HARI SOEKERSI

1
 1. Ultrasonography
 2. X-Ray
 3. Hysterography
 4. Hysteroscopy
 5. CT Scan Topik hari ini

 6. MRI
 7. PET

2
 • Transabdominal : Sensitivias 88-96 %, Spesifitas 90 - 97%
• Transvaginal : Sensitivitas 88 – 98 %, spesifitas rendah
USG

• Sensitivias 89 – 100 % ,
• Spesifitas 78,3 – 93 %.
MRI

• Sensitivitas 58 – 78 %, spesifitas 76 – 87 %
• Assess Recurrence :
PET CT • Sensitivitas 91,3 % , Spesifisitas 100 %.

• CT Konvensinal : Sensitivitas 63 – 79 %, spesifisitas 82 %

• MDCT : Sensitivitas 85 – 93 %, Spesifisitas 91- 96 %
CT SCAN

• Imaging manifestations very various , such as narrowing, dilatation, filling defects,

irregularities and diverticular
projections.
HSG

3
 In general CT is more sensitive than MRI in
demonstrating bone involvement,
calcifications, and gas bubbles
 Whereas MRI is superior in detecting soft
tissue invasion and bone marrow alterations
and in displaying the extent of a presacral
mass
 CT is recommended for staging patients with
gynecologic malignancies
 MRI is preferred in patients with presacral
mass lesions
4
5
 Sufficient information to demonstrate the
medical necessity of the examination and
allow for its proper performance and
interpretation.
 Signs and symptoms and relevant history
(including known diagnoses).
 Additional information regarding the specific
reason for the examination

6
1. Evaluation pelvic pain
2. Evaluation of known or suspected pelvic masses
or fluid collections, including gynecological
masses.
3. Evaluation of primary or metastatic
malignancies
4. Assessment for recurrence of tumors following
surgical resection.
5. Detection of complications following pelvic
surgery, e.g., abscess, radiation change, and
fistula/sinus tract formation.
6. Evaluation of pelvic inflammatory processes

7
7. Assessment of abnormalities of pelvic vascular
structures .
8. Evaluation of pelvic trauma.
9. Clarification of findings from other imaging
studies or laboratory abnormalities.
10. Evaluation of known or suspected congenital
abnormalities of pelvic organs
11. Guidance for interventional or therapeutic
procedures within pelvic.
12. Treatment planning for radiation and
chemotherapy and evaluation of tumor
response to treatment.

8
 There are no absolute contraindications to
pelvic CT examinations.
 Px with pregnancy :
It is not applicable when benefits of an
activity far exceed risk.

9
 CT Scan  Clinical practice  1970
 2 types :
- Single slice
- Multi Slice

10
 * An adult’s approximate Comparable to natural
For this procedure:
effective radiation dose is: background radiation for:

ABDOMINAL REGION:

Computed Tomography (CT)-Abdomen and Pelvis 10 mSv 3 years

Computed Tomography (CT)-Abdomen and Pelvis, repeated with and 20 mSv 7 years
without contrast material

Computed Tomography (CT)-Colonography 6 mSv 2 years

Intravenous Pyelogram (IVP) 3 mSv 1 year

Radiography (X-ray)-Lower GI Tract 8 mSv 3 years

Radiography (X-ray)-Upper GI Tract 6 mSv 2 years

11
 Tissue Intensity value (HU)
Bone 1000
Liver 40-60
White matter in brain 46
Gray matter in brain 43
Blood 40
Muscle 10-40
Kidney 30
Cerebrospinal fluid 15
Water 0
Fat -50 - 100
Air -1000

12
13
14
15
16
17
18
19
20
21
22
23
 Puasa minimal 4 jam
 GFR untuk laki-laki: (140 – umur) x BB(kg) /
[72 x Serum Kreatinin]
GFR untuk perempuan: GFR(perempuan =
GFR(laki-laki) x 0.85
 Klasifikasi gagal ginjal kronis adalah sebagai
berikut:

24
KD stage GFR level
(mL/min/1.73 m2)

Stage 1 ≥ 90

Stage 2 60 – 89

Stage 3 30 – 59

Stage 4 15 – 29

Stage 5 < 15

25
 To female pelvis imaging  orally and
intravenously
 Oral : 2% iodinated water-soluble contrast
material or 2.1% wt/vol barium sulfate
suspension
 Rectal administration of contrast material is
not routinely performed but may in some
circumstances help differentiate an adnexal
process from a primary disorder of the
rectosigmoid colon.

26
 Intravenous contrast material : 100–145 mL
of 60% iodinated intravenous contrast
material at a rate of 1.5–2 mL/sec with a
scan delay of 80–90 seconds.
 Images are obtained with 5-mm collimation
from the level of the iliac crests to the pubic
symphysis with a reconstruction interval of 4
mm and a pitch of 1.5.

27
 Use 7-mm collimation
 Reconstruction interval of 6 mm.
 In multisection helical CT, we obtain images
of the abdomen and pelvis with a 4 × 2.5-mm
detector configuration and a pitch of 6 to 7.
 Rotation time of 0.5–0.8 seconds, 
coverage of 30 mm/sec and a nominal
section thickness of 2.5 mm.
 Delayed images provide better delineation of
the ureters.
 Pregnancy must be excluded
28
14
Disadvantage
• Unable to see CT SCAN
parametrial invasion

• Radiation (Radiation
dose is 20 mSv)

Advantage:
cervical parenchyma
• Determining the relatively homogeneous
extent of the structure
disease
• Metastasis to
peritoneum, the
KGB and the solid
organ.
• For detecting CT Konvensional :
calcifications Sensitivitas 63 – 79 %, spesifisitas 82 %
MDCT
• For Std III-IV Sensitivitas 85 – 93 %, spesifisitas 91,-
96 %

29
 CERVIX CANCER ENDOMETRIAL CANCER
SENSITIVITY SPECITIVITY
SENSITIVITY SPECITIVITY

USG 88-95% 61-90%

USG 78-88% 78-87%

85-93% 91-96% CT-SCAN 67-90% 83-92%

CT-SCAN

MRI 89-100% 76-87% MRI 83-93% 85-95%

PET-CT 58-99% 76-87% 53-92% 80-99%

PET-CT

Chitra Viswanathan1, Kimberly Kirschner1,2, Mylene Truong

30
 OVARIES CANCER
SENSITIVITY SPECITIVITY

USG 78-88% 78-87%

CT-SCAN 97 % 91 %

MRI 89-100% 76-87%

PET-CT 58-99% 76-87%

Chitra Viswanathan1, Kimberly Kirschner1,2, Mylene Truong

31
32
 4

Nodus
Paraaorta
Pleksus
hipogastrik Nodus iliaka
Superior komunis Artery and
vein cerviks
Nodus iliaka
interna

Pleksus
hipogastrik
inferior Nodus iliaka
eksterna

Nodus
Pleksus uterus Inguinal

Nervous system
Lymphatic system
33
1. Cervix Cancer
2. Ovarium Cancer
3. Endometrium Cancer

34
ENDOMETRIAL CANCER

35
 The number of new cases of endometrial
cancer was 25.4 per 100,000 women per
year based on 2009-2013 cases. Endometrial
cancer is most frequently diagnosed among
women aged 55-64.

 https://seer.cancer.gov/statfacts/html/corp.html

36
37
Diffuse endometrial abnormality

38
39
40

Most common gynecologic malignancy,
and 95% of endometrial cancers occur in
women older than 40 years.
The important prognostic factors include histologic
subtype and grade
The overall mortality of endometrial cancer has
decreased by 28 % over the last two decades, due to
earlier diagnosis and treatment advances

ENDOMETRIAL
CANCER

Which is the most common histologic

Transvaginal ultrasonography (TVUS) is
subtype, tumors of grade 1 or 2 confined
widely accepted as the initial modality
within the uterine cavity (stage IA) are
to evaluate patients with abnormal
expected to show 100% disease-free
genital bleeding, providing sensitivity of
survival even without any postoperative
higher than 95% with a threshold of 5
treatment, whereas tumors of grade 3
mm

Togashi K, Nishimura K, Sagoh T, Minami S, Noma S, Fujisawa I, Nakano Y, Konishi J, Ozasa H, Konishi I et al(1989) Carcinoma
41 of the cervix: stagiinng with
MR imaging. Radiology 171:245–251
42
43
44
45
46
47
48
49
50
51
 STAGE Five-year Description
survival rates
Stage 0 90% This is known as carcinoma in situ, precancerous lesion

Stage I A 88% Cancer is found in the endometrium and less than halfway through
the muscle layer of the uterus
Stage I B 75% This is the same as stage IA but has spread more than halfway through
the muscle layer of the uterus
Stage II 69% Cancer has spread beyond the body of the uterus and into the
connective tissues of the cervix
Stage III A 58% Cancer has spread to the outer surface of the uterus and/or the
fallopian tubes or ovaries
Stage III B 50% Cancer has spread to the vagina or tissues around the uterus

Stage III C1 47% Cancer has spread to pelvic lymph nodes and some nearby tissues but
no inside the bladder or rectum
Stage III C2 Unavailable This is the same as stage IIIC1, but cancer has spread to lumbar or
para-aortic lymph nodes
Stage IV A 17% Cancer has spread to the inner linning of the bladder or rectum; it
may or may not have spread to lymph nodes but hasn't spread to
distant sites
Stage IV B 15% Cancer may or may not have spread to nearby lymph nodes but has
spread to distant lymph nodes, upper abdomen, omentum, bone, or
lung. 52
53
 CT has a role in assessing for distant
metastases.
 Although not generally used for initial
diagnosis or local staging, endometrial
carcinoma may be encountered on CT:
 noncontrast CT: difficult to differentiate
from normal uterus (especially in local
disease)
 post contrast CT: may show diffuse
thickening or mass within endometrial cavity

54
55
CT image shows a relatively hypoattenuated mass in the region of
the endometrial cavity. Diffuse myometrial thinning is evident.
Surgical pathology revealed approximately 4.0 cm of pedunculated
endometrial tumor associated with only superficial myometrial
invasion (limited to inner one third)
56
57
58
CERVIX AND VAGINAL
CANCER

59
 Infection of the cervix with human
papillomavirus (HPV) is the most common cause
of cervical cancer, although not all women with
HPV infection will develop cervical cancer.
 The number of new cases of cervix uteri cancer
was 7.5 per 100,000 women per year based on
2009-2013 cases.

https://seer.cancer.gov/statfacts/html/cervix.html

60
61
Shaaban et al. Diagnostic Imaging Gynecology.Elseviere. 2015

62
63
64
65
66
67
68
69
70
71
LYMP NODE SPREAD CARCINOMA CERVIX

72
 10

Direct Extension
 Lateral spread to involve the parametria-- the cardinal ligaments eventually are
involved. Distal to involve the vaginal fornices. Posteriorly to involve the rectum or
the uterosacral ligaments. Rectal spread is usually associated with posterior vaginal
involvement. Anterior spread to the bladder is unusual in the absence of large-
volume tumors with parametrial extension.

Lymphatic
 Parametria and drain to the external iliac, hypogastric, obturator, and common iliac
nodes. Small anterior channels pass behind the bladder and terminate in the
external iliac nodes. Posterior channels drain directly into the common iliac and
para-aortic nodes and superior rectal nodes

Hematogenous Spread
 Veins and lymphatic spaces lie close to the basement membrane. Direct blood vessel
invasion, by way of lacerated capillaries and veins, through the thoracic or through
smaller lymphatic and venous channels. Blood vessel invasion usually occurs in veins
rather than arteries. About 5% of patients with cervical cancer have hematogenous
spread.

73
74
75
76
77
78
79
80
81
82
83
84
The image shows a mass with slightly heterogeneous attenuation
that expands the cervix and is surrounded by a thin rim of
relatively preserved stroma. The cervical margins are smooth, well
defined, and intact. Parametrial soft-tissue stranding or masses are
lacking, and the periureteral fat planes are preserved.
85
This image shows a hypoattenuating tumor occupying the
entire cervix and extending to the outer posterior and right
cervical margins. This finding is consistent with full-thickness
stromal invasion. Minimal air in the center is related to the
biopsy. A vaginal tampon is present to the right of the cervix
86
This image of the mid abdomen shows borderline enlarged lymph node
in the left para-aortic region, presumably secondary to metastasis,
which is consistent with stage IVB disease. Multiple findings are
visualized in this patient in other anatomic regions

87
88
OVARIUM CANCER

89
 Ovarian cancer is rare. Women with a family
history of ovarian cancer have an increased
risk for the disease.
 The number of new cases of ovarian cancer
was 11.9 per 100,000 women per year
based on 2009-2013 cases.
 Ovarian cancer is most frequently diagnosed
among women aged 55-64.

 https://seer.cancer.gov/statfacts/html/cervix.html
90
 In ovarian cancer, CT scan is not usually needed
for diagnosis, but recognition of the appearance
of ovarian cysts is important because they are
often unsuspected findings on CT studies
 Follicular and corpus luteal cysts cannot be
differentiated on the basis of CT findings alone
 Uncomplicated ovarian cysts appear as well-
circumscribed low-attenuation (<20 HU unit)
 On MRI, the cysts demonstrate a low signal
intensity on T1-weighted images and a high
signal intensity on T2

91
 Although staging is the primary objective,
always consider alternative etiologies
 The features of endometrial and cervical
carcinoma overlap, and the chief
distinguishing characteristic is endometrial vs
endocervical origin (if this can be
ascertained)
 Unless a fibroid is confidently diagnosed,
biopsy or excision is the next step

92
93
94
95
96
97
98
99
100
101
102
 In girls:
 < 8 years mean ovarian volume on CT range
0.4-0.8cm3
 > 9 years mean ovarian volume on CT range
2.1-6.9cm3
 Corpus luteum follicle range between 9mm-
30mm
 Cystic mass larger than 30mm considered
pathologic

103
 Approximately 65% to 80% ovarian tumor are
true neoplasm, 65% are benign, 35% are
malignant
 Most common benign ovarian tumor is cystic
teratoma. Cystadenoma occur less frequently

104
 Accounts for more than 90% ovarian germ
cell tumor
 Range between 5-10 cm, and bilateral in 25%
cases

105
106
107
108
Seventy-six year old woman with a right sided malignant ovarian
mass (arrow head). The mass extends to the right pelvic side wall
and abuts the right external iliac vein (arrows). A distance of less
than 3 mm from the pelvic side wall structures is highly suggestive
of invasion 109
Eighty year old woman with stage IIIC papillary serous adenocarcinoma
of the ovary (arrowhead). Extensive resectable metastatic peritoneal
nodules are arrowed in the abdomen. The pelvic disease causes
bilateral ureteric obstruction with resultant bilateral hydronephrosis
110
111
112
113
 Ny. RT 60th
114
 Nn. YR 20th
115
 Ny. WP 70th
116
117
118
119
120
121
122
THANK YOU

123
124