ultrasound characteris<cs in fibroma and fibrothecoma of the ovary. Paladini D et al UOG 2009;34:188-­‐95 Imaging of gynecological disease (6): clinical and ultrasound characteris<cs of ovarian dysgerminoma. Guerriero S et al UOG 2011;37:596-­‐602 Imaging of gynecological disease (7): clinical and ultrasound features of Brenner tumors of the ovary. Dierickx I et al UOG 2012;40:706-­‐713 Imaging of gynecological disease (8): ultrasound characteris<cs of recurrent borderline ovarian tumors. Franchi D et al UOG 2013;41:452-­‐458 Imaging of gynecological disease (9): clinical and ultrasound characteris<cs of tubal cancer. Ludovisi M et al 2014;43:328-­‐35 Imaging of gynecological disease (10): clinical and ultrasound characteris<cs of decidualized endometriomas surgically removed during pregnancy. Mascilini F et al UOG 2014;44:354-­‐60 ISUOG Educa<onal Series: Gynecological and early pregnancy ultrasound. Editors: Luca Savelli/Bruno Cacciatore