malignant diseases of uterus and vagina.pptx

Uterine cancer is a general term that describes cancer in your uterus:

Endometrial cancer develops in the endometrium, the inner lining of your uterus. It’s one of the most common gynecologic cancers — cancers affecting your reproductive system.
Uterine sarcoma develops in the myometrium, the muscle wall of your uterus. Uterine sarcomas are very rare.
Are endometrial cancer and uterine cancer the same?
Uterine cancer can refer to either endometrial cancer or uterine sarcoma. But people often consider the terms “endometrial cancer” and “uterine cancer” the same. That’s because endometrial cancer makes up about 95% of all cases of uterine cancer. A diagnosis of uterine sarcoma is rare.

What does the uterus do?
The uterus is part of the reproductive system of women and people who are assigned female at birth (AFAB). It’s where a fetus develops during pregnancy.

The top part of your uterus is called the body or corpus. At the end of your uterus is your cervix, which connects your uterus to your vagina. Uterine cancer refers to cancer in the body of your uterus. Cancer in your cervix — cervical cancer — is a different type of cancer.

What does the endometrium do?
The endometrium is the inner layer of your uterus. It changes during your menstrual cycle.

Hormones called estrogen and progesterone cause the endometrium to thicken in case of pregnancy. If no pregnancy occurs, your body produces less progesterone which causes the endometrial lining to shed. That’s when periods take place.

How common is uterine cancer?
In the United States, endometrial cancer is the most common cancer affecting the reproductive system of women and people AFAB. Endometrial cancer mainly develops after menopause. About 3% of women and people AFAB will receive a diagnosis of uterine cancer at some point during their lives. Each year, about 65,000 people receive a diagnosis.

Symptoms and Causes


Risk factors for uterine cancer.
What are the symptoms of uterine cancer?
Signs of uterine cancer can resemble those of many conditions. That’s especially true of other conditions affecting reproductive organs. If you notice unusual pain or irregular vaginal bleeding, talk to your healthcare provider. An accurate diagnosis is important so you can get the proper treatment.

Symptoms of endometrial cancer or uterine sarcoma include:

Vaginal bleeding between periods before menopause.
Vaginal bleeding or spotting after menopause, even a slight amount.
Lower abdominal pain or cramping in your pelvis, just below your belly.
Thin white or clear vaginal discharge if you’re postmenopausal.
Extremely prolonged, heavy or frequent vaginal bleeding if you’re older than 40.
What causes uterine cancer?
Researchers aren’t sure of the exact cause of uterine cancer. Something happens to create changes in cells in your uterus. The mutated cells grow and multiply out of control, which can form a mass called a tumor.

Certain risk factors can increase the chances you’ll develop uterine cancer. If yo

1. MALIGNANT DISEASES OF UTERUS AND VAGINA SCROTAL DISEASES DR. SHIVANGI LAHOTY

2. UTERINE MALIGNANCIES Normal T2 zonal anatomy T2-weighted MRI sequence can distinguish the three layers of the uterus. • Endometrial stripe: T2 hyperintense (glandular) • Junctional zone (first zone of myometrium): T2 hypointense. • Outer myometrium: Relatively T2 hypointense, although less so than junctional zone.

3. ENDOMETRIUM Endometrial thickness The thickest portion of the endometrium should be measured transvaginally. Information about the last menstrual period is critical to adequately evaluate the endometrium. Ideally, the endometrium should be measured in the menstrual phase.

4. ENDOMETRIAL CANCER Endometrial carcinoma is the most common female gynecologic malignancy and is thought to be caused by prolonged estrogen exposure . Specific risk factors include nulliparity, hormone replacement therapy (HRT), and tamoxifen. In patients with postmenopausal bleeding , endometrial thickness ≥5 mm requires further workup (usually biopsy and/or hysteroscopy). For patients on HRT, postmenopausal bleeding with endometrial thickness ≥8 mm requires further workup. This cutoff accounts for effects of HRT on endometrial proliferation. Without bleeding, endometrium thickness ≥8–11 mm requires workup. Although uncommonly seen in the absence of bleeding, the finding most suggestive of endometrial carcinoma is the presence of ill-defined margins separating the endometrium and the myometrium

5. Endometrial cancer: Grayscale ultrasound of the uterus (left image) shows a mildly echogenic, irregular endometrial mass (arrows). Fluid in the endometrial canal has likely accumulated due to cervical stenosis. Color Doppler shows vascularity within the mass.

6. STAGING OF ENDOMETRIAL CARCINOMA Staging of endometrial carcinoma is based on FIGO system.

7. MRI can be used for staging once endometrial carcinoma is confirmed by histologic sampling.

8. LEIOMYOSARCOMA It is a uterine myometrial malignancy . Uterine leiomyosarcoma is very rare and may arise de-novo or from malignant degeneration of a fibroid. Although signal heterogeneity, restricted diffusion, internal haemorrhage, and ill-defined contour have been described in leiomyosarcomas, imaging cannot reliably differentiate between leiomyoma and leiomyosarcoma. In the absence of obvious malignant features (such as local invasion or regional metastases), an unusual-looking fibroid is overwhelmingly likely to represent a degenerating benign fibroid rather than a leiomyosarcoma. Tamoxifen increases the risk of leiomyosarcoma in addition to endometrial carcinoma

9. CERVICAL CARCINOMA Cervical carcinoma is the third most common gynecologic malignancy, cause of which is mostly the HUMAN PAPILLOMA VIRUS. There has been a steep decline in prevalence over the past 50 years due to screening with Pap smears. Ultrasound may show a hypoechoic or isoechoic soft tissue mass involving the cervix with/ without intratumoral necrosis. The endometrial cavity may be distended by fluid or blood products due to cervical obstruction. MRI typically shows a T2 intermediate to hyperintense signal mass replacing the normally T2 hypointense cervical stroma. Enhancement is variable on postcontrast images.

10. MRI images show a heterogeneous, T2 intermediate cervical mass with well circumscribed margins.

11. A cervical mass >1.5 cm should be evaluated by MRI for staging. Staging of cervical carcinoma is also based on the FIGO system.

12. Sagittal T2-weighted MRI Sagittal T1-weighted MRI with fat saturation.

13. ADENOMA MALIGNUM Adenoma malignum is a rare subtype of well-differentiated mucinous adenocarcinoma of the cervix. It has an unfavorable prognosis due to peritoneal dissemination in early stage and poor response to radiation and chemotherapy. Classic imaging appearance is a multicystic mass (cluster of cysts) with solid components that extends from the endocervical glands to deep cervical stroma. Associations with Peutz-Jeghers syndrome and mucinous ovarian neoplasms have been reported.

14. MALIGNANT VAGINAL DISEASES VAGINAL CANCER Squamous cell carcinoma of the vagina accounts for 80–85% of primary vaginal malignancies and usually presents in older women. It is associated with HPV. Adenocarcinoma of the vagina presents in younger women (15% of vaginal malignancies) and can arise from vaginal adenosis. Clear cell carcinoma of the vagina is rare and associated with previous diethylstilbestrol (DES) exposure. These patients will often have a “T-shaped” uterus. Primary vaginal melanoma is rare and most commonly presents in postmenopausal women. It has an aggressive course. Vaginal sarcoma presents as rhabomyosarcoma in the pediatric population. This is the most common vaginal tumor in children. It has a bimodal distribution, usually ages 2–6 and 14–18

15. VULVAR CANCER Vulvar cancer commonly involves the labia majora and minora, accounting for up to 5% of female genital tract malignancies with peak age 65–70 years old. METASTASIS Metastasis to the vagina can occur from the upper genital tract or the GI tract. Metastasis located in the upper 1/3 of the vagina is usually from the upper genital tract. Metastasis located in the lower 1/3 is usually from the GI tract.

16. SCROTAL DISEASES

17. SCROTAL ANATOMY

18. TESTICULAR TORSION Testicular torsion is twisting of the testicle around the spermatic cord and the vascular pedicle. Torsion presents with acute scrotal pain and is a surgical emergency. Torsion may lead to irreversible testicular infarction if not de- torsed within a few hours.

19. SCROTAL HEMATOMA The sonographic appearance of an acute scrotal hematoma is an echogenic, extra-testicular mass with no Doppler flow. When large, the hematoma can compress the testicle. When the hematoma evolves into a complex, multi septated mass-like lesion, the distinction between the extra-testicular hematoma and the testicle may become difficult.

20. TESTICULAR HEMATOMA Testicular hematoma: Sagittal grayscale ultrasound (left image) shows a heterogeneous hypoechoic mass within the testicle, which has no internal Doppler flow (right image) Testicular hematoma produces a peripheral hypoechoic lesion that may mimic a tumor. Even with a history of trauma, a suspicious testicular lesion requires further evaluation to exclude malignancy, typically with a short-term follow-up.

21. EPIDIDYMITIS Epididymitis is infection of the epididymis, almost always ascending from the urinary tract. The classic clinical presentation of epididymitis is acute unilateral scrotal pain. A key ultrasound finding of epididymitis is an enlarged epididymis with increased color Doppler flow relative to the testicle . An associated hydrocele may be present, which often contains low-level echoes. The main differential based on clinical presentation is testicular torsion, which would demonstrate decreased testicular blood flow. In contrast, epididymitis features normal testicular blood flow.

22. Epididymitis: Sagittal grayscale ultrasound (left image) of the testicle and epididymis shows a markedly enlarged epididymis. Incidental note is made of an epididymal cyst (arrow). The testicle has a normal sonographic appearance. Transverse color Doppler of the epididymis (right image) demonstrates markedly increased flow.

23. EPIDIDYMO-ORCHITIS Epididymo-orchitis is infection which has spread from the epididymis to the testicle. Epididymo -orchitis has a similar ultrasound appearance to epididymitis, but blood flow to the testicle will also be increased . Infection and secondary inflammation can cause venous hypertension, which is a risk factor for focal testicular ischemia

24. FOURNIER GANGRENE Fournier gangrene is necrotizing fasciitis of the scrotum and perineum, a highly morbid and surgically emergent condition. Infection is usually polymicrobial. The key imaging finding is the presence of subcutaneous gas , often evaluated with CT. The appearance on ultrasound is of multiple echogenic foci in the subcutaneous tissues with dirty posterior shadowing

25. Fournier gangrene: Axial unenhanced CT shows a right ischial decubitus ulcer (yellow arrows) and soft tissue gas (better seen on bone window, right image; red arrows) in the right perineum tracking along the lateral margin of the penile base.

26. TESTICULAR MASSES Intratesticular masses are usually malignant . Conversely, most extra testicular masses are benign in an adult, although a pediatric mass in this location may be malignant. The retroperitoneum should always be evaluated if an intratesticular mass is seen. Likewise, if retroperitoneal adenopathy is seen in a reproductive-age male, the testicles should always be examined. Most scrotal masses are hypoechoic relative to normal testicular parenchyma. On Doppler ultrasound, most masses will have increased vascularity with high diastolic flow, producing a low resistance waveform

27. SEMINOMA Seminoma is the most common testicular malignancy. It has a favorable prognosis. Seminoma typically occurs in middle-aged men and it accounts for about half of all Germ cell tumors. It is usually more homogeneous than nonseminomatous germ cell tumors (NSGCT). It tends to be uniformly hypoechoic on ultrasound. Uncommonly, hCG may be elevated Seminoma: Grayscale (left image) and color Doppler show a heterogeneous hypoechoic vascular mass (yellow arrows) in the left testis.

28. NON SEMINOMATOUS GERM CELL TUMORS Nonseminomatous germ cell tumors (NSGCT) include: Embryonal carcinoma Teratoma Yolk sac tumor Choriocarcinoma Mixed subtypes NSGCT generally occur in younger patients compared to seminomas, typically in young men in their twenties and thirties. NSGCT tend to be more aggressive than seminomas. Local invasion into the tunica albuginea and visceral metastases are common. A heterogeneous testicular mass which contains solid and cystic components and coarse calcification is a typical appearance for a NSGCT. It is not possible to distinguish the various subtypes of NSGCT on ultrasound.

29. TESTICULAR MICROLITHIASIS Testicular microlithiasis is the presence of multiple punctate intratesticular calcifications. There is a controversial association between microlithiasis and testicular neoplasm. Current guidelines do not support screening by ultrasound or tumor markers, but patients with microlithiasis may perform self-examinations and be seen in follow-up as needed. At least 5 microcalcifications must be present per image to be called microlithiasis. If there are less than 5 microcalcifications the term limited microlithiasis is used. Microlithiasis can produce starry sky appearance if calcifications are numerous.

30. Transverse grayscale ultrasound shows numerous echogenic foci within both testes, consistent with microlithiasis

31. BENIGN TESTICULAR TUMORS An epidermoid is a keratin-filled cyst with a distinctive onion skin appearance of concentric alternating rings of hypo- and hyperechogenicity. If suspected, local excision is performed instead of the standard orchidectomy typically performed for presumed malignant masses. Sex cord-stromal tumors are 90% benign but are sonographically indistinguishable from malignant tumors. Orchidectomy is therefore the standard treatment. Ultrasound (left image) demonstrates a circumscribed, encapsulated mass in the testicle with peripheral calcification and onion skin appearance. There is no demonstrable Doppler flow within the mass (right image)

32. HYDROCELE • A hydrocele is excess fluid in the scrotum surrounding the testicle. Most are asymptomatic. • A hydrocele may be congenital (due to patent processus vaginalis in utero or infancy), idiopathic, or post-inflammatory. Regardless of etiology , there is never fluid at the bare area where the testicle is attached to the tunica vaginalis . HEMATOCELE A hematocele is blood in the scrotum due to trauma or torsion.

33. VARICOCELE A varicocele is a dilated venous pampiniform plexus in the scrotum. A primary varicocele is due to incompetent valves of the internal spermatic vein. A secondary varicocele is due to increased venous pressure caused by obstruction, usually caused by retroperitoneal mass. Varicoceles are much more common on the left, as the left testicular vein drains into the left renal vein at straight angle, whereas the right testicular vein drains directly into the infrarenal IVC. On ultrasound, varicoceles appear as multiple tubular and serpentine anechoic structures >2–3 mm in diameter in the region of the upper pole of the testis and epididymal head. The varicoceles follow the spermatic cord into the inguinal canal and can be compressed by the transducer. Ultrasound of the left scrotum (left image) shows dilated serpiginous vessels posterior to the left testes, which demonstrate increased Doppler flow.

34. EPIDIDYMAL CYST AND SPERMATOCELE A spermatocele is cystic dilation of the epididymis filled with spermatozoa, usually occurring in the epididymal head, but potentially occurring anywhere in the epididymis. Classic ultrasound appearance is an epididymal cyst with internal low-level mobile echoes. A simple epididymal cyst and a spermatocele cannot be reliably distinguished by ultrasound

35. TUBULAR ECTASIA OF RETE TESTIS Tubular ectasia of the rete testis is nonpalpable, asymptomatic, cystic dilation of the tubules at the mediastinum testes caused by epididymal obstruction. Tubular ectasia is often accompanied by an epididymal cyst or spermatocele. Tubular ectasia of the rete testis is common in older patients and may be bilateral. Imaging shows numerous tiny dilated structures in the region of the mediastinum testis, often seen in conjunction with an epididymal cyst/spermatocele. Tubular ectasia is benign and no treatment is necessary. Color Doppler ultrasound of the right testicle shows cystic dilation at the mediastinum testes (arrow). There is no flow within the lesion. This appearance is highly suggestive of tubular ectasia .

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