Histerosalpingografi

Indikasi :
• Indikasi utamanya adalah infertilitas baik primer
maupun sekunder, untuk melihat patensi tuba
(paten : terjadi pelimpahan kontras ke dalam
rongga peritoneum)
• Untuk menentukan apakah IUD masih ada dalam
kavum uteri
• Perdarahan pervaginam sedikit, misalnya karena
mioma uteri, polip endometrium, adenomatorus
• Abortus habitualis dalam trisemester kedua
• Sesudah sectio caesaria  untuk melihat parut-
parut pada serviks dan uterus
• Tumor maligna kavum uteri
• Graviditas ekstra-uterin yang lanjut
• Sebelum Inseminasi buatan  untuk melihat
apakah ada kelainan pada traktus genitalis
Kontraindikasi :
• Proses-proses inflamasi akut pada abdomen
• Pada hamil muda
• Perdarahan pervaginam yang berat
• Infeksi vagina
• Setelah kuretase atau dilatasi kanalis servikalis
• Penyakit ginjal dan jantung
• Sebelum dan sesudah menstruasi
 
Prosedur HSG

− Waktu optimum adalah hari ke 9-10 setelah haid

karena diperkirakan pada waktu tersebut uterus
sudah tenang.
− Sejak awal menstruasi sampai pemeriksaan pasien
dilarang coitus.
− Dilakukan pembuatan foto polos posisi litotomi
dengan atau tanpa fluoroskopi untuk mengetahui
adanya tumor
− Dipasang spekulum, portio dijepit dimasukkan
kontras melalui kanula.
− Karena kontras dimasukkan ke rongga (intra
caviter) dan bukannya vasa darah, kontras yang
digunakan dapat berupa kontras ionik yang
jarang menimbulkan alergi
− Kontras yang dimasukkan pertama 5 cc
− Kemudian diperhatikan, apakah kontras masuk
ke peritoneum atau tidak (peritoneal spill), atau
terjadi obstruksi seperti misalnya fibrosis post
infeksi sehingga kontras tampak menggembung
(hydrosalphynx)
− Dilakukan pemotretan saat kontras masuk ke
tuba dan saat peritoneal spill dengan posisi AP
dan Oblik
Komplikasi :
• Nyeri
• Infeksi
• Reaksi vasovagal
• Intravasasi vena
• Reaksi alergi terhadap kontras media
 
 HSG Normal

• Kanalis servikalis 3-4 cm (1/3 panjang uterus),

bentuknya lonjong
• Ismus antara kavum uteri dan kanalis servikalis lebih
sempit
• Ostium uteri internum tampak seperti penyempitan
pendek
• Kavum uteri berbentuk segitiga, sisi dan fundus uteri
lurus atau konkaf
• Fundus kadang-kadang konfeks dan lebih lebar
daripada panjang uterus
• Jarak kornu kanan dan kiri rata-rata 3,5 cm
• Sfingter kornu berbentuk seperti bawang
• Apeks kornu langsung berkanjut pada ismus tuba
yang nampak seperti garis potlot pada radiogram
dan jalannya bergelombang kemudian melebar
sebagai ampula tuba
 Congenital Uterine Abnormalities

• Uterus dibentuk oleh penggabungan sepasang

mullerian duct
• Sudut > 90˚ diantara horn diduga sebagai uterus
bikornus
 Other Uterine Abnormalities
• Fibrosis
• fibrosis subserosa : dapat menyebabkan pergeseran
rongga
• fibrosis mural : pembesaran rongga dapat disertai /
tidak disertai distorsi
• fibrosis submokosa : gambaran polypoid filling defects
dalam rongga uterus

• Polip/hiperplasia endometrium
- gambaran multiple small filling defect
• Adhesi intrauterine
• Kehamilan
 Tubal Disease

• Penyebab oklusi tuba : PID, endometriosis,

postpuerperali infection, tuberculosis
• Salpingitis isthmica nodosa  gambaran khas :
multiple diverticula
• Cornual polyps  gambaran : filling defect yang
tipis di kornu
• Indikasi mamografi :
− Skrining :
• >40th setiap tahun
• 20-30th  setiap 3 tahun
• Resiko tinggi

− Diagnostik :
• Bila ada keluhan
• Kontraindikasi :
− Hamil
− Mendekati menstruasi
− Infeksi berat pada mammae
− Beberapa saat setelah operasi mammae
• Prosedur :
− Informed consent
− Anamnesa :
• riw. Pernikahan (usia), riw menyusui, riw
keluarga, riw menopause, riw KB
• Keluhan : benjolan, ukuran, mobile, batas
• Terapi
• Riwayat nyeri, discharge, retraksi,
perubahan kulit
− Persiapan : tidak memakai logam,
perhiasan, ganti pakaian
 Kelebihan Kekurangan
MLO Bisa melihat KGB axilla Keterbatasan melihat
fibroglandular inferior
CC Semua fibroglandular terlihat Tidak bisa melihat KGB/aksila

Posisi lainnya :
1.Spot magnifikasi : daerah/ lesi tertentu saja yang diperbesar
untuk melihat ditorsi jaringan/ margin
2.Zooming : semua bagian diperbesar

Distorsi jaringan :
1.Maligna
2.Benigna : inflamasi / sikatriks
• Craniocaudal :
− Marker  lateral
• HISTOLOGI :
− Nipple : stratified squamous epithelium
− Parenkim : adipose and fibroglandular tissue
− Acinus : underlying myoepithelial
• ANATOMI :
− Lobulus : kelenjar yang memproduksi air susu
− Duktus : saluran yang membawa air susu dari
lobulus ke putting
− Stroma : jaringan lemak dan ikat yang
mengelilingi duktus dan lobulus, serta terdiri
dari pembuluh darah dan limfatik
• Batas payudara :
− Superior : klavikula
− Inferior : Inframammary fold
− Lateral : m. latissimus
− Medial : sternum
• Struktur makroskopis : nipple (jadi patokan
karena paling stabil), areola, glandula
sebacea, cauda axillaris
• Struktur mikroskopis : alveola – duktus
laktiferus intralobular-duktus laktiferus
ekstralobular- sinus laktiferus - nipple
• Zona mammae :
− Pre mammary : retronipple, mencari ca
insitu, pelebaran duktus
− Mammary : fibroglandular
− Retro mammary
• Bila ditemukan mikrokalsifikasi  BIRADS
3
• Bila ada spikula  BIRADS 5 (95% maligna)
• Makrokalsifikasi >0,5mm
• Mikrokalsifikasi <0,5mm
 MAmmografi MRI
Mikrokalsifikasi Bisa menilai fibroglandular (soft
tissue)
Tidak bisa menilai fibroglandullar

Kalau Mammo (+)  USG untuk melihat massa solid / kistik

Mammography Lexicon
• Mass : seen in 2 different projections
• if seen in only a single projection 
asymmetry
• Characteristic of mass :
− Shape : oval (may include 2 or 3
lobulations), round or irregular
− Margins : circumscribed, obscured,
microlobulated, indistinct, spiculated
− Density : high, equal, low or fat containing
A fat-containing lesion with a popcorn-like calcification
 hamartoma or fibroadenolipoma
Multiple round
circumscribed low density
masses in the right breast
 transplantation of body
fat to the breast
(lipofilling)

Hyperdense mass
with an irregular
shape and
spiculated margin.
Notice focal skin
retraction
 BIRADS 5
Architectural distortion : when normal architecture is distorted with
NO DEFINITE mass visible, include : thin straight lines or
spiculation radiating from a point, focal retraction, distortion or
straightening at the edges of the parenchyma.
DD/ : scar tissue or carcinoma
• Asymmetries :
Represent unilateral deposits of fibroglandular
tissue, NOT CONFORMING to the definition of a
mass
−Asymmetry : visible on only one
mammpographic projection  mostly caused by
superimposition of normal breast tissue
−Focal asymmetry : visible on two projections
−Global asymmetry : an asymmetry over at least
one quarter of the breast  usually a normal
variant
−Developing asymmetry : new, larger, and more
conspicuous than on a previous examination
 A focal asymmetry on MLO and CC view.
After local compression views and ultrasound 
NO MASS
ASYMMETRY MASS
Concave outward borders, usually Convex outward borders and appears
interspersed with fat denser in the center than at
GLOBAL ASYMMETRY. There is also skin
thickening, thickened septa and subtle nipple
Kalsifikasi

<1mm
• Suspicious morphology :
− Amorphous (BI-RADS 4B) : so small and/or hazy in
appearance that a more specific particle shape
cannot be determined
− Coarse heterogeneous (BI-RADS 4B) : irregular,
conspicuous calcifications (0,5-1mm), tend to
coalesce but smaller than dystrophic calcification
− Fine pleomorphic (BI-RADS 4C) : have discrete
shapes, without fine linear and linear branching
forms, usually <0,5mm
− Fine linear or fine linear branching (BI-RADS 4C) :
rhin, linear irregular calcifications, may be
discontinuous, occasionally branching forms can
be seen. Usually <0,5mm
Distribution of Calcifications
• Diffuse : distributed randomly throughout the
breast
• Regional : occupying a large portion of breast
tissue > 2cm greatest dimension
• Grouped (historically cluster) : few calcifications
occupying a small portion of breast tissue : lower
limit 5 calcifications within 1 cm and upper limit a
large number of calcifications within 2 cm
• Linear : arranged in a line, which suggests
deposits in a duct
• Segmental : suggests deposits in a duct or ducts
and their branches
Morphology: some are coarse heterogenous and some look more like
fine pleomorphic.
Distribution: Some calcifications are in a group ( <2cm) and some are
Associated features play a role in the final assessment.
For instance a BI-RADS 4-mass could get a BI-RADS 5
assessment if seen in association with skin retraction.
ULTRASOUND LEXICON
• Breast composition :
− Homogeneous echotexture – fat
− Homogeneous echotexture – fibroglandular
− Heterogeneous echotexture
• Mass :
− Orientation : parallel (benign) or not parallel
(suspicious finding)
− Echo pattern : anechoic, hypoechoic, complex
cystic and solid, isoechoic, hyperechoic,
heterogeneous
− Posterior features : enhancement, shadowing
• Calcifications : US poorly characterized
compared with mammography, but can be
recognized as echogenic foci, particularly
when in a mass.
• Associated features :
− Architectural distortion
− Duct changes
− Skin changes
− Edema
− Vascularity
− Elasticity assessment
• Special cases : cases with unique diagnosis or
pathognomonic ultrasound appearance :
− Simple cyst
− Complicated cyst
− Clustered microcysts
− Mass in or on skin
− Foreign body including implants
− Lymph nodes – intramammary
− Lymph nodes – axillary
− Vascular abnormalities
− Postsurgical fluid collection
− Fat necrosis
Final assessment categories
• BI-RADS 0 :
− Is utilized when further imaging evaluation
(e.g. additional views or ultrasound) or
retrieval of prior examinations is
required.
− Always try to avoid this category by
immediately doing additional imaging or
retrieving old films before reporting
This patient presented with a mass on the mammogram at screening,
which was assigned as BI-RADS 0 (needs additional imaging
evaluation).

Additional ultrasound demonstrated that the mass was caused by an

• BI-RADS 1 :
− The breasts are symmetric and no masses,
architectural distortion or suspicious
calcifications are present
− Do :
• Use BI –RADS 1 if there are abnormal
imaging findings in a patient with palpable
abnormality, possible a palpacle cancer,
BUT add a sentence recommending surgical
consultation or tissue diagnosis if clinically
indicated
• BI-RADS 2 :
− Like :
• Follow up after breast conservative surgery
• Involuting, calcified fibroadenomas
• Multiple large, rod like calcifications
• Intramammary lymph nodes
• Vascular calcification
• Implants
• Architectural distortion clearly related to prior
surgery
• Fat containing lesions such as oil cysts, lipomas,
galactoceles and mixed density hamartoma. They
all have characteristically benign appearances and
may be labeled with confidence
• Do :
− Agree in a group practice on whether and when to
describe benign findings in a report
− Use in screening or in diagnostic imaging when a
benign finding is prsent
− Use in the presence of bilateral lymphadenopathy,
probably reactive or infectious in origin
− Use in diagnostic imaging and recommend management
if appropriate, as in abscess or hematoma and in
implant rupture and other foreign bodies
• Don’t :
− Don’t use when a benign finding is present but nor
described in the report, then use category 1
− Don’t recommend MRI to further evaluate benign
finding
• BI-RADS 3 :
− Non palpable, circumscribed mass on a
baseline mammogram (unless it can be
shown to be a cyst, an intramammary
lymph node, or another benign finding)
− Focal asymmetry which become less dense
on spot compression view
− Solitary group of punctate calcification
a non-palpable sharply defined mass with a group of punctate
calcifications.
The mass was categorized as BI-RADS 3.
 The initial short-term follow-up of a BI-RADS 3 lesion is a unilateral
mammogram at 6 months, then a bilateral follow-up examination at
12 months. Assuming stability perform a follow-up after one year and
optionally after another year.
If the findings shows no change in the follow up the final assessment
A: benign vascular malformation.
The upper image shows a few amorphous calcifications initially
classified as BI-RADS 3.
At 12 month follow up more than five calcifications were noted in
a group.
• Do :
− Do perform initial short term follow up
after 6 months. Assuming stability perform
a follow up after one year and optionally
another year, then use category 2.
− Use in findings on mammography like :
• Noncalcified circumscribed solid mass
• Focal asymmetry
• Solitary group of punctuate calcifications
− Use in findings on US with robust evidence
to suggest :
• Typical fibroadenoma
• Isolated complicated cyst
• Clustered microcyst
− Use in a probably benign finding , while
the patient or referring clinician still
prefers biopsy.Then add sentence :
“Instead of follow up tissue diagnosis will
be performed, due to patient or referring
clinician concern”
• DON’T:
− Don’t use if unsure whether to render a benign
or suspicious. Then use category 4
− Don’t use in a screening examination
− Don’t use in a diagnostic examination if
additional imaging is required to make a final
assessment
− Don’t use if a lesion, previously assessed as
category 3 has incresed in size or extent, like
a mass on US with an increase of 20% or more
of longest dimension  use category 4
− Don’t recommend MRI to further evaluate a
probably benign finding
• BI-RADS 4 :
− Reserved for findings that do not have the classic appearance of
malignancy but are sufficiently suspicious to justify a
recommendation for biopsy
− Do :
• Use for findings sufficiently suspicious to justify biopsy
• Use in the presence of suspicious unilateral lymphadenopathy without
abnormalities in the breast
• Use category 4a in:
− Partially circumscribed mass, suggestive of (atypical) fibroadenoma
− Palpable, solitary, complex cystic and solid cyst
− Probable abscess
• Use category 4b in :
− Group amorphous or fine pleomorphic calcifications
− Nondescript solid mass with indistinct margins
• Use category 4c in :
− New group of fine linear calcifications
− New indistinct, irregular solitary mass
This finding is sufficiently suspicious to justify biopsy.
A benign lesion, although unlikely, is a possibility.
This could be for instance ectopic glandular tissue within a
heterogeneously dense breast.
Here another BI-RADS 4
abnormality.
The pathologist could report to you
• BI-RADS 5
− Highly suggestive of malignancy  for findings
that are classic breast cancers.
− Do :
• Use if a combination of highly suspicious
findings are :
− Spiculated, irregular + high density mass
− Segmental or linear arrangement + fine
linear calcifications
− Irregular spiculated mass + associated
pleomorphic calcifications
• Use in findings for which any nonmalignant
percutaneous tissue diagnosis is automatically
considered discordant
• BI-RADS 6
− Do :
• Use after incomplete excision
• Use after monitoring response to neoadjuvant
chemotherapy
− Don’t :
• Don’t use after attempted surgical excision
with positive margins and no imaging findings
other than postsurgical scarring. Use category
2 and add sentence stating the absence of
mammographic correlate for pathology.
• Don’t use for imaging findings, demonstrating
suspicious findings other than the known
cancer, then use category 4 or 5
On the initial mammogram a marker is placed in the palpable tumor.
Due to the dense fibroglandular tissue the tumor is not well seen.
Ultrasound demonstrated a 37 mm mass with indistinct and angular
margins and shadowing. After chemotherapy the tumor is not visible on
− Don’t :
• Don’t use if only highly suspicious finding is
present  4c
 YUN WOO CHANG SUBTYPES OF CYSTIC MASSES OF
THE BREAST

Type I simple cyst

type II clustered cysts
type III cyst with thin septa benign
type IV complicated cyst
type V cyst with a thick wall/septa or nodules  aspirated, treated symptom
type VI complex solid and cystic mass  biopsy with pathologic confirmation
TYPE V, VIMALIGNANt
• Sifat sel kanker :
− Infiltratif
− Invasif
− Neoangiogenesis
− Metastasis
Terima
Kasih