Female reproductive system Flashcards

Question

61) A 30-year-old, nulliparous woman with Stein–Leventhal syndrome is being treated for subfertility with clomiphene. She develops abdominal pain, distension, nausea and vomiting. Ultrasound examination of the abdomen reveals both ovaries to be larger than 7 cm in length and packed with large follicles, and also reveals an ovarian cyst 12 cm in diameter. Ascites and a pleural effusion are also seen. What is the most likely diagnosis? a. endometriosis b. ovarian cyst torsion c. ovarian hyperstimulation syndrome d. ovarian serous cystadenoma e. corpus luteum of menstruation

Answer 1

c. ovarian hyperstimulation syndrome Ovarian hyperstimulation syndrome is more commonly seen with human menopausal gonadotrophin therapy but can also be seen with clomiphene. Severe complications relate to volume depletion, such as hypovolaemia, oliguria, electrolyte imbalance and thromboembolic events. Intra-abdominal haemorrhage is also reported.

Answer 2

c. it is normal for a premenopausal ovary but large for a postmenopausal ovary Normal ovarian volume is less than 18 cm3 before the menopause and less than 8 cm3 after. The volume can be estimated by multiplying the three diameters and dividing by two.

Answer 3

d. 7–14 mm The menstrual endometrium is under 4mm. After menstruation and up to date 14, the proliferative endometrium is 4–8mm. Days 14–28 are secretory with the endometrium 7–14mm. On ultrasound scan, the endometrium is seen as an echo-bright stripe. Unless the patient is taking tamoxifen or hormones, the postmenopausal endometrium should be less than 4mm. A cut-off of 3mm when performing screening for endometrial cancer has a 99% negative predictive value.

Answer 4

e. malignant ovarian neoplasm Features of an ovarian cyst that suggest malignancy are thick irregular walls and thick septations (.2mm), large overall size, solid elements and, on Doppler scan, a high peak systolic velocity and low-impedance diastolic flow. Together, these give a resistive index (RI) of ,0.4 and a pulsatility index (PI) of ,1.

Answer 5

c. Mayer–Rokitansky–Kuster–Hauser syndrome The uterus, fallopian tubes and upper vagina arise from the paired paramesonephric (mullerian) ducts. The caudal parts fuse and ultimately form the uterus and upper vagina with resorption of the midline septum. The cranial parts remain unfused and form the fallopian tubes. Congenital uterine abnormalities arise with failure of development or fusion of this duct, or failure of midline resorption following fusion. Mayer–Rokitansky–Ku¨ster–Hauser syndrome describes uterine agenesis accompanied by hypoplastic proximal/middle third of the vagina but normal tubes and ovaries. Forty per cent of patients with the syndrome have pelvic kidneys and other urinary tract anomalies are also associated. They have a normal genotype.

Answer 6

d. breast cancer The patient is receiving tamoxifen. Side effects include subendometrial cystic atrophy, endometrial hyperplasia and endometrial polyps. Less frequent side effects are endometriosis, polypoid endometriosis, adenomyosis and cervical polyps. There is an increased risk of endometrial carcinoma. On MRI, an endometrioma can appear as a multicystic adnexal mass of high T1 and both hypo- and hyperintense T2 signal, but without the fat suppression that would be expected with a mature cystic teratoma. Adenomyosis on MRI may manifest as a uterus with a thickened, low-signal, junctional zone on T2W images, containing small foci of high T2 signal.

Answer 7

e. repeat transvaginal ultrasound scan in 4 months The Risk of Malignancy Index (RMI) is used to stratify the likelihood of an incidentally identified ovarian cyst being malignant. The RMI is the product of the ultrasound score, the CA-125 level and the score assigned according to menopausal status. Low-risk cysts can be managed conservatively. A cyst below 5cm in diameter that is unilocular, unilateral and echo-free, and has no solid parts or papillary formations has a risk of malignancy of less than 1%, and a 50% chance of resolving spontaneously in 3 months.

Answer 8

b. amputated ovary An amputated ovary occurs as the result of ovarian torsion and infarction. Both an ovarian teratoma and leiomyoma will enlarge the affected ovary rather than appear atrophic. A follicular cyst will usually be a simple cyst, although it may have internal echoes produced by haemorrhage.

Answer 9

d. leiomyosarcoma Uterine fibroids are oestrogen dependent and should involute following the menopause. Increase in size of a fibroid after the menopause should raise the possibility of sarcomatous degeneration. On ultrasound scan, the appearance of leiomyosarcoma may be indistinguishable from that of a benign fibroid

Answer 10

c. pelvic inflammatory disease The patient’s fallopian tubes are occluded, giving bilateral hydrosalpinx. The commonest cause of proximal or distal tubal occlusion is pelvic inflammatory disease. Endometriosis, infection following birth or abortion, and tuberculosis are other causes. Indications for hysterosalpingogram include infertility, recurrent miscarriage, assessment of the tubes after surgery and assessment of the integrity of a post-caesarean uterine scar. Contraindications are pregnancy, purulent vulval or cervical discharge, pelvic inflammatory disease in the preceding 6 months and contrast sensitivity. Historical contraindications include the immediate post-menstruation phase and recent dilatation and curettage, because of the risks associated with intravasation of oily contrast media.

Answer 11

d. polycystic ovarian disease Polycystic ovarian disease is diagnosed by clinical, biochemical and ultrasound findings. Clinically, oligomenorrhoea, hirsutism and obesity are features. Luteinizing hormone is increased as is the luteinizing hormone: follicle-stimulating hormone ratio. Androgen levels are increased. Sonographic findings vary from normal-looking ovaries through hypoechoic ovaries without individual cysts to multiple, 5mm or more, peripherally located cysts in bilaterally larg

Answer 12

e. bladder mucosal involvement Endometrial carcinoma is the commonest gynaecological malignancy, and the fourth commonest site of female malignancy. It is very unlikely if the endometrial thickness on transvaginal ultrasound scan is less than 4mm. Endometrial carcinoma becomes stage T4 when bladder or bowel mucosa is involved, whereas the stage remains T3 if other layers of bowel or bladder are invaded. On MRI, endometrial carcinoma has homogeneous signal intensity, isointense to myometrium on T1W images and hypointense to endometrial lining on T2W images. Endometr cancers shows slower contrast enhancement to a lower peak of enhancement than normal myomet.

Answer 13

b. high, low, intermediate The premenopausal uterus normally has a bright endometrium within a dark junctional zone and an intermediate outer myometrium on T2W images. Cancer disrupts the zonal anatomy seen on T2W MRI. T1W sequences do not demonstrate uterine zonal anatomy. On T2W images, the uterine cervix has a distinct zonal signal pattern that is particularly well seen on sequences acquired perpendicular to the long axis of the cervix. These are especially useful for cervical cancer staging. The cervix lumen is bright, the cervical mucosa is intermediate to bright, and the fibromuscular cervical stroma is dark and surrounded by the intermediate signal outer layer of cervical stroma. With age or radiation treatment, the uterus involutes and loses this zonal appearance on T2W MRI. Notably, the outer corpus and especially the cervical muscles return a lower signal.

Answer 14

c. cystocele Suspected pelvic floor prolapse can be investigated with MRI. Usually, there is minimal movement of pelvic organs even on maximal strain. When the pelvic floor is lax, the organs descend below the pubococcygeal line by 1–2cm. When descent exceeds 2cm, the prolapse may require surgical intervention. An enterocele describes small bowel descending 2cm or more between vagina and rectum. Anterior bulging of the rectal wall is known as a rectocele, while bladder descent of more than 1cm is a cystocele.

Answer 15

c. vagina The pelvic floor is supported by the endopelvic fascia and the levator ani muscle complex. This complex consists of three muscle groups, iliococcygeal, pubococcygeal and puborectalis. The anterior compartment of the female pelvic floor contains the bladder and urethra. The middle compartment contains the vagina and the posterior compartment the rectum.

Answer 16

a. cervical cancer staging In the pelvis, 18FDG PET/CT is recommended for use in staging colorectal cancer, cervical cancer and non-Hodgkin’s lymphoma. It is also indicated for detecting recurrence of colorectal, cervical, endometrial and ovarian cancers. It is not recommended for primary urothelial malignancy or prostate cancer. Usefulness is limited in the renal tract by urinary excretion of FDG. It is less than satisfactory in prostate cancer because of the poor sensitivity for osseous metastases

Answer 17

(d) Dermoid cyst Dermoid cysts are common congenital benign germ cell tumours that usually present in the reproductive age range. 15% are bilateral. They have a spectrum of appearances ranging from the classic fat or bone containing lesions to (less commonly) a predominantly cystic lesion with a fluid-fluid level. They can be diagnosed on plain radiographs in up to 40% of cases when the presence of fat, teeth or bone can be identified. They can be complicated by malignant degeneration (in 1-3%), torsion (4-16%) and rupture (rarely).

Answer 18

(c) She is in the secretory phase of her menstrual cycle An endometrial thickness of up to 16 mm may be seen in the secretory phase of the menstrual cycle. This is maximal during the mid-secretory phase. It is imperative to include the LMP, whether known or unknown as part of the report. In the proliferative phase (day 6-14), endometrial thickness is 5-7 mm and in the periovulatory phase, endometrial thickness up to 11 mm is seen.

Answer 19

(e) Ovarian cyst 18FDG shows physiological uptake in brain, myocardium, liver, spleen, bone marrow, GI tract, testes, and skeletal muscle and is excreted by the kidneys. Increased uptake is also seen in healing fractures, inflammatory and granulomatous disease and infectious processes.

Answer 20

(d) Ovarian fibroma Ovarian fibroma is a well defined tumour containing extensive collagen. It is associated with Gorlin's syndrome (fibromas seen in 17%) and occasionally presents as Meig's syndrome.

Answer 21

(d) Asymmetrical ovarian size The diagnosis of polycystic ovary syndrome is made on the basis of clinical and biochemical findings in conjunction with the sonographic findings, which alone are non-specific. Similar sized ovaries is a key finding. The classic finding of bilaterally enlarged ovaries with multiple small peripheral follicles is seen in 50%. Hyperechoic central stroma is also usually seen. Normal ovaries are seen in 25%.?

Answer 22

(b) T1 W sequences post gadolinium administration is employed T1W imaging after the administration of intravenous gadolinium is not routinely employed for the assessment of endometriosis.

Answer 23

(d) Pyosalpinx Pyosalpinx is characterized by dilatation of the fallopian tube with pus within it. It characteristically demonstrates amorphous or geographic shading on T2W

Answer 24

(e) High-cellularity tumour Diffusion-weighted MRI is increasingly being used in body MRI and offers functional information over and above conventional morphological images. These features are typical of tumour.

Answer 25

(a) Enhancement of the solid component on CT Lack of enhancement of the solid component of the mass is seen on CT and MRI. Other features include a whorled paraovarian structure on CT, representing the ovarian pedicle

Answer 26

(b) Endometrioma The classic features of an endometrioma are described, others include wall nodularity, a fluid-fluid level and acoustic enhancement. A haemorrhagic ovarian cyst or a tubo-ovarian abscess wou1d present more acutely. A dermoid may have similar appearances but would usually have fat and/or calcium within. A cystic ovarian tumour is in the differential and typically appears as a multilocular cyst with large associated soft tissue component mass, sometimes with papillary excrescences into the cysts.

Answer 27

(a) Arcuate uterus Arcuate uterus is the most common uterine anomaly associated with reproductive failure. Uterus didelphys is a duplication defect with 2 vaginas, 2 cervices and 2 uterine horns. Bicornuate and unicornuate abnormalities demonstrate an abnormal fundal contour.

Answer 28

(c) If she is taking HRT, normal endometrial thickness can be up to 20 mm HRT can increase the normal thickness of the post-menopausal endometrium up to 15 mm (depending on the HRT). Measurements should be of bi-layer thickness. For post-menopausal women not on HRT, 5 mm is the upper limit of normal.

Answer 29

(e) The Mirarla is commonly used for the treatment of dysfunctional uterine bleeding The Mirena is a polyethylene IUCD and is well seen on MRI. Metal IUCDs are not a contraindication to 1.5T MRI examination although safety in a 3T machine has not been fully evaluated. Threads of a lost coil can ball up to form an echogenic mass on ultrasound. IUCDs do not increase the risk of ectopic pregnancy per se, but a higher percentage of ectopic pregnancies are seen in patients with IUCDs as endometrial implantation is restricted. The Mirena is commonly used for treatment of dysfunctional uterine bleeding with success rates of up to 70%.

Answer 30

(c) Hysterosalpingography should be performed in the first half of the menstrual cycle Laparoscopy and blue dye instillation (with spillage of dye into the peritoneal cavity indicating patency) is the gold standard, but requires a general anaesthetic. MRI and standard pelvic US do not clearly demonstrate the fallopian tubes. HSG provides an accurate indication of tubal patency but employs ionizing radiation. It should therefore be performed in the first half of the menstrual cycle to avoid irradiating a patient with possible early pregnancy. Hysterosalpingo-ContrastSonography uses microbubbles to demonstrate the fallopian tubes and has the advantage of not using ionizing radiation or requiring anaesthesia but is less accurate than the other methods.

Answer 31

(a) Adenomyosis Adenomyosis is a term relating to benign invasion of the myometrium by endometrium. It can exist in either focal or diffuse forms. The diffuse form is characterised by junctional zone widening. Dilated cystic glands or haemorrhagic foci can be seen within the myometrium in 40% of diffuse cases.

Answer 32

(d) Resistance to flow on Doppler imaging of the ovary is greatest in the luteal phase of the menstrual cycle Highest resistance to flow on Doppler is seen on days 1-8 of the menstrual cycle, gradually reducing with follicular development until day 21

Answer 33

(b) It cannot be employed after reversal of sterilization surgery Although primarily used in cases of proximal tubal obstruction, it can be used to treat mid tubal obstructions after reversal of sterilization surgery.

Answer 34

(d) Endometrial carcinoma Other features to suggest malignancy include a resistive index of <0.7, disruption of the junctional zone or other evidence of myometrial invasion

Answer 35

1. c. Adenomyosis Adenomyosis is a focal or diffuse benign invasion of myometrium by endometrium, which incites reactive myometrial hyperplasia. It is associated with endometriosis (20–40%). It typically presents in multiparous women in the late reproductive years. Symptoms include pelvic pain, menorrhagia and dysmenorrhea, although adenomyosis it may be an incidental finding. Adenomyosis may be diffuse or focal. Ultrasound appearances are variable but usually there is slight enlargement of the uterus with loss of homogeneity of the myometrium. There may be pseudo-widening of the endometrium due to increased myometrial echogenicity. MRI is more specific and demonstrates thickening of the junctional zone. When diffuse, a widened low-intensity junctional zone >12 mm confirms the diagnosis whereas <8 mm excludes the disease. For indeterminate sizes, further findings may aid the diagnosis, such as high-signalintensity linear striations extending out from the endometrium into the myometrium on T2 and high signal foci on T1 – representing ectopic endometrial tissue/haemorrhagic foci. When focal (adenomyoma), there is typically an oval/elongated mass with ill-defined margins residing within the myometrium which is in continuity with the junctional zone. Distinction from leiomyomas may be difficult but these tend to be round, sharply marginated masses occurring anywhere in the myometrium and they may contain calcifications.

Answer 36

2. d. T3b Cervical neoplasms are staged according to the TNM/FIGO classification. Stage I tumours are confined to the uterus. In stage IIA, there is involvement of the upper two-thirds of the vagina. Stage IIB shows parametrial invasion without pelvic sidewall involvement. Stage IIIA demonstrates invasion into the lower third of the vagina, and IIIB includes pelvic sidewall invasion with or without hydronephrosis. Tumour invasion into the bladder and rectal mucosa or distant metastasis accounts for stage IV disease. Pelvic nodal metastases do not alter the FIGO stage but para-aortic or inguinal node metastases are classified as stage IVB.

Answer 37

3. c. Ovarian fibroma The condition described is Meigs syndrome. This occurs in about 1% of ovarian fibromas but is characterised by a large fibroma, ascites and a pleural effusion (typically right-sided). Ascites and effusion resolve after tumour resection. Fibromas are benign stromal tumours composed of fibrous tissue. On ultrasound they are typically solid hypoechoic lesions with posterior acoustic enhancement.

Answer 38

13. a. Mature cystic teratoma Mature cystic teratomas (dermoid cysts) account for approximately 15% of all ovarian tumours. They are benign germ cell tumours containing tissues from all three germ cell layers. They most commonly present in younger women of reproductive age (20–40 years) and may be bilateral in up to 25%. They are generally cystic masses that may contain a pathognomonic distinct hyperechoic mural nodule (dermoid plug/Rokitansky nodule) which projects into the cystic lumen and causes posterior acoustic shadowing. This nodule represents in-growth of solid tissue such as hair or teeth from the tumour wall.

Answer 39

14. d. Gartner duct cyst Gartner’s duct cysts are remnants of mesonephric ducts and have a reported incidence of 1–2%. They are ovoid, thin-walled cysts located at the anterolateral aspect of the upper vagina and generally measure less than 2 cm. They may contain proteinaceous material, making them slightly hyperintense on T1. They may be associated with Herlyn–Werner– Wunderlich syndrome (ipsilateral renal agenesis and ipsilateral blind vagina) and ectopic ureter inserting into the cyst. Bartholin cysts are located at the lateral introitus adjacent to the labia minora. Nabothian cysts are epithelial inclusion cysts which develop in the endocervical canal and are most commonly found in the perimenopausal period. Cervical fibroids and cervical polyps show mainly as solid lesions.

Answer 40

15. e. Endometrial polyp Endometrial polyps are common benign tumours of the endometrial cavity. They are most common after the age of 40 years and are rare before menarche. Typical ultrasound appearance is of a hyperechoic endometrial mass which may or may not contain cystic spaces. A feeding vessel is often demonstrated from its base on power Doppler. (Submucosal fibroids are generally of reduced echogenicity). On MRI, a mass which contains a central fibrous core that enhances post-contrast and also contains well-demarcated T2-hyperintense cysts suggests endometrial polyp. An intact junctional zone and smooth tumour-myometrium interface also favour a polyp.

Answer 41

25. e. Follicular cyst These are common ovarian masses that result from a failure of the mature Graafian follicle to rupture and release ova. Typically, they are smooth, thin-walled, unilocular anechoic cysts that show spontaneous regression within four to six weeks. They may undergo haemorrhagic change producing internal echogenic material. They are generally larger than 2.5 cm and may occasionally grow up to 10 cm.

Answer 42

27. e. Ovarian volume >10 ml when no follicles measuring over 10 mm in diameter are present Diagnosis of polycystic ovary syndrome should not be made on imaging findings alone; clinical and biochemical studies must be obtained. The diagnosis can be supported when one or more of the following ultrasonographic features are demonstrated:Twelve or more follicles (3–12 mm diameter) are present in an ovary (either peripheral or diffusely arranged).Ovarian volume >10 ml when no follicles measuring over 10 mm in diameter are present. If a follicle >10 mm is present then the volume should be recalculated on a repeat scan when the ovary is quiescent to prevent overestimation of the ovarian volume.

Answer 43

26. b. Ovarian torsion Ovarian torsion usually presents in the first three decades of life and is predisposed inpatients with co-existing ovarian pathology such as follicular cyst. There may be history of similar episodes indicating intermittent torsion and spontaneous detorsion. Torsion causes venous outflow obstruction and engorgement of the ovary. Eventually arterial supply is compromised and necrosis ensues. Diagnosis is suggested by unilateral enlargement of a round or oval-shaped ovary containing multiple enlarged peripheral cysts (caused by transudation of fluid into follicles). Free fluid is present in the majority of cases. Peripheral blood flow may be present but may be absent with infarction. Ovarian hyperstimulation can present with abdominal pain and may show an enlarged multicystic ovary associated with ascites. However, the condition usually arises from ovarian hormone stimulation in the setting of infertility. Polycystic ovary syndrome typically presents with menstrual disturbance, obesity and hyperandrogenism

Answer 44

37. c. Krukenberg’s tumour Krukenburg’s tumours are metastatic tumours of the ovary. The colon and stomach are the most common primary tumour sites, but other sites, such as the breast, lung and pancreas, have also been reported. They display characteristic imaging features, including bilateral, sharply marginated oval tumours which preserve the contour of the ovary. Identification of hypointense solid components on T2-weighted imaging corresponding to areas of dense collagenous stroma is also considered characteristic.

Answer 45

38. e. Granulosa cell tumour Granulosa cell tumours are the most common ovarian tumours with oestrogenic manifestations that are classified as sex-cord-stromal tumours. They are subdivided into adult and juvenile types. The juvenile form affects prepubertal children and causes pseudoprecocity. In about a third of cases Sertoli–Leydig cell tumours cause virilisation. Thecomas are oestrogen-producing tumours but more than 80% occur in postmenopausal women. Immature teratomas are extremely rare but do occur in children. Elevated alpha-fetoprotein is found in up to 65% of cases. Sclerosing stromal tumours usually affect women younger than 30 years of age and a few cases have shown androgenic or oestrogenic manifestations. They are also known as hypervascular tumours which show early peripheral enhancement with centripetal progression.

Answer 46

39. a. Hydrosalpinx Hydrosalpinx describes a fallopian tube filled with fluid. The fluid is most often anechoic. When the fluid becomes infected, the term pyosalpinx is used and the fluid contents tend to be echogenic. Hydro/pyosalpinx appear as tortuous, well-defined, fluid-filled, oval-shaped structures which extend from the cornua to the ovaries. They are often mistaken for multicystic adnexal masses or septated ovarian cysts due to apparent internal septations. However, the septa, actually the folded wall of the fallopian tube, do not cross the lumen completely. Hydro/pyosalpinx occur most commonly as a result of acute salpingitis and pelvic inflammatory disease (history of early sexual activity/multiple sexual partners). They have also been reported following pelvic surgery. Tubo-ovarian abscesses tend to be multilocular, irregular, thick-walled, complex masses containing debris and internal septations. Internal fluid-fluid levels or gas may also be seen.

Answer 47

49. c. Haematocolpos Haematocolpos is the accumulation of blood within the vagina and is typically caused by an imperforated hymen. This causes acute-on-chronic lower abdominal/pelvic pain as menstrual blood is prevented from normal discharge (apparent lack of menstruation). Ultrasound reveals an echogenic cystic mass with or without fluid-debris levels in the region of the vagina. The distended vagina often causes displacement of the uterus and compression of the bladder so that the latter may not be visualised. Cloacal malformation is a single perineal orifice for the bladder, vagina and rectum caused by early embryonic arrest. It manifests in the newborn period. Hydrometra is fluid within the uterus and may be due to cervical or vaginal dysgenesis. Rectal duplication cysts may reveal an echogenic cystic mass in childhood but they often present with constipation and faecal soiling.

Answer 48

50. d. An endometrial thickness of 4 mm in a patient using sequential combined HRT An endometrial thickness of 3 mm can be used to exclude endometrial cancer in women who: Have never used HRT, or Have not used any form of HRT for one year, or Are using continuous combined HRT. In the above conditions the post-test risk of a patient having endometrial cancer is 0.6–0.8% when the endometrial thickness is 3 mm but 20–22% when the endometrial thickness is >3 mm. An endometrial thickness of 5 mm can be used to exclude endometrial cancer in women using sequential combined HRT (or having used it within the past year). In this scenario the post-test risk of a patient having endometrial cancer is 0.1–0.2% when the endometrial thickness is 5 mm but 2–5% when the endometrial thickness is >5 mm.

Answer 49

51. a. Endometriosis The ovaries are the most common site for endometriosis, accounting for greater than 80%. Other sites include the uterosacral ligaments, pouch of Douglas, uterine serosal surface, fallopian tubes and rectosigmoid. MRI is more specific than either CT or ultrasound in its detection. Typically, MR demonstrates a homogeneously hyperintense cyst due to the presence of methaemoglobin, which shortens T1. It is also hyperintense on fat-suppressed T2-weighted imaging, which virtually excludes a dermoid cyst. On T2-weighted imaging there may be faint or complete loss of signal. This phenomenon is referred to as ‘shading’ and results from the high protein and iron concentration from recurrent haemorrhage into the endometrioma.

Answer 50

A On post-gadolinium Tlw images, the thickened endometrium enhances less than the adjacent myometrium.

Answer 51

D A left ovarian mass yielding low signal on both Tlw and T2w images Ovarian fibromas have characteristic low signal on both Tlw and T2w sequences, due to the presence of densely packed connective tissue.

Answer 52

B Bilateral endometriomas Theca lutein cysts contain straw-coloured fluid which is low signal on Tlw and high signal on T2w images

Answer 53

A On T2w images, a well-circumscribed myometrial mass that is of lower signal than the surrounding myometrium

Answer 54

A Adenomyosis

Answer 55

E The endometrial cancer demonstrates delayed/little enhancement compared to the normal surrounding myometrium on postcontrast Tlw images

Answer 56

B Enlarged ovaries with multiple peripheral cysts In polycystic ovarian syndrome, the ovaries are enlarged with an echogenic central stroma and more than ten peripherally placed cysts (each less than 9 mm in diameter). Option A describes ovarian hyperstimulation syndrome

Answer 57

D Papillary projections

Answer 58

B Bicornuate uterus

Answer 59

2. D. Adenomyosis. This appears as focal or diffuse thickening of the junctional zone of 12 mm or greater. Thickening of 8–12 mm is indeterminate, while thickening less than 8 mm usually allows exclusion of the disease. The bright foci on T2WI correspond to islands of ectopic endometrial tissue and cystic dilatation of glands, and have been reported to be present in up to 50% of cases of adenomyosis. Occasionally haemorrhage within these areas of ectopic endometrial tissue can result in areas of high signal within the junctional zone on T1WI. Pseudothickening of the junctional zone can mimic adenomyosis. It occurs in the menstrual phase (especially the first 2 days) and thus scanning should not be performed at this time. Myometrial contractions can also mimic adenomyosis, but they result in focal, rather than diffuse, thickening of the junctional zone. The contractions are transient and thus will not persist on different sequences. They can therefore be more easily detected with multiphase–multisection imaging, rather than static fast SE. Neither pseudothickening nor myometrial contractions alone would result in high T2WI foci. The appearances are not consistent with endometrial carcinoma or hyperplasia.

Answer 60

5. C. Fibrothecoma of the ovary. oiOvarian fibroma is the most common sex-cord stromal neoplasm and is almost always benign. Occasionally there will be histologic features of both fibroma and thecoma, giving rise to the term ‘fibrothecoma’. These are typically solid lesions on ultrasound and have marked acoustic shadowing in 18–52% of cases. This shadowing is not secondary to calcification, but is related to marked attenuation of sound by the dense hypoechoic mass itself. This can be a useful sign for identifying fibrothecoma on ultrasound. Classification of ovarian neoplasms is based on histologic features and typically includes the general categories of epithelial, germ cell, sex cord-stromal, and metastatic neoplasms. Cystadenomas/adenocarcinomas belong to the epithelial group of malignancies and make up over 90% of primary ovarian malignancies. Sertoli–Leydig cell tumours, granulosa cell tumours, and fibrothecomas belong to the sex cordstromal group of neoplasms. Sertoli–Leydig cell tumours may be subtle on ultrasound, as many are small and solid. They can secrete androgens and cause virilization. Granulosa cell tumours often have a sponge-like consistency and may produce oestrogen and cause endometrial disease. Dysgerminomas and embryonal cell carcinomas are very rare germ cell neoplasms. The most common germ cell neoplasm is of course a mature cystic teratoma (dermoid cyst). A hyperechoic area (not usually as intensely echogenic as calcification) with acoustic shadowing is highly predictive of this lesion. Hyperechoic lines and dots, sometimes known as the dermoid mesh, are also highly predictive of a mature teratoma. Less common associated signs include a fluid–fluid level and floating globules. Calcification can be seen, but is not specific to dermoids, as other ovarian neoplasms can calcify

Answer 61

7. C. recommend a repeat trans-abdominal ultrasound in 6 weeks’ time. At ultrasound, a functional ovarian cyst is typically anechoic with a thin, smooth wall and posterior acoustic enhancement. Regardless of size, these cysts are unlikely to be malignant. A unilocular cyst greater than 3 cm in a premenopausal or greater than 5 cm in a postmenopausal female patient should be rescanned in approximately 6 weeks (which will usually be at a different stage of the menstrual cycle in the case of premenopausal patients). Premenopausally this is the case, even if there are some internal echoes (but not other findings raising the possibility of malignancy), as these quite often represent haemorrhage within a cyst. In the premenopausal patient, the follow-up scan is to ensure there is reduction in size or resolution of what is usually a benign finding and commonly merely a dominant follicle; in the postmenopausal patient, it is to ensure there is no interim enlargement. If the cyst is smaller than the above dimensions (i.e. <3 cm pre and <5 cm post menopausal) then, in the absence of other sinister findings or history, it can be assumed that the cysts are benign. Sonographic findings which increase the likelihood of malignancy include wall thickening, solid elements, septations, blood flow within solid elements, abnormal blood flow, and findings of metastatic disease. If a cyst displays any of the latter features or increases in size on interval scanning, then options A, B, and D may be valid steps in management

Answer 62

8. B. Renal imaging. Mullerian duct anomalies are associated with renal tract anomalies in up to 30% of cases due to the close embryologic relationship between the Mullerian and mesonephric ducts. The most common renal tract abnormality is renal agenesis. Other associated anomalies include duplicated collecting system, renal duplication, horseshoe kidney, crossed renal ectopy. and cystic renal dysplasia. Renal imaging is therefore essential in all patients with Mullerian duct anomalies. Surgical intervention is not required in patients with a unicornuate uterus and a non-functioning rudimentary horn.

Answer 63

14. B. Gartner duct cyst. Anatomical location is useful in the differential diagnosis of periurethral cysts. A Gartner duct cyst is a retention cyst arising from Wolffian (mesonephric duct remnant). It is typically located in the antero-lateral aspect of the vagina above the level of the pubic symphysis. It is usually solitary and less than 2 cm in size. At MRI, the lesion may appear hypo- or hyperintense on T1WI depending on whether the contents are simple fluid or haemorrhagic/proteinaceous. They do not displace or deform the urethra. A Bartholin cyst is located in the posterolateral aspect of the lower vagina, at or below the level of the pubic symphysis. Skene cysts are located lateral to the external urethral meatus, below the level of pubic symphysis. It may be difficult to differentiate Bartholin and Skene cysts. Urethral diverticula communicate with the urethra whereas periurethral cysts do not. A urethral caruncle manifests as T2 hyperintense soft tissue surrounding the external urethral meatus.

Answer 64

16. D. Referral for surgery. The findings are consistent with a mature cystic teratoma or dermoid cyst. They are derived from all three germ cell layers and thus contain fat and may contain desquamated epithelium, skin, hair, and teeth. The classical finding is of high T1WI signal, which suppresses on fat saturation imaging. They can often have a fat–fluid level. The low signal on T2WI may represent tooth or calcification. Soft-tissue protuberances represent Rokintansky nodules or ‘dermoid plugs’ of sebaceous material. It is the most common ovarian tumour, accounting for 20% of all ovarian neoplasms. Dermoids can be bilateral in 8–25% of cases. The chance of malignant transformation is low but surgical resection is indicated, not just for relief of symptoms, but because of the risk of torsion (in 4–16% of cases) or rupture (the latter is rare but can lead to chemical peritonitis). Adjuvant treatment need not be considered unless the case is complicated by malignant transformation.

Answer 65

33. B. Juvenile granulosa cell tumour. This is a sex cord stromal tumour arising from the granulose-thecal cells. They typically affect prepubescent girls and are unilateral. They are usually hormonally active (secrete oestrogen), resulting in precocious puberty. Granulosa cell tumours have a varied appearance on imaging. They may be completely solid with or without haemorrhagic or fibrotic changes, multilocular solid/cystic, or a completely cystic neoplasm. On T2WI they have a characteristic sponge-like appearance with innumerable cystic areas in a solid lesion of intermediate signal. Inhibin is the tumour marker used to monitor these lesions. Sertoli–Leydig cell tumour is also hormonally active, but it results in virilization and hirsutism. Malignant epithelial neoplasms of the ovaries are extremely rare in prepubertal girls. Mature cystic teratoma is the most common type of ovarian neoplasm in the paediatric age group, containing derivatives of at least two of the three germ cell layers: ectoderm, mesoderm, or endoderm. Fibroma is rare in children.

Answer 66

25. D. Bartholin’s gland cyst. Bartholin’s glands are located behind the labia minora and their ducts open onto the posterolateral vestibules on each side. The cysts are due to blockage of the ducts and retention of secretions. They are common in reproductive age and are usually cystic in appearance (high T2WI signal). Their T1WI signal is variable and can be high due to mucoid content. They are usually discovered as incidental findings on imaging for another cause, although they may be palpable or clinically visible. The radiologist should recognize them as a benign pathology. Primary carcinoma of the vagina is rare, as 80–90% of tumours affecting the vagina are due to extension of primary bladder, cervical, vulval, or rectal tumours. Ninety per cent of primary carcinomas are squamous cell carcinoma. The majority occur in elderly women and the two most common presenting complaints are vaginal discharge and bleeding. Squamous cell carcinomas of the vagina are usually of low T1WI and intermediate T2WI signal. As for vulval and cervical squamous cell carcinoma, human papilloma virus (HPV) infection is a risk factor. Urethral divertcula are best seen on T2WI sequences as hyperintense lesions adjacent to or surrounding the urethra: a connection to the urethra is not always seen. They are usually of low signal on T1WI sequences. They predispose to stones (low signal on T2WI sequences) and carcinoma (enhancing on T1W fat saturation post gadolinium). Nabothian cysts are found at the external os of the cervix. They are benign retention cysts that develop secondary to obstruction of endocervical glands. They have high T2WI signal and may have high T1WI signal due to mucinous content. They are usually multiple and measure less than 2 cm. They become clinically relevant when they are mistakenly diagnosed as adenoma malignum, a subtype of mucinous adenocarcinoma of the cervix. A vaginal septum is a low-signal T2WI band. If transverse, it may present in adolescence with primary amenorrhea and abdominal pain, and an abdominal mass if complete. A longitudinal septum is usually asymptomatic and is associated with duplication of the uterus, cervix, or vagina.

Answer 67

40. A. Krukenberg tumours. The history points towards a GI source, namely gastric carcinoma. Approximately 5–15% of ovarian tumours are metastatic lesions. They are bilateral in 75% of cases. They are often asymptomatic and may present before the primary tumour. They should be considered, along with serous epithelial tumours of the ovary, when bilateral complex ovarian masses are demonstrated. Krukenberg tumours represent ovarian metastases that contain mucin-secreting ‘signet-ring’ cells from colonic or gastric neoplasms. Other primary neoplasms that less commonly metastasize to the ovary are breast, lung, and the contra-lateral ovary (not strictly Krukenberg tumours due to the cell types). Imaging findings in metastatic lesions are nonspecific, consisting of predominately solid components or a mixture of cystic and solid areas. In Krukenberg tumours, there are distinctive findings, including solid components secondary to stromal reaction that are low T2WI and high T1W signal. A Sertoli–Leydig tumour is a sex cord-stromal tumour that occurs in young women (less than 30 years old). It manifests as a well-defined, enhancing solid mass with intra-tumoral cysts. They constitute 0.5% of ovarian tumours. They are rarely bilateral. Dysgerminomas are rare ovarian tumours that occur predominantly in young women. Serum E-HCG is increased in 5%. Calcification may be present in a speckled pattern. Characteristic imaging findings include multilobulated solid masses with prominent fibrovascular septa. They are rarely if ever bilateral. Fibromas are benign solid tumours of the ovary, which are of low signal on T1W and very low signal on T2W sequences. They can be associated with ascites and pleural effusions (Meigs syndrome), and dense calcifications are often seen. Together with fibrothecomas they form a spectrum of benign tumours. Endodermal sinus tumour, also known as yolk sac tumour, is a rare malignant ovarian tumour that usually occurs in the second decade of life. These tumours manifest as a large, complex pelvic mass that extends into the abdomen and contains both solid and cystic components. They are rarely bilateral. They grow rapidly and have a poor prognosis. Affected patients have an elevated serum alpha feta protein.

Answer 68

51. C. Uterine leiomyomas. Also known as uterine fibroids, these are very common. They are usually of low signal on T2WI and intermediate signal on T1WI. Benign metastasizing leiomyoma is an unusual variant, with tumours in the lungs, lymph nodes, or peritoneal nodules, not uncommonly from a benign uterine fibroid, which has been removed many years earlier. Malignant transformation to leiomyosarcoma is very rare and it is thought the latter may arise de novo even in the presence of leiomyomas. Endometrial sarcoma might produce peritoneal metastases, but would be expected to show a large heterogenous mass with indistinct or irregular borders arising from the endometrial canal. Endometriosis and adenomyosis are diseases of the reproductive years. Metastases to the uterus are rare and if present represent advanced malignancy. There is usually diffuse enlargement of the myometrium, which can be of low or high signal.

Answer 69

68. C. Adenomyosis. This is a condition in which the endometrium extends into the myometrium in either a diffuse or a focal distribution. It generally manifests as pelvic pain or abnormal bleeding. It is more commonly detected on MR imaging as thickening of the junctional zone or on ultrasound as diffuse or focal heterogenous myometrium. On HSG, adenomyosis appears as small diverticula extending from the endometrial cavity into the myometrium. Salpingitis isthmica nodosa appears as small outpouchings from the isthmic portion of the fallopian tube. Multiple uterine synechiae (linear filling defects in the uterine cavity) associated with infertility is known as Asherman syndrome. Polyps would appear as filling defects on HSG.

Answer 70

56. B. Multiple small peripheral rounded high T2WI signal areas with hypointense central stroma in both ovaries. The clinical features suggest polycystic ovarian syndrome (PCOS). The diagnosis is based on hormonal imbalance and patients often show an abnormality in the ratio of luteinizing hormone to follicle stimulating hormone. The MRI findings are those described, with multiple small peripheral cysts with low signal central stroma. MRI is not specific or sensitive, and 25% of patients with PCOS can have normal appearing ovaries. Multiple small, T2WI hyperintense cysts have been seen in patients with anovulation, medication-stimulated ovulation, or vaginal agenesis. The other descriptions are associated with infertility, but not particularly hirsutism or obesity. Option A describes bilateral hydrosalpinx. Option D describes a unicornuate uterus, which is associated with the poorest foetal survival among all uterine anomalies. Option E describes adenomyosis and using a junctional zone thickness of 12 mm or above optimizes the accuracy of MRI for this diagnosis.

Answer 71

61. B. Tamoxifen therapy. The normal endometrial stripe is of high T2WI signal and measures 3–6 mm in diameter in the follicular phase and 5–13 mm in the secretory phase. The description of the endometrium in this case is consistent with endometrial hyperplasia, but there is in addition myometrial enlargement. An enlarged uterus is frequently encountered in the presence of endogenous or exogenous hormonal abnormalities. In these cases the uterus usually has normal zonal anatomy, although the signal intensity of the endometrium and myometrium is abnormally increased. However, with tamoxifen, the uterus can display marked zonal anatomy distortion. It is a weak oestrogen agonist and can result in endometrial hyperplasia, polyps, and carcinoma. The findings of multiple cysts or lattice-like enhancement of the endometrium post contrast are encountered frequently in relation to tamoxifen therapy and favour a benign diagnosis. IUCDs are widely used for contraception. A study has found that the IUCD-bearing uterus is enlarged. IUCD placement most likely results in myometrial hypertrophy. The associated findings are symmetrical globular enlargement of the uterine corpus, cervical elongation and enlargement, and diffuse or localized myometrial thickening. The IUCD will usually be seen as a band of low signal intensity within the endometrium. The uterus is rarely the primary site for lymphoma, but when it does occur, the most common manifestation is diffuse symmetrical uterine enlargement with relatively high signal on T2WI and epithelial preservation: the endometrium is usually normal. The myometrium will also lack its standard zonal appearance. There will almost always be associated lymphadenopathy. Endometrial stromal sarcoma invariably exhibits myometrial involvement. Imaging will typically show a large mass that replaces the endometrial cavity and infiltrates the myometrium: at the very least the endometrial-myometrial border will be obscured. Myometrial involvement is commonly so extensive that a myometrial component predominates. Bands of low signal may be present within the area of myometrial invasion and these correspond to preserved bundles of myometrium at histologic examination. Extension along the vessels, fallopian tubes, or ligaments is another characteristic of the tumour. Pelvic congestion syndrome involves symptoms, including chronic pelvic pain, that are associated with dilated ovarian veins and pelvic varices resulting from left renal vein reflux. This results in a thickened myometrium containing multiple large signal voids, the latter corresponding to engorged arcuate vessels. Additional findings include varicose veins around the uterus and ovaries with retrograde filling of ovarian veins.

Answer 72

68. C. Intercornual distance of more than 4 cm. Incomplete fusion of the Mullerian ducts results in bicornuate uterus. MRI demonstrates divergent uterine horns with an external fundal cleft that is more than 1 cm deep and an intercornual distance of more than 4 cm. In bicornuate bicollis uterus, two separate cervical canals are seen. This is distinguished from uterus didelphys by a greater degree of fusion between the horns in the lower uterine segment. Septate uterus results from incomplete septal resorption following Mullerian duct fusion. It is the most common uterine anomaly (55%). At MRI, the external fundal countour may be convex, flat, or minimally concave (less than 1 cm deep). MRI is also useful in characterizing the type (fibrous/ muscular) and extent of the septum. Differentiation between bicornuate and septate uterus is important, as septate uterus is amenable to surgical management.

Answer 73

69. A. Uterus didelphys. This is caused by complete failure of fusion of the paramesonephric ducts, resulting in a completely duplicated system (two uterine cavities and two cervices) with no communication between the two cavities. It is associated with complete or partial vaginal septum in 75% of cases, which can result in obstruction and haematometrocolpos. Ipsilateral renal agenesis is associated with a vaginal septum. Bicornuate uterus is caused by partial fusion of the paramesonephric ducts. Bicornuate bicollis uterus demonstrates a septum extending from the fundus to the external os, but some degree of communication remains between the two horns. Septate uterus is the most common mullerian/paramesonephric duct anomaly. It is also the most common anomaly associated with infertility and recurrent miscarriage. A complete or partial septum divides the uterine cavity, but there is no fundal cleft. Arcuate uterus is associated with a small indentation in the fundal endometrial canal but the external contour is normal. It has no pathological consequence and is considered by some to be a normal variant.

Answer 74

73. A. Enlarged ovary. Ovarian torsion can occur in all age groups, with the highest prevalence in the reproductive age group. Large heavy cysts and cystic neoplasms commonly predispose to ovarian torsion. Torsion of normal ovaries is unusual but more common in adolescents. Clinical symptoms are often nonspecific c and therefore imaging is routinely requested. On ultrasound, an enlarged ovary is the most constant finding. The enlarged ovary may be heterogenous due to haemorrhage and oedema. Other findings include multiple small cysts aligned in the periphery of the enlarged ovary (string of pearls sign), coexistent mass, pelvic free fluid, and twisted ovarian pedicle. Benign cystic teratoma is the most common tumour predisposed to ovarian torsion. Absent arterial flow is described as the classic colour Doppler finding. However, the most frequent Doppler finding is decreased or absent venous flow with or without reduced arterial flow. A twisted ovarian pedicle with a ‘ whirlpool’ sign is a useful finding on colour Doppler.

Answer 75

66. D. Minimal deviation adenocarcinoma of the cervix. This is also known as adenoma malignum and, as in this scenario, is often associated with Peutz– Jeghers syndrome (characterized by mucocutaneous pigmentation, multiple hamartomatous polyps of the GI tract, and mucinous tumours of the ovary). Adenoma malignum makes up about 3% of adenocarcinoma of the cervix. Its MRI appearances are as described in the question, but the differential diagnosis includes deep nabothian cysts, florid endocervical hyperplasia, and even well-differentiated adenocarcinoma. It disseminates into the peritoneal cavity even in the early stage of the disease and its response to radiation or chemotherapy is poor. Cervical squamous carcinoma makes up to 90% of cervical carcinoma. The tumour is of high signal compared to the hypointense cervical stroma, but not cystic as in our vignette. It advances predominantly by direct extension and local spread; haematogenous dissemination is only occasionally seen in the form of hepatic metastases. Carcinoid tumour of the cervix is a subgroup of small cell carcinoma of the cervix. It cannot be differentiated from squamous cell carcinoma of the cervix on MRI findings. Malignant melanoma of the female genital tract accounts for 1–5% of all melanomas. It usually occurs in the vaginal mucosa and occasionally involves the cervix. Malignant melanoma arising in the cervix is very rare (only about 30 reported cases). There is usually high signal intensity on T1WI. The incidence of cervical pregnancy has been increasing, possibly due to the increased number of induced abortions. Reported risk factors include multiparity, prior cervical surgical manipulation, cervical or uterine leiomyomas, atrophic endometrium, and septate uterus. The major symptom is painless vaginal bleeding. At MR it is characterized by a mass with heterogenous signal intensity and a partial or complete dark ring on T2WI sequences. As it contains haematoma, it often consists of some high signal on T1WI.

Answer 76

75. B. Endometriotic cyst. Also known as a chocolate cyst, the methaemoglobin within the lesion causes T1 shortening, resulting in increased signal on the T1WI sequence. This high signal remains and becomes more conspicuous on the T1WI with fat saturation sequence. Endometriosis is characterized by the presence of tissue resembling endometrium outside the uterus. The ovaries are the most commonly involved site, and endometriotic cysts usually have a thick fibrotic wall with chocolate-coloured hemorrhagic material. An endometriotic cyst may be high or low signal on T2WI sequences. Chronic cyclical haemorrhage and increased viscosity of the cyst material will produce T2 shortening, leading to the low signal, or ‘T2 shading’. The patient usually presents with cyclical pain. The cysts have a propensity for multicentric growthand are often associated with fibrous adhesions. These latter features increase the MR sensitivity. Small peritoneal implants of endometriosis may be identified elsewhere and their conspicuity is increased by the use of fat saturation techniques. Endometroid and clear cell carcinoma of the ovary are malignancies associated with endometriosis and these represent 17.5 and 7.4% of ovarian carcinomas, respectively. Chocolate cysts with multiple locules, mural foci, or nodules within the cyst are suspicious for malignancy and contrast should be administered if this appearance is seen. The findings in this question are not consistent with a follicular cyst, which would show low T1WI and high T2WI signal. Brenner tumours show low T2WI signal due to their abundant fibrous content and calcification, but also low T1WI signal. Fibrothecomas show intermediate T1WI signal and usually low (although sometimes it can be mixed high and low) T2WI signal. They sometimes show associated uterine enlargement, as they may be oestrogenic.

Answer 77

25 Answer B: CT followed by biopsy In a patient with a clinical history, ultrasound findings and CA-125 level consistent with ovarian carcinoma, a staging CT examination should be the next investigation. As well as staging the patient this will also need a guided biopsy. Omental biopsy can be undertaken percutaneously via ultrasound or CT guidance but ovarian disease biopsy would usually have to be performed surgically. MRI of the pelvis is used in the investigation of an adnexal mass which is not definitely ovarian in origin as a problem-solving tool.

Answer 78

26 Answer D: Peritoneal metastases FIGO Staging of Ovarian Carcinoma Answer (a): FIGO stage IC Answer (b): FIGO stage IIA Answer (c): FIGO stage IIC Answer (e): FIGO stage IV

Answer 79

27 Answer A: Endometrioma Although ultrasound appearances can be variable approximately 95 % of endome- triomas demonstrate the above findings. They may be unilocular or multilocular with thick or thin septae. Rarely, they are anechoic, mimicking a functional ovarian cyst.

Answer 80

28 Answer B: Ovarian fibroma Endometriosis is typically high signal on routine and fat-saturated Ti sequences due to methaemoglobin. Similarly, a haemorrhagic mass would be expected to be bright on T1. Dermoids often contain fat which is high signal on routine Ti sequences and mucinous lesions can also be high signal but not as high as the Ti signal of fat and blood

Answer 81

29 Answer E: Aching muscles Occurrence in surgical scars, particularly after gynaecological surgery, is recognised. Catamenial pneumothorax occurring at the onset of menses as well as haemothorax and lung nodules can occur in the chest. In the bladder endometrial deposits can cause haematuria and often biopsy is required for definitive diagnosis. Malignant transformation is rare (<1 %) and 75% of the malignancies arise from endometriosis of the ovary

Answer 82

30 Answer C: Cervix Normal FDG activity is seen in brain, myocardium, liver, spleen, bone marrow, GI tract, testes and skeletal muscle. In the pelvis pitfalls of sites of increased uptake include cyclical uptake in the endometrium and ovaries, renal collecting system (ureters and bladder) and the blood pool.

Answer 83

31 Answer D: Pelvic ultrasound examination after six weeks Functional cysts are common, and benign features on ultrasound include unilocular thin-walled cysts with no solid component. If the cyst is larger than 3 cm, follow-up ultrasound at a different time in the menstrual cycle is recommended to ensure resolution.

Answer 84

32 Answer A: Endometrial.

Answer 85

34 Answer D: Hypertension Nulliparity is a risk factor as is unopposed oestrogen therapy and obesity.

Answer 86

35 Answer C: Referral to gynaecologist for Pipelle biopsy or hysteroscopy Measurement of endometrial thickness post menopause: in a patient not on HRT <5 mm homogeneously echogenic, in a patient on HRT <8 mm. In premenopausal patients: menstrual phase (1-4mm), proliferative phase (5-7mm), periovulatory phase (up to 11 mm) and secretory phase (up to 16 mm). There are alternative diagnoses that increase endometrial thickness such as endometrial polyps and endometrial hyperplasia and therefore radiological staging is performed once there is a histological diagnosis.

Answer 87

36 Answer C On T2-weighted images three distinct layers can be seen: the endometrium is high signal, junctional zone is low signal and myometrium medium signal. On T1-weighted images the uterus is medium to low signal intensity

Answer 88

37 Answer B: II FIGO staging of endometrial carcinoma is stage II for cervical invasion irrelevant of the depth of myometrial invasion.

Answer 89

24 Answer C: Septate uterus Uterine anomalies are due to failure of fusion of Mullerian duct. Arcuate uterus is the most common uterine anomaly not associated with reproductive failure. Septate uterus is associated with 90% abortion rate which can be treated with excision of the septum.

Answer 90

25 Answer D: Hypointense rim of cervical stroma A continuous hypointense rim representing the cervical ring measuring >3 mm is most reliable in excluding parametrial invasion with a quoted specificity of 96-99%. Nodularity and thickening of the parametrial tissue are signs of frank invasion.

Answer 91

27 Answer C: Distinct hypointense transient bulge in the myometrium on T2 -weighted images Transient areas of low signal in the myometrium are a recognised pitfall in the diagnosis of adenomyosis and reflect myometrial contraction. These areas can also be mistaken for leiomyomas.

Answer 92

28 Answer B: Parametrial invasion FIGO staging of cervical carcinoma. Stage IA - preclinical invasive carcinoma, stage IB - 1 < 4 cm, stage IB - 2 >4 cm, stage IIA - vaginal extension excluding lower third vagina, stage IIB – parametrial invasion, IIIA - invasion of lower third vagina, stage IIIB - pelvic side wall invasion and hydronephrosis, stage IVA - invasion bladder/rectum, stage NB - distant organ spread.

Answer 93

29 Answer A: Epithelial ovarian carcinoma The radiological findings are consistent with a malignant lesion and CA-125 levels are not raised in 20% of malignant ovarian cancers. CA-125level is raised in 60% for mucinous type, 20% for nonmucinous. In benign processes such as fibroids, pregnancy, endometriosis, liver cirrhosis, pancreatitis and PID raised in 30%. Raised in 1 % of normal individuals

Answer 94

30 Answer A: Right ovarian thrombosis This is the typical clinical scenario for ovarian vein thrombosis, which is an important differential to consider as it has a mortality of 5%. Eighty per cent occur in right ovarian vein, 14% bilateral and only 6% in left ovarian vein. On CT a tubular structure is seen of low density in the location of the vein.

Answer 95

35 Answer D: Torsion of the ovary A pre-existing ovarian lesion is present in torsion in >50% of cases. The appearances on ultrasound are of a complex mass and Doppler ultrasound may demonstrate absence of arterial Doppler waveforms, but this should not be relied upon due to the dual blood supply from both ovarian and uterine arteries. Immediate surgery is indicated in these cases.

Answer 96

36 Answer B: A `ground-glass' pattern Haemorrhage into a functional cyst is common and can produce echogenic material within the cyst without Doppler signal.

Answer 97

37 Answer C: Rapid change in size Malignant transformation is rare (approximately 0.2%) and is very difficult to interpret given the variable appearances and signal characteristics of benign leiomyomas. A rapid increase in size, irregular margin and loss of outer capsule are concerning. High signal on T2-weighted images is seen in cystic degeneration. Low signal on T2-weighted images is seen in hyaline or calcific degeneration.

Answer 98

38 Answer A: Fat density on plain film Mature teratoma (dermoid) is the most common ovarian neoplasm and is benign. It contains mature tissue from all three germ cell layers with 88% of cases containing sebaceous material. Calcifications (tooth) can be seen but are also seen in other germ cell tumours whereas fat on plain film is specific.

Answer 99

20 Answer B: Haematocolpos Imperforate hymen at puberty may cause haematocolpos which distends the vagina with blood causing low-level echoes on ultrasound examination.

Answer 100

22 Answer C: Multiple further lesions in the pelvis Multiplicity, multilocularity and adhesions to other organs are features that may distinguish endometriomas. They may also have a hypointense thick wall.

Answer 101

23 Answer E: Vessel visualised within stalk on colour Doppler Seventy-nine per cent of endometrial polyps have the appearance of a welldefined smooth hyperechoic homogeneous intracavitary mass but the diagnosis can be confusing particularly if there is heterogene ty

Answer 102

24 Answer A: Adult granulosa cell tumour Adult granulosa cell tumour is the most common oestrogenic tumour

Answer 103

25 Answer B: Hypointensity on T2-weighted images Cervical carcinoma is hyperintense on T2-weighted images but non-degenerated leiomyomas are low signal.

Answer 104

27 Answer E: Low signal on T2-weighted images Fibroids have variable appearances on ultrasound but are commonly hypoechoic and can distort the uterine cavity when large. The typical appearances on MRI examination are well defined areas which are low signal on T2-weighted images and are isointense to myometrium on T1-weighted images. The appearances are variable if there is haemorrhage or cystic degeneration

Answer 105

30 Answer C: Bartholin's gland cyst Bartholin's glands are located behind the labia minora and their ducts can become blocked. This can cause retention of secretions and is most common in women of reproductive age.

Answer 106

31 Answer A: High signal on T1-weighted images Melanin has a paramagnetic effect causing shortening of Ti relaxation time and therefore is high signal on T1-weighted images and low signal on T2-weighted images.

Answer 107

32 Answer B: Bilateral disease Female genital tuberculosis causes salpingitis in 94% and is mostly bilateral. It can also cause tubo-ovarian abscess with extension into extraperitoneal compartment.

Answer 108

2. (a) Ovarian dermoid This is a germ cell tumour which contains skin and dermal appendages. These are diagnosed by characteristic ectodermal contents of hair, teeth fat and bone. Identifcation of a sebum-fluid level and calcifcation is diagnostic. There is risk of malignant degeneration, torsion and rupture.

Answer 109

5. (b) Endometriosis Endometriosis can be found in surgical scars or needle tracts. Most cases of subcutaneous endometriosis occur in Pfannenstiel incisions. Abdominal wall endometriosis is thought to occur in up to 1% of cases. Clinically it presents as a cyclical painful lump and c n arise many years after surgery.

Answer 110

6. (b) Carcinoma of the cervix Cervical carcinoma typically presents with bleeding and pelvic pain. MRI is the imaging of choice which shows high signal on T2 images

Answer 111

8. (c) Bilateral hydrosalpinx This is usually a result of continuous secretion of the tubal epithelium into the lumen of a fallopian tube obstructed at two sides. Ultrasound shows undulating or folded tubular structures which are extraovarian. This may be secondary to endometriosis, adhesions, infection, tubal surgery or ectopic pregnancies

Answer 112

9. (d) Endometrioma MRI is highly sensitive and specifc in the diagnosis of endometrioma. The endometrioma returns high signal on T1 and T2 and STIR sequences due to blood products. On ultrasound the lesion may show diffuse homogenous low-level internal echoes (haemorrhagic debris). Other features may include septations or echogenic material suggesting a clot.

Answer 113

10. (d) Luteal phase Immediately after menstruation, the endometrium is 1–4 mm thick. In the proliferative phase the endometrium increases to 7–10 mm. It measures 8–12 mm in follicular phase and in the luteal phase it becomes echogenic throughout with a thickness of 8–16 mm.

Answer 114

11. (c) Uterus didelphys This has complete duplication, with two vaginas, two cervices and two uterine horns. Bicornuate uterus has a fundal cleft with the septum between the two uterine cornua comprised of myometrium. Each uterine horn has a biconvex shape with lateral convex margins. Septate uterus is the most common type of uterine anomaly with a fbrous septum dividing the uterine cavity and the endocervical canal. The fundal contour is convex or flat. Uterine arcuatus show no division of the uterine horns and have a single uterine canal with a saddle shaped fundus on hysterosalpingography.

Answer 115

12. (c) Endometrial carcinoma Endometrial carcinoma is the fourth most common female cancer, with a peak between 55 and 65 years. In postmenopausal women endometrial thickness more than 5 mm should be investigated for endometrial carcinoma. Sarcomas are rare in this age group.

Answer 116

13. (c) Carcinoma of the cervix Cervical carcinoma is high signal as compared to fbrous cervical stroma on T2 and enhances with contrast.

Answer 117

14. (c) Ovarian carcinoma Malignant ovarian tumours commonly have solid and cystic components. The solid component has neovascularisation demonstrating a characteristic waveform with a low resistive index.

Answer 118

15. (d) Asherman’s syndrome Synechiae or intrauterine adhesions were described by Asherman and are usually a result of uterine curettage or evacuation of retained products of conception. The hysterosalpingogram fndings are diagnostic

Answer 119

24. (b) Adenomyosis This is the presence of endometrial tissue within the myometrium with secondary smooth muscle hypertrophy/hyperplasia. MRI features are typically as described in the fndings. Foci of high signal on T1 represent endometrial rests and/or haemorrhages.

Answer 120

34. (c) Stage T2b Stage 1 lesions are confned to cervix. Stage 2a lesions involve the vagina, while T2b tumours invade the parametrium as well. Stage 3 lesions involve the lower third of vagina and/or the lateral pelvic wall. Stage 4 tumours are seen to invade other surrounding organs such as the bladder and rectum.

Answer 121

35. (b) Stein–Leventhal syndrome Also known as polycystic ovary disease, patients may have reduced fertility, hirsutism, obesity and menstrual irregularities. The ovaries are generally enlarged with multiple small follicles measuring less than 10 mm, usually subcapsular

Answer 122

36. (c) Menstruation Ongoing bleeding at the time of examination is an absolute contraindication to hysterosalpingography. It increases the risk of infection, and risks flushing endometrial tissue into the abdomen. Recent tubal surgery within last 6 weeks is also a contraindication for this procedure. Other contraindications include pregnancy, immediate pre- and post-menstrual phases, recent untreated pelvic infection and contrast allergy.

Answer 123

41. (a) Vaginal foreign body This is a very common cause of vaginal bleeding in pre-pubertal girls. Other causes include vaginal rhabdomyosarcoma, precocious puberty, haemangioma and vascular malformation.

Answer 124

42. (c) Ovarian dermoid Fibrous lesions in the adnexa are of low signal intensity on MRI. Ovarian dermoids return high signal because of their fat content, with signal drop-out on fat suppression images. Other causes of lesions which may return high signal on T1 include endometrioma, mucinous cystic neoplasm, haemorrhagic cysts and ovarian carcinoma.

Answer 125

Answers: (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Correct Explanation: In leiomyomas (fibroids) cystic degeneration is rare, seen only in 4 % cases. Calcification is seen associated with red degeneration, and is typically scattered and amorphous marking the site of hyaline degeneration.

Answer 126

Answers: (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Correct Explanation: Bartholin’s cyst occurs in posterolateral wall of lower third of vagina. Mucous retention within endocervical glands is known as nabothian cyst and can be seen in any wall of cervix. 40% cases of unicornuate uterus is associated with renal and ureteric anomalies

Answer 127

Answers: (a) Not correct. (b) Not correct. (c) Correct. (d) Not correct (e) Not correct. Explanations: The cysts are typically subcapsular in polycystic ovaries with central stroma showing increased echogenicity. In 25% cases ovaries are hypoechoic with no demonstrable follicle. The ovaries are bilaterally enlarged (more than 14 cm3) in 70% cases and of normal size in 30% cases. There is increase in ratio of luteinising hormone to follicular stimulating hormone resulting in immature follicles. Trophoblastic disease typically causes hyperstimulation of ovaries with multiseptated cysts secondary to increased HCG levels.

Answer 128

Answers: (a) Not correct (b) Correct (c) Not correct (d) Not correct (e) Correct Explanation: Endometrial cancer is the most common gynaecological malignancy. CA-125 is not specific for ovarian cancer, it is increased in benign conditions like fibroids, endometriosis and inflammatory pelvic disease. CT only has a pre-operative staging accuracy of 70% - 90%.

Answer 129

Answers: (a) Not correct. (b) Correct. (c) Correct (d) Not correct (e) Not correct Explanation: Mature Teratomas are unilocular. Sebaceous fluid has high signal on T1WI. Calcification outside the mural nodule is suspicious of malignancy.

Answer 130

Answers: (a) Correct (b) Not correct (c) Correct (d) Correct (e) Correct Explanation: 0.1% to 0.5% women of reproductive age are affected by congenital abnormalities of uterus. Approximately 25% of patients with anomaly have sub-fertility

Answer 131

Answers: (a) Correct (b) Correct (c) Correct (d) Not correct (e) Not correct Explanation: On MRI adenomyosis and leiomyoma have overlapping features. Features favouring adenomyosis are: 1) poorly defined borders 2) oval shaped lesion along endometrium 3) minimal mass effect on endometrium relative to size of lesion 4) linear striations perpendicular to endometrium radiating into myometrium 5) absence of large feeding vessels.

Answer 132

Answers: (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Not correct Explanation: The paracervical, parametrial, obturator and iliac nodes are involved first. Later there is spread to the common iliac and para-aortic nodes with worse prognosis. The adrenal glands is next common solid organ involvement after liver. The kidneys and pancreas are involved rarely. The recurrent tumour commonly involve the rectum and recto-vaginal fistula may develop.

Answer 133

Answers: (a) Correct (b) Correct (c) Not correct (d) Correct (e) Correct Explanation: In the ovary cancer, lymph node spread is typically along the path of the gonadal vessels to the para-aortic nodes and along the parameterial channels to the external iliac and hypogastric group.

Female reproductive system Flashcards

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