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    8 views12 pages

    Jurnal Awak

    Uploaded by

    adityailham
    rad

    Copyright:

    © All Rights Reserved
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    psjuoG Pet Imaging Modalities in Gynecology Raydeen M Busse ‘Acsistant Potessor, Osteis ans Gynecology, maging Ovison, partment of eters, Cynecolagy ans Women's Heath ohn A Bums Scheot of Medicine, Univers of Hawai, Honol, Hawai, USA ‘Correspondence: Raydeen M Busse, Kap lan Medical Center fr Women's and Chien, 1319 Punahou Stee, Sue $30 Honolulu, Hawal 96325, USA, Pnone: (800}271-957' e-mal: rbusse@havai eau nm ‘Abstract ‘though ulrasund i he primary imaina malty for noe gnetlogedagresos a condtons, owe of oer danosic rang procedures import to gynecabgss,emerpeney aon pyscans and ables who exe ft wore ofa ages. Shee {ho ay 1800s when utascad was reed ir he we n cbse ad grecoogy. te sraghg ecmues hae apy come Ins pay duto te rence advances earls iealgy ain We ef enieetng Wchoores uso Secae fia an rowldgeable about he rncosn Boo svapng tocinauee mn to gather ost oration nth shores rau of Une {9 .ewe or pense most eoert ang eastetecive ay. This eves maar fr De use fs! race pyar ae izes commer as wal as uncononojrecaoge conte, Perr the tran aragey Modis AScused Us abe [ined to utasaund (5), empuied trophy (C7), and magnet resorance agg MF otjoties 1 Undestanng ofthe stenaths and mans of trasound land CT * ann Kowiedge of nent af he mot aproprats maging teique fr 2 een cic stuatons Keywords: Trnsvapnal stung (TVS) computed tomography (CT), magnet resonance magia (MR), gynecsoge dseases ULTRASOUND Transibdommal gynecologic ultrasound combined with transvaginal scanning isa technique that was initially {nnroduced in the early 1980°s and quickly became a “imust- have” procedure for gynecologists and emergency roor physicians for assistance in diagnosing many evaccolosic conditions. Rap advances inthe quality of the equipment techtiques used to obtain best inmges, end esearch designed ‘help physicians interpret their indings have contuibuted fo ultrasound’s quick rise im use and popularity. Te is ubiquitous thar lrasound s the imasing modality of choice for gynecologic conditions The advantages of ultrasound are umerous. I is fs, easy to obtain, has a hioh patient tolerance and is relatively ‘mexpensive when compared to CT and MRI Many physicians offices have ultrasound machines that are moro ‘than sufficient to male common diagnoses thereby alleviating patient anxiety and physician concer ifan abnosmaity 5 found daring @ physical eam. Appropriate referrals and ‘reatments can be imtiated in. timely manner at minimum expense. The ability to nie the traaevaginal ultrasound a6 an exteasion of a pelvic exam is extremely useful ‘puticlary whea the source of pain is wicertin diving Dimanualexsm oF a mass is found of werine or overia origin. An obvious advantage. especially when compared 0 CT. is that no radiation exposure occurs. As will be discussed in more deta. pelvic ultrasound has been shown, ‘ngmumerous sades. to havea high acgatve predictive valve and offers excellent resolution ofthe ulerus and adaexal structures especially when compared to CT and MRL There are disadvantages; however, that should be adesced Even with routine woe of tansahonsinal scan ‘which utilizes the acoustic window of a fll badder, the field of view is very limited, especially, compared to CT and MRL Transvaginal sonography limits the field. however, ‘ie efective in obtining excellent resoltion ofthe ters, ‘endouietrim and adaenalsructues, Uhrasound visualizes the bowel poorly and st 18 well-known that bowel gas comps the utrasound signal allowing for potential “missed” masses nt sible underthe bowel An addtional denwcke is tat poor contrast occurs between dissimilar tsues (ie ‘lood and fat) making it difficult to characterize certain ‘ovarian masses accurately Ultrasound characterizes gynecologic pathology ‘extemely well Hbroids,endometioms, demnoids. masses ‘hat are suspicious for malignancy, uterine anomalies, KID complications. ectopic preguancies, and endometrial pathology (with the help of trmsvaginal saline infusion sonoeraphy) are diagnoses that are detected with his acenacy. The following will give illustrations of the clinic vilty of diagnostic gyaccologie ultasouad for specific nial conditions Donald Schoo! Jounal of Urasound in Obsteies and Gynecology, anary March 2070 (171-12 1 Raydeen M Busse PELVIC PAIN OF UNDETERMINED ORIGIN, Reproductive aged women presenting with pelvic pain eqire irumodiateevalsation orale out ectopic pregnaacy cor other pregnancy complication. Should these conditions be euled out by 9 negative serum beta-hCG, other possibilities ofthe cause of pelvic pin ean be investigated. ‘Nonobstetrcal presentations of acute and chronic pelvic pin account for 10% ofall gynecologic visits" Identifying fovatian cysts and their complications, ovarian torsion, endometriosis, rvbo-ovarian abscesses, degenerating ‘roids, and TUD complications area few added beneficial ‘uses of transvaginal sonography. OVARIAN/ADNEXAL CYSTS The incidence of ovarian cysts resting in pelvic pain has sot been reported: but in reproductive-aged women, it is the most common cause of pelvic pa emergency rooms. Its also the most common Finding i asymptomatic women during routine pelvic exams that present for US. There are many types of ovarian cysts ranging from simple cysts (-2.5 crm,’ endometual cysts. ceystadenomas and cystadenoearcimomas as well as paraovaria cysts It should also be aoted that not all fobserved cysts are the source of pelvic pain. The vasinal probe is abe toachieve close proximity tote ovaries which ‘ids in the determination of cyst being the probable source ‘ofppin or if pin is external othe “incidental” cyst finding ‘Beyoud identfvang a cyst or ovarian mass as the cause ‘of the pain: the perennial dilemma is asessing the risk of ‘malignancy ina mass. Many morphologic eiteri are used to differentiate between benign v5 malignant masses and ‘wansvaginal ultrasound has shown to have a sensitivity ‘erveen 88 10 100% and a specificity berween 62 109286? Improvements to this risk assessment are assisted by Doppler ow studies and measurements and most recently, 3D imaging of power Doppler patterns * Morphologie scoring systems vse whrasound findings such as presence ‘of sepiations, thickness of septations. Quid density. wall ‘excrescences and other parameters in scoring a mass to etenmine, if there isa high-risk of malignancy, or most ‘commonly, eystihatis benign. These morphologic seoring systems consistently show a high negative predictive value ‘and high sensitivity °¥ Besides the benefit of assessing the risk of cysts or masses to be malignant, ultrasound is very presente ia eS ig aR fr an acute hiemorthage into the ovary. Temporal sssessment can further assist in definitive a diagnosis, cepecially. ifthe cyst resolution is coincident with pain resolution Figure 1). OVARIAN TORSION ‘Ovarian torsion isthe cause of 3% of puns presening vwithacute pelvic prin andi sugcal emergency that my ses te los of ovary in youu client women of reproductive age. In 50% of cases. an ovasian mass is soci withthe torsion * Uhrsound is considered the imaging modality of choice for thi ingnosisaldough its accuracy is fir Som perfect. Clasic findings of ovasisn enlargement (edema), mutiple peripheral follicles and absence of Doppler venous and aerial ow, fe fd in the pelvis ae aot seen in dhe majoiy of the cates. Diagnoses oflen times ae elusive and should be based on clinical resecation and suspicion The possibilty of torsion scent increased an ovarian mass (particularly alarge follicular cyst cystic teratoma or a hemonbagic cyst)" thats tender wit pressure fromthe US vaginal wansdacer ‘As far as doplen and color Doppler flow studies are concerned, the studies have been “confusing and inconsistent”? The most predictive use of color Doppler tne Ben the visnlizntion ofa "ised pedicle ac wir pool sign described by Lee! 1998 witha diagnostic accuracy oF 88% for torsion Figure 2). Tacoaclsion, here isn ight specific testo diagnose asovarian andlor adoesal torsion, Also focusing ox Doppler studies is awed due othe dal arterial Uood supply toe Gs AVPEE igre 2: Penpneral teas nan eras tres ovary cvaryffom the aorta to che main ovarian srory and from branches ofthe uterine artery. The venous systems simeay complex" PELVIC INFLAMMATORY DISEASE/ TUBO-OVARIAN ABSCESS ‘Acute PID is estimated to affect 1 million women per year sad also causes 100,000 women to become infertile per year. It is also a significant ficter in a sumber of ectopic pregnancies per year If any one ofthe following criteria ‘are found, PID may be suspected in a reproducive-aged ‘womaa: pelvic pain cervical motion eademess and uterine oradaeraltendemess "Although imaging snot indicated im evary suspected case of PID, women with more severe symptoms or those with high possibility ofhaving a pelvic sas will equite maging or more specific diagnostic tess asmuanagement may need to altered based on these findings ‘Ultasound is excellent fr visualizing uterine enlargement, endometrial thickening or presence of fluid, ineceased ovarian size (with or without evidence of abscesses), hhydrosalpinx as well as pyosalpinx"* Thick-walled. tubular adacxal masses (With of without fee fuid ia the pelvis) have been seported to have a sensitivity or 85% and specificity of 100% for the diagnosis of PID." As PID becomes more severe other imaging modalities (MRUCT) may be more beneficial in distinguishing soft tissue stetutes better than US (Figure 3) DEGENERATING FIBROIDS Uterine fibroids are the most common benign tumor of the female reproductive tract and their incidence is not known precisely, but ranges from 30 to 70% in premeno- pavsal women aad their incidence increases with age pamicilarly inthe Sth decade of life Pelvic pain dive to maging Motes n Gynecology Fig Tuo tse win conn mld econ Figure &: Cys egeneratn ina subsersal fed Aibroids is most commonly due to degenerating Bibroids as they outgrow their blood supply." Although, there are many forms of degeneration (hyaline, calcific, cystic, and Demosthagic) there ae charactesstic US findings foreach, Other imaging modalities discussed laterin tis articleanay ‘be more useful in unclear cases related to pelvie pain and ‘abroids (Figure 4) ENDOMETRIOSIS Endometriosis, which is a pathologic condition of endometrial glands and stroma pre locations i foand in 10% of reproductive-aged women and ent in extrauterine 1s more common in iaferle women. It is also commaoaly ‘ound in women with ante and chronic pelvic pain! Since ‘Donald Sanoo! Jourra of Uirasound in Obseties and Gynecology, January-March 2070;4 +2 3 ‘Raydeen M Busse Figure 5 ‘Classic’ endometiona wih “ground glass" dense tad fanless wih ickoned was 80% ofall pelvic endometriosis is found in the ovaries, US ‘isthe optimal method diagnose his condition. Staties by Mais eta and Kusjak et "and mumerous others, have shown high sensitivities of 75 to 99% and specificities of 99% using US criteria. This development was pasicularly significaat for those womiea who were to be followed conservatively. without surgery orto those who had limited, conservative surgery (Le. laparoscopy). It was therefore important to attempt to determine the depree of risk for malignancy i these complex masses. Again, temporal imaging may be optimal in confining a diagnosis without the nced of surgical confirmation dine to ability to absenve thei chracteiste appearance over time. Other imaging snodalitics may best determine extent of disease (MIR) as vill be discussed Inter inthis paper Fire 5) ENDOMETRIAL PATHOLOGY Ubteasonndis the imaging modality ofchoice for detecting endometrial abuormalities such as polyps, submucosal ‘Sbroids, thickening ofthe lining in posimenopausal patients and uterine anomalies. Again, the ability of the hi frequency transducer in close proximity to the anatomme stctures in question allows for excellent visualization of the endometrium asitselates othe myometsium aad eve ‘The addition of saline infusion sonography (SIS), with or without 3-dimeusioual sonography. greatly cubances the ability to detect pathology. In fact, SIS, when compared to the “gold standard” of hysteroscopy or hysterectomy ty (87-96%) and even higher specificity 86) whea performed for abnormal bleeding” igure 6 and 7). ‘Transvaginal sonography in the evaluation of ‘postmenopausal bleeding has been extensively studied, Figure 6 Transvaginal senchysteooraphy imape with multiple ‘endometiat pays Flow T: Submucosal foi with > 50% fesposie io he ute cay sesulting in an excellent review of US's role an a recent American College of Obstetricians and Gynecologists Committee Opinion which states that postmenopausal bleeding may be assessed initially with either endowetrial biopsy or transvaginal ultrasound, There is noneed to uilize Doth ests. Transvaginal ultrasound my be used to “tage! patients ta determine which patient may foeego endometrial Diopsy (Le. if their endometrial thickness 3s less than or fequal to 4 mm) and those wha may require further evaluation, a5 transvaginal sonography has a very high negative predictive value as determined by several snalicente trials IUD COMPLICATIONS Sonography plays a crucial role in the visualization of an intrauterine device (IUD). When checking for proper 4 nvr maging Mecattes in Gynecoogy Fite @:Threedimensiona andra of te ues coral pane sang 29D Figue & Tee dimensional endehg of ie staue mine coor pane a mop am intrauterine loestion, sonography 36 the est method of detection in lines cases ofan IUD string no longer fet or Seen on exam, of for detecting an absent or ralpositioned TUD. Further imaging may be necessary inthe case of @ suspected uterine perforation; but for the most pat, two mensional maging suScesin thisegatd** Most seceatly ‘however, thte-dmensional imaging in visualizing the uterus in the coronal plane has been found woe superior i cases of malposiioned IUDs" (Figures 8 and 9). COMPUTED TOMOGRAPHY (CTreame int clinical practice in the early 1970s asthe fest ‘maging molality that could acquire a view of anatomy in supe slices” Ithas improved much since then and CT techaology has enjoyed a resurgence of popularity du to snore rapid acquisition technology called spiral CT that not ‘only acquires sliced images, but also obnins volume images. CCT scanners are now widely available in most hospital stings and sm many outpatient faites as well, Images are now acquired with the use of auhidetector machines ‘hat complete their acquisitions within seconds, and they can be displayed in mulple planes va reconstction of ata and images. The spatial resolution is exclleat and

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