"People only see what they are prepared to see.

" Ralph Waldo Emerson

SIU M CHN ON BUNG TRNG

BS. NGUYN QUANG TRNG (Update 30/05/2009)

KHOA CHN ON HNH NH BNH VIN AN BNH - TP.HCM

NI DUNG
Gii phu. Nang chc nng bung trng (functional cyst). Nang bung trng xut huyt (hemorrhagic cyst). U qui bung trng (ovarian teratoma). U nang tuyn thanh dch (serous cystadenoma). U nang tuyn nhy (mucinous cystadenoma). Carcinoma bung trng (ovarian carcinoma). Carcinoma nang tuyn thanh dch. Carcinoma nang tuyn nhy. Di cn bung trng (ovarian metastasis). Lc ni mc t cung (endometriosis). Xon bung trng (ovarian torsion). Ti liu tham kho.

GII PHU
Dy chng treo bung trng Vi trng

B. trng D/chng TC-BT Dy chng rng

T cung

BUNG TRNG NHN T PHA SAU

H BUNG TRNG THNH SAU-BN VNG CHU

M&TM bung trng (chy trong d. chng treo b. trng) Bung trng Vi trng Niu qun T cung

TM chu ngoi

Dy chng trn

MCH MU BUNG TRNG

M bung trng

Niu qun TM bung trng

Vi trng M&TM chu ngoi Bung trng

 Hai bung trng c hnh bu dc nm hai bn hoc sau-bn TC, c gii hn kh r trn siu m. Bnh thng ta thy bung trng c hi m ng dng v c nhiu nang rt nh, kch thc khong 2 3mm nm ngoi vi bung trng. Nh n m ta nhn bit c bung trng. thi k mn kinh, do bung trng teo li v khng cn nhng nang nh ngoi vi bung trng cho nn rt kh thy bung trng.
C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

 lt ct theo trc dc ca bung trng, ta o chiu di (L) v b dy (T) ca bung trng. lt ct theo trc ngang ca bung trng ta o chiu ngang (W) ca bung trng. Kch thc mi bung trng khong 1,5 x2,5 x 4cm. Th tch mi bung trng c tnh theo cng thc: V = L(cm)xW(cm)xT(cm)

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

SA qua ng thnh bng

SA qua ng m o

Bung trng ph n ang tui sinh

Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Dy chng rng v bung trng hai bn thy r nh dch t do trong bng.

Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Bung trng ph n mn kinh

Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

 Nang bung trng c kch thc < 3cm c th thy 15% ph n mn kinh. Nhiu nghin cu ch ra rng: tn sut c tnh rt thp nhng nang khng vch, khng chi, c ng knh < 5 cm. Do vy vi nhng nang ny, ch cn theo di bng siu m nh k m khng cn phi phu thut. Tn sut c tnh chim n 65% khi ph n tui mn kinh c nang bung trng ng knh > 10 cm.
C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

 Phu thut cn c p dng vi nhng nang tng kch thc hoc thay i c tnh theo thi gian. Phu thut cng c ch nh ph n mn kinh c: Nang bung trng > 5 cm. Nang c vch v/ hoc c chi.

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

NANG BUNG TRNG NANG CHC NNG (FUNCTIONAL CYST)

T tun th II ca chu k kinh, c 1 nang non pht trin tri ln. c im ca nang non (follicular cyst) l khng vch, khng chi, gia tng kch thc trung bnh 2mm/ngy t kch thc khong 20-24mm ti thi im chun b rng trng. Sau khi rng trng, nang hong th (corpus luteal cyst) hnh thnh, nang ny c vch dy, giu ti mu, to thnh ring-of-fire. Nang hong th thoi trin vo cui chu k kinh.
C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

Nang non ang pht trin (Developing follicles). Nang non trng thnh (Mature follicle Graafian).

Hnh thnh hong th (Corpus luteum).

Rng trng (Discharged ovum).

Nang non

Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Nang hong th vi vch dy v ring-of-fire

LU 1. Khng phi lc no ta cng thy c bung trng khi siu m qua ng thnh bng. Bung trng c nhn bit v kho st tt hn qua ng m o, tuy nhin i khi ta vn khng thy c bung trng v n ngoi vng kho st ca u d. 2. Th tch bung trng tr cha dy th # 3 ml, ph n trong tui sinh # 8 ml v ph n mn kinh < 6 ml. 3. Hai loi nang chc nng ca bung trng (nang non v nang hong th) thng c kch thc khng qu 25 mm.
Faysal A. Saksouk, MD et al. Recognition of the Ovaries and Ovarian Origin of Pelvic Masses with CT. RadioGraphics 2004;24:S133-S146

U NANG BUNG TRNG NANG XUT HUYT (HEMORRHAGIC CYST)

C ch xut huyt trong nang: Lp ht (granulosa layer) ca bung trng (bao quanh nang) v mch cho n lc rng trng. Ti thi im rng trng, khi nang non trng thnh, cc t bo m bao quanh cng to ra, tr nn trn cng. S thay i ny TB m c gi l hong th ha (luteinization). Cc TB hong th ha giu ti mu hn cc TB m bnh thng. Khi nang non v, phng thch trng, v mau chng tr thnh hong th. Lp ht tr nn c ti mu. Nhng mch mu trong thnh ca nang rt gin v d v. Nu v chng s gy nn xut huyt trong nang hong th.
Kiran A. Jain, MD. Sonographic Spectrum of Hemorrhagic Ovarian Cysts. J Ultrasound Med 2002 21:879-886

 Nang hong th xut huyt thng gy au vng chu cp. Hnh nh siu m thay i ty thuc lng mu v thi gian xut huyt. V nang xut huyt him gp, cho bnh cnh lm sng v siu m ging nh thai lc ch v.

NANG XUT HUYT (HEMORRHAGIC CYST)

- Nang xut huyt cp tnh c hi m dy, d lm vi u c. Tuy nhin, chng
thng trn, thnh mng nhn v tng m pha sau. - Tip n l hnh nh nhiu vch ngn do nhng si fibrins hnh thnh. in hnh cho hnh nh mng nhn (spider web) hoc li nh c (fish netting). * Phn bit gia nang c vch ngn (septations) v li fibrins (fibrin strands): + Vch ngn thng c s lng < 20, trong khi li fibrins l v s (innumerable). + Vch ngn thng dy hn cng nh c hi m dy hn so vi li fibrins. + Vch ngn c th c tn hiu Doppler, trong khi li fibrins khng c tn hiu Doppler. - Tip n cc mu ng co li, hnh nh lc ny d lm vi nang c chi. * Phn bit gia chi v cc mu ng: + Chi c b li, trong khi cc mu ng do co rt thng c b lm. + Chi c cng hi m vi thnh nang, trong khi cc mu ng thng c hi m km hn so vi thnh nang. + Chi c th c tn hiu Doppler, trong khi cc mu ng khng c tn hiu. - Giai on tip theo: nang gim kch thc ri t t bin mt.

Nang xut huyt

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

Nang bung trng xut huyt

Nang hong th xut huyt in hnh vi hnh nh mng nhn (spider web).

Nang bung trng (P) xut huyt v

U NANG BUNG TRNG U QUI BUNG TRNG (OVARIAN TERATOMA)

15-20% u nang bung trng l u qui bung trng (cystic teratoma). U lnh tnh, him khi chuyn dng c tnh. U xut pht t t bo mm (germ cell) chng gm 3 lp ngoi b (ectoderm), trung b (mesoderm) v ni b (endoderm). V thnh phn ngoi b thng chim u th cho nn u qui cn c gi l u nang b (dermoid cyst).
C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

 U in hnh c cha m, i khi c xng, rng, tc. U gp tui sinh sn, 10-15% b c hai bn. U thng khng triu chng v pht hin tnh c khi siu m. C bit chng c th gy au bng di, kinh nguyt khng u. Bin chng thng gp nht l xon u nang.

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

U QUI BUNG TRNG (OVARIAN TERATOMA)

- U qui bung trng c hnh nh rt thay i, t cu trc nang c

hi m trng hon ton cho n nang hon ton c hi m dy. - Nhng hnh nh c hiu bao gm: + Dermoid plug (nt b): nang chim u th vi mt nt vch, nt thng cha m gy gim m pha sau. + Tip-of-the-iceberg sign (du hiu chp tng bng): tc trong nt vi nhiu mt ngn cch to bng lng v xa thnh sau ca nang. + Dermoid mesh (li b): nhiu ng hi m dy do tc ni trong lng nang. + Fat-fluid level (mc m-dch): thnh phn m nh hn s ni ln trn. + Hair-fluid level (mc tc-dch): do tc to mt ngn cch. + Teeth or bone (rng hoc xng ): to hi m dy v bng lng rt r.

Dermoid plug
Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Dermoid plug

Dermoid plug

Dermoid plug

Tip-of-the-iceberg sign
C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

Tip-of-the-iceberg sign

Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Dermoid mesh
C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

Dermoid mesh
Kiran A. Jain, MD. Sonographic Spectrum of Hemorrhagic Ovarian Cysts. J Ultrasound Med 2002 21:879-886

Dermoid mesh

Dermoid mesh (arrows) and dermoid plug (*)

Fat-fluid level and dermoid plug

Fat-fluid level

Fat lobules (*) and dermoid mesh (arrows)

Hair-fluid level v dermoid plug

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

Bone
C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

Mc m-dch (mi tn cong), cu trc hi m dy c bng lng (s). M: teratoma vi cu trc rng (to bng lng), m v tc.

U NANG BUNG TRNG

U NANG TUYN THANH DCH (SEROUS CYSTADENOMA)

U xut pht t t bo biu m-m m (epithelialstromal tumors). Chim 20-25% u nang bung trng lnh tnh. Thng gp nht la tui 40-50. 20% u hai bn.

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

U NANG TUYN THANH DCH (SEROUS CYSTADENOMA)

- U thng c kch thc ln, thnh mng. - C th cha nhiu vch mng. - U c th c nt vch. Doppler c th khng bt dc tn hiu hoc bt c ph M c tr khng RI > 0,4.

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

U nang vch mng

U nang c nt vch

Nt vch nang khng c ph Doppler

Serous cystadenoma

SA c chch thuc tng phn: khng tng m

U nang vch dy, RI = 0,43

Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Nt vch, RI = 0,61
Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

U NANG BUNG TRNG U NANG TUYN NHY (MUCINOUS CYSTADENOMA)

U xut pht t t bo biu m-m m (epithelialstromal tumors). Chim 20-25% u nang bung trng lnh tnh. Thng gp nht la tui 30-50. Ch 5% u hai bn.

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

U NANG TUYN NHY (MUCINOUS CYSTADENOMA) - U thng c kch thc rt ln (15-30cm) chim ton b khung chu v bng. - U c th c nhiu vch mng. - Dch c hi m nm phn thp ca nang (cht nhy). - Nt vch him gp.

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Nang chim ton b bng, c hi m phn thp.

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

CARCINOMA BUNG TRNG (OVARIAN CARCINOMA)

Carcinoma bung trng l nguyn nhn gy cht ngi ng hng th 5 ph n sau phi, v, i trng v ty. 75% bnh nhn b di cn ra ngoi bung trng ti thi im c chn on. Tt c cc u ny u c tin lng ngho nn khi di cn. Tuy nhin, nu c chn on sm th tin lng rt tt.

Paula J. Woodward, MD et al. Radiologic Staging of Ovarian Carcinoma with Pathologic Correlation. Radiographics. 2004;24:225-246

 U xm ln trc tip ra xung quanh, gieo rc trong bng, qua ng mu v qua ng bch huyt. 90% carcinoma bung trng xut pht t biu m b mt. V m hc, cc loi carcinoma gm c: u thanh dch (serous cystadenocarcinoma), nhy (mucinous cystadenocarcinoma), dng ni mc (endometrioid tumor), t bo trong (clear cell tumor), v khng bit ha (undifferentiated tumor).
Paula J. Woodward, MD et al. Radiologic Staging of Ovarian Carcinoma with Pathologic Correlation. Radiographics. 2004;24:225-246

 Bnh sinh ca carcinoma bung trng c nhiu yu t: 90% l u tin pht (gp tui tin mn kinh-mn kinh). 10% c yu t di truyn (gp tui tr). V u tin pht, gi thuyt vi chn thng minor trauma: S rng trng gy nn nhng vi chn thng lp i lp li v s sa cha t bo biu m b mt d lm u pht sinh. Gi thuyt ny c hu thun bi nhiu kho st dch t. Nguy c ung th cao ph n khng sinh con, c kinh sm, mn kinh mun (nhiu chu k rng trng). Nguy c thp ph n sinh nhiu con, c kinh mun, mn kinh sm, dng thuc nga thai (t chu k rng trng hn).

Paula J. Woodward, MD et al. Radiologic Staging of Ovarian Carcinoma with Pathologic Correlation. Radiographics. 2004;24:225-246

 V di truyn c 3 hi chng: Breast-ovarian cancer syndrome: hi chng ung th vbung trng. Non-polyposis colorectal cancer syndrome: hi chng ung th i-trc trng khng polyp. Site-specific ovarian cancer syndrome: hi chng ung th bung trng chuyn bit (ch ung th bung trng, khng nh hng v hoc i trng).

Paula J. Woodward, MD et al. Radiologic Staging of Ovarian Carcinoma with Pathologic Correlation. Radiographics. 2004;24:225-246

CARCINOMA BUNG TRNG (OVARIAN CARCINOMA)

- in hnh c kch thc > 10 cm (thng > 5 cm).

- Nang c nt thnh nang, thnh nang khng u. - Nang c vch dy. - Doppler c ti mu nt v vch trong nang vi RI < 0,4 (hoc PI < 1 - pulsatility index). * Doppler vi RI < 0,4 (PI < 1) khng phi l du hiu c hiu chn on u nang c tnh bung trng. C tc gi cn cho rng siu m en-trng c gi tr hn Doppler trong vic chn on v loi tr carcinoma bung trng. - Du hiu gi xm ln trc tip: + Ranh gii gia u v c TC b xon vn, khng u. + Xa mt ngn cch gia u v bng quang hoc trc trng. + Khong cch < 3mm gia u v thnh chu. + X y hoc bao bc cc mch mu vng chu. - Di cn mng bng biu hin bng dch, nt v bnh mc ni (omental cake): + Nt mng bng thng c kch thc 5-10mm, hnh trn hoc bu dc, hi m km, thng nm trn b mt bao gan, bm vo cc dy chng. + Bnh mc ni l nhng mng hi m dy khng ng nht, b khng u, b dy trung bnh 3-5 cm.

SIU M 1. Kch thc 2. Thnh nang 3. Trong nang

GI LNH TNH < 5 cm Mng, nhn - Nang khng vch ngn. - Vch ngn mng. > 5 cm

GI C TNH

Dy, khng u - Nang c hoc phc hp. - Vch ngn dy hoc khng u. - Nt vch ngn. - Chi thnh nang. RI < 0,4 Nt, chi c tn hiu Doppler. - Dch bng. - Nt mng bng.

4. Doppler 5. Khc

- RI > 0,4 hoc khng c tn hiu Doppler.

NANG Khng c vch ngn (unilocular) C vch ngn (multilocular) C nh (papillary projection) c Dch bng Phn b 2: Lnh tnh. 3-4: Nghi ng. > 4: kh nng c tnh.

DCH

B TRONG (INTERNAL BORDERS)

- Hi m trng (clear) (0) - Nhn (smooth) (0) - C hi m (internal echoes) (1) - Khng u (irregular) (2) - Hi m trng (1) - C hi m (1) Nghi ng (1) ng nht (1) Khng c (0) Mt bn (0) - Nhn (smooth) (1) - Khng u (irregular) (2) Xc nh (2) Khng ng nht (2) C (1) Hai bn (1)

Dev Maulik. Doppler Ultrasound in Obstetrics and Gynecology. 2nd Edition. 2005

DOPPLER MU - Khng thy ph mu (0) - Mch mu phn nhnh u n (regular separate) (1) - Mch mu phn nhnh ty tin (randomly dispersed) (2)

DOPPLER XUNG - Khng c tn hiu xung (0) - RI 0,40 (1) - RI < 0,40 (2) * Nang hong th c ph RI thp, do vy nu nghi ng nang ny th hn ti khm vo chu k k tip (thi k tng sinh N6-N13).

2: Lnh tnh. 3-4: Nghi ng c tnh.

Dev Maulik. Doppler Ultrasound in Obstetrics and Gynecology. 2nd Edition. 2005

CARCINOMA NANG TUYN THANH DCH (SEROUS CYSTADENOCARCINOMA) - Chim 40-50% u nang bung trng c tnh. - 50% u hai bn. - U c th rt ln, nhiu vch, nhiu chi. - Thng c dch t do trong bng.

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

OVARIAN CYSTADENOCARCINOMA

Nt vch nang c ph Doppler

Adenocarcinoma

SA c chch thuc tng phn: tng m nt

U c c ph Doppler

SA c chch thuc tng phn: tng m.

RI < 0,4

OVARIAN SEROUS CYSTADENOCARCINOMA Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

U nang bung trng P, tng ti mu, RI < 0,4, bng bng c tnh, bnh mc ni

LU Bnh mc ni (omental cake) khng phi l hnh nh c trng ca carcinoma bung trng di cn mng bng, n cn gp trong: - Carcinoma i trng di cn. - U mng bng. - Nhi mu mc ni (trong bnh l ny khng c nt mng bng).

Break-time

CARCINOMA NANG TUYN NHY (MUCINOUS CYSTADENOCARINOMA) - Chim 5-10% u nang bung trng c tnh. - 20% u hai bn. - U thng ln, nhiu vch, nhiu chi. - Dch trong nang c hi m. - S v nang hoc xm ln ra ngoi nang, khin cho TB tit nhy lan trn trong khoang phc mc, gy nn tnh trng gi u nhy phc mc (pseudomyxoma peritonei): + Hnh nh siu m ging nh dch t do. + Mt gan, lch b m lm l du hiu nhn bit.
C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

LU
Gi u nhy phc mc (pseudomyxoma peritonei) khng phi l hnh nh c trng ca carcinoma nang tuyn nhy (mucinous cystadenocarcinoma) di cn mng bng, n cn gp trong: - V nang tuyn nhy (mucinous cystadenoma). - V u nhy (mucocele) ca rut tha. - V u nhy (mucocele) ca i trng.

OVARIAN MUCINOUS CYSTADENOCARCINOMA

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p527-579

OVARIAN MUCINOUS CYSTADENOCARCINOMA

Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

OVARIAN CARCINOMA, RI < 0,4

Juan Luis Alczar, MD et al. Transvaginal Gray Scale and Color Doppler Sonography in Primary Ovarian Cancer and Metastatic Tumors to the Ovary. J Ultrasound Med 2003 22:243-247

Pseudomyxoma peritoneii BN c bit l b mucinous cystadenocarcinoma

CARCINOMA BUNG TRNG

Giai on I: u cha xm ln. + U gii hn mt (IA) hoc hai bn (IB) bung trng. V bao bung trng nguyn vn, khng c xm ln TB u b mt bung trng. + IC: dch bng c tnh (malignant ascites) c th xut hin vi s hin din TB u b mt bung trng hoc v bao bung trng. Giai on II: xm ln vng chu. + IIA: xm ln vo TC hoc vi trng. + IIB: xm ln xa hn vo cc c quan khc vng chu: trc trng, bng quang, mng bng vng chu. Giai on III: lan trn trong bng. + U lan trn ra ngoi vng chu: mng bng, mc treo, mc ni. + Nhng nt di cn mng bng c th vi th (IIIA) hoc nh (IIIB), cho nn khng th nhn bit bng chn on hnh nh. Giai on IV: di cn theo ng mu. + Ngoi vic xm ln trc tip ra cc tng xung quanh, mng bng, mc treo, mc ni; di cn theo ng mu vo cc tng nh gan, phi, mng phi + Cn phn bit cc nt trn b mt bao gan (di cn lan trn trong bng) v nt trong nhu m gan (di cn theo ng mu).

IA

IB

IIA

IIB

Xm ln t cung

III

IV
Carcinoma bung trng di cn vi cc nt mng bng, nt mng phi

GIAI ON I: cha xm ln

GIAI ON II: xm ln vng chu

GIAI ON III: lan trn trong bng

GIAI ON IV: di cn theo ng mu

Giai on I: t l sng st sau 5 nm l 90%. Giai on II: t l sng st sau 5 nm l 50%. Giai on III: t l sng st sau 5 nm l 30%. Giai on IV: t l sng st sau 5 nm < 10%.

Paula J. Woodward, MD et al. Radiologic Staging of Ovarian Carcinoma with Pathologic Correlation. Radiographics. 2004;24:225-246

DI CN BUNG TRNG (OVARIAN METASTASIS)

Khong 10% u bung trng l di cn. Bung trng l v tr di cn thng thy ca cc u ng tiu ha (v c gi l u Krukenberg). V, ni mc TC, melanoma v lymphoma cng l cc u hay di cn bung trng. U ng tiu ha thng hay di cn bung trng nht l u d dy k tip l u i trng. 80% u Krukenberg l hai bn.

DI CN BUNG TRNG

- U bung trng di cn thng l cu trc c hoc hnh nh mt gm (moth-eaten cystic pattern). - U thng thy hai bn. - Tuy vy i khi rt kh phn bit trn hnh nh gia u tin pht v u di cn bung trng.

BN c tin cn ung th d dy, bu c bung trng hai bn: Krukenberg tumors

BN c tin cn ung th i trng, bu c bung trng hai bn: Krukenberg tumors

N, 27 tui, c thai 32 tun, au bng cp, SA u c bung trng hai bn, tin cn u d dy: Krukenberg tumors

U di cn bung trng, ph Doppler cng c tr khng (RI) thp ging nh u tin pht.

LC NI MC T CUNG (ENDOMETRIOSIS)

Lc ni mc TC l s hin din ca ni mc TC c chc nng bn ngoi TC. Ni mc lc ch chu s chi phi ca hormone ca chu k kinh ging nh ni mc TC. iu ny khin cho bnh nhn b xut huyt theo chu k kinh, hnh thnh nang lc ni mc, trn mu bng, tiu mu, i cu ra mu, trn mu hoc trn kh mng phi, ho ra mu, xut huyt khoang di nhn.
Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

 V tr lc ni mc thng gp nht l bung trng, vi trng, dy chng rng, ti cng sau, nhng cng c th cc ni khc trong c th nh bng quang, niu qun, ng tiu ha, ph qun, mng phi, mng no, di da

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

 V mt thut ng, trc y ngi ta chia endometriosis ra lm 2 loi: endometriosis interna v endometriosis externa. Endometriosis interna l tnh trng lc ni mc trong c TC. Ngy nay thut ng c dng thay th l adenomyosis (xem trong bi Siu m chn on t cung). Endometriosis externa l tnh trng lc ni mc cc v tr khc. Ngy nay thut ng c dng n gin l endometriosis.
Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

 Bnh gp ph n trong tui sinh , tn sut 5-10%. Triu chng thng gp l au vng chu kinh nin, au lng, giao hp au (dyspareunia), v sinh (infertility). So v dnh vng chu thng l hu qu ca tnh trng lc ni mc TC.

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

 C ch hnh thnh lc ni mc phc tp v gm nhiu yu t, trong gi thuyt lm t sau tro ngc kinh (retrograde menstrual implantation) c nhiu tc gi ng h (ngi ta thy rng c n 90% ph n c mu bng trong thi k hnh kinh). Ngi ta cng nhn thy rng, lc ni mc c th hnh thnh ngay v tr vt m thnh bng sau m t cung.
Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

a. Lm t sau tro ngc kinh (retrograde menstrual implantation). b. Lan truyn theo bch huyt (lymphatic spread). c. Lan truyn theo ng mu (hematogenous spread). d. D sn khoang c th (coelomic metaplasia).

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

LC NI MC T CUNG (ENDOMETRIOSIS) - Nu khng hnh thnh nang th khng thy trn siu m. - Khi nang lc ni mc (endometrioma hoc chocolate cyst) hnh thnh, c th rt d nhn bit trn siu m, nhng i khi cng kh chn on: + Hnh nh in hnh (thy trong 95% trng hp): biu hin mt knh m (ground glass) Hi m thp, ng nht. + Hnh nh c th ging ht nang xut huyt. + C th c hnh nh mc dch-dch (fluid-fluid level). + C th c nt hi m dy hoc nt vi ha thnh nang. + C th c nhiu nang lc ni mc.

Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Ground glass

Nang lc ni mc hai bn: kissing ovaries sign

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

Fluid-fluid level
Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003

Fluid-fluid level

p xe vi-bung trng vi mc dch-m

Sau m: Endometriosis !

Nang lc ni mc c hi m hn hp ti cng sau

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

Nang lc ni mc c vch ngn v nt hi m dy vch

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

Nang lc ni mc c vch ngn v nt hi m dy vch

Endometriosis trong c thng bng (P) sau m ct TC (khng c tin cn lc ni mc TC).

Tin cn au bng kinh. i cu ra mu, hp i xng ti khp ni T sigma-trc trng Endometriosis

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

Tin cn lc ni mc TC vng chu. i tiu ra mu, chp UIV pht hin u c b khng u vm bng quang Endometriosis
Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

Dy v hp lng niu qun on xa, bn P Endometriosis

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

Ba ln trn kh mng phi u xy ra theo k kinh. Tin cn ct TC v lc ni mc TC, 3 nm au ngc, ho ra mu> X quang: TKMP (P) + nt y phi (P) (mi tn) Endometriosis
Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

Nt n c y phi (P) Endometriosis

Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216.

Bnh nhn n, 40 tui, tin cn no ng thy bm sinh, c dn lu dch no ty no tht-mng bng. Gn y BN than nhc u CT v MRI

Dipanka Sarma et al. Cerebellar Endometriosis. AJR 2004; 182:1543-1546

XON BUNG TRNG (OVARIAN TORSION) Xon bung trng l nguyn nhn cp cu ph khoa ng hng th 5. Bnh thng thy bung trng c u nang, nhng cng c th xy ra bung trng bnh thng (v s di ng ca bung trng) thng thy tr em v ph n tr. Thng b bn (P) hn bn (T) (do bn (T) c t khong trng v T sigma chim ch).
S. Boopathy Vijayaraghavan, MD . Sonographic Whirlpool Sign in Ovarian Torsion. J Ultrasound Med 2004 23:1643-1649

XON BUNG TRNG (OVARIAN TORSION)

1. Du hiu gin tip:
- Bung trng to ra gp nhiu ln so vi bung trng i bn, dy v bao trng ca bung trng, c nhng nang non (8-12mm) ngoi vi to du hiu chui ngc (string of pearls sign), hi m bung trng c th khng ng nht do xut huyt hoc hoi t. - C th c u nang cng tn ti bung trng xon. - Bung trng c th nm v tr bt thng (pha trc TC, trn bng quang). - C dch ti cng. - Doppler mch mu bung trng: + Khng c ph M v TM chn on xc nh. + C ph TM, khng c ph M Xon khng hon ton. + C ph M, khng c ph TM Xon khng hon ton. * Ty theo mc xon khng hon ton m EDV = 0, EDV m, hoc ph tardus-parvus. + Lu rng, c ph M v TM Khng loi tr chn on ! Lc ny ta cn phi ch n EDV ph M khng b st chn on xon khng hon ton. * Bung trng c kh nng c bo tn nu ta bt c ph Doppler.

- Th tch bung trng trung bnh b gi trc tui dy th l 3 ml,

cn ngi trng thnh l 8 ml. -Bung trng xon tng th tch t nht l 8 ln so th tch trung bnh ngi trng thnh. - Lu rng vi mt khi hnh cu, ng knh tng gp 2 tng ng vi th tch tng gp 8.
It has been reported that a torsed ovary is at least 34 times larger than the average prepubescent ovary and 8 times larger than the average adult ovary. Ngun: O. John Ma et al. Emergency Ultrasound. 2nd edition (Trch dn t: Uhrich PC, Sanders RC: Ultrasound characteristics of pelvic inflammatory masses. Clin Ultrasound 4:199204, 1976).

Ph ng mch bung trng

Ph tnh mch bung trng

Ph ng mch bung trng P, bung trng ng (dormant ovary): RI=0,75 (tr khng cao)

Ph ng mch bung trng T, bung trng u th (dominant ovary): RI=0,375 (tr khng thp)

Bung trng nm mt trc t cung, trn ng gia, c kch thc rt ln so vi TC. C nhng nang nh trong bung trng. C t dch ti cng.

Xon bung trng b gi 10 tui: bung trng to ra, c nhng nang non to ra ngoi vi
Laurent Garel, MD et al. US of the Pediatric Female Pelvis: A Clinical Perspective. Radiographics. 2001;21:1393-1407.

Ct ngang vng h v Xon bung trng b gi 15 tui, bung trng T (cc u mi tn) to ra, c nhng nang non to ra ngoi vi

N, 30 tui, au h chu T 2 ngy: bung trng T (cc u mi tn) to ra (25,6 ml), c nhng nang non to ra ngoi vi. Bung trng P bnh thng (8,5 ml).

N, 27 tui, au d di tng cn 2 ngy: bung trng T to ra c nhng nang non ngoi vi.

Bung trng (T) to ra, c mt vng tng hi m do xut huyt (u mi tn)

Y. Kaakaji et al. Sonography of Obstetric and Gynecologic Emergencies. Part II, Gynecologic Emergencies. AJR 2000; 174:651-656

Ph n tr, au bng cp, ct dc vng h v thy cu trc nang ln nm trc TC, pha trn BQ. V tr bt thng ny gi xon bung trng.

XON KHNG HON TON

XON HON TON

A. C. Fleischer et al. Sonography in Obstetrics and Gynecology. 6th Edition. 2001

Bung trng P to ra (so vi bung trng T- hnh C), nm ng gia, vn cn ti mu. Hnh MRI xc nhn xon bung trng P.

Ba thng sau m tho xon, bung trng tr li kch thc bnh thng.

Ph n tr, au bng cp, CT c chch thuc tng phn: vng h v thy bung trng to ra, nm ng gia trc TC Kh nng xon bung trng.

Bung trng P to ra, nm ng gia trc TC, c nhng nang ngoi vi, khng thy ti mu Xon bung trng P.

Bung trng (P) to ra (V=53ml), hi m khng ng nht, vi nhng nang non ngoi vi.

Doppler bt c ph M trong BT, BT c bo tn sau m tho xon.

Y. Kaakaji et al. Sonography of Obstetric and Gynecologic Emergencies. Part II, Gynecologic Emergencies. AJR 2000; 174:651-656

Xon khng hon ton: khng c ph tm trng

A. C. Fleischer et al. Sonography in Obstetrics and Gynecology. 6th Edition. 2001

Xon khng hon ton: bung trng to ra, hi m khng ng nht vi nhng nang non ngoi vi. Ph tardus-parvus

BN c thai vi bung trng b kch thch qu mc (hyperstimulated), vo vin v au bng cp: SA thy bung trng T rt to, Doppler c ph tardus-parvus. M: xon 3 vng.

Bung trng (P) bnh thng

Xon bung trng (T)

N, 24 tui, au cp tnh HCP: BT (P) to ra, c nhng nang nh ngoi vi, c t dch bao quanh (*).

Doppler: khng c ph M ln TM

BN c thai 7 tun vi bung trng b kch thch qu mc (hyperstimulated), vo vin v au bng cp: SA thy bung trng T rt to, chiu di 11cm, Doppler c tn hiu mu.

M: Xon bung trng T

XON BUNG TRNG (OVARIAN TORSION)

2. Du hiu trc tip:
Du hiu xoy nc (whirlpool sign) c xem l du hiu c hiu: + Du hiu thy c trn siu m trng-en khi di chuyn u d ti-lui (to and fro) dc theo trc ca cung xon. l hnh nh xoy nc cng hoc ngc chiu kim ng h Chn on xc nh xon bung trng. + Nu siu m Doppler thy c tn hiu mu hoc bt c ph ca mch mu trong xon nc Bung trng cn kh nng bo tn.

Xon bung trng P - Du hiu xoy nc

A. C. Fleischer et al. Sonography in Obstetrics and Gynecology. 6th Edition. 2001

Du hiu xoy nc km theo u nang bung trng xon bung trng.

S. Boopathy Vijayaraghavan, MD . Sonographic Whirlpool Sign in Ovarian Torsion. J Ultrasound Med 2004 23:1643-1649

Xon bung trng T - Du hiu xoy nc

Whirlpool sign

Bung trng xon cn kh nng cu cha

S. Boopathy Vijayaraghavan, MD . Sonographic Whirlpool Sign in Ovarian Torsion. J Ultrasound Med 2004 23:1643-1649

N, 24 tui, au d di HCT. SA thy bung trng (T) to ra

Du hiu xoy nc trn SA 2D v SA Doppler

Cn phi phn bit gia xon bung trng v bnh l bung trng a nang. - Xon bung trng n khm vi bnh cnh lm sng cp tnh, tn thng thng ch mt bn, c hnh nh chui ngc v th tch bung trng tng ln nhiu ln (t nht l 8 ln). V nht l ta c th thy du hiu xoy nc. - Bnh l bung trng a nang bao gi cng nh hng hai bn, c hnh nh chui ngc nhng th tch bung trng ch tng va phi (ti a l 3 ln), khng c du hiu xoy nc.

TI LIU THAM KHO

C.M.Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005. p1185-1212 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003 Kiran A. Jain, MD. Sonographic Spectrum of Hemorrhagic Ovarian Cysts. J Ultrasound Med 2002 21:879-886 Paula J. Woodward, MD et al. Radiologic Staging of Ovarian Carcinoma with Pathologic Correlation. Radiographics. 2004;24:225-246 Paula J. Woodward, MD et al. Endometriosis: Radiologic-Pathologic Correlation. Radiographics. 2001;21:193-216. Ewa Kuligowska, MD et al. Pelvic Pain: Overlooked and Underdiagnosed Gynecologic Conditions. RadioGraphics 2005;25:3-20 S. Boopathy Vijayaraghavan, MD . Sonographic Whirlpool Sign in Ovarian Torsion. J Ultrasound Med 2004 23:1643-1649 Juan Luis Alczar, MD et al. Transvaginal Gray Scale and Color Doppler Sonography in Primary Ovarian Cancer and Metastatic Tumors to the Ovary. J Ultrasound Med 2003 22:243247 Yumiko O. Tanaka, MD et al. Functioning Ovarian Tumors: Direct and Indirect Findings at MR Imaging. RadioGraphics 2004;24:S147-S166 Laurent Garel, MD et al. US of the Pediatric Female Pelvis: A Clinical Perspective. Radiographics. 2001;21:1393-1407. Dipanka Sarma et al. Cerebellar Endometriosis. AJR 2004; 182:1543-1546 Y. Kaakaji et al. Sonography of Obstetric and Gynecologic Emergencies. Part II, Gynecologic Emergencies. AJR 2000; 174:651-656