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[email protected] 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
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La diagnostica
ecografica
delle masse ovariche
Francesco P.G. LeoneClinica Ostetrica e Ginecologica
Direttore Prof. Irene Cetin
Dipartimento di Scienze Cliniche L. Sacco
Università degli Studi di Milano
Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
high resolutionwideband (3-9 MHz) endocavitary probe
high accuracy
TVS: L’alta frequenza …
Il primo tempo di
esecuzione
dell’esame
prevede una
profondità e una
focalizzazione utile
a visualizzare
tutta la pelvi
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
Metodologia dello studio ecografico della pelvi femminile
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….
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
Esame organ oriented: peritoneo
La valutazione del peritoneo viscerale…
dolorabilità “push&pull manoeuvres”
aderenze (“spider in a web”, “flapping sail”)
Strumentazione e tecnologia: sonovaginografia
evidenzia noduli endometriosici
del setto retto-vaginale
J Ultrasound MedFeasibility 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 tertiaryconsultation (second opinion).
Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
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 Gynecol 2000; 16: 395-8)
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
A, B (= 5,000-
10,000 TVS)
Subjective assessment (n=300)
C (= 1,000 TVS)
D, E, F (= 200-
300 TVS)
False positive rate
Se
nsitiv
ity
Accuracy
D,E,F= 82-86%
C = 89%
A,B = 92%
Timmerman „99
Logistic regression model
Papillarities >3mm(0,1)
Color score (1,2,3,4)
Menopause (0,1)
CA 125 (1 - 31 090)
~Probability
of cancer
“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
Unilocular cyst
Multilocular cyst
Unilocular-solid cyst
Multilocular-solid cyst
Solid
Qualitative assessment of morphology
Cystic contents
Anechoic
Low-level echogenicity
Ground glassappearance
Haemorrhagic
Mixed
Measurement and quantitative assessment of
morphology
• LesionThe 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 projectionThe largest projection is measured in height and base. The number
of separate papillary projections and whether blood flow can be
detected.
• 1 : no flow
• 2 : minimal flow
• 3 : rather strong flow
• 4 : very strong flow
Color score
Color score
1 : no flow
2 : minimal flow
3 : rather strong flow
4 : very strong flow
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
Unilocular cyst
Multilocular cyst
Unilocular-solid cyst
Multilocular-solid cyst
Solid
0.5-1%
10%
37%
43%
65%
% of malignancyIOTA 2005
Sensitivity 95%, specificity of 91%. LR+ = 10.45 LR− = 0.06.
The rules were applicable in 76% of the tumors.
Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
“Il primo grande amore non dura tutta la vita
ma la cambia per sempre.”
Claudio Baglioni
Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
International Ovarian Tumour Analysis (IOTA)
Sonographic assessment of morphology: qualitative classification
typical
AnechoicLow level Ground glass
Mixed
: : : : : : :
: : : : : : :
: : : : : : :
: : : : : : :
Hemorrhagic
AnechoicLow level Ground glass
Mixed
: : : : : : :
: : : : : : :
: : : : : : :
: : : : : : :
Hemorrhagic
typical
International Ovarian Tumour Analysis (IOTA)
Sonographic assessment of morphology: cystic contents
Typical endometrioma
Ground glass appearance (homogeneously dispersed echogenic)
cystic content
Unilocular cyst with regular internal wall
AnechoicLow level Ground glass
Mixed
: : : : : : :
: : : : : : :
: : : : : : :
: : : : : : :
Hemorrhagic
AnechoicLow level Ground glass
Mixed
: : : : : : :
: : : : : : :
: : : : : : :
: : : : : : :
Hemorrhagic
atypical
International Ovarian Tumour Analysis (IOTA)
Sonographic assessment of morphology: cystic contents
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)
legamento
utero-sacrale dx
legamento
utero-sacrale dx
sigma-retto
Endometriosi posteriore: legamenti utero-sacrali
Intestinal endometriosis @ 3DTVS-VCI
Intestinal endometriosis @ LPS
Intestinal endometriosis @ 3DTVS-VCI
Intestinal endometriosis @ 3DTVS-VCI
Courtesy of Valentino Remorgida & Simone Ferrero
“pulling-out sign”
globular appearing uterus
a mottled inhomogeneous myometrial texture
… diffuse adenomyosis
small cystic spaces within the myometrium
a "shaggy" indistinct endometrial stripe
Bromley B. et al., J Ultrasound Med 2000
persistent, irregular, slightly dilated radial uterine vessels
Reinhold C. et al., Radiology 1995
cystic spaces within the myometrium
… focal adenomyosis
Perrot N. et al., UOG 2001increased microvessel density in adenomyosis uteri
Schindl M.et al., Fertil Steril 2001
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 uretero-
vesical junction. A LNG-IUS was inserted. At 8 months follow-up, the patient
persisted free of symptoms.
Conclusion: Accurate diagnosis by TVS of deep infiltrating
endometriosis may permit a conservative medical treatment
based on LNG-IUS.
8Fr
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Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
