Ultrasound Assessment in Gynecologic Oncology, 1st Edition

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Library of Congress Cataloging-in-Publication Data

Names: Alcazar, Juan Luis, author.
Title: Ultrasound assessment in gynecologic oncology / Juan Luis Alcazar.
Description: Boca Raton, FL : CRC Press, 2018. | Includes bibliographical references and index.
Identifiers: LCCN 2017048078| ISBN 9781138044326 (pack- hardback and ebook : alk. paper) | ISBN
 9781315172392 (ebook : alk. paper)
Subjects: | MESH: Genital Neoplasms, Female--diagnostic imaging | Ultrasonography
Classification: LCC RC280.G5 | NLM WP 145 | DDC 616.99/46--dc23
LC record available at https://lccn.loc.gov/2017048078

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Contents

Foreword
Preface
1 Ultrasound Scanning of the Female Pelvis: Normal Findings
Introduction
Pelvic Wall Structures
Nonreproductive Organs
Reproductive Organs
References

2 Ultrasound for Differential Diagnosis of Adnexal Masses

Introduction
Pattern Recognition
Scoring Systems
Simple Rules
Logistic Regression Models
Reporting Ultrasound Findings of Adnexal Masses
Other Imaging Techniques for Differential Diagnosis of Adnexal Masses
Ultrasound-Based Imaging Techniques
Other Imaging Techniques
References
3 Ultrasound Features of Ovarian Malignancies
Introduction
Borderline Tumors
Primary Epithelial Invasive Ovarian Carcinoma
Primary Nonepithelial Ovarian Malignancies
Dysgerminoma
Sertoli Cell Tumors
Granulosa Cell Tumors
Other Nonepithelial Ovarian Tumors
Metastatic Tumors to the Ovary
References
4 Ultrasound Assessment of Intra-Abdominal Spread of Ovarian Cancer
Introduction
Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET)
Ultrasound
References

5 Ultrasound Features of Endometrial Cancer

Introduction
Ultrasound for Diagnosing Endometrial Cancer
Ultrasound Features of Endometrial Cancer
References

6 Ultrasound Features of Uterine Sarcomas

Introduction
Ultrasound Features of Uterine Sarcomas
Ultrasound Features of Uterine LMS
Ultrasound Features of EES
Other Imaging Techniques for the Diagnosis of Uterine Sarcomas
References

7 Ultrasound Assessment of Locoregional Spread of Endometrial Cancer

Introduction
Ultrasound for Assessing Myometrial and Cervical Infiltration in Endometrial
Cancer
Two-Dimensional Ultrasound
Three-Dimensional Ultrasound
Other Imaging Techniques
References
8 Ultrasound Features of Uterine Cervical Cancer
Introduction
Ultrasound Features of Uterine Cervical Cancer
Ultrasound for Assessing Locoregional Spread of Cervical Cancer
Tumor Size and Stromal Invasion
Parametrial Infiltration
Ultrasound for Assessing Treatment Response in Locally Advanced Cervical
Cancer
References
9 Ultrasound Features of Gestational Trophoblastic Disease
 Introduction
Hydatiform Mole
Gestational Trophoblastic Neoplasia
The Role of Doppler Ultrasound in GTD
Role of Other Imaging Techniques for Assessing GTD
References

10 Ultrasound-Guided Procedures in Gynecologic Oncology

Introduction
Tru-Cut Biopsy
Fine Needle Aspiration (FNA) Biopsy
Drainage
Other Ultrasound-Guided Procedures
References

11 Ultrasound in Vulvar and Vaginal Cancer

Introduction
Role of Ultrasound in Vulvar Cancer
Role of Ultrasound in Vaginal Cancer
References
Index
Foreword

I thank Dr. Alcázar for giving me the opportunity to write the Foreword to his fine book on
the role of ultrasound in gynecologic oncology: Ultrasound Assessment in Gynecologic
Oncology. The combination of both his experience as a gynecologist treating gynecological
cancer and his long and exceptional experience in ultrasonography make this book a real
opportunity to learn about this matter in a comprehensive way. Coherent from beginning to
end, this book is one of the first published in this field; it includes an extensive set of
clinical images that will be invaluable to both the general gynecologist and gynecologist–
oncologist in the management of this pathology.
I know Dr. Alcázar personally and have been fortunate to be able to follow his scientific,
professional, and teaching careers. He completed his residency in the Department of
Gynecology and Obstetrics at the Clinica Universidad de Navarra in Pamplona, Spain,
where I met him as a resident. He began his training in the field of ultrasound under the
mentoring of Dr. Mercé, who is world renowned in gynecological ultrasonography and who
worked with us for several years. Dr. Alcázar’s numerous publications, his brilliant
collaboration in the national and international ultrasound societies, and his more than
remarkable participation in scientific forums have given him exceptional credentials for a
work of this type.
I was privileged to be his mentor in his training in Gynecologic Oncology, and I have
enjoyed his personal assistance for many years. I shared with him many ideas regarding the
“crossover” between gynecological oncology and ultrasound that have been transformed
into a reality with his research. It is also fair to mention the great many gynecologists, both
from within our country and from overseas, who have come here to train with him.
More than merely an elucidation of theory, this book combines qualities that make it of
great practical use, as well as an invaluable reference. It includes all of the important topics
for daily practice, from an exhaustive description of the normal anatomy of the pelvic
contents to comprehensive discussions of those less common topics in which more recent
definitive experience has been gained, such as adnexal masses and endometrial cancer. This
book also includes chapters on a novel staging system for ovarian, endometrial, and
cervical uterine neoplasms; a number of preliminary studies, among them those published
by Dr. Alcázar, support its application in the very near future. Finally, it also includes some
chapters on invasive diagnostic procedures guided by ultrasound and the treatment of more
infrequent tumors such as cancer of the vulva or vagina.
 I would like to conclude by thanking Dr. Alcázar for his generosity and continued support
in the treatment of so many oncological patients to whose healing or improvement he has
contributed. The excellence that routinely characterizes his professional work has made
successful therapy possible. It is gratifying to see the product of years of training and
dedicated practice and research made available to all of us in this challenging discipline.

Prof. Dr. Matías Jurado

Professor of Gynecology and Obstetrics
Director of the Gynecologic Oncology Section
Clinica Universidad de Navarra
Pamplona, Spain
Preface

Gynecologic oncology is one of the most important specialties in the field of gynecology.
Gynecologic oncology focuses on the diagnosis and treatment of cancers developed from
the female reproductive system. The clinical relevance of this specialty is highlighted by
the fact that three gynecological cancers are among the top six most frequent malignancies
suffered by women around the world, namely, cancer of the uterine cervix, endometrial
cancer, and ovarian cancer.
For more than 30 years, ultrasound has been an imaging technique frequently used in
gynecological practice. It has become an essential diagnostic tool for most clinicians.
The main role of ultrasound in the field of gynecologic oncology has been the differential
diagnosis of uterine and ovarian lesions, with good performance. However, in the last
decade, significant advances have been achieved in the use of ultrasound in the assessment
of gynecological cancers, not only for diagnosis but also for staging.
After many years of practicing and teaching both ultrasound and gynecologic oncology, I
realized the lack of a dedicated handbook about this topic: the use of ultrasound in
gynecologic oncology practice. This text aims to summarize current state-of-the-art use of
ultrasound in the field of gynecologic oncology, providing to the reader both theoretical
knowledge and practical tips, adding a brief description about the role of other diagnostic
imaging techniques such as computed tomography scan, magnetic resonance imaging, and
positron emission tomography scan. I intend to address not only the most frequent cancers
from the female genital tract but also those less common.

Juan Luis Alcázar

Pamplona, Spain
1
Ultrasound Scanning of the Female Pelvis: Normal Findings

Introduction
Transvaginal ultrasound is currently considered as the first-line technique for imaging the
female pelvis, especially for assessing the uterus and the adnexa. Transabdominal
ultrasound is needed in some circumstances for assessing the entire pelvis or the abdomen
for evaluating large structures or disease that spread intra-abdominally. Certainly,
ultrasound has become an essential diagnostic tool for most clinicians involved in the
clinical management of gynecological diseases, specifically tumoral entities.
In this chapter, we review the normal findings of the female pelvic organs as scanned by
transvaginal ultrasound.
When assessing the female pelvis by ultrasound, we must clearly identify the anatomical
landmarks to be assessed, especially when we focus on gynecological malignancies. From a
practical perspective, the female pelvis can be divided into three parts: reproductive organs,
nonreproductive organs, and pelvic wall structures.
Pelvic wall structures refer to the pelvic great vessels, muscles, and bones.
Nonreproductive organs refer mainly to the bladder, ureter, recto-sigmoid, and bowel.
Reproductive organs refer to the uterus, fallopian tubes, and ovaries. We should also
include vaginal fornices, recto-vaginal septum, cardinal ligaments, or parametria and utero-
sacral ligaments.

Pelvic Wall Structures

When assessing pelvic wall structures, we should image the great pelvic vessels, muscles,
and bones. We focus on the pelvic vessels, as they are the main landmarks for pelvic scan in
a gynecological oncological setting.
Pelvic vessels assessable by transvaginal ultrasound are mainly external iliac vessels
(artery and vein), internal iliac vessels (artery and vein), and the uterine vessels (artery and
venous plexus). Other vessels less frequently assessed by transvaginal ultrasound are the
ovarian vessels. Due to the limitation of depth when using a high-frequency transvaginal
probe, ovarian vessels are more difficult to assess. The identification of the great iliac
vessels is essential for evaluating the presence of lymph nodes.
External iliac vessels are easily identified running parallel to the pelvic wall (Figure 1.1).
The vein is larger than the artery and is located over the artery. The latter is clearly seen
beating in virtually all women. It is important to insonate the vessels parallel to them in
order to obtain a sagittal view of the vessels. This can be achieved by moving the
endovaginal probe laterally and anteriorly.

FIGURE 1.1 Transvaginal ultrasound showing right external iliac vessels. The ovary is seen lying over these vessels.

The internal iliac vessels are visible displacing the probe medially and posteriorly (Figure
1.2). Color Doppler may help in identifying these vessels.
FIGURE 1.2 Transvaginal ultrasound depicting internal iliac vessels and utero-ovarian vessels.

Finally, the uterine vessels can be identified laterally to the cervix, either in the
longitudinal or axial planes (Figure 1.3).

FIGURE 1.3 Transvaginal ultrasound showing both uterine arteries (UAs) at both sides of the cervix. The cervical
canal (CC) can be observed.

Nonreproductive Organs
The bladder is easily identified as a central cystic structure located between the uterus and
the abdominal wall (Figure 1.4). Bladder wall thickness can be measured, and the internal
wall surface may be evaluated. It is a common finding to observe some irregularities of the
bladder mucosa. When scanning an oncological patient, it is quite important to determine
the presence of sliding of the bladder wall over the cervix, since this is a sign that indicates
that the bladder wall is not involved, for example, in a case of cervical carcinoma.

FIGURE 1.4 Transvaginal ultrasound showing the uterus in the longitudinal plane. The bladder can be seen as an
anechoic structure located anteriorly to the uterus.

The ureters can be seen passing through the bladder wall, and the ureteral meatus can be
identified in both sides (Figure 1.5a). They are commonly identified as a hypoechoic
creeping structure within the bladder wall (Figure 1.5b). More laterally, they can be
observed crossing under the uterine artery (Figure 1.5c).
FIGURE 1.5 (a) Transvaginal ultrasound showing the bladder. The ureteral meatus can be observed in the
longitudinal plane moving the endovaginal transducer laterally. (b) The transmural portion of the ureter can be
observed here as a hypoechogenic structure (arrows). In real-time ultrasound, a creeping movement can be seen. (c)
Displacing the endovaginal transducer laterally and a little bit anteriorly, the ureter (arrows) can be seen crossing under
the uterine artery.

The recto-sigmoid is also easily identified as a central pelvic structure located between
the uterus and the sacrum. Sometimes it can be seen as a straight structure (Figure 1.6a),
but most of the time it is observed as a snaky structure (Figure 1.6b). The recto-sigmoid
wall layers can be identified when it is empty (Figure 1.6a). Sliding of the rectum over the
posterior surface of the uterus is important to observe, and this is a good sign for assessing
whether the Douglas pouch is obliterated or not.
FIGURE 1.6 (a) Transvaginal ultrasound depicting the recto-sigmoid colon. The layers of recto-sigmoid can be
visualized (A, muscularis propria; B, submucosa; C, mucosa; L, lumen). A deep infiltrating endometriosis (DIE) is
observed. (b) The recto-sigmoid (RS) is seen as a snaky structure.

Reproductive Organs
The uterus is located between the bladder anteriorly and the recto-sigmoid posteriorly, and
it can be divided into two parts: the body, or corpus, and the cervix.
The uterus is usually anteverted (the fundus of the corpus tends to lie over the bladder)
(Figure 1.7a), but it may be retroverted (the fundus is positioned to the rectum or even the
cul-de-sac) (Figure 1.7b). Therefore, the corpus is mobile, but the cervix is fixed in the
midline.
The shape and size of the uterus vary depending mainly on a woman’s age and parity. In
reproductive-age, nongravid women, the uterus is an ellipsoid structure with regular
contour (Figure 1.7a). It can be accurately measured by ultrasound, and normal size ranges
between 7.5 and 9 cm in length, 4.5–6 cm in width, and 2.5–4 cm in thickness (Figure 1.7a)
(1). Parity increases size by 1–2 cm in all three orthogonal planes (1).
In menopause, uterine size decreases to 3.5–6.5 cm in length, and 1.2–1.8 cm in thickness
(1). When evaluating the uterus by ultrasound, two distinct structures should be assessed:
the myometrium and the endometrium.