Gynecological Imaging: A Reference Guide to Diagnosis

This book provides a detailed guide to the use and interpretation of color Doppler ultrasound, CT, and MR imaging in
patients with gynecological disorders. The advantages and limitations of each modality in imaging different pathologies
are clearly presented, and advice is provided on the most appropriate option when ultrasound does not permit a definite
diagnosis or fails to determine the precise extension of a lesion. Throughout, emphasis is placed on the importance of
microscopic and macroscopic findings for a full understanding of the radiological appearances, and relevant points from
the basic sciences are also highlighted. Special attention is paid to issues of differential diagnosis and imaging
results that are characteristic of a particular type of lesion. The authors are recognized experts in the field who
draw upon their considerable experience to provide an up-to-date reference book highly relevant to everyday clinical
practice.


xi
Contents
1 General
1 Embryology of the Urogenital System and Intersexual Disorders3
J.N. Buy
1.1 Embryology of the Urogenital System . . . . . . . . . . . . . . . . . . 3
1.2 Intersexual Disorders. . . . . . . . . . . . . . 10
1.3 Congenital Abnormalities Related or Not to Intersexual Disorders. . . . . . . . . . 16
2 Anatomy and Radioanatomy of the Pelvis and the Perineum
and Anatomical Locations of Pelvic and Perineal Masses. . . . . . . . . 17
J.N. Buy
2.1 Anatomy and Radioanatomy of the Pelvis and the Perineum. . . . . . . . . . . . . . . 17
2.2 Anatomical Locations of Pelvic Masses . . . . . . . . . . . . . . . . . 31
3 Ovarian and Adrenal Hormonal Synthesis . . . . . . . 47
J.N. Buy
3.1 Ovarian Hormonal Synthesis. . . . . . . 48
3.2 Adrenal Gland Hormonal Synthesis49
4 Methods of Examination and Methods of Analysis of a Pelvic Mass or Process . . . . . 51
J.N. Buy
4.1 Bases of Diagnosis.. . . . . . . . . . . . . . . . 51
4.2 Methods of Examination. . . . . . . . . . 52
4.3 Methods of Analysis. . . . . . . . . . . . . . . 52
2 Ovary
5 Embryology, Anatomy, and Histology . . . . . . . . . . . 57
J.N. Buy
5.1 Embryology . . . . 57
5.2 Anatomy . . . . . . . 57
5.3 Histology . . . . . . 59
6 Congenital Lesions. . . . . . . . . . . . . 67
J.N. Buy
6.1 Absent Ovary . . 67
6.2 Lobulated, Accessory, and Supernumerary Ovary . . . . . . . 67
6.3 Adrenal Cortical Rests. . . . . . . . . . . . . 68
6.4 Uterus-Like Ovarian Mass. . . . . . . . . . 68
6.5 Splenic-Gonadal Fusion. . . . . . . . . . . 68
xii Contents
7 Functional Lesions of the Ovary . . . . . . . . . . . . . . . . . . 71
M. Ghossain and P. Rousset
7.1 Introduction . . . 71
7.2 Functional Lesions in Nonpregnant Women During the Reproductive Age Group . . . . . . . . . . . . . . . 71
7.3 Functional Lesions in Postmenopausal (and in Perimenopausal) Women. . . 90
7.4 Pregnancy . . . . . 94
7.5 In Young Girls . . 98
7.6 Others . . . . . . . . . 98
8 Ovarian Infertility. . . . . . . . . . . . . . 101
J.N. Buy and C. Sciot
8.1 Evaluation of Ovarian Reserve. . . . . 102
8.2 Causes of Ovarian Infertility.. . . . . . . 102
9 Surface Epithelial-Stromal Tumors of the Ovary 107
J.N. Buy
9.1 Introduction . . . 108
9.2 Principles of Imaging Characterization . . . . . . . . . . . . . . . . . 112
9.3 Serous Tumors . 114
9.4 Mucinous Tumors. . . . . . . . . . . . . . . . . 159
9.5 Endometrioid Tumor. . . . . . . . . . . . . . 193
9.6 Clear Cell Tumors. . . . . . . . . . . . . . . . . . 201
9.7 Transitional Cell Tumor: Brenner Tumor . . . . . . . . . . . . . . . . 207
9.8 Other Epithelial and Mixed Tumors214
9.9 Particular Presentations. . . . . . . . . . . 222
9.10 Extension . . . . . . 226
9.11 Tumoral Markers. . . . . . . . . . . . . . . . . . 239
9.12 Follow-Up and Recurrence. . . . . . . . . 240
10 Germ Cell Tumors. . . . . . . . . . . . . . 249
J.N. Buy and D. Vadrot
10.1 Introduction . . . 249
10.2 Classification and Frequency. . . . . . 250
10.3 Mature Cystic Teratoma (MCT). . . . . 251
10.4 Other Teratomas. . . . . . . . . . . . . . . . . . 298
10.5 Primitive Germ Cell Tumors. . . . . . . . 314
10.6 Germ Cell-Sex Cord-Stromal Cell Tumors . . . . . . . . . . . . . . . 324
11 Sex Cord-Stromal Tumors. . . . . 329
J.N. Buy
11.1 Introduction . . . 329
11.2 Embryology . . . . 329
11.3 Definitions . . . . . 330
11.4 Frequency . . . . . 330
11.5 Biology of the Normal Ovary. . . . . . . 331
11.6 Classification and General Features331
11.7 Radiologic Findings. . . . . . . . . . . . . . . 331
Contents xiii
12 Metastatic Tumors of the Ovary and Lymphomas. . . . . . . . . . . . . . . . . 377
J.N. Buy
12.1 General Features. . . . . . . . . . . . . . . . . . 377
12.2 Metastatic Tumors. . . . . . . . . . . . . . . . . 378
12.3 Malignant Lymphomas. . . . . . . . . . . . 394
13 Tumors with Functioning Stroma . . . . . . . . . . . . . . . . . 399
J.N. Buy
13.1 Definition . . . . . . 399
13.2 Frequency and Distribution. . . . . . . . 399
13.3 Mechanism of Hormone Secretion. 400
13.4 Microscopy Findings and Histochemical Investigations . 400
13.5 Types of Tumors with Functioning Stroma . . . . . . . . . . . . . . 400
13.6 Imaging Findings. . . . . . . . . . . . . . . . . 400
14 Hyperandrogenism. . . . . . . . . . . . 403
J.N. Buy
14.1 Biosynthesis of Adrenal and Ovarian Androgens . . . . . . . . 403
14.2 Clinical and Biological Findings. . . . 404
14.3 Etiology . . . . . . . . 404
14.4 Methods of Examination. . . . . . . . . . 404
14.5 Functional Lesions of the Ovary. . . . 404
14.6 Androgen-Producing Ovarian Tumors . . . . . . . . . . . . . . . . . . 406
14.7 Ovarian Gonadoblastoma. . . . . . . . . 408
14.8 Tumors with Functioning Stroma. . 408
15 Nonspecific Tumors of the Ovary Including Mesenchymal Tumors . . . . . . . . . . . . . . . . . . . 409
J.N. Buy and C. Sciot
15.1 Tumors of Fibrous Tissue Origin. . . . 409
15.2 Tumors of Muscle Origin. . . . . . . . . . . 409
15.3 Tumors of Vascular and Lymphatic Origin . . . . . . . . . . . . . . 411
15.4 Tumors of Cartilage Origin. . . . . . . . . 411
15.5 Tumors of Bone Origin. . . . . . . . . . . . 411
15.6 Tumors of Neural Tissue Origin. . . . . 411
15.7 Tumors of Adipose Tissue Origin. . . 411
15.8 Tumors of Mesothelial Origin. . . . . . 411
15.9 Ovarian Tumors of Probable Wolffian Origin . . . . . . . . . . . . 412
15.10 Rete Cysts and Tumors.. . . . . . . . . . . . 412
15.11 Hamartomas . . . 412
3 Peritoneum
16 Diseases of the Peritoneum. . . 417
J.N. Buy and K. Hassen
16.1 Inflammatory Lesions. . . . . . . . . . . . . 417
16.2 Tumor-Like Lesions. . . . . . . . . . . . . . . . 421
xiv Contents
16.3 Mesothelial Neoplasms. . . . . . . . . . . . 427
16.4 Metastatic Tumors. . . . . . . . . . . . . . . . . 431
16.5 Other Diseases of the Peritoneum. 431
4 Secondary Mullerian System
17 Secondary Mullerian System. . 439
C. Sciot and J.N. Buy
17.1 Endometriosis . . 439
17.2 Endosalpingiosis. . . . . . . . . . . . . . . . . . 502
17.3 Endocervicosis . 503
17.4 Extra-Ovarian Serous and Mucinous Tumors . . . . . . . . . . . . 503
17.5 Leiomyomatosis 503
5 Muller Duct
18 Introduction . 509
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18.1 Embryology . . . . 509
18.2 Diff erent Types of Lesions Along the Mullerian Duct
According to Histology. . . . . . . . . . . . 511
19 Congenital Abnormalities of the Mullerian Ducts. . . . . . . . . . . . . . . . . 513
J.N. Buy and M. Ghossain
19.1 Three Main Types. . . . . . . . . . . . . . . . . . 513
19.2 Associated Lesions. . . . . . . . . . . . . . . . 522
19.3 Other Abnormalities. . . . . . . . . . . . . . 524
20 Diseases of the Fallopian Tube531
J.N. Buy
20.1 Anatomy and Histology. . . . . . . . . . . 531
20.2 Non-Tumoral Tubal Lesions. . . . . . . . 534
20.3 Benign Tubal Neoplasms. . . . . . . . . . 535
20.4 Malignant Tubal Neoplasms. . . . . . . 536
21 Anatomy, Histology, and Normal Imaging of the Endometrium. . 543
J.N. Buy
21.1 Vascular Anatomy. . . . . . . . . . . . . . . . . 543
21.2 Morphology and Physiology of the Normal Endometrium. . . . . . . . . . . . . . . . . 544
21.3 Morphology of the Gestational Endometrium . . . . . . . . . . 545
21.4 Morphology of Inactive and Atrophic Endometrium . . . . 545
21.5 Normal Imaging 545
22 Benign and Malignant Endometrium . . . . . . . . . . . . 549
J.N. Buy and M. Ghossain
22.1 Atrophy . . . . . . . . 549
22.2 Polyps . . . . . . . . . 550
22.3 Endometrial Hyperplasia. . . . . . . . . . 558
Contents xv
22.4 Primitive Malignant Tumors. . . . . . . . 562
22.5 Endometritis . . . 579
22.6 Eff ects of Therapy. . . . . . . . . . . . . . . . . 579
23 Anatomy and Histology of the Uterus Body . . . . . 589
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23.1 Anatomy . . . . . . . 589
23.2 Structure of the Myometrium. . . . . . 590
23.3 Vascular Supply and Lymphatic Drainage . . . . . . . . . . . . . . 592
23.4 Histology . . . . . . 593
23.5 Radioanatomy of the Myometrium593
24 Benign and Malignant Mesenchymal Tumors of the Uterus. . . . . . 597
J.N. Buy
24.1 Introduction . . . 597
24.2 Classification . . . 598
24.3 Smooth Muscle Tumors.. . . . . . . . . . . 598
24.4 Endometrial Stromal Tumors.. . . . . . 620
24.5 Miscellaneous Mesenchymal Tumors . . . . . . . . . . . . . . . . . . . 624
24.6 Adenomyosis, Adenomyoma, and Adenomyotic Cyst . . . 626
25 Mixed Epithelial Mesenchymal Tumors . . . . . . . . . . 639
J.N. Buy
25.1 Definition . . . . . . 639
25.2 Adenofibroma . 639
25.3 Adenosarcoma . 640
25.4 Malignant Mesodermal Mixed Tumor (MMMT) or Carcinosarcoma. . . . . . . . . 642
26 Embryology, Anatomy and Histology of the Cervix. . . . . . . . . . . . . . . . 649
J.N. Buy
26.1 Embryology . . . . 649
26.2 Anatomy . . . . . . . 649
26.3 Histology . . . . . . 651
27 Benign Diseases of the Cervix653
J.N. Buy
27.1 Inflammatory Diseases. . . . . . . . . . . . 653
27.2 Metaplasia-Hyperplasia. . . . . . . . . . . 653
27.3 Cysts . . . . . . . . . . . 654
27.4 Benign Tumors . 656
28 Carcinoma and Other Tumors of the Cervix . . . . . 663
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28.1 Squamous Cell Carcinoma. . . . . . . . . 663
28.2 Adenocarcinoma. . . . . . . . . . . . . . . . . . 673
28.3 Other Epithelial Tumors. . . . . . . . . . . 680
28.4 Malignant Mesenchymal Tumors. . . 681
28.5 Mixed Epithelial and Mesenchymatous Tumors . . . . . . . . . 681
xvi Contents
28.6 Miscellaneous . . 681
28.7 Secondary Tumors. . . . . . . . . . . . . . . . 681
29 Embryology, Anatomy, and Histology of the Vagina. . . . . . . . . . . . . . 685
J.N. Buy
29.1 Embryology . . . . 685
29.2 Anatomy . . . . . . . 685
29.3 Histology . . . . . . 688
30 Diseases of the Vagina. . . . . . . . . 691
J.N. Buy
30.1 Cysts . . . . . . . . . . . 691
30.2 Benign Neoplasms. . . . . . . . . . . . . . . . 694
30.3 Malignant Neoplasms. . . . . . . . . . . . . 695
30.4 Other Pathologies. . . . . . . . . . . . . . . . . 706
30.5 Recurrence and Follow-Up. . . . . . . . . 707
6 Broad Ligament
31 Embryology Anatomy, Histology and Diseases of the Broad Ligament . . . . . . . . . . . . . . 713
J.N. Buy
31.1 Embryology, Anatomy, and Histology . . . . . . . . . . . . . . . . . . 713
31.2 WHO Classification of Tumors of the Broad Ligament and Other Uterine Ligaments . . . . . . . . . . . . . 713
31.3 Imaging Findings. . . . . . . . . . . . . . . . . 714
7 Complications of Adnexal Masses
32 Complications of Adnexal Masses . . . . . . . . . . . . . . . . 725
M. Ghossain
32.1 Intracystic Hemorrhage. . . . . . . . . . . 725
32.2 Hemorrhage in a Solid Portion of a Tumor . . . . . . . . . . . . . . 726
32.3 Rupture or Leakage. . . . . . . . . . . . . . . 726
32.4 Adnexal Torsion 732
32.5 Necrosis . . . . . . . 752
32.6 Infection . . . . . . . 753
32.7 Fistula . . . . . . . . . 754
32.8 Hernia . . . . . . . . . 755
8 Pelvic Inflammatory Disease (PID)
33 Pelvic Inflammatory Disease. . 759
J.N. Buy and C. Sciot
33.1 Anatomy and Histology of the Tube759
33.2 General Features. . . . . . . . . . . . . . . . . . 759
33.3 Acute Manifestations of PID. . . . . . . 760
Contents xvii
33.4 Chronic Manifestations of PID. . . . . 777
33.5 Chronic with Acute Inflammatory Response . . . . . . . . . . . . 782
33.6 PID Related to Uncommon Infections . . . . . . . . . . . . . . . . . . 782
9 Vulva
34 Vulva or Pudendum Embryology, Anatomy, and Histology. . . . . . . 787
J.N. Buy
34.1 Definitions . . . . . 787
34.2 Embryology . . . . 789
34.3 Anatomy . . . . . . . 790
34.4 Histology . . . . . . 792
34.5 Normal MR Imaging. . . . . . . . . . . . . . . 792
35 Benign Diseases of the Vulva. 795
J.N. Buy and J.P. Akakpo
35.1 Cysts . . . . . . . . . . . 795
35.2 Inflammatory Diseases. . . . . . . . . . . . 797
35.3 Benign Tumors . 797
35.4 Endometriosis of the Vulva. . . . . . . . 798
35.5 Congenital Abnormalities. . . . . . . . . 798
36 Premalignant and Malignant Tumors of the Vulva. . . . . . . . . . . . . . . . . 801
J.P. Akakpo and J.N. Buy
36.1 Introduction . . . 801
36.2 Squamous Tumors. . . . . . . . . . . . . . . . 801
36.3 Glandular Tumors. . . . . . . . . . . . . . . . . 806
36.4 Mesenchymal Tumors. . . . . . . . . . . . . 807
36.5 Other Malignant Vulvar Tumors. . . . 807
10 Pathology of the Pelvic Floor
37 Pelvic Floor Dysfunction. . . . . . 811
P. Rousset and B. Deval
37.1 Introduction . . . 811
37.2 Definitions . . . . . 812
37.3 Clinical Findings 813
37.4 Anatomy of Pelvic Floor Structures and Physiopathology. . . . . . . . . . . . . . . . . . 815
37.5 Imaging . . . . . . . 821
37.6 Conclusion . . . . . 837
Index . . . . . . . . . . . . . . . . 841