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

 6. MRI
 7. PET

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 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

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 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

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 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
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 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

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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

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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.

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

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

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 * 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

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 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

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 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:

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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

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 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.

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 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.

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 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
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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 %

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 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
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1. Cervix Cancer
2. Ovarium Cancer
3. Endometrium Cancer

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ENDOMETRIAL CANCER

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 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

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 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

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Diffuse endometrial abnormality

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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
43 of the cervix: stagiinng with
MR imaging. Radiology 171:245–251
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A.

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B.

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 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. 53
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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)
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CERVIX CANCER

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 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

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 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

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Shaaban et al. Diagnostic Imaging Gynecology.Elseviere. 2015

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 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.

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LYMP NODE SPREAD CARCINOMA CERVIX

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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.
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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
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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

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Ca cervix invasi parametrium Ca cervix invasi parametrium
Fat Set T1 Sagital Fat Set T2 Axial

T1 post contrast
T2 post delayed contrast

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OVARIUM CANCER

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 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
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 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

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 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

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

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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 100
peritoneal nodules

Left hydronephrosis
Right hydronephrosis

Right ureteric obstruction

Left ureteric obstruction

Eighty year old woman with stage IIIC papillary. Extensive resectable
metastatic peritoneal nodules are arrowed in the abdomen. The pelvic
disease causes bilateral ureteric obstruction with resultant bilateral
hydronephrosis 101
Omental cake

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 Endometrial Cervical Ovarian
CT has a role in assessing for always consider alternative CT scan is not usually needed
distant metastases. etiologies for diagnosis

May incidentally found on CT The features of endometrial and recognition of the appearance is
cervical carcinoma overlap important because unsuspected
findings on CT studies

Noncontrast CT: difficult to Biopsy or excision is the next Follicular and corpus luteal
differentiate from normal step cysts cannot be differentiated
uterus on the basis of CT findings alone

Post contrast CT: may show Uncomplicated ovarian cysts

diffuse thickening or mass (<20 HU unit)
within endometrial cavity

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 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

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 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

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THANK YOU

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