超音波教學 Section 2

1. 超音波教學Section 2 陳志堯 Director 洪正修主任 趙灌中主任 September 15, 2006

2. Ultrasonic Characteristics & Differential Diagnosis on Leiomyoma, Adenomyosis and AdenomyomaReview of the Literature

3. What is Leiomyomata? The elephant in the room

4. Uterine leiomyomas are benign myometrial neoplasms enriched in extracellular matrix.

5. Uterine leiomyomas are the most common gynecologic disease of the corpus uteri and are readily detected by trans-vaginal sonography. They are the primary indication for hysterectomy, over 200000 cases annually in US. Science June, 2005

6. Tumors occur in 77% women and approximately 25% of Caucasians have clinical significant lesions. • In African-American women, clinical disease is more severe more and concordant with prevalence. Science June, 2005

7. Risk Factors & Prevalence • The prevalence of clinical significant fibroids peaks in the perimenopausal years and declines after menopause. • Increased Risk: obesity & early menarche, race • Decreased Risk: old age of the last child birth. (COX-2, PGE) Science June, 2005

8. Genetics of Uterine Leiomyoma • Approximately 40% display cytogenetic alternations, frequently involving chromosome 12, t(12;14). (HMGA2) • Hereditary leiomyomatosis and RCC (HLRCC): Fumarate hydratase gene (FH). • Tuberous sclerosis complex gene (TSC); BHD. • CYP19 & CYP17 (black African women). • Deletions of 7q, 3q and 1p; rearrangements of 6p, 10q and 13q. Science. June 2005; Obs & Gyn. April 2006

9. Obesity Parity Race Genetic Alter FH BHD TSC2 HMG2A Autocrine: TGF.etc Estrogen & Progesterone Tumor Growth ECM

10. Leiomyomata  Leiomyosarcoma? • However, it appears that a subset of myomas with a deletion of a specific portion of chromosome 1 have both a specific cellular morphology and gene transcription profiles akin to those of leiomyosarcomas. Christacos NC. Genes Chromosomes Cancer 2006;45:304–12.

11. Location of Leiomyoma • Sub-serosa • Intra-mural • Sub-mucosal • Cervical • Broad Ligament

12. Subserosa

17. Intramural

20. Submucosa

23. Cervical

27. Broad Ligament

32. KC Wen. 2005

34. Misguided Mass Mimics Myoma

36. The Major impacts of Leiomyomata • Symptoms • Infertility a. Mechanical b. Alter the biochemical nature of intrauterine fluid C. Abnormal ultrastructure

37. Submucous and Outer Myometrium Leiomyomas are Two Distinct Clinical Entities Fertility Sterility 2003

38. Junctional Zone Myometrium • Expression levels of E and P receptors are significantly higher in submucous fibroids compared to subsersal leiomyomas. • Submucous leiomyomas have significantly less karyotype aberrations than outer myometrial leiomyomas.

39. Using color Doppler sonography, Tsuda identified a leiomyoma artery in 85% submucous leiomyoma, but only in 42% intramural leiomyoma. 4. Growth rate is less in submucous type.

40. What is Adenomyosis? What is Adednomyoma?

41. Adenmyosis is a common gynecological disorder that is characterized by the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia. Bryann Bromley. J Ultrasound Med 19:529–534, 2000 Caroline Reinhold. Human Reprod Update 4:337-349, 1998

42. Prevalence: 5~70% • This broad range is due to the different criteria used for diagnosis, as well as the diligence with which adenomyosis is pursued on pathologic examination. Kurman RJ. Pathology of the Female Genital Tract. 2nd Edition. New York, Springer-Verlag, 1984, p 297 • The frequency has been estimated between 20 and 40% of hysterectomy specimens.

43. Adenomyoma is the Nodular Form of Adenomyosis

44. Sonographic Accuracy (84.3%) • General enlargement of uterine size • Global appearance (95%) • Mottled inhomogeneous myometrial texture (Sun-shine pattern) (100%) • Small cystic spaces within myometrium (82%) • Shaggy indistinct endometrial stripe (82%) Bromley B. J Ultrasound Med. 2000

45. The Clinical Triads • Uterine enlargement • Dysmenorrhea • Menorrhagia

50. Small myometrial lucent areas