Diagnostic Imaging Gynecology - 3rd Edition

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 Elsevier
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DIAGNOSTIC IMAGING: GYNECOLOGY, THIRD EDITION ISBN: 978-0-323-79692-7

Inkling: 978-0-323-79693-4
Copyright © 2022 by Elsevier. All rights reserved.

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Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

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 Dedications
To my parents, who taught me the value of perseverance and hard work.
To my wife, Inji, my son, Karim, and my daughters, May and Jena, the jewels
of my life, thanks for your understanding and tremendous support.
To all my residents and fellows, whose challenging questions made
me a better radiologist.

AMS

To the people who make academic radiology worthwhile, including

my mentors, who believe in the merit of my work and continue to teach me,
and the residents with passion, who make teaching fulfilling.

DR

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Contributing Author
Refky Nicola, MS, DO
Associate Professor of Radiology
SUNY Upstate Medical University Hospital
Syracuse, New York

Additional Contributing Authors

Oguz Akin, MD
Nyree Griffin, MD, FRCR
Winnie Hahn, MD
Olga Hatsiopoulou, MD, FRCR
Marcia C. Javitt, MD, FACR
Shephard S. Kosut, MD
Deborah Levine, MD, FACR
Patricia Noël, MD, FRCPC
Caroline Reinhold, MD, MSc
Evis Sala, MD, PhD
Marc S. Tubay, MD
Paula J. Woodward, MD

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 Preface
We are delighted to present Diagnostic Imaging: Gynecology, third edition, the most
comprehensive point-of-care imaging resource for gynecologic disorders. The goal of this
book is to take the wide range of wonderfully complex topics related to gynecologic imaging
and simplify them into a useful and easy-to-understand reference for caretakers at any level
of experience, including trainees, general radiologists, gynecology imaging specialists, and
gynecologists. This has been achieved using concise, bulleted text and thoughtful grouping
of pertinent disease entities by organ, including uterus, cervix, vagina/vulva, ovary, fallopian
tubes, multiorgan disorders, and pelvic floor.

Our passionate team of radiologists has thoroughly updated the text and references from
the successful second edition, reflecting recent advances in technology and understanding of
pathologic conditions as well as changes to TNM/WHO classifications, FIGO staging, and AJCC
prognostic groups. Extensive efforts have been made to revamp the already fabulous image
galleries with new, high-quality, instructive cases for every entity. More than 2,300 annotated
images (and an additional 840 supplemental digital images) exhibit multimodality correlation
between ultrasound, sonohysterography, hysterosalpingography, MR, PET/CT, and gross
pathology.

The superb radiologic images we present were only possible because of the fine work of our
remarkable sonographers and CT/MR technologists. We are also fortunate to collaborate with
Laura Wissler, Lane Bennion, and Richard Coombs, who are the most talented and experienced
medical illustrators. They possess a rare combination of profound anatomic knowledge and an
ability to generate elegant representations of complex structures. Their contributions allow
those who contemplate their illustrations to quickly attain a deeper level of comprehension.

This production was especially efficient because of the cohesive efforts of our team, including
the image editors (Lisa Steadman and Jeffrey Marmorstone), text editors (Arthur Gelsinger,
Rebecca Bluth, Nina Themann, Terry Ferrell, and Megg Morin), graphic designer (Tom Olson),
production editors (Emily Fassett and John Pecorelli), lead editor (Kathryn Watkins), and senior
manager (Karen Concannon).

Our team is very proud of this work, and we are sure that this new volume will be a rich and often-
used addition to your practice’s collection of resources.

Akram M. Shaaban, MBBCh

Professor
Department of Radiology and Imaging Sciences
University of Utah
Salt Lake City, Utah

Douglas Rogers, MD
Assistant Professor
Department of Radiology and Imaging Sciences
University of Utah
Salt Lake City, Utah

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Acknowledgments
LEAD EDITOR
Kathryn Watkins, BA

LEAD ILLUSTRATOR
Laura C. Wissler, MA

TEXT EDITORS
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Nina Themann, BA
Terry W. Ferrell, MS
Megg Morin, BA

IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

ILLUSTRATIONS
Richard Coombs, MS
Lane R. Bennion, MS

ART DIRECTION AND DESIGN

Tom M. Olson, BA

PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS

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Sections
SECTION 1:
Techniques

SECTION 2:
Uterus

SECTION 3:
Cervix

SECTION 4:
Vagina and Vulva

SECTION 5:
Ovary

SECTION 6:
Fallopian Tubes

SECTION 7:
Multiorgan Disorders

SECTION 8:
Pelvic Floor

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 TABLE OF CONTENTS

98 Endometritis
SECTION 1: TECHNIQUES Douglas Rogers, MD and Christine O. Menias, MD
PELVIS 102 Pyomyoma
Douglas Rogers, MD
4 Ultrasound Technique and Anatomy
Douglas Rogers, MD and Marc S. Tubay, MD BENIGN NEOPLASMS
10 Sonohysterography
Akram M. Shaaban, MBBCh and Douglas Rogers, MD MYOMETRIUM
14 Hysterosalpingography
Douglas Rogers, MD and Marc S. Tubay, MD 106 Uterine Leiomyoma
20 CT Technique and Anatomy Jeffrey Dee Olpin, MD and Maryam Rezvani, MD
Marc S. Tubay, MD and Refky Nicola, MS, DO 112 Leiomyomas: Degeneration, Variants, and
24 MR Technique and Anatomy Complications
Marc S. Tubay, MD and Refky Nicola, MS, DO Jeffrey Dee Olpin, MD and Marc S. Tubay, MD
28 PET/CT Technique and Imaging Issues 120 Benign Metastasizing Leiomyoma
Marc S. Tubay, MD and Refky Nicola, MS, DO Akram M. Shaaban, MBBCh and Winnie Hahn, MD
122 Diffuse Leiomyomatosis
SECTION 2: UTERUS Douglas Rogers, MD and Christine O. Menias, MD
124 Intravenous Leiomyomatosis
INTRODUCTION AND OVERVIEW Douglas Rogers, MD
128 Disseminated Peritoneal Leiomyomatosis
36 Anatomy of the Uterus
Douglas Rogers, MD and Christine O. Menias, MD
Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
132 Lipomatous Uterine Tumors
AGE-RELATED CHANGES Douglas Rogers, MD and Christine O. Menias, MD
56 Endometrial Atrophy ENDOMETRIUM
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD 136 Endometrial Polyps
CONGENITAL Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
142 Endometrial Hyperplasia
58 Introduction to Müllerian Duct Anomalies Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
Akram M. Shaaban, MBBCh
62 Müllerian Agenesis MALIGNANT NEOPLASMS
Akram M. Shaaban, MBBCh
68 Unicornuate Uterus ENDOMETRIUM
Akram M. Shaaban, MBBCh
146 Endometrial Carcinoma
74 Uterus Didelphys
Maryam Rezvani, MD
Akram M. Shaaban, MBBCh, Nyree Griffin, MD, FRCR, and
162 Uterine Adenosarcoma
Caroline Reinhold, MD, MSc Douglas Rogers, MD
80 Bicornuate Uterus 166 Endometrial Stromal Sarcoma
Akram M. Shaaban, MBBCh Douglas Rogers, MD
84 Septate Uterus 170 Uterine Carcinosarcoma
Akram M. Shaaban, MBBCh Douglas Rogers, MD
90 Arcuate Uterus 174 Gestational Trophoblastic Neoplasms
Akram M. Shaaban, MBBCh Akram M. Shaaban, MBBCh
92 DES Exposure
Akram M. Shaaban, MBBCh MYOMETRIUM
INFLAMMATION/INFECTION 184 Uterine Leiomyosarcoma
Douglas Rogers, MD
94 Asherman Syndrome, Endometrial Synechiae
Douglas Rogers, MD and Christine O. Menias, MD

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 TABLE OF CONTENTS
VASCULAR SECTION 4: VAGINA AND VULVA
188 Uterine Arteriovenous Malformation INTRODUCTION AND OVERVIEW
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
194 Uterine Artery Embolization Imaging 288 Vaginal and Vulvar Anatomy
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD Marc S. Tubay, MD

TREATMENT-RELATED CONDITIONS CONGENITAL

200 Tamoxifen-Induced Changes 296 Lower Vaginal Atresia
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD Douglas Rogers, MD
206 Contraceptive Device Evaluation 298 Imperforate Hymen
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Douglas Rogers, MD
214 Post Cesarean Section Appearance 300 Vaginal Septa
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Douglas Rogers, MD

ADENOMYOSIS BENIGN NEOPLASMS

218 Adenomyosis 302 Vaginal Leiomyoma
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD Akram M. Shaaban, MBBCh, Olga Hatsiopoulou, MD,
224 Adenomyoma FRCR, and Evis Sala, MD, PhD
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD 308 Vulvar Slow-Flow Vascular Malformation
228 Cystic Adenomyosis Douglas Rogers, MD
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD 312 Vaginal Paraganglioma
Douglas Rogers, MD
SECTION 3: CERVIX
MALIGNANT NEOPLASMS
INTRODUCTION AND OVERVIEW 316 Vaginal Carcinoma
234 Anatomy of the Cervix Akram M. Shaaban, MBBCh
Marc S. Tubay, MD 328 Vaginal Leiomyosarcoma
Akram M. Shaaban, MBBCh, Olga Hatsiopoulou, MD,
BENIGN NEOPLASMS FRCR, and Evis Sala, MD, PhD
240 Endocervical Polyp 330 Embryonal Rhabdomyosarcoma
Douglas Rogers, MD Douglas Rogers, MD
244 Cervical Leiomyoma 334 Vaginal Yolk Sac Tumor
Douglas Rogers, MD Akram M. Shaaban, MBBCh, Olga Hatsiopoulou, MD,
FRCR, and Evis Sala, MD, PhD
MALIGNANT NEOPLASMS 338 Bartholin Gland Carcinoma
248 Corpus Uteri Sarcoma Douglas Rogers, MD
342 Vulvar Carcinoma
Maryam Rezvani, MD
Maryam Rezvani, MD
260 Adenoma Malignum
354 Vulvar Leiomyosarcoma
Douglas Rogers, MD
264 Cervical Sarcoma Douglas Rogers, MD
Douglas Rogers, MD 356 Vulvar and Vaginal Melanoma
268 Cervical Melanoma Akram M. Shaaban, MBBCh
Akram M. Shaaban, MBBCh 362 Aggressive Angiomyxoma
Douglas Rogers, MD
TREATMENT-RELATED CONDITIONS 366 Merkel Cell Tumor
Douglas Rogers, MD
272 Posttrachelectomy Appearances
Jeffrey Dee Olpin, MD and Maryam Rezvani, MD LOWER GENITAL CYSTS
MISCELLANEOUS 368 Gartner Duct Cysts
Marc S. Tubay, MD and Akram M. Shaaban, MBBCh
274 Cervical Glandular Hyperplasia 372 Bartholin Cysts
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Marc S. Tubay, MD and Akram M. Shaaban, MBBCh
278 Nabothian Cysts 378 Urethral Diverticulum
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Marc S. Tubay, MD and Akram M. Shaaban, MBBCh
282 Cervical Stenosis 382 Skene Gland Cyst
Douglas Rogers, MD Marc S. Tubay, MD and Akram M. Shaaban, MBBCh

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 TABLE OF CONTENTS
532 Yolk Sac Tumor
MISCELLANEOUS Akram M. Shaaban, MBBCh, Evis Sala, MD, PhD, and
386 Vaginal Foreign Bodies Christine O. Menias, MD
Douglas Rogers, MD 536 Choriocarcinoma
394 Vaginal Fistula Akram M. Shaaban, MBBCh and Evis Sala, MD, PhD
Marc S. Tubay, MD and Akram M. Shaaban, MBBCh 540 Carcinoid
Akram M. Shaaban, MBBCh, Evis Sala, MD, PhD, and
SECTION 5: OVARY Christine O. Menias, MD
546 Ovarian Mixed Germ Cell Tumor and Embryonal
INTRODUCTION AND OVERVIEW
Carcinoma
402 Anatomy of the Ovaries Akram M. Shaaban, MBBCh
Paula J. Woodward, MD and Akram M. Shaaban, MBBCh 550 Struma Ovarii
Akram M. Shaaban, MBBCh
PHYSIOLOGIC AND AGE-RELATED CHANGES
410 Follicular Cyst
SEX CORD-STROMAL
Akram M. Shaaban, MBBCh 556 Granulosa Cell Tumor
414 Corpus Luteum Akram M. Shaaban, MBBCh
Marc S. Tubay, MD and Akram M. Shaaban, MBBCh 562 Fibroma, Thecoma, and Fibrothecoma
420 Hemorrhagic Ovarian Cyst Akram M. Shaaban, MBBCh
Paula J. Woodward, MD 568 Sertoli and Sertoli-Leydig Cell Tumors
426 Ovarian Inclusion Cyst Akram M. Shaaban, MBBCh and Christine O. Menias, MD
Marc S. Tubay, MD 574 Sclerosing Stromal Tumor
Akram M. Shaaban, MBBCh and Evis Sala, MD, PhD
NEOPLASMS
METASTASES AND HEMATOLOGIC
432 Overview of Ovary, Fallopian Tube, and Primary
Peritoneal Carcinoma 578 Ovarian Metastases
Akram M. Shaaban, MBBCh Akram M. Shaaban, MBBCh
584 Ovarian Lymphoma
EPITHELIAL Akram M. Shaaban, MBBCh
452 Serous Cystadenoma
Akram M. Shaaban, MBBCh, Marcia C. Javitt, MD, FACR,
NONNEOPLASTIC OVARIAN LESIONS
and Shephard S. Kosut, MD 590 Endometrioma
458 Mucinous Cystadenoma Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
Akram M. Shaaban, MBBCh, Winnie Hahn, MD, and 600 Endometriosis
Deborah Levine, MD, FACR Maryam Rezvani, MD and Jeffrey Dee Olpin, MD
464 Adenofibroma and Cystadenofibroma 610 Ovarian Hyperstimulation Syndrome
Akram M. Shaaban, MBBCh Marc S. Tubay, MD and Refky Nicola, MS, DO
470 Serous Carcinoma 614 Theca Lutein Cysts
Akram M. Shaaban, MBBCh and Oguz Akin, MD Akram M. Shaaban, MBBCh, Patricia Noël, MD, FRCPC,
476 Mucinous Carcinoma and Caroline Reinhold, MD, MSc
Akram M. Shaaban, MBBCh 618 Polycystic Ovary Syndrome
482 Seromucinous Tumors Maryam Rezvani, MD and Refky Nicola, MS, DO
Akram M. Shaaban, MBBCh and Christine O. Menias, MD 624 Peritoneal Inclusion Cysts
488 Endometrioid Carcinoma Marc S. Tubay, MD and Refky Nicola, MS, DO
Akram M. Shaaban, MBBCh
494 Clear Cell Carcinoma VASCULAR
Akram M. Shaaban, MBBCh and Oguz Akin, MD 632 Ovarian Vein Thrombosis
500 Carcinosarcoma (Mixed Müllerian Tumor) Marc S. Tubay, MD and Akram M. Shaaban, MBBCh
Akram M. Shaaban, MBBCh 638 Pelvic Congestion Syndrome
504 Brenner Tumors Douglas Rogers, MD
Akram M. Shaaban, MBBCh 642 Acute Adnexal Torsion
Akram M. Shaaban, MBBCh
GERM CELL 648 Massive Ovarian Edema and Fibromatosis
510 Mature Cystic Teratoma (Dermoid Cyst) Akram M. Shaaban, MBBCh
Akram M. Shaaban, MBBCh
520 Immature Teratoma
Akram M. Shaaban, MBBCh
526 Dysgerminoma
Akram M. Shaaban, MBBCh and Oguz Akin, MD

xvi
 TABLE OF CONTENTS
756 MR of Stress Urinary Incontinence
SECTION 6: FALLOPIAN TUBES Rania Farouk El Sayed, MD, PhD
CONGENITAL MIDDLE COMPARTMENT
656 Paratubal Cyst 762 Anatomy of Uterocervical and Vaginal Support
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Rania Farouk El Sayed, MD, PhD
774 MR of Pelvic Organ Prolapse
INFLAMMATION/INFECTION
Rania Farouk El Sayed, MD, PhD
660 Hydrosalpinx
Maryam Rezvani, MD POSTERIOR COMPARTMENT
664 Salpingitis Isthmica Nodosa 782 Anatomy of Anal Canal and Anal Sphincter Complex
Paula J. Woodward, MD Rania Farouk El Sayed, MD, PhD
796 MR of Fecal Incontinence
BENIGN NEOPLASMS Rania Farouk El Sayed, MD, PhD
668 Tubal Leiomyoma 804 MR of Obstructed Defecation
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Rania Farouk El Sayed, MD, PhD

MISCELLANEOUS MULTICOMPARTMENTAL
672 Hematosalpinx 816 Multicompartmental Imaging
Maryam Rezvani, MD and Jeffrey Dee Olpin, MD Rania Farouk El Sayed, MD, PhD

SECTION 7: MULTIORGAN DISORDERS

PELVIC INFLAMMATION
676 Pelvic Inflammatory Disease
Akram M. Shaaban, MBBCh and Maryam Rezvani, MD
686 Genital Tuberculosis
Maryam Rezvani, MD
690 Actinomycosis
Maryam Rezvani, MD

MALIGNANT NEOPLASMS
694 Genital Lymphoma
Douglas Rogers, MD and Christine O. Menias, MD
700 Genital Metastases
Douglas Rogers, MD

ABNORMAL SEXUAL DEVELOPMENT

704 Complete Androgen Insensitivity Syndrome
Douglas Rogers, MD and Christine O. Menias, MD
706 Disorders of Sexual Development
Douglas Rogers, MD
710 Gonadal Dysgenesis
Douglas Rogers, MD and Christine O. Menias, MD

SECTION 8: PELVIC FLOOR

OVERVIEW
716 Anatomy of the Pelvic Floor
Rania Farouk El Sayed, MD, PhD
734 MR of the Pelvic Floor
Rania Farouk El Sayed, MD, PhD

PELVIC FLOOR DYSFUNCTION

ANTERIOR COMPARTMENT
738 Anatomy of Bladder and Urethral Support
Rania Farouk El Sayed, MD, PhD

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 THIRD EDITION

Shaaban
Rogers | Olpin
Rezvani | El Sayed | Menias