La diagnostica ecografica delle masse ovariche

Transcription

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
leone.francesco@hsacco.it
Metodologia
Definizione massa ovarica
Screening Ca Ovaio
Valutazione pre-operatoria
Endometriosi
Teratoma
Ca Ovaio
Metodologia
Screening Ca Ovaio
Endometriosi
Teratoma
Ca Ovaio
anamnesi
visita
Semeiotica ginecologica
Courtesy of P.Catapano
EcoTV
TVS: L’alta frequenza …
high resolution
wideband (3-9 MHz) endocavitary probe
high accuracy
Semeiotica ecografica ginecologica
Courtesy of P. Catapano
Metodologia dello studio ecografico della pelvi femminile
Il primo tempo di
esecuzione
dell’esame
prevede una
profondità e una
focalizzazione utile
a visualizzare
tutta la pelvi
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: ovaio - mobilità e dolenzia
….possibilità di eseguire con enorme semplicità manovre di
mobilizzazione degli organi e di identificazione dei punti di
massima dolenzia….
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: sigma-retto
La valutazione del sigma-retto…
Esame organ oriented: peritoneo
La valutazione del peritoneo viscerale…
aderenze (“spider in a web”, “flapping sail”)
dolorabilità “push&pull manoeuvres”
Strumentazione e tecnologia: sonovaginografia
evidenzia noduli endometriosici
del setto retto-vaginale
J Ultrasound Med
Feasibility 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 tertiary
consultation (second opinion).
2mm slices
Metodologia
Screening Ca Ovaio
Endometriosi
Teratoma
Ca Ovaio
Analisi macroscopica
Analisi microscopica
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)
Subjective assessment (n=300)
100
A, B (= 5,00010,000 TVS)
90
80
Sensitivity
70
D, E, F (= 200300 TVS)
60
Accuracy
D,E,F= 82-86%
C
= 89%
A,B = 92%
50
C (= 1,000 TVS)
40
30
20
10
0
False positive rate
0
20
40
60
80
100
Timmerman „99
Logistic regression model
Papillarities >3mm
(0,1)
Color score
(1,2,3,4)
~Probability
of cancer
Menopause
(0,1)
CA 125
(1 - 31 090)
“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
Qualitative assessment of morphology
Unilocular cyst
Multilocular cyst
Unilocular-solid cyst
Multilocular-solid cyst
Solid
Cystic contents

Anechoic

Low-level echogenicity

Ground glassappearance

Haemorrhagic

Mixed
Measurement and quantitative assessment of
morphology
• Lesion
The 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 projection
The largest projection is measured in height and base. The number
of separate papillary projections and whether blood flow can be
detected.
• 1 : no flow
Color score
• 2 : minimal flow
• 3 : rather strong flow
• 4 : very strong flow
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
% of malignancy
IOTA 2005
Unilocular cyst
0.5-1%
Multilocular cyst
10%
Unilocular-solid cyst
37%
Multilocular-solid cyst
43%
Solid
65%
Sensitivity 95%, specificity of 91%. LR+ = 10.45 LR− = 0.06.
The rules were applicable in 76% of the tumors.
Nuove strategie?
Mezzi di contrasto endovascolari
Endometrioma
Ecografia transvaginale 3-D
Rendering
Color Rendering  Branching of vessels
VOCAL
Metodologia
Screening Ca Ovaio
Endometriosi
Teratoma
Ca Ovaio
http://www.pnlg.it/
Metodologia
Screening Ca Ovaio
Endometriosi
Teratoma
Ca Ovaio
“Il primo grande amore non dura tutta la vita
ma la cambia per sempre.”
Claudio Baglioni
Valutazione ombelicale
Valutazione pelvica
Metodologia
Screening Ca Ovaio
Endometriosi
Teratoma
Ca Ovaio
Endometriosi ovarica
International Ovarian Tumour Analysis (IOTA)
Sonographic assessment of morphology: qualitative classification
typical
Sonographic assessment of morphology: cystic contents
typical
:::::::
:::::::
:::::::
:::::::
Anechoic
Low level
Ground glass
Hemorrhagic
Mixed
Typical endometrioma
 Unilocular cyst with regular internal wall
 Ground glass appearance (homogeneously dispersed echogenic)
cystic contentleone.francesco@hsacco.it
Typical endometrioma
 Blood flow score 1-2 (no or only minimal flow)
Sonographic assessment of morphology: cystic contents
atypical
:::::::
:::::::
:::::::
:::::::
Anechoic
Low level
Ground glass
Hemorrhagic
Mixed
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)
Endometriosi posteriore
Endometriosi posteriore: legamenti utero-sacrali
legamento
utero-sacrale dx
legamento
utero-sacrale dx
sigma-retto
Endometriosi posteriore: sigma-retto
Endometriosi posteriore: sigma-retto
Intestinal endometriosis @ 3DTVS-VCI
Intestinal endometriosis @ LPS
Intestinal endometriosis @ LPS
“pulling-out sign”
Courtesy of Valentino Remorgida & Simone Ferrero
Bromley B. et al., J Ultrasound Med 2000
a mottled inhomogeneous myometrial texture
globular appearing uterus
small cystic spaces within the myometrium
a "shaggy" indistinct endometrial
stripe
… diffuse adenomyosis
Reinhold C. et al., Radiology 1995
… focal adenomyosis
cystic spaces within the myometrium
persistent, irregular, slightly dilated radial uterine vessels
increased microvessel density in adenomyosis uteri
Perrot N. et al., UOG 2001
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 - f.leone@hsacco.it
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 ureterovesical junction. A LNG-IUS was inserted. At 8 months follow-up, the patient
persisted free of symptoms.
8Fr
14Fr
1
a
2
b
Conclusion: Accurate diagnosis by TVS of deep infiltrating
endometriosis may permit a conservative medical treatment
based on LNG-IUS.
3
Metodologia
Screening Ca Ovaio
Endometriosi
Teratoma
Ca Ovaio
Metodologia
Screening Ca Ovaio
Endometriosi
Teratoma
Ca Ovaio

La diagnostica ecografica delle masse ovariche

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