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Shaaban Rogers | Olpin

| Menias

Rezvani | El Sayed

THIRD EDITION

Akram M. Shaaban, MBBCh

Professor

Department of Radiology and Imaging Sciences

University of Utah

Salt Lake City, Utah

Douglas Rogers, MD

Assistant Professor

Department of Radiology and Imaging Sciences

University of Utah

Salt Lake City, Utah

Jeffrey Dee Olpin, MD

Professor of Radiology, Abdominal Imaging Division

Department of Radiology and Imaging Sciences

University of Utah

Salt Lake City, Utah

Maryam Rezvani, MD

Associate Professor of Radiology

Department of Radiology

University of Utah School of Medicine

Salt Lake City, Utah

Rania Farouk El Sayed, MD, PhD

Assistant Professor of Radiology

Head of Cairo University MRI Pelvic Floor Center of Excellency and Research

Lab Unit

Department of Radiology

Cairo University Hospitals

Cairo, Egypt

Christine O. Menias, MD

Professor of Radiology

Mayo Clinic School of Medicine

Scottsdale, Arizona

Adjunct Professor of Radiology

Washington University School of Medicine

St. Louis, Missouri

Elsevier

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

DIAGNOSTIC IMAGING: GYNECOLOGY, THIRD EDITION

ISBN: 978-0-323-79692-7

Inkling: 978-0-323-79693-4

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous edition copyrighted 2015.

Library of Congress Control Number: 2021943237

Printed in Canada by Friesens, Altona, Manitoba, Canada

Dedications

To my parents, who taught me the value of perseverance and hard work.

To my wife, Inji, my son, Karim, and my daughters, May and Jena, the jewels of my life, thanks for your understanding and tremendous support.

To all my residents and fellows, whose challenging questions made me a better radiologist.

AMS

To the people who make academic radiology worthwhile, including my mentors, who believe in the merit of my work and continue to teach me, and the residents with passion, who make teaching fulfilling.

Contributing Author

Refky Nicola, MS, DO

Associate Professor of Radiology

Additional Contributing Authors

Oguz Akin, MD

Nyree Griffin, MD, FRCR

Winnie Hahn, MD

Olga Hatsiopoulou, MD, FRCR

Marcia C. Javitt, MD, FACR

Shephard S. Kosut, MD

Deborah Levine, MD, FACR

Patricia Noël, MD, FRCPC

Caroline Reinhold, MD, MSc

Evis Sala, MD, PhD

Marc S. Tubay, MD

Paula J. Woodward, MD

Preface

We are delighted to present Diagnostic Imaging: Gynecology, third edition, the most comprehensive point-of-care imaging resource for gynecologic disorders. The goal of this book is to take the wide range of wonderfully complex topics related to gynecologic imaging and simplify them into a useful and easy-to-understand reference for caretakers at any level of experience, including trainees, general radiologists, gynecology imaging specialists, and gynecologists. This has been achieved using concise, bulleted text and thoughtful grouping of pertinent disease entities by organ, including uterus, cervix, vagina/vulva, ovary, fallopian tubes, multiorgan disorders, and pelvic floor.

Our passionate team of radiologists has thoroughly updated the text and references from the successful second edition, reflecting recent advances in technology and understanding of pathologic conditions as well as changes to TNM/WHO classifications, FIGO staging, and AJCC prognostic groups. Extensive efforts have been made to revamp the already fabulous image galleries with new, high-quality, instructive cases for every entity. More than 2,300 annotated images (and an additional 840 supplemental digital images) exhibit multimodality correlation between ultrasound, sonohysterography, hysterosalpingography, MR, PET/CT, and gross pathology.

The superb radiologic images we present were only possible because of the fine work of our remarkable sonographers and CT/MR technologists. We are also fortunate to collaborate with Laura Wissler, Lane Bennion, and Richard Coombs, who are the most talented and experienced medical illustrators. They possess a rare combination of profound anatomic knowledge and an ability to generate elegant representations of complex structures. Their contributions allow those who contemplate their illustrations to quickly attain a deeper level of comprehension.

This production was especially efficient because of the cohesive efforts of our team, including the image editors (Lisa Steadman and Jeffrey Marmorstone), text editors (Arthur Gelsinger, Rebecca Bluth, Nina Themann, Terry Ferrell, and Megg Morin), graphic designer (Tom Olson), production editors (Emily Fassett and John Pecorelli), lead editor (Kathryn Watkins), and senior manager (Karen Concannon).

Our team is very proud of this work, and we are sure that this new volume will be a rich and oftenused addition to your practice’s collection of resources.

Akram M. Shaaban, MBBCh

Professor

Department of Radiology and Imaging Sciences

University of Utah

Salt Lake City, Utah

Douglas Rogers, MD

Assistant Professor

Department of Radiology and Imaging Sciences

University of Utah

Salt Lake City, Utah

Acknowledgments

LEAD EDITOR

Kathryn Watkins, BA

LEAD ILLUSTRATOR

Laura C. Wissler, MA

TEXT EDITORS

Arthur G. Gelsinger, MA

Rebecca L. Bluth, BA

Nina Themann, BA

Terry W. Ferrell, MS

Megg Morin, BA

IMAGE EDITORS

Jeffrey J. Marmorstone, BS

Lisa A. M. Steadman, BS

ILLUSTRATIONS

Richard Coombs, MS

Lane R. Bennion, MS

ART DIRECTION AND DESIGN

Tom M. Olson, BA

PRODUCTION EDITORS

Emily C. Fassett, BA

John Pecorelli, BS

SECTION 1: Techniques

SECTION 2: Uterus

SECTION 3: Cervix

SECTION 4: Vagina and Vulva

SECTION 5: Ovary

SECTION 6: Fallopian Tubes

SECTION 7: Multiorgan Disorders

SECTION 8: Pelvic Floor

Shaaban Rogers | Olpin

| Menias

Rezvani | El Sayed

TERMINOLOGY

UltrasoundTechniqueandAnatomy

KEYFACTS

•Ultrasoundisimagingmodalitythattransmitshighfrequencysoundwavesintotissuesandgeneratesimages fromreflectedwaves

•Pelvicsonographycanbeperformedusingnumberof techniques(B-mode,M-mode,Doppler,3D,4D)

PREPROCEDURE

•Transabdominalultrasound(TAUS)isusuallyperformed withfullbladder

•Transvaginalpelvicultrasound(TVUS)isperformedwith emptybladder

PROCEDURE

•Mostpelvicsonographicexaminationsutilizeboth transabdominalandtransvaginaltechniques

○TAUSallowsforlargerfieldofviewwithlowerresolution comparedtoTVUS

(Left)Longitudinal transvaginalultrasound demonstratesnormal appearanceoftheuterus, includingendometriumﬅ, myometriumﬆ,cervix﬇, andcul-de-sac﬈.The endovaginalprobeis positionedwithintheanterior vaginalfornix﬉.By convention,theleftsideofthe imageisanterior,andthe rightisposterior.(Right) Transversetransvaginal ultrasounddemonstrates normalappearanceofthe uterus,includingendometrium ﬅandmyometriumﬆ.

(Left)Longitudinal transabdominalultrasound showstheuterusﬅ,vagina ﬆ,andurinarybladder﬇. Transabdominalultrasound offersalargerfieldofview butlessresolutioncompared totransvaginalultrasound.

(Right)Transvaginal ultrasoundshowsanormal ovaryﬅwithfewsmall folliclesﬆandadjacent bowel﬇.

○TVUSprovideshigh-resolutionimagesofuterus,cervix, andadnexawithconstrainedfieldofviewcomparedto TAUS

•Pelvicultrasoundrequiresdedicatedevaluationand reportingof

○Uterus:Size,contour,positioning,myometrial echotexture/masses

○Endometrium:Thickness,appearance, presence/positioningofIUD

○Adnexa:Ovariansize,presenceofcystic/solidmass, ovarianvascularflow,tubalabnormalities

○Cul-de-sac:Presenceoffluidormass,uterinesliding

•Probesmustbethoroughlycleansedaccordingto manufacturerandlocalinstitutionguidelines

LongitudinalTransvaginalUltrasound TransverseTransvaginalUltrasound

LongitudinalTransabdominalUltrasound OvaryTransvaginalUltrasound

UltrasoundTechniqueandAnatomy

TERMINOLOGY

Abbreviations

•Transabdominalultrasound(TAUS)

•Transvaginalultrasound(TVUS)

•Saline-infusedsonohysterogram(SIS)

Definitions

•Ultrasoundisimagingmodalitythattransmitshighfrequencysoundwavesintotissuesandgeneratesimages fromreflectedwaves

○TAUSprovideslargefieldofview

–Lowerfrequenciesareusedtoallowforgreaterdepth ofview

□Resultsinlowerresolutionimages

–Usefulforlargemasses

–Characterizeslesionsthatareoutofrangeofvaginal probe

–Mid-tolategestationsaregenerallybetterevaluated withTAUS

○TVUSprovideshigherresolutionimagesofuterus,cervix, andadnexa

–Higherfrequenciesallowforhigherresolutionimages butwithconstrainedfieldofview

–Keymodalityforuterine,cervical,andadnexal pathology

–Usefultoevaluateearlypregnancy

•B-mode(grayscale,2Dmode)ultrasound

○Reflectedsoundwavedataisreconstructedtoproduce 2Dgrayscaleimageofplaneoftissue

○Mostcommonlyusedmode

•M-modeultrasound

○Columnoftissueperpendiculartoprobeisinterrogated toevaluateformotion/velocity

○Demonstratesembryonic/fetalcardiacactivityandheart rate

•Dopplerultrasoundusesfrequencyshiftsofreflected soundwavestodetectflowingblood

○ColorDoppler:Flowisassignedcolorbasedondirection offlowandoverlaidonB-modeimages

○PowerDoppler:MeasuresintensityofDopplershift overlaidongrayscaleimage;moresensitivethancolor Dopplerfordetectionofslowflow

○Pulsed-wave(spectral)Doppler:Velocitytracingis generated,allowingforwaveformanalysis

–DuplexDoppler:Pulsed-waveDopplerdisplayedwith grayscaleanatomicimages

–TriplexDoppler:Pulsed-waveDopplerdisplayedwith grayscaleimagesoverlaidwithcolorDoppler

○Superbmicrovascularimaging:Newtechniquewithhigh sensitivityforbloodflowwithinsmalldiameterandslowflowvessels

•3Dultrasound

○Acquiresvolumeofultrasounddatathatcanbe manipulatedatultrasoundmachineoratdedicated workstationtoproducemultiplanarimagesor3D reconstructions

○Canproduceimagesofsimilarorientationandqualityto MR

•4Dultrasound:3Dultrasounddataisacquiredcontinuously overtime

○Allowsgenerationof3Dsonographicmovies

PREPROCEDURE

Indications

•Commonindicationsforpelvicsonographyinclude abnormaluterinebleeding,pelvicpain,contraception

evaluation,pelvicmass,andpregnancy

Contraindications

•TVUSshouldbeavoidedinpatientswithintacthymenor priortohavinghadintercourse

○Transperineal/translabialsonographycanbeperformed whenneeded

○Patientsmaydeclinestudyduetobeinguncomfortable withprocedure

GettingStarted

•Thingstocheck

○FullbladderforTAUS

–Fullbladderactsasacousticwindowfor uterus/adnexa

–Displacessmallbowelfromfieldofview

○EmptybladderforTVUS

–Describeuseoftransvaginalprobetopatient

–Somesonographersprefertohavepatientinsert endovaginal(EV)probe

–Examshouldberelativelypainless

–Ifbladderistoodistended,itmaypushuterusand ovariesoutoffieldofview

○Inwomenofchildbearingage,serumβ-hCGlevelsmay benecessary

○Havechaperone

•Equipmentlist

○Ultrasoundmachine

○Appropriatetransducers

–3.5-7MHzfortransabdominalscans(curvedorsector)

–5-12MHzforEVscans(dedicatedEVprobe)

–7-15MHzforsuperficialtranslabial/transperineal scans(linearprobe)

○Safetyissues

–Thermalandmechanicalindicesareusedasproxies forbioeffectsofultrasound

□Theseshouldbeminimized,particularlywhen imagingembryos

○CommercialprobecoverorcondomtocoverEVprobe forTVUS

–Iflatexallergy,donotuselatexprobecovers

○DedicatedEVprobecleaningsystemandsolution

PROCEDURE

PatientPosition/Location

•Bestprocedureapproach

○TAUS:Supineposition

○TVUS:Lithotomyposition

–Feetinstirrupsifbedisequipped

–Pillowunderbuttockscanbeutilizedifneeded, especiallyifbeddoesnothavestirrups

–Similarpositioningfortranslabialortransperineal examinations

Techniques

UltrasoundTechniqueandAnatomy

•Inmanycenters,routinepelvicultrasoundexaminations includebothTAUSandTVUS

○PatientundergoesTAUSwithfullbladder

○Aftervoiding,patientundergoesTVUS

•Transperineal/translabialevaluations

○Usesectororlineartransducercoveredwithcondomor commerciallyavailableprobecover

○Usefulforvisualizationoflabial/vulvar,distalurethral, andvaginalabnormalities

○Evaluationofprimaryamenorrheainpatientswithintact hymen

○Evaluationofcervixandloweruterusinlate-term pregnantpatientswhenTVUSiscontraindicated

•Transrectalultrasoundisrarelyusedtoevaluateanal sphincterinsettingofpelvicfloordysfunction

EquipmentPreparation

•Probesmustbemeticulouslycleansedaccordingto manufacturer'sandlocalinstitutionalguidelines

•MusthavegelbothinsideandoutsideofEVprobecoverto preventartifactfrominterposedair

•Postmenopausalwomenwithatrophicvaginitismaynot tolerateTVUS

○Usesmallprobeandextralubricatinggel

○AllowpatienttoinsertEVprobe

•Warmedultrasoundgelisbettertoleratedbypatients

ProcedureSteps

•TAUSandTVUSexaminationsshouldinclude

○Uterineimaging

–Uterineflexion/version

–Uterinemeasurements

□Measureuteruslengthonlongitudinal/sagittal midlineimagefromfundustoexternalcervicalos

□APmeasurementisperpendiculartolength measurement

□Uterinewidthismeasuredon transverse/orthogonalimageofuterus

–Myometriumevaluation

□Longitudinalandtransverseimages/cinesthrough entireuterus

□Myometrialmassesshouldbe documented/measured

□Evaluateforadenomyosis

□Incasesofsuspectedmüllerianductanomalies,3D ultrasoundcandepictexternaluterinecontourto helpcharacterizeanomaly

–Endometriumevaluation

□Measureendometrialthicknessperpendicularto longaxisofuterusonmidlinesagittalimage

□Ifthereisfluidwithinendometrialcavity,itshould beexcludedbymeasuringeachendometriallayer separately

□Evaluatefocalendometrialthickeningormasses (colorDopplermaybehelpfultoevaluatefor vascularstalk)

□IfIUDispresent,dedicatedimaginginlongitudinal andtransverseplanesshouldbeobtained

□Acquisitionof3Dvolumewithcoronalreformatted imageisusefultoevaluateIUDposition

–Cervicalimages

□Transverseandlongitudinalimagesthroughcervix

–Insettingofpriorhysterectomy,vaginalcuffshould beevaluated

○Adnexalimaging

–Ovariesshouldbemeasuredin3orthogonalplanes

–ObtaincolorandpulsedwaveDopplerimagesof ovaries,documentingarterialandvenouswaveforms

–Measureanyabnormaladnexallesionin3planesand evaluateforDopplerflowwithinlesion

–Determineiflesionarisesfromovaryorisseparate fromovary

□GentlypresswithEVprobe;adnexallesionarising fromovarywillmovewithovary,whereas paraovarianlesionwillmoveindependentfrom ovarywithpressure

–Bladderfilling&/oremptyingcanhelpdetermine etiologyandlocationofpelviccystincaseswhere largecystismistakenforurinarybladder

–Ifovariesaredifficulttofind,obtaincoronalviewof uterinefundusandanglelaterallytoregionofbroad ligament

□Alternatively,locateiliacvasculatureinlongitudinal planeandslowlyimagetowardmidline

–Scanbetweenuterusandovariestoassessforother adnexalmasses

□Mayidentifyparaovariancysts/masses,ectopic pregnancy,ordilatedfallopiantube

□3Dultrasoundcanhelpconfirmtubularnatureof suspectedhydrosalpinx

○Posteriorcompartment/cul-de-sacimaging

–Evaluateforfreefluid

–Torusuterinusiscommonlocationforadhesionsfrom deeppelvicendometriosis;mayperform"slidingsign" betweenposterioruterusandanteriorrectum

○Inpatientswithfocaltenderness/pain,thisregionshould bethoroughlyevaluated

•Incasesofpelvicmasses,TAUSmayalsoincludeevaluation ofkidneysforhydronephrosis/hydroureter

•ForTVUSevaluation,EVprobeshouldbeslowlyandgently inserted

○Asprobeisbeinginserted,assessforvaginalwallmasses

○Scangenerallyperformedthroughanteriorvaginalwall withprobepositionedinanteriorfornix

○Ifuterusisretrovertedorretroflexed,scanmaybe performedthroughposteriorvaginalwall

○Somepatientshavepainwhencervixismanipulated,so avoidexcessprobepressure

○Inpatientswithbowelgasobscuringvisualizationof ovary,gentleabdominalpressurecandisplacebowel loopsandallowforbettervisualization

•Transperinealevaluation

○Sagittalmidlineviewsofvagina,cervix,andloweruterus areobtained

○Parasagittalviewsasindicated

○Ifperformedduringpregnancy

–Relationshipbetweeninternalcervicalosand placentalmarginshouldbeevaluated

–Measurecervixandassessforfunneling

FindingsandReporting

•Uterinesize

•Uterinecontour

•Uterinepositioning

UltrasoundTechniqueandAnatomy

○Version:Positioningofuteruswithrelationtovagina

○Flexion:Positioningofuterinefundusinrelationtocervix

•Descriptionofmyometrialechotexture

•Descriptionofmyometrialmasses,includinglocation,size, andpositionwithinuterinewall

•Appearanceofcervix

•Descriptionofendometrium

○Endometrialthickness

○Presenceofendometrialmasses,fluid,cysticchange, IUD,focalthickening,orareasthatareilldefinedornot wellimaged

•Ovariansize

•Ovarianarterialandvenouswaveformsdetectedonduplex

Dopplerevaluation

•Descriptionofadnexalmasses

○Ovariancysts

○Complexorsolidadnexalmasses

○Tubalabnormalities

•Freefluid

•Evaluationfordeeppelvicendometriosis

POSTPROCEDURE

ExpectedOutcome

•Noharmfuleffectsfrompelvicsonography

•TAUSandTVUSaregenerallywelltolerated

ThingstoDo

•Cleanseprobesaccordingtomanufacturerandinstitution guidelines

SELECTEDREFERENCES

1. ShwayderJM:Normalpelvicanatomy.ObstetGynecolClinNorthAm. 46(4):563-80,2019

2. CunninghamRKetal:Adenomyosis:asonographicdiagnosis.Radiographics. 38(5):1576-89,2018

3. VandenBoschTetal:Ultrasounddiagnosisofendometriosisand adenomyosis:stateoftheart.BestPractResClinObstetGynaecol.51:16-24, 2018

4. ArmstrongLetal:Three-dimensionalvolumetricsonographyingynecology: anoverviewofclinicalapplications.RadiolClinNorthAm.51(6):1035-47, 2013

5. SakhelKetal:Beginwiththebasics:roleof3-dimensionalsonographyasa first-lineimagingtechniqueinthecost-effectiveevaluationofgynecologic pelvicdisease.JUltrasoundMed.32(3):381-8,2013

6. AndreottiRFetal:Sonographicevaluationofacutepelvicpain.JUltrasound Med.31(11):1713-8,2012

7. LangerJEetal:Imagingofthefemalepelvisthroughthelifecycle. Radiographics.32(6):1575-97,2012

8. AmericanInstituteofUltrasoundinMedicine:AIUMpracticeguidelinefor theperformanceofpelvicultrasoundexaminations.JUltrasoundMed. 29(1):166-72,2010

9. DietzHP:Pelvicfloorultrasound:areview.AmJObstetGynecol.202(4):32134,2010

10.ForsbergFetal:Comparingimageprocessingtechniquesforimproved3dimensionalultrasoundimaging.JUltrasoundMed.29(4):615-9,2010

11.ValskyDVetal:Three-dimensionaltransperinealultrasonographyofthe pelvicfloor:improvingvisualizationfornewclinicalapplicationsandbetter functionalassessment.JUltrasoundMed.26(10):1373-87,2007

12.Timor-TritschIEetal:Three-dimensionalinversionrendering:anew sonographictechniqueanditsuseingynecology.JUltrasoundMed. 24(5):681-8,2005

13.BegaGetal:Three-dimensionalultrasonographyingynecology:technical aspectsandclinicalapplications.JUltrasoundMed.22(11):1249-69,2003

14.LangerRDetal:Transvaginalultrasonographycomparedwithendometrial biopsyforthedetectionofendometrialdisease.Postmenopausal Estrogen/ProgestinInterventionsTrial.NEnglJMed.337(25):1792-8,1997

15.Lev-ToaffAS:Sonohysterography:evaluationofendometrialand myometrialabnormalities.SeminRoentgenol.31(4):288-98,1996

16.FreimanisMGetal:Transvaginalultrasonography.RadiolClinNorthAm. 30(5):955-76,1992

17.LyonsEAetal:Transvaginalsonographyofnormalpelvicanatomy.Radiol ClinNorthAm.30(4):663-75,1992

18.ForrestTSetal:Cyclicendometrialchanges:USassessmentwithhistologic correlation.Radiology.167(1):233-7,1988

19.FleischerACetal:Sonographicdepictionofnormalandabnormal endometriumwithhistopathologiccorrelation.JUltrasoundMed.5(8):44552,1986

Diagnostic imaging: gynecology 3rd edition akram m. shaaban - Read the ebook now or download it for

Farm Management 8th Edition

Baking

Shaaban Rogers | Olpin

| Menias

THIRD EDITION

Notices

Dedications

Contributing Author

Additional Contributing Authors

Preface

Acknowledgments

TABLEOFCONTENTS

TABLEOFCONTENTS

SECTION3:CERVIX

TABLEOFCONTENTS

VASCULAR

TABLEOFCONTENTS

Shaaban Rogers | Olpin

| Menias

UltrasoundTechniqueandAnatomy

KEYFACTS

UltrasoundTechniqueandAnatomy

TERMINOLOGY

PREPROCEDURE

PROCEDURE

Techniques

UltrasoundTechniqueandAnatomy

UltrasoundTechniqueandAnatomy

SELECTEDREFERENCES

Techniques