Imaging of Gynecological Disease 2.0

Dear Colleagues,

The evaluation of a pelvic mass, detected at routine ultrasounds or in the context of having acute symptoms, requires certain methodical steps. It is necessary to diagnose the primary site or origin of the lesion; understand whether the lesion is an intra- or an extra-peritoneal lesion; attempt to discriminate between the benign or malignant nature of the lesion; formulate a specific diagnosis; and, furthermore, in the case of a possible malignant mass, define the stage of the disease process. Transvaginal ultrasonography is a dynamic and interactive examination and, in addition to an analysis of the echostructure and “elasticity” of a pelvic mass, it also permits an assessment of site-specific pain in different pelvic areas and an evaluation of the movement of the mass in relation to adjacent structures. All these “dynamic” features, together with morphological and vascular parameters, are essential for making a correct diagnosis.

Ovarian cancer is the seventh most common cancer among women in the developed world, and most women with ovarian cancer are diagnosed at an advanced stage of disease, when large intraperitoneal dissemination has already occurred. An accurate preoperative assessment of the tumor dissemination is pivotal for adequate counseling among risks and benefits of an aggressive surgical procedure, often required to achieve a complete cytoreduction. When performed by an experienced sonographer, ultrasound has an invaluable role in the primary diagnosis of gynecological cancer, in the assessment of tumor extent in the pelvis and abdominal cavity. Finally, ultrasound allows performing a biopsy in patients with peritoneal carcinomatosis, obtaining an adequate specimen for histologic diagnosis.

Intraoperative ultrasound techniques have been used for a long time in some surgical areas, especially in liver surgery, where some authors describe the role of intraoperative ultrasound during radiofrequency ablation or hepatic resection. However, in gynecology, these methods are not yet commonly employed.

An appropriate preoperative evaluation is required to obtain an optimal surgical procedure, and transvaginal ultrasound is the most used diagnostic method due to its feasibility and availability. However, and also in benign pathology, some fibroids are difficult to detect during surgery, especially when the palpation is not possible or limited, such as during laparoscopy or mini-laparotomy.

Recently, intraoperative ultrasound examination has been proposed in this setting as a useful method to guide the surgeon during myomectomy. Ultrasound examiners and surgeons should work together more often to guarantee the best therapeutic management for the patient in a gynecological setting.

The prevalence of pelvic urinary tract infiltration on transvaginal ultrasound examination in women with gynecologic malignancy was 10%. Pelvic urinary tract assessment plays a key role during transvaginal ultrasound examination, to plan the management of patients with gynecologic cancers.

Improvements in the treatment of cervical carcinoma have made it possible to offer optimal and personalized treatment. Cervical cancer staging is based on clinical examination and histological findings. Magnetic resonance imaging is considered the optimal method for staging cervical carcinoma because of its high accuracy in assessing local extension of disease and distant metastases. Ultrasound has gained increased attention in recent years; it is faster, cheaper, and more widely available than other imaging techniques and is highly accurate in detecting tumor presence and evaluating local extension of disease. Both are often used together with computed tomography or positron emission tomography, combined with computed tomography to assess the whole body, for a more accurate detection of pathological lymph nodes and metabolic information of the disease.

Ultrasound examination is an indisputable imaging method in the diagnosis of endometriosis, as the first step in the detection, as the fundamental tool in planning the management, and as the best diagnostic instrument during surveillance of affected women.

Dr. Manuela Ludovisi
Guest Editor

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• ultrasound
• ovarian cancer
• cervical cancer
• gynecologic oncology
• endometriosis
• ultrasound biopsy
• imaging
• treatment