This simple presentation was designed as a part of the basic ultrasound knowledge for junior clinicians held half annually in the Department of Obstetrics and Gynecology - Mansoura University- Egypt, as a component of continuous medical education offered by the department.

1. ULTRASOUND AND
GYNECOLOGICAL ONCOLOGY
Osama M Warda MD
Professor of Obstetrics & gynecology
Mansoura University-EGYPT

2. NORMAL GYNECOLOGICAL
ANATOMY- introduction
Ultrasound exam of the uterus & ovaries is best
performed trans-vaginally
The ultrasound morphology & size of the uterus
& ovaries change during the menstrual cycle.
In menopausal transition the ovaries are
smaller & contain fewer follicles than during
reproductive years. They continue to shrink after
the menopause, when the uterus also becomes
smaller.
Warda12 May 2014

3. NORMAL GYNECOLOGICAL
ANATOMY- introduction
A small amount of fluid in the pouch of Douglas is normal in
women of fertile age but abnormal after the menopause.
Normal tubes can only be seen if they float freely in fluid in
the pouch of Douglas .
On saline infusion sonography a normal uterine cavity is
regular and outlined by smooth endometrium.
hystero-contrast salingosonography is used to assess tubal
patency. If one can observe moving contrast in the interstitial
part of the tube for 10 seconds, and if no hydrosalpinx is seen,
the tube is probably patent, even if free spill of contrast
around the ovary is not clearly seen.
-
Warda12 May 2014

4. Ultrasound of Normal uterus
The myometrium is homogeneous
Morphology of endometrium changes during menstrual
cycle
At beginning of cycle the uterus is small and endometrium
thin
In follicular phase, uterus increases in size and
endometrium becomes thicker and manifests ‘triple-layer’
appearance
After ovulation the ‘triple-layer’ appearance disappears and
the endometrium becomes homogeneously hyperechoic.
Warda12 May 2014

5. Early follicular endometrium
Trtriple –layer
appearance
Luteal phase
Warda12 May 2014

6. Ultrasound of Normal cervix
Ultrasound examination of the uterus should always start
with examination of the cervix.
The cervical canal should be identified & followed towards
the corpus uteri so that it can be seen to join the
endometrium .
This examination technique ensures that it is indeed the
uterus & the endometrium that have been identified.
The myometrium of a normal cervix is homogeneous. In late
proliferative phase of MC, clear fluid, corresponding to
ovulatory cervical mucus, can be seen in cervix.
The finding of many & even large retention cysts in the
cervix is normal.
Warda12 May 2014

7. Warda12 May 2014

8. cervix
Nabothian follicle
Nabothian f
Warda12 May 2014

9. Ultrasound of Normal ovary
Ovarian us morphology changes with the MC.
In the beginning of the MC both ovaries usually contain 6-
7 follicles of <10mm diameter.
The non-dominant ovary retains this appearance
throughout the MC .
In early FP, it is not possible to determine which ovary is
going to become the dominant one. It can be identified 6-
9d before the LH surge, i.e. between D5-D12 of the MC
(mean D8).
The DF displays a linear growth of ±1.7mm/day. At the
time of LH surge the DF = 18-22mm
Warda12 May 2014

10. Ultrasound of Normal ovary(contd.,)
After ovulation the follicle becomes a CL.
The CL is usually smaller than the DF, its wall is thicker, and with
high resolution US it is possible to see the crenellated appearance
of its wall. Bleeding into CL explains presence of internal echoes in
the CL at US.
The CL is well vascularized & therefore it is surrounded by a ‘color
ring’ or ‘fire ring’ on CD or PD ultrasound.
On the 3rd of MC the CL of the previous cycle is no longer
distinguishable even by CD ultrasound.
Ovarian size changes during MC , vol. of non-dominant ovary 7-8ml
remains unchanged, while DO increases from 7-8ml in FP to 20ml on
day befor ovulation
Warda12 May 2014

11. Natural cycle-dominant F Stimulated ovary
Warda12 May 2014

12. Normal US of uterus & ovary in
post-menopause
The uterus & ovaries are smaller in
postmenopausal women than in CBP.
A normal uterus in a woman 5 years
postmenopause = 5-6 length x2.5 AP x3 cm width.
Normal ovary volume=1-4ml & with no follicles
The endometrium is thin (<5mm), uniform (no
cyclic changes, and hyperechoic.
Calcified BV in the periphery of the myometrium
are common & seen as bright echoes.
Warda12 May 2014

13. Warda12 May 2014

14. Post-menopausal ovary
Post menopausal uterus
and ovary
Warda12 May 2014

15. GYNECOLOGICAL
MALIGNANCY-OVERVIEW
Gynecologic cancers represent 14% of all solid
tumors in women and 11% of deaths from them.
Cervical, uterine and ovarian cancer represent
95% of gynecologic cancers and collectively rank
the fourth in both incidence and mortality
among cancers that affect women in developed
countries.
Worldwide, these tumors account for even
larger share of cancer mortality in women
Warda12 May 2014

16. Number of Cases of Cancer
Cervix in Egypt, Jordan, USA
EGYPT
(1999-2001)
JORDAN
(1996-2001)
USA
(1999-2001)
TOTAL per
100,000
96 194 5284
Age distribution
(Years)
30-49 38.5% 45.3% 48.4%
50-69 52.1% 42.8% 36.2%
70+ 9.4% 11.9% 15.4%
Warda12 May 2014

17. Endometrial carcinoma
Worldwide it represents 3.9% of female
cancers
It is more common in developed countries :
18/100,000 in USA & Canada compared to
6/100,000 in Africa and is related to:
- Prolonged high estrogen levels
- Few number of children
- Use of HRT
Warda12 May 2014

18. Number of cases of Endometrial
Carcinoma in Egypt, Jordan, USA
Egypt
(1999-2001)
Jordan
(1996-2001)
USA
(1999-2001)
Total per
100,000
124 405 14129
Age
distribution
%
<50 33.1 26 15.5
50-69 56.4 50.5 49.9
70+ 10.5 13.1 34.6
Warda12 May 2014

19. Ovarian cancer
Epithelial ovarian carcinoma account for
90% of cases and is the leading cause of
death in women with pelvic malignancies
The incidence is higher in industrial
countries of the world
Women who are single and have low
parity and a history of breast cancer are
at risk.
Warda12 May 2014

20. Age-standard incidence rate of Ovarian
Carcinoma in Egypt, Jordan , USA
TOTAL per
100,000
Egypt
1999-2001
Jordan
1996-2001
USA
1999-2001
All ages 5.4 4.6 10
<50 2.5 2.1 3.2
50-69 17.7 14.1 33.5
70+ 14.9 17.3 52.7
Warda12 May 2014

21. Ovarian Pathology
Warda
Haemorragic cyst. Small unilocular cyst, with some internal echoes, irregularly
distributed. Thick, but smooth wall, absence of papillary projections. Normal ovarian
tissue is visible medially. The picture is typical for haemorragic cyst/corpus luteum.
12 May 2014

22. Ovarian Pathology
Warda
Unilocular ovarian cyst. Thin, smooth margins, absence of papillary projections,
virtually anecoic, suggestive a follicular cyst.12 May 2014

23. Ovarian Pathology
Warda
Slightly enlarged "solid" ovary in a woman of 63 years of age. The texture is
moderately inhomogeneous. Marigin irregular but well defined. Histology confirmed
the presence of a benign ovarian fibroma.12 May 2014

24. Ovarian Pathology
Warda
Unilocular ovarian cyst. "Ground glass" hypoecoic texture, slightly thickened
but regular margins, some normal ovarian tissue is visible cranially, around
the cyst. The picture is very suggestive for an ovarian endometrioma.
12 May 2014

25. Ovarian Pathology
Warda
Small dermoid in an otherwise normal sized ovary. Note the homogeneous,
hyperechoic texture typical of a dermoid cyst. In this case shadowing was not
detectable.
12 May 2014

26. Ovarian Pathology
Warda
Power Doppler well depict blood vessels around a normal sized corpus luteum, with
the typical aspect of a "ring of fire".
12 May 2014

27. Ovarian Pathology
Warda
Unilocular ovarian cyst, few small papillary intracavitarian projections deform
the caudal portion of the cyctic wall, otherwise smooth. Internal echoes are
regularly distributed, with a "ground glass" texture. Histology confirmed the
presence of a border-line ovarian cystadenoma of endometrioic type.
12 May 2014

28. Ovarian Pathology
Warda
Unilocular ovarian cyst, with "ground glass" internal texture, suggestive of endometrioma. A
small "papillary-like" projection, deforms the lateral wall of the cyst. This an example of
socolled "atypical endometrioma". In such cases, Power Doppler analysis is very useful to
differentiate it from a true neoplasm.
12 May 2014

29. Ovarian Pathology
Warda
Small multilocular solid ovarian cyst, with few small septa and papillary projections. As such
the picture would appear highly suspicious for malignancy. Subsequent evaluation with
power and pulsed Doppler showed however, scanty vascularity and high impedance to
blood flow. Histology demonstrated a benign cystic ovarian adenofibroma.
12 May 2014

30. Ovarian Pathology
Warda
Multilocular ovarian cyst. Several septa of different length and thickness, but no
papillary projections or solid areas are present. Margins are well defined. Internal
echoes are scanty. Histology diagnosed a benign ovarian cystadenoma of serous type.
12 May 2014

31. Ovarian Pathology
Warda
A small, round shape unilocular cyst, close but external to the ovary,
suggestive to be a paraovary cyst.
12 May 2014

32. Ovarian Pathology
Warda
The ovary is enlarged, solid, with undefined margin, slightly unhomogeneous
texture. Normal ovarian texture is not visible. The picture is suggestive of a
primary malignant ovarian neoplasm or of an ovarian metastasis.
12 May 2014

33. Ovarian Pathology
Warda
Unilocular solid ovarian cyst, with 2 large intracavitarian solid, papillary areas,
occupying almost 1/3 of the lumen of the cyst. Internal echoes are visible. Histology
diagnosed a malignant cystadenocarcinoma of serious type.
12 May 2014

34. Ovarian Pathology
Warda
Very large (>22 cm) multilocular solid ovarian cyst. There are many
septations forming a thick "web" and solid intra-cavitarian areas.
Internal echoes are abundant. The picture is suggestive of a malignant
cystadenocarcinoma of mucinous type.
12 May 2014

35. Ovarian Pathology
Warda
Enlarged, "solid" ovarian mass. Power Doppler show intense vascularisation.
At histology an ovarian metastasis of breast cancer was diagnosed.
12 May 2014

36. Ovarian Pathology
Warda
Large ovarian solid tumor. Texture is homogeneous, margins are well
defined. At histology a granulosa cell tumor was diagnosed.
12 May 2014

37. Ovarian Pathology
Warda
Superimposed power Doppler examination of a solid ovarian mass
proved to be a granulosa cell tumor. Showing abundant and
irregularly distributed vascularisation.
12 May 2014

38. Ovarian Pathology
Warda
Pulsed Doppler examination of blood flow impedance in an ovarian solid mass, proved to be a
granulosa cell tumor. Maximum velocity is high and impedance to flow low.
12 May 2014

39. Ovarian Pathology
Warda
Neoplastic ovarian cyst with internal papillae
12 May 2014

40. Ovarian Pathology
Warda
Ovarian fibroma
12 May 2014

41. Ovarian Pathology
Warda
Mucinous cystadenocarcinoma
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42. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CD
12 May 2014

43. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CDUTERINE FIBROID
12 May 2014

44. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CD
12 May 2014

45. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CD
ENDOMETRIAL
CANCER
12 May 2014

46. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CD
UTERINE LEIOMYOSARCOMA
12 May 2014

47. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CD
Enlarged uterus in a 53-year-old woman with abnormal bleeding. The uterus is enlarged
slightly and heterogeneous in echotexture but has no focal masses. Histologic
examination revealed adenomyosis.
12 May 2014

48. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CDFOCAL adenomyosis- no line of demarcation+ presence of hypoechoic dots
12 May 2014

49. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CDCervical masses. (A) Sagittal view of the cervix demonstrates a large
cervical fibroid which deviates the lower uterine segment anteriorly.
fibroid
Uterus
12 May 2014

50. Uterine Pathology
Warda
Submucous fibroid polyp/ sonohysterography+ CDMultiple endometrial polypi (sono hysterography
12 May 2014

51. Thank
You
Warda12 May 2014