USG Intensif 5. Adnexa Normal & Pathology JJE 20090525

MATERI AJAR INI MATERI AJAR INI HANYA UNTUK HANYA UNTUK

DIPERGUNAKAN DALAM DIPERGUNAKAN DALAM KEGIATAN PENDIDIKAN KEGIATAN PENDIDIKAN

DAN KESEHATANDAN KESEHATAN

JJE-13/07/2009Hanya untuk Pendidikan dan

Kesehatan


Kesehatan

Motto :

• Jalani hidup ini dengan sabar, jujur dan ikhlas,

• Mau mengerti dan melaksanakan tatacara (adab) yang benar, dan

• Mempunyai kemauan untuk selalu berbuat baik memperbaiki

diri dan lingkungan, serta membuat orang lain lebih baik


Kesehatan

KEUTAMAAN ILMU

Barang siapa mengamalkan apa-apa yang ia ketahui, maka Allah SWT akan mewariskan kepadanya ilmu yang belum diketahuinya, dan Allah SWT akan menolong dia dalam amalannya sehingga ia mendapatkan surga. Dan barang siapa yang tidak mengamalkan ilmunya, maka ia

tersesat oleh ilmunya itu, dan Allah SWT tidak menolong dia dalam amalannya sehingga ia akan mendapatkan neraka (sabda Rasulullah Muhammad SAW)

Ilmu lebih utama dari harta, ilmu adalah pusaka para Nabi, sedangkan harta adalah pusaka Karun atau Fir’aun.

Ilmu lebih utama dari harta, karena ilmu akan menjagamu sementara harta malah engkau yang harus menjaganya.

Ilmu lebih utama dari harta karena di akherat nanti pemilik harta akan dihisab, sedangkan orang berilmu akan memperoleh syafaat.

Ilmu lebih utama dari harta karena pemilik harta bisa mengaku menjadi Tuhan akibat harta yang dimilikinya, sedangkan orang berilmu justru mengaku sebagai hamba Tuhan karena

ilmunya.Harta itu jika engkau berikan menjadi berkurang, sebaliknya ilmu jika engkau berikan malahan

semakin bertambah.

Pemilik harta disebut dengan nama kikir dan buruk, tetapi pemilik ilmu disebut dengan nama keagungan dan kemuliaan.

Pemilik harta itu musuhnya banyak, sedangkan pemilik ilmu temannya banyak.Harta akan hancur berantakan karena lama ditimbun zaman, tetapi ilmu tidak akan rusak dan

musnah walau ditimbun zaman.

Harta membuat hati seseorang menjadi keras, sedangkan ilmu malah membuat hati menjadi bercahaya.

(hamba Allah)

JJE-13/07/2009Hanya untuk Pendidikan

dan Kesehatan

Mampu melakukan pemeriksaan USG adneksaMampu melakukan pemeriksaan USG adneksa Mampu menilai adneksa normal, lesi jinak dan Mampu menilai adneksa normal, lesi jinak dan

curiga malignansicuriga malignansi Mampu mengetahui kelainan adneksa yang Mampu mengetahui kelainan adneksa yang

sering terjadisering terjadi Mampu memberikan Mampu memberikan informed consent informed consent dengan dengan

baik dan benarbaik dan benar Mampu membuat laporan hasil pemeriksaan Mampu membuat laporan hasil pemeriksaan

USG adneksaUSG adneksa


Kesehatan

Ovarian cancer is the Ovarian cancer is the fourthfourth leading cause of leading cause of cancer deaths in American women today. cancer deaths in American women today.

About About one in seventy one in seventy women will be diagnosed women will be diagnosed with this cancer in their lifetime.with this cancer in their lifetime.

The The death rate death rate (see table) from ovarian cancer is (see table) from ovarian cancer is highhigh, due in part to the fact that most women have , due in part to the fact that most women have advanced disease advanced disease that has spread outside the that has spread outside the ovaries at the time of diagnosis.ovaries at the time of diagnosis.

http://www.macgn.org/newsletter/nl27b.html


Kesehatan


Kesehatan

http://www.femalehealthmadesimple.com/OvariumSewe.jpg

http://labstend.ru/site/index/folies/univ/anatomy/p0077.gif

http://library.med.utah.edu/WebPath/jpeg4/FEM082.jpg


Kesehatan



Kesehatan

Size, location, and characteristicsSize, location, and characteristics

Benign : Benign : < 5 cm, uniloculare < 5 cm, uniloculare

MalignantMalignant : : > 5 cm, complex mass, thick > 5 cm, complex mass, thick septum, papillary projections or noduleseptum, papillary projections or nodule

Less sensitiveLess sensitive to differentiate the to differentiate the malignancymalignancy

B. Karsono : Pemeriksaan ultrasonografi tumor ginekologik, 2006


Kesehatan

Vary in size depending on age and menopausal status. . Normal size is approximately Normal size is approximately 3 x 2 x 2 cm3 x 2 x 2 cm

Almond shapedAlmond shaped

Contain follicles in women of Contain follicles in women of childbearing agechildbearing age

Arthur C Fleischer, 2004


Kesehatan

↑ ↑ frequency → ↑ resolution → better imagefrequency → ↑ resolution → better image Sliding organs signSliding organs sign : adhesions: adhesions Pelvic painPelvic pain At the end of menstruation periodAt the end of menstruation period DDDD : : corpus luteum, lutein cystcorpus luteum, lutein cyst

Bilateral ovaries (60%), unilateral (80%) → Bilateral ovaries (60%), unilateral (80%) → atrophy, pelvic adhesion, compression by atrophy, pelvic adhesion, compression by ovarium or pelvic tumorovarium or pelvic tumor


Kesehatan

Follicles are less than 10 mm when immature

10 – 15 mm at intermediate maturity

18 – 25 mm when mature

Arthur C Fleischer, 2004


Kesehatan

Corpora lutea : thick wall, vascular ring

The main arterial supply of the uterus and ovaries arises from the aorta through the infundibulopelvic ligament;

Other blood supply is from the adnexal branch of the uterine artery

Arthur C. Fleischer, 2004


Kesehatan

There is high-There is high-impedance arterial flow impedance arterial flow except around the except around the mature follicle / corpora mature follicle / corpora lutea, where lutea, where low-impedance high-diastolic flow can be can be seenseen

Arthur C. Fleischer, 2004


Kesehatan

History of ovarian cancer History of ovarian cancer in the immediate family in the immediate family (More details).(More details).

Age (over Age (over 5050 years). years).

No children No children (pregnancies protect against ovarian (pregnancies protect against ovarian cancer so that two or more pregnancies lower the cancer so that two or more pregnancies lower the risk for developing ovarian cancer).risk for developing ovarian cancer).

Self history of Self history of breast cancerbreast cancer. .

http://www.geocities.com/HotSprings/Sauna/1913/SymptomsandRiskFactors.htm


Kesehatan

RaceRace --- --- ovarian cancer appears to occur more ovarian cancer appears to occur more frequently in frequently in CaucasianCaucasian women than African women than African American women, but African-American women American women, but African-American women that are socioeconomically similar to Caucasian that are socioeconomically similar to Caucasian women may take on the Caucasian risk due to women may take on the Caucasian risk due to smaller families and having children latersmaller families and having children later..

JewishJewish descent descent http://www.geocities.com/HotSprings/Sauna/1913/SymptomsandRiskFactors.htm


Kesehatan

HRTHRT in post-menopausal women may account for in post-menopausal women may account for a a very slight increase very slight increase in ovarian cancer risk.in ovarian cancer risk.

Infertility drug Infertility drug use --- a nearly use --- a nearly 3-fold 3-fold increase in increase in risk characterizes women who fail to conceive.risk characterizes women who fail to conceive.

However, this risk may be due to an However, this risk may be due to an underlying underlying ovarian dysfunction in combination with a failure ovarian dysfunction in combination with a failure to gain a protective advantage from pregnancyto gain a protective advantage from pregnancy. .



Kesehatan

High fat diets High fat diets have been reported to be have been reported to be associated with higher rates of ovarian associated with higher rates of ovarian cancer in cancer in industrialized nationsindustrialized nations..

TalcTalc-use in feminine hygiene sprays or in -use in feminine hygiene sprays or in sanitary napkins has been suggested as a sanitary napkins has been suggested as a factor factor associated with some riskassociated with some risk. .



Kesehatan

the risk of ovarian cancer is the risk of ovarian cancer is 11 in in 5555 (1.8%), but (1.8%), but AgeAge and and Family Family historyhistory may may increase this riskincrease this risk..

Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA Cancer J Clin. 2002;52:23-47. Cancer J Clin. 2002;52:23-47.

Dr. Mohammed Abdalla Egypt / Domiat general hospital


Kesehatan


Kesehatan

Symptoms Symptoms significantly associated with ovarian significantly associated with ovarian cancer cancer when occurring when occurring more than 12 days a more than 12 days a monthmonth:: Pelvic / abdominal painPelvic / abdominal pain Frequent or urgent urinationFrequent or urgent urination Increased abdominal size/ bloatingIncreased abdominal size/ bloating Difficulty eating / feeling fullDifficulty eating / feeling full

Goff et. al. Cancer 2007; 109:221-227.Goff et. al. Cancer 2007; 109:221-227.



Kesehatan

Diagnostic value of Diagnostic value of pelvic examination, ultrasound, pelvic examination, ultrasound, and serum CA 125and serum CA 125 in postmenopausal women with a in postmenopausal women with a

pelvic mass. An international multicenter studypelvic mass. An international multicenter study

Ninety-five Ninety-five malignant (41.7%) malignant (41.7%) and 127 benign and 127 benign (55.7%) pelvic tumors were found in addition to 6 (55.7%) pelvic tumors were found in addition to 6 borderline ovarian tumors (2. 6%) in the 228 borderline ovarian tumors (2. 6%) in the 228 patients.patients.

Seventy-two patients had ovarian carcinoma, 49 of Seventy-two patients had ovarian carcinoma, 49 of

whom (whom (68%68%) were International Federation of ) were International Federation of Gynecology and Obstetrics Gynecology and Obstetrics Stage III or IVStage III or IV. .

Eltjo M. J. Schutter, et al, JUOG, 1994

http://www3.interscience.wiley.com/journal/112686925/abstract


Kesehatan

Diagnostic value of Diagnostic value of pelvic examination, ultrasound, pelvic examination, ultrasound, and serum CA 125and serum CA 125 in postmenopausal women with a in postmenopausal women with a

pelvic mass. An international multicenter studypelvic mass. An international multicenter study

Borderline tumors were excluded from the Borderline tumors were excluded from the statistical calculations.statistical calculations.

The The individual accuracy individual accuracy of pelvic examination, of pelvic examination,

ultrasound, and serum CA 125 in discriminating ultrasound, and serum CA 125 in discriminating between benign and malignant pelvic masses was between benign and malignant pelvic masses was approximately the same (approximately the same (76, 74, and 77%76, 74, and 77%, , respectively).respectively).

Eltjo M. J. Schutter, et al, JUOG, 1994http://www3.interscience.wiley.com/journal/112686925/abstractJJE-20080821JJE-13/07/2009

Hanya untuk Pendidikan dan Kesehatan

BenignBenign : : uniloculare, thin uniloculare, thin septum, thin wall, smooth internal septum, thin wall, smooth internal surface, low echogenicity or surface, low echogenicity or sonoluscentsonoluscent

MalignantMalignant : : multiloculare, thick multiloculare, thick septum, thick wall, papillary septum, thick wall, papillary projections from internal surface, projections from internal surface, high echogenicity or not high echogenicity or not homogenoushomogenous



Kesehatan

Prospective assessment of Prospective assessment of simple rules simple rules to to distinguish between distinguish between malignant and benign malignant and benign adnexal adnexal

masses prior to surgerymasses prior to surgery

Sunday, 24 August 2008Sunday, 24 August 2008 D. Timmerman 1 *, L. Ameye 2, C. Van Holsbeke 3, R. Fruscio 4, A. D. Timmerman 1 *, L. Ameye 2, C. Van Holsbeke 3, R. Fruscio 4, A.

Czekierdowski 5, S. Guerriero 6, A. C. Testa 7, V. Vandenbroucke 1, T. Czekierdowski 5, S. Guerriero 6, A. C. Testa 7, V. Vandenbroucke 1, T. Bourne 8, B. Van Calster 2, G. Betsas 1, P. Neven 1, S. Van Huffel 2, L. Bourne 8, B. Van Calster 2, G. Betsas 1, P. Neven 1, S. Van Huffel 2, L. Valentin 9Valentin 9

1Dept Obstetrics and Gynecology, UZ Leuven, Leuven, Belgium1Dept Obstetrics and Gynecology, UZ Leuven, Leuven, Belgium 2Electrical Engineering (ESAT-SISTA), Katholieke Universiteit Leuven, Leuven, Belgium2Electrical Engineering (ESAT-SISTA), Katholieke Universiteit Leuven, Leuven, Belgium 3Dept Obstetrics and Gynecology, UZ Leuven and ZOL Genk, Leuven and Genk, Belgium3Dept Obstetrics and Gynecology, UZ Leuven and ZOL Genk, Leuven and Genk, Belgium 4Dept Obstetrics and Gynecology, San Gerardo Hospital, Monza, Italy4Dept Obstetrics and Gynecology, San Gerardo Hospital, Monza, Italy 5Dept Obstetrics and Gynecology, Medical University, Lublin, Poland5Dept Obstetrics and Gynecology, Medical University, Lublin, Poland 6Dept Obstetrics and Gynecology, Ospedale San Giovanni di Dio, Cagliari, Italy6Dept Obstetrics and Gynecology, Ospedale San Giovanni di Dio, Cagliari, Italy 7Dept Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy7Dept Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy 8Dept Obstetrics and Gynecology, St George's Hospital and UZ Leuven, London and Leuven, 8Dept Obstetrics and Gynecology, St George's Hospital and UZ Leuven, London and Leuven,

United KingdomUnited Kingdom 9Dept Obstetrics and Gynecology, University Hospital, Malmö, Sweden9Dept Obstetrics and Gynecology, University Hospital, Malmö, Sweden

*Correspondence to D. Timmerman, Dept Obstetrics and Gynecology, UZ *Correspondence to D. Timmerman, Dept Obstetrics and Gynecology, UZ Leuven, Leuven, BelgiumLeuven, Leuven, Belgium


Kesehatan

The five simple rules to The five simple rules to predict malignancy (predict malignancy (M-M-rulesrules) ) (Timmerman D, et al, JUOG, 2008) (Timmerman D, et al, JUOG, 2008)

Irregular solid tumor; Irregular solid tumor; Ascites; Ascites; At least four papillary structures; At least four papillary structures; Irregular multilocular-solid tumor with a Irregular multilocular-solid tumor with a

largest diameter of at least 100 mm; largest diameter of at least 100 mm; Very high color score using color Doppler.Very high color score using color Doppler.

http://www3.interscience.wiley.com/cgi-bin/fulltext/121375169/HTMLSTART


Kesehatan

http://www.femalehealthmadesimple.com/FileSevenFinal.html


Kesehatan

The five simple rules to The five simple rules to suggest a benign tumor (suggest a benign tumor (B-B-

rulesrules)) Unilocular cyst; Unilocular cyst; Presence of solid components where the largest Presence of solid components where the largest

solid component is < 7 mm in largest diameter; solid component is < 7 mm in largest diameter;

Acoustic shadows; Acoustic shadows; Smooth multilocular tumor less than 100 mm in Smooth multilocular tumor less than 100 mm in

largest diameter; largest diameter; No detectable blood flow at Doppler examination.No detectable blood flow at Doppler examination.


Kesehatan

Sassone Morphology Scoring System for Ovarium and Pelvic Tumor

Score Internal Wall Septum Tumor Surface Thickness Echogenicity

1 Smooth ≤ 3 mm No-septum Sonoluscent

2 Irregular > 3 mm ≤ 3 mm Low echogenicity ≤ 3 mm

3 Papil can’t be > 3 mm Low echogenicity> 3 mmm measurement Echogenic nodule

> solid mass

4 can’t be _ _ complex echogenicevaluation> solid mass

5 _ _ _ High echogenicity


JJE-13/07/2009


Which parameters could be useful to predict Which parameters could be useful to predict malignancy in sonographically malignancy in sonographically solidsolid adnexal adnexal

masses? masses? (Acazar JL, et al, JUOG, 2008)(Acazar JL, et al, JUOG, 2008)

Symptoms suggestive Ovarian cancer 5.4% 49.5% < 0.0001Suspicious Physical exam 17.9% 69.2% < 0.0001Menopause 39.3% 69.2% < 0.0001Ascites 3.6% 61.5% < 0.0001Bilaterality 3.6% 23.4% < 0.0001Central blood flow 16.1% 95.7% < 0.0001Abundant blood flow 12.5% 67.6% < 0.0001High PSV/Low RI 19.6% 58.1% < 0.0001Median CA-125 (IU/mL) 19.6 312.1 0.005

After logistic regression analysis only central blood flow (odd ratio: 64.2, 95% CI: 17.07 to 242.03) and presence of ascites (odd ratio: 32.77, 95% CI: 5.38 to 199.72) were identified as independent predictors of malignancy. The presence of one of these two features correlated to malignancy in 98.6% of cases. The absence of both was found in 82.1% of benign tumours.

http://www3.interscience.wiley.com/cgi-bin/fulltext/121375594/HTMLSTARTJJE-13/07/2009Hanya untuk Pendidikan dan

Kesehatan

Cut-off value of RI ?? Cut-off value of RI ?? Malignancy ? Malignancy ? CONTROVERSIAL CONTROVERSIAL !! !! (equipment, knowledge of Doppler, (equipment, knowledge of Doppler, experience, and skills)experience, and skills)

RI : 0.30 – 0.60RI : 0.30 – 0.60 PI : 0.30 – 1.50PI : 0.30 – 1.50

Suspect malignancySuspect malignancy : RI < : RI < 0.40 or PI < 1.00.40 or PI < 1.0

Benign : RI > 0.70 or PI > 2.00 Benign : RI > 0.70 or PI > 2.00 B. Karsono : Pemeriksaan ultrasonografi tumor ginekologik, 2006


Kesehatan

The clinical usefulness evaluation of The clinical usefulness evaluation of new new ultrasonographic method E-flowultrasonographic method E-flow in Doppler in Doppler index ovarian tumors malignancy predictionindex ovarian tumors malignancy prediction

Ultrasound examinations was performed Ultrasound examinations was performed preoperatively in 53 patients with ovarian tumors. preoperatively in 53 patients with ovarian tumors. Malignant tumors were in 12 (22.6%) cases and 41 Malignant tumors were in 12 (22.6%) cases and 41 cases non malignant tumors. cases non malignant tumors.

We estimated vascularisation as We estimated vascularisation as Doppler index Doppler index ((number of vessels, localization, regularity, number of vessels, localization, regularity, vascular impedance and notchvascular impedance and notch) of the tumors ) of the tumors using Color Doppler (CD), Power Doppler (PD) and using Color Doppler (CD), Power Doppler (PD) and E-flow and compared this methods.E-flow and compared this methods.

D. Szpurek et al, JUOG, 32,3, 2008


Kesehatan

The clinical usefulness evaluation of new The clinical usefulness evaluation of new ultrasonographic method ultrasonographic method E-flow E-flow in Doppler in Doppler index ovarian tumors malignancy predictionindex ovarian tumors malignancy prediction

Doppler index in occurrence of ovarian cancers has: Doppler index in occurrence of ovarian cancers has: sensitivitysensitivity of 83.3%, 83.3% and of 83.3%, 83.3% and 91.7%91.7% for CD, PD and E- for CD, PD and E-flow, respectively; flow, respectively; specificityspecificity of 90.2%, 87.8%, of 90.2%, 87.8%, 92.7%92.7% and and accuracyaccuracy of 88.7%, 86.8% and of 88.7%, 86.8% and 92.5%92.5% for CD, PD and e-flow, for CD, PD and e-flow, respectively.respectively.

Negative and positive predictive values Negative and positive predictive values for e-flow for e-flow estimation were estimation were 97.4%97.4% and and 78.6%78.6%, respectively., respectively.

Prognostic values Prognostic values of analyzed methods in our group of of analyzed methods in our group of patients based on the area under ROC was: 0.940, 0.945 patients based on the area under ROC was: 0.940, 0.945 and and 0.9600.960 respectively respectively

D. Szpurek et al, JUOG, 32,3, 2008


Kesehatan


Kesehatan

↑ ↑ Accuracy of the Accuracy of the location, volume, and location, volume, and morphology (tumor and morphology (tumor and vascular)vascular)

Contrast- enhanced 3D Contrast- enhanced 3D power Dopplerpower Doppler



Kesehatan

Functional Cysts : Functional Cysts : Follicular cysts, Corpus Follicular cysts, Corpus luteum cysts, corpus luteum of pregnancy, luteum cysts, corpus luteum of pregnancy, theca lutein cyststheca lutein cysts

Surface Epithelium Inclusion CystsSurface Epithelium Inclusion Cysts Rete CystsRete Cysts Hyperreactio LuteinalisHyperreactio Luteinalis Ovarian Hyperstimulation SyndromeOvarian Hyperstimulation Syndrome Polycystic Ovarian SyndromePolycystic Ovarian Syndrome Ovarian Remnant SyndromeOvarian Remnant Syndrome Neonatal Ovarian CystsNeonatal Ovarian Cysts Paratubal, Paraovarial CystsParatubal, Paraovarial Cysts EndometriosisEndometriosis PIDPID Peritoneal Inclusion CystsPeritoneal Inclusion Cysts Marcus J. Dill-Macky et al, 2000


Kesehatan

Tabel 17.1. Jumlah kasus baru dan lama Tabel 17.1. Jumlah kasus baru dan lama neoplasma jinak neoplasma jinak ovarium tahun 2005 di RSPAD Gatot Soebrotoovarium tahun 2005 di RSPAD Gatot Soebroto

BULAN KASUS LAMA KASUS BARU

Januari 16 8

Februari 31 8

Maret 22 4

April 38 3

Mei 12 3

Juni 27 3

Juli 14 7

Agustus 20 7

September 23 6

Oktober 15 4

November 8 5

Disember 11 5

Jumlah 237 63 JJE-13/07/2009


Tabel 17.2. Penilaian prabedah dan risiko malignansi neoplasma ovariumTabel 17.2. Penilaian prabedah dan risiko malignansi neoplasma ovarium Pemeriksaan standar Risiko Malignansi Pemeriksaan Lanjutan

Anamnesis Data reproduksi (paritas, abortus), riwayat haid, KB pil, terapi infertilitas, terapi

sulih hormon, riwayat operasi (ovarium).

Umur Premanopause Pascamenopause

RendahTinggi

Riwayat Keluarga kanker ovarium dan atau payudara Ada Tidak ada

TinggiRendah

Konseling genetik

Keluhan (bila ada) Pembesaran perut, rasa penuh atau penekanan didaerah perut atau pelvik, nyeri

perut atau pinggang bagian bawah, sering berkemih, lekas lelah, nafsumakan berkurang, dan penurunan berat badan

TinggiSingkirkan kelainan yang bukan berasal dari

ovarium (Rontgent, CT-scan, MRI)

Palpasi bimanual Halus, bundar, mobilitas baik, unilateral, diameter < 10 cm Ada bagian padat/padat, tidak bergerak (ada perlekatan), bilateral, batas tidak

tegas, dan diameter > 10 cm

RendahTinggi

USG Transvaginal 2D : volume < 20 cm3 – premenopause < 10 cm3 – postmenopause > 20 cm3 – premenopause > 10 cm3 – postmenopauseUSG Transvaginal 2D : morfologi dinding halus, sekat tipis, tidak ada bagian padat, dan anekhoik ada pertumbuhan intrakista, papil-papil, sekat tebal, bagian padat, dan

ekhogenitas campuran

RendahRendahTinggiTinggi

RendahTinggi

USG 3D lebih superior dari 2D dalam hal : tampilan karakteristik dinding dalam massa Identifikasi infiltrasi tumor pada kapsul kista Pengukuran volume

USG Transvaginal Doppler berwarna dan Power Doppler, parameter arus darah :

PI > 1,0 , RI > 0,42 PI < 1,0 , RI ≤ 0,42Lokasi arus darah Perifer Sentral

RendahTinggi

RendahTinggi

Pemeriksaan kualitatif arus darah tumor dengan USG 3D Power Doppler

Posisi Struktur Pola

Petanda tumor Ca 125 < 35 U/ml Ca 125 > 35 U/ml

RendahTinggi

Generasi kedua Ca 125, Ca 15-3, Ca 19-9JJE-13/07/2009


Ovarian TorsionOvarian Torsion Massive Ovarian Massive Ovarian

EdemaEdema Ovarian Vein Ovarian Vein

ThrombosisThrombosis

Marcus J. Dill-Macky et al, 2000


Kesehatan

Surface Epithelial Stromal TumorsSurface Epithelial Stromal Tumors : : Serous Serous tumors, Mucinous tumors, Endometrioid tumors, tumors, Mucinous tumors, Endometrioid tumors, Clear cell tumors, Transitional cell (Brenner) Clear cell tumors, Transitional cell (Brenner) tumorstumors

Germ Cell TumorsGerm Cell Tumors : : Mature cystic teratomas Mature cystic teratomas (ovarian dermoid cysts), mature solid teratomas, (ovarian dermoid cysts), mature solid teratomas, Immature teratomas, Struma ovarii, Immature teratomas, Struma ovarii, dysgerminoma, Yolk sac tumorsdysgerminoma, Yolk sac tumors

Sex Cord Stromal TumorsSex Cord Stromal Tumors : : Fibroma, Fibroma, Thecoma, Granulosa cell tumors, Sertoli-Leydig Thecoma, Granulosa cell tumors, Sertoli-Leydig cell tumorscell tumors

Metastatic TumorsMetastatic Tumors

Ovarian LymphomaOvarian Lymphoma


DYSGERMINOMA

FIBROMA OVARII


Kesehatan

Thin walled Unilocular 3 – 8 cm Smooth & thin wall Contents : from serous or

serosanguineous fluid to clotted blood

Marcus J. Dill-Macky et al, 2000http://www.femalehealthmadesimple.com/FileSevenFinal.html


Kesehatan

Commonly complicated Commonly complicated by hemorrhage (corpus by hemorrhage (corpus rubrum hemorrhagicum)rubrum hemorrhagicum)

Thick hyperechoic, occasionally crenulated wall, echogenic content

Contents :Contents : from serous from serous or serosanguineous fluid or serosanguineous fluid to clotted bloodto clotted blood



Kesehatan

Enlarged and cysticEnlarged and cystic

Kobayashi et al (1997) Kobayashi et al (1997) : : monitored as a functional cyst if the cysts gradual diminution and without complication


JJE-13/07/2009 Hanya untuk Pendidikan dan Kesehatan

Frequently multilocular

The largest of the functional cysts

Overstimulation by hCG

Trophoblastic disease or iatrogenic hyperstimulation

Often bilateral

Persist for days to weeks after withdrawal of the stimulus


http://library.med.utah.edu/kw/human_reprod/mml/hrot_ot_1.html

JJE-20080821


Kesehatan

TAS : Adams criteria (1985) → ≥ 10 cysts, 2 - 18 mm, single plane, peripherally,

↑ central stroma or small cysts 2 - 4 mm

TVS : Fox criteria (1991) : ≥ 15 cysts, 2 – 10 mm

Marcus J. Dill-Macky et al, 2000http://www.femalehealthmadesimple.com/FileEightFinal.html


Kesehatan


Kesehatan

Mesonephric (Wolffian), Mesonephric (Wolffian), paramesonephric paramesonephric (Mullerian), or mesothelial (Mullerian), or mesothelial structuresstructures

Indistinguishable from simple functional cysts

Normal ipsilateral ovary Normal ipsilateral ovary close to, but separate from close to, but separate from the cystthe cyst


JJE-20080821

JJE-13/07/2009


Variety of appearanceVariety of appearance

Anechoic cysts to Anechoic cysts to diffuse low level echoes w / wo solid components to a solid-appearing mass

DD : DD : functional hemorrhage cysts functional hemorrhage cysts or other echogenic cystsor other echogenic cysts



Kesehatan

25% benign ovarian neoplasms25% benign ovarian neoplasms

50 – 70% of all ovarian serous 50 – 70% of all ovarian serous tumorstumors

Sharply marginated, anechoic masses, may be large, and usually unilocular

Internal thin walled septation

Occasionally papillary projectionsOccasionally papillary projections


JJE-20080821


Kesehatan

20 – 25% of all benign ovarian 20 – 25% of all benign ovarian neoplasmsneoplasms

75 – 85% of all ovarian mucinous 75 – 85% of all ovarian mucinous tumorstumors

Thicker & more numerous Thicker & more numerous septationsseptations

Frequently contains fine, gravity-dependent echoes produced by the thick contents

Gentle tapping Gentle tapping on the cyst wallon the cyst wall



Kesehatan

Ovarian dermoid cystsOvarian dermoid cysts

5 – 25% of all ovarian neoplasms5 – 25% of all ovarian neoplasms

Reproductive yearsReproductive years

Regional diffuse bright echoes w / wo posterior acoustic shadowing, hyperechoic lines and dots, shadowing echodensity, and fluid-fluid level



Kesehatan

Peritoneal inclusion cysts, Peritoneal inclusion cysts, inflammatory cysts of the peritoneuminflammatory cysts of the peritoneum

Trapping by peritoneal adhesions

A history of trauma, abdominal A history of trauma, abdominal surgery, PID, endometriosis, or surgery, PID, endometriosis, or combinationscombinations

May measure up to 20 cm, lined by mesothelial cells

Spider-web patternSpider-web pattern Marcus J. Dill-Macky et al, 2000


Kesehatan

The current tests available to us are The current tests available to us are not not “routine“routine,” unless you have a ,” unless you have a family history family history of ovarian cancer of ovarian cancer or have several relatives or have several relatives with early-onset with early-onset breast cancerbreast cancer..

Unfortunately, Unfortunately, 75 percent 75 percent of women with of women with ovarian cancer are diagnosed after the ovarian cancer are diagnosed after the disease has reached an disease has reached an advanced stageadvanced stage. .

Judith R at http://www.msnbc.msn.com/id/20359612/


Kesehatan

Is ovarian cancer screening a Is ovarian cancer screening a routine test?routine test?

These results were These results were notnot considered by statisticians to considered by statisticians to meetmeet the "we should routinely screen with these tests" criteria.the "we should routinely screen with these tests" criteria.

For a test to be For a test to be cost-effective cost-effective (in simple terms, worth doing (in simple terms, worth doing

on a large basis), it should have a on a large basis), it should have a PPV of 10 percentPPV of 10 percent. . This means that 10 surgeries are necessary to detect one This means that 10 surgeries are necessary to detect one

cancer. cancer.

In this study the In this study the PPV was 4 percent for an abnormal CA-PPV was 4 percent for an abnormal CA-125125 result and result and 1.6 percent for an abnormal transvaginal 1.6 percent for an abnormal transvaginal ultrasound. ultrasound.



Kesehatan

Is ovarian cancer screening a Is ovarian cancer screening a routine test?routine test?

When When both tests were abnormalboth tests were abnormal, this value was , this value was 23.5 percent 23.5 percent (meaning approximately four (meaning approximately four surgeries were needed to detect one cancer), but surgeries were needed to detect one cancer), but in women where one or both tests were not in women where one or both tests were not abnormal, abnormal, 12 out of 20 invasive cancers were 12 out of 20 invasive cancers were missed (missed (60%60%))..

That's an awful lot of cancers to miss in women That's an awful lot of cancers to miss in women

who were reassured that their tests were fine.who were reassured that their tests were fine.



Kesehatan

Role of US in Ovarian Cancer Role of US in Ovarian Cancer ScreeningScreening

Long-term survival : Long-term survival : minimalminimal

If 25% stage I If 25% stage I 75% 75% the number of women dying would the number of women dying would be be ↓ 50% ↓ 50% (Van Nagell Jr JR, 1991)(Van Nagell Jr JR, 1991)

The best studied technique for ovarian cancer screening : Ca 125 + Ultrasound examination

Ultrasound : TAS, TVSUltrasound : TAS, TVS Problems with ScreeningProblems with Screening Population to be screenedPopulation to be screened



Kesehatan

Only about Only about 85%85% of all women with ovarian of all women with ovarian cancer have raised CA125cancer have raised CA125

Only Only 50%50% of women with early stage ovarian of women with early stage ovarian

cancer have raised CA125cancer have raised CA125 Women with other conditions can also have Women with other conditions can also have

raised CA125 raised CA125 http://www.cancerhelp.org.uk/help/default.asp?page=3076


Kesehatan

Tabel 17.3. Hubungan diagnostik neoplasma ovarium secara sonografis dan patologi anatomi di RSPAD Gatot soebroto

NO. NAMA PASIEN

DATA USG TEMUAN SAAT OPERASI PATOLOGIANATOMI

1 SG(47 th)

Kistik, ekhointernal halus, 102x70 mm. D/: NOK, DD : kista simpleks

Kista paraovarial kiri Kista hidatid Morgagni paratubae

2 EA(44 th)

Kistik, unilokular, 170x131 mm, asites(-), neovas-kularisasi (-). D/ : Kista endometriosis

Kista endometriosis.Ca 125 : 29,8

Tidak ditemukan

3 LK(60 th)

Kistik, > 200 mm, partikel halus bergerak, sekat 4 mm, neovaskularisasi (-), asietes (-). Hidronefrosis dekstra. D/ : NOK permagna

Kistadenoma ovarium musinosum multilokular papiliferum

Ca 125 : 118,4

Kistadenoma musinosum papiliferum multilokular ovarium

4 NL(27 th)

Kistik, multilokular, 224x86 mm, berisi ekhointernal halus, RI : 0,4. D/: NOK multilokular kiri suspek musinosum. DD : kista endometriosis

Kista musinosum.Ca 125 : 1258,18

Kistadenoma musinosum papiliferum multilokular ovarium

5 MN(38 th)

Kistik, 137x108x167 mm, ekhointernal, RI : 0,489. D/ : NOK suspek malignansi

VC : kista endomet-riosis dengan sel atipik

Ca 125 : 961,5

Kista endometriosis, tidak ditemukan sel ganas

6 DW(29 th)

Padat, di posterior uterus, mengisi rongga abdomen, arus darah arteri sulit dinilai, asites berisi partikel kasar. D/: NOP suspek malignan. DD : mioma uteri

VC : karsinoma dengan diferensiasi buruk.

Ca. Ovarium III-CCa 125 : 273,72

Karsinoma ovarium berdiferensiasi buruk

7 IR(28 th)

Kistik, multilokular, mengisi rongga pelvik dan abdomen (asal massa tak jelas), RI : 0,513. D/: kista ovarium permagna, keganasan belum dapat disingkirkan

Kista musinosum Ca 125 : 15

Kistadenoma musinosum papiliferum ovarium dengan bagian borderline

8 RN(44 th)

Ovarium kanan : kista simpleks, 34x25,4x29,6 mm. Ovarium kiri : D/ : NOK dgn bagian padat, 60x56x67 mm, multi lokular, RI : 0,536

Kista endometriosis kiri dan kista ovarium kanan.

Ca 125 : 68,42

Kista endometriosis bilateral

9 SN(40 th)

Kistik, ekhointernal, 46x46 mm, melekat pd dinding belakang uterus. D/: suspek kista endometriosis kanan

Kista coklat bilateralCa 125 : 20,5

Kista endometriosis kanan dan kista lutein kiri yang disertai perdarahan

10 TN(28 th)

Kistik, 44x43 mm, ekho-internal kasar dengan bercak-bercak hiperekhoik. D:/ Kista dermoid kiri

Kista dermoid kiri.Ca 125 : 10,2

Kista dermoid ovarium

11 NR(44 th)

Kistik, ekhointernal kasar, batas tegas, dinding tebal, nyeri tekan, tidak tampak neovaskularisasi pada dinding. D/ : suspek NOK terinfeksi

Kista ovarium terinfeksiCa 125 : 25,35

Kista endometriosis dan mengesankan adanya abses tubo-ovarial


Kesehatan

http://www.sah.org.au/SUW/hycosy.html


Kesehatan


Kesehatan

http://www.jultrasoundmed.org/cgi/content/full/21/10/1171/F2

Figure 2. Transvaginal Doppler sonogram of a large projection showing internal vascular flow.

Figure 3. Transvaginal spectral sonogram showing a relatively low resistive index with the mural projection, indicative of a tumor.

JJE-13/07/2009


Choosing the appropriate techniques and equipments

From normal to pathological conditions, and from benign to malignant

Knowing the frequent cases

Good Informed consent, reporting & archiving

CPD


Kesehatan

Perhaps the biggest obstacle to effective screening, early Perhaps the biggest obstacle to effective screening, early detection, and (ultimately) the prevention of ovarian detection, and (ultimately) the prevention of ovarian cancer, is cancer, is our lack of understanding of exactly how and our lack of understanding of exactly how and why this disease developswhy this disease develops. .

For the time being, women who are concerned about their For the time being, women who are concerned about their ovarian cancer risk should be sure to have ovarian cancer risk should be sure to have regular regular gynecologic checkgynecologic checks and maintain an open and ongoing s and maintain an open and ongoing dialogue with their health care providers about appropriate dialogue with their health care providers about appropriate ways to address their health concerns.ways to address their health concerns.



Kesehatan

JJE-13/07/2009



Kesehatan

USG Intensif 5. Adnexa Normal & Pathology JJE 20090525

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