CANCER of the FEMALE GENITAL TRACT

Anatomy

Ultrasound

• Ultrasound of the pelvis can be carried out two ways: either by scanning through the abdominal wall or transvaginally with a specialized ultrasound probe inserted directly into the vagina. With the transvaginal route the pelvic organs are nearer the ultrasound probe so image quality is much improved. Moreover it is not necessary for the patient to have a full bladder.

• When abdominal scanning is undertaken it is essential for the patient to have a full bladder to act as a 'window' through which the pelvic structures can be seen. Scans are usually made in the longitudinal and transverse planes

On a midline longitudinal scan the vagina can be recognized as a tubular structure, with a central linear echo arising from the opposing vaginal surfaces. The uterus lies immediately behind the bladder, and the body of the uterus can be seen to be in continuity with the cervix and vagina. The myometrium shows low level echoes, whereas the endometrial cavity gives a high amplitude linear echo. The precise appearances of the uterus depend on the age and parity of the patient and also on the lie of the uterus. The normal fallopian tubes are too small to be visualized sonographically.

Normal uterus and vagina. Longitudinal section. The central echo of uterus (U) corresponds to the endometrial cavity; the uterus itself has a homogeneous echo texture; V, vagina; B, bladder

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MRI The pelvic anatomy is very well demonstrated because of the excellent soft tissue contrast afforded by MRI. Images are usually taken in the transverse and sagittal planes but may be supplemented by coronal images, particularly for examining the ovaries. Images in the transverse plane give appearances similar to CT. The sagittal plane shows the vagina and cervix in continuity with the body of the uterus which can be readily recognized on a T2-weighted scan because the endometrium has a high signal. The ovaries and broad ligaments can also be identified

Normal uterus, sagittal T2-weighted MRI scan. There is a high signal from the endometrium (arrows). B, bladder; V, vagina

Normal Anatomy

Pelvic masses

CT, ultrasound and MRI will be abnormal in virtually any patient in whom a mass can be felt on physical examination. With ultrasound, it is possible to tell whether the mass is cystic or solid. Unfortunately, there is no clear association of cystic with benign disease, or of solid characteristics with malignant disease. A limitation of imaging is that it is sometimes not possible to determine from which organ the mass arises; an ovarian mass which lies in contact with the uterus may appear similar to a mass arising within the uterus and vice versa.

Cancer of the Female genital tract

• Cancer of the Cervix

• Cancer of the VULVA

• Cancer of the VAGINA

• Cancer of the UTERUS

• Cancer of the FALLOPIAN TUBES

• Cancer of the OVARY

Colposcopy

а в

б

Conization of the cervix

Werthaim operation

Endometrial Hyperplasia and Polyps Endometrial hyperplasia occurs under conditions that produce a constant stimulus of estrogen, which prevents the progestational or secretory phase of the menstrual cycle to take place. The gross appearance of endometrial hyperplasia is a thickened and edematous mucosa. Estrogenic stimulation produces an overgrowth of glands, stroma, and microvessels. In long-standing cases, the glands show irregular cystic dilatation with a lining of low cuboidal epithelium, which leads to the "Swiss cheese" pattern. The exuberant growth may be difficult to distinguish from well-differentiated adenocarcinoma. Atypical hyperplasia is defined as complex glandular crowding and cytologic atypia. Endometrial hyperplasia may give rise to single or multiple endometrial polyps. The diagnosis of endometrial hyperplasia usually is made from pathologic examination of endometrial curettings from a woman with abnormal uterine bleeding. Occasionally, examination reveals an infectious process, including tuberculosis.

Endometrial Hyperplasia and Polyps

Leiomyoma (Fibroid)Uterine myomata, the most common tumors in the female pelvis, have an incidence of approximately 4% to 11% in adult women. Commonly called fibroids, these tumors are composed of benign proliferations of uterine smooth muscle cells with a typical whorled pattern on histologic examination and are, therefore, leiomyomata. The tumors, which vary in size, location, and position (intramural, subserous, or submucosal), occur most frequently in the fifth decade of life and are more common in black women. Leiomyomata also are found in the cervix and broad ligament (intraligamentary myoma). The most common symptom, profuse or prolonged uterine bleeding, occurs in approximately 50% of cases. The uterine bleeding and the growth of the leiomyomata may have a common cause in excess estrogen stimulation, so that excision of the leiomyoma may or may not cure the uterine bleeding.

Leiomyoma: Secondary Changes

• The evaluation of infertility should take uterine leiomyomata into account, particularly if there are submucous myomas. Indications for surgery, either removal of the leiomyoma (leiomyectomy) or hysterectomy, include recurrent uterine bleeding, pelvic pressure, pelvic pain, and rapid growth suggesting sarcomatous transformation. Pedunculated submucous leiomyomas are prone to torsion of the pedicle, cutting off the blood supply and causing sloughing and necrosis. Occasionally, a myoma on a long pedicle can prolapse through the cervix and cause complete inversion of the uterus. Large leiomyomas sometimes exceed their blood supply, leading to cystic degeneration and calcification. Leiomyomas may not affect a successful pregnancy but, if located in the cervix, may obstruct the passage of the fetal head through the birth canal. During pregnancy, the vascular supply to an interstitial leiomyoma may be compromised, leading to necrosis and hemorrhage, so-called red degeneration, which may become a serious complication.

Uterine tumours Fibroid

• Leiomyomas (fibroids) are common in women over 30 years of age. They are often asymptomatic but may cause menorrhagia or present as a palpable mass. When sufficiently large, a fibroid can be seen on a plain film as a mass in the pelvis and may show multiple irregular but well-defined calcifications. Ultrasound and CT both show a spherical or lobular uterine mass. At ultrasound, the mass may be either sonolucent or echogenic, whereas at CT, fibroids are usually the same density as the adjacent myometrium. Magnetic resonance imaging can readily identify fibroids as they have a different signal characteristic from the normal uterus. Degenerating and non-degenerating fibroids can also be distinguished

Uterine tumour, (a) CT scan

showing enlarged uterus

(arrows) which was due to

fibroids. It is not possible to

distinguish this appearance

from adenocarcinoma

confined to the uterus. B,

bladder; R, rectum.

(b) Transverse ultrasound

scan showing a large fibroid

in the uterus. Its extent is

indicated by the arrows. B,

bladder.

Carcinoma of the cervix and uterus

Neither CT, MRI nor ultrasound play much part in the initial diagnosis of these conditions, which is normally made by physical examination and biopsy or cytology.

Carcinoma of the cervix may be staged by CT or preferably by MRI because the stage determines whether the patient is managed with surgery, radiotherapy or a combination of treatments. In essence the observations to be made are whether the tumour is confined to the cervix or whether it extends into the parametrium, rectum or pelvic side walls. Computed tomography and MRI also enable detection of enlarged lymph nodes and dilatation of the ureters in cases where the tumour has caused ureteric obstruction.

Endometrial carcinoma is usually treated by surgical removal of the uterus, ovaries and pelvic lymph nodes. Therefore the use of imaging to stage the tumour at presentation is limited. Magnetic resonance imaging can predict the depth of myometrial invasion by tumour, and both CT and MRI can demonstrate lymph node involvement.

Carcinoma of cervix, (a) CT scan showing a large tumour of the cervix (T) invading the parametrium (arrows) and extending into the rectum (R) posteriorly, (b) Sagittal MRI scan showing a tumour confined to the cervix (arrows). B, bladder; R, rectum.

SarcomaSarcoma of the uterus accounts for approximately 3% to 4% of malignancies of the female genital tract. Uterine sarcomas, whether primary or secondary to a preexisting fibroid (rate of sarcomatous degeneration is approximately 1%), grow rapidly and have a grave prognosis. Sarcomas arising in a fibroid appear grossly as soft, meaty areas, often with foci of central necrosis or hemorrhage due to an inadequate blood supply. The size and extent of tumor are more important for prognosis than is location or histologic characteristics. Histologically, the sarcoma cells may be spindle-shaped or round and show nuclear pleomorphism and mitoses. Occasionally, uterine polyps show sarcomatous degeneration. Sarcoma botryoides ("grape" sarcoma) is a rare and almost invariably fatal condition that occurs only in young children.

Ovarian tumoursThe commonest ovarian tumours are the cystadenoma and the cystadenocarcinoma. Ovarian tumours can be cystic, solid or a mixture of the two. Those that are cystic may be multilocular. Evidence of invasion of neighbouring structures or metastasis indicates a malignant tumour. Although ultrasound, CT and MRI are reliable at showing the size, consistency and location of an ovarian mass, it is often not possible to say whether the mass is benign or malignant unless there is evidence of local invasion or distant spread. A malignant nature is suggested if the septa are thick and there are coexisting solid nodules within or adjacent to the cyst. With disseminated malignancy, ascites may be visible, but frequently omental and peritoneal metastases are difficult to detect due to their small size. Computed tomography, MRI and ultrasound may show hydronephrosis from ureteric obstruction by the tumour and may also demonstrate enlarged lymph nodes and liver metastases. Treatment of ovarian carcinoma is usually by hysterectomy, oophorectomy and surgical removal of all macroscopic tumour and staging is carried out during surgery. The main role of imaging is for follow-up to assess response to treatment and disease recurrence.

Ovarian carcinoma, (a) Longitudinal ultrasound scan showing a very large multilocular cystic tumour containing septa (S) and solid nodules (N). The lesion was a cystadenocarcinoma. (b) CT scan showing large partly cystic, partly solid ovarian carcinoma (arrows). The tumour, which contains irregular areas of calcification, has invaded the right side of the bladder (B). The rectum is indicated by a curved arrow, (c) MRI scan showing a partly solid (arrows) and partly cystic tumour. The cystic component shows as a high signal on this T2-weighted scan. B, bladder.

Ovarian cyst, (a) Longitudinal ultrasound scan to right of midline showing a 5 cm cyst (C) in right ovary with no internal echoes. B, bladder, (b) CT scan of same patient showing the cyst in the right ovary (arrows). Note the uniform water density centre of the cyst, (c) Coronal T2-weighted MRI scan showing a left sided ovarian cyst (arrows) in a patient with an enlarged uterus due to adenomyosis. B, bladder; U, uterus