1、女性盆腔解剖与CT诊断子宫的韧带：v子宫阔韧带v子宫圆韧带v子宫主韧带v骶子宫韧带卵巢的韧带：v卵巢韧带v卵巢悬韧带女性盆腔的韧带女性盆腔的韧带vThe broad ligament is formed by two layers of peritoneum,which drape over the uterus and extend laterally from the uterus to the pelvic sidewall。vThe round ligament is a band of fibromuscular tissue that attaches to the anterol
2、ateral uterine fundus just below and anterior to the fallopian tube and anterior to the ovarian ligament。vThe cardinal ligament(transverse cervical ligament,Mackenrodt ligament)forms the base of the broad ligament and provides the primary ligamentous support for the uterus and upper vagina。vThe uter
3、osacral ligament extends posteriorly from the lateral cervix and vagina at the level of the internal cervical os and forms a curved arc toward the anterior body of the sacrum at S-2 orS-3女性盆腔的韧带vThe ovarian ligament(round ligament of the ovary)extends medially from the ovary to the uterus,just infer
4、ior and posterior to the fallopian tubes and round ligaments。vThe suspensory ligament of the ovary(infundibulopelvic ligament)occupies the lateral aspect of the free upper edge of the broad ligament。Axial view of the female pelvic viscera and ligaments.Visualization of the broad ligament with CT.(a)
5、CT scan shows a large amount of ascites outlining the right cephalic free edge of the broad ligament(BL).The subtle soft-tissue structure(white arrow)extending from the posterolateral aspect of the broad ligament toward the right ovary is most consistent with the mesovarium.(b)CT scan obtained just
6、superior to a shows that the suspensory ligament attachment at the anterolateral margin of the right ovary(Ov)is contiguous to the mesovarium.Normal round ligaments.Axial view of the cardinal and uterosacral ligaments.Normal cardinal ligaments.Normal and abnornal uterosacral ligaments.Normal suspens
7、ory ligament of the ovary.女性盆腔的血供髂内动脉 阴道动脉前支 宫颈、阴道子宫动脉 子宫 输卵管、宫底、卵巢腹主动脉 卵巢动脉Uterine arteries and their normal anatomic relationship to the pelvic ureters.(a)CT scan through a normal,anteflexed uterus(U)shows bilateral uterine arteries(large arrows)arcing anteriorly over the ureters(small arrows).正常子
8、宫CT表现v三角形或卵圆形软组织团块v大小：8 cm5 cm2.5cm 9 cm 6 cm 4 cmv平扫：内膜或少量积液显示为低密度影，=12mm,高度支持子宫内膜异位；结合带=1cm，准确率75%88%v淋巴结中央坏死，准确率100%Lymph node metastases.(a)Obturator node metastasis in a 32-year-old woman who underwent radical hysterectomy.Contrast-enhanced CT scan shows a peripherally enhancing low-attenuation
9、 mass(arrows)attached to the left ilium.(b)Paraaortic node metastases in a 55-year-old woman who underwent radiation therapy.CT scan shows conglomerate enlarged lymph nodes(arrows)in the portacaval space.远处转移v腹部：腹膜种植、肝转移v胸部：肺内结节，淋巴结转移v骨转移：常见于继发淋巴结转移的骨侵犯。卵巢结构和病变正常解剖结构vDiameter:about 2.55 cm long,1.53
10、 cm wide,and 12 cm thick.体积：11cm3,最大径4cm.v卵巢系膜、子宫卵巢韧带、卵巢悬韧带.vLocation:lateral to the uterus,the posterior cul-de-sac,and superior or posterior to the uterine fundus;anterior or anteromedial to the pelvic ureter.正常卵巢CT表现vChildbearing age：usually contain visible cystic follicles or physiologic cysts。v
11、Postmenopausal ovaries：small,and often not identified，featureless soft-tissue attenuation。vPremenarchal ovaries：less frequently identified,small cysts(9 mm in diameter),with macrocysts(9 mm)being evident in older girls.CT features of normal ovaries.(1)CT scan shows that the suspensory ligaments（SL)l
12、ead to the ovaries(Ov(2)CT scan shows that the ovaries(Ov)have a characteristic morphologic appearance,with distinct cystic follicles seen in the right ovary.Normal ovaries.(a)CT scan through an anteverted uterine body(U)shows a normal right ovary with multiple large follicles(arrows).(b)Dynamic CT
13、scan through a central small cervical tumor(7)shows an anatomic variation with a low position of the ovaries(o)bilaterally.卵巢囊肿v滤泡囊肿和黄体囊肿v边界清楚，均匀低密度，直径通常小于5cm。v边界清楚，低密度，密度均匀。v囊内密度增高，边缘强化 囊内出血滤泡囊肿卵黄囊囊肿输卵管卵巢脓肿v子宫颈炎症上行感染，引发内膜炎，最后累及输卵管和卵巢。vCT特征：v宫颈增大、强化；输卵管、卵巢肿大，强化。v骶子宫韧带增厚，骶前脂肪密度增高，肾积水，临近肠管边界不清。Bilater
14、al tubo-ovarian abscesses in a 38-year-old woman who presented with fever and pelvic pain.(a)Axial contrast-enhanced CT scan shows bilateral,peripherally enhancing,thick-walled complex cystic structures with an adjacent serpiginous component(arrow).(b)Coronal oblique reformatted image helps confirm
15、the tubular nature of these structures,which proved to be bilateral tubo-ovarian abscesses at urgery.Tubo-ovarian abscesses in a 42-year-old woman.(a)Axial contrast-enhanced CT scan demonstrates secondary inflammatory involvement of the appendix(arrow).(b)CT scan obtained cephalad to a emonstrates t
16、hickening of the cecal wall(black arrows).Note the infiltration of the greater omentum (white arrow).Tubo-ovarian abscess in a 60-year-old woman who presented with pelvic discomfort and a palpable pelvic mass.(a)Axial contrast-enhanced CT scan shows a thick-walled,partially cystic enhancing mass pos
17、terior to the urinary bladder(b)in the left adnexa and displacing the uterus(U)to the right.A similar-appearing smaller mass(not shown)was also seen in the right adnexa.(b)CT scan obtained more inferiorly shows irregular thickening of the adjacent urinary bladder wall(arrow).附件扭转v50%81%并发卵巢囊肿或肿瘤v输卵管
18、水肿v附件囊性病灶，壁光滑增厚。v子宫向对侧移位v腹水v出血性坏死：病灶壁厚度大于10mm，病变实性成分无强化；输卵管出血，肿瘤内出血；血性腹水Torsion of a benign left ovarian cyst in a 43-year-old woman with a 9-day history of gradually increasing lower abdominal pain.(a)Contrast-enhanced CT scan shows a unilocular cystic mass with a mildly enhancing wall(arrows).(b)C
19、ontrast-enhanced CT scan obtained caudad to a shows a poorly enhanced masslike structure(arrows)connecting the ovarian cystic mass(M)and the uterus(U).This finding represents a twisted,thickened fallopian tube.Torsion of a left ovarian cyst with hemorrhagic infarction in an 85-year-old woman.Contras
20、tenhanced CT scan shows a high-attenuation fluid collection in the Douglas pouch(arrows),a finding that suggests hemoperitoneum.Torsion of a benign left ovarian cyst in a 55-year-old woman with a 3-day history of lower abdominal pain.Contrast-enhanced CT scan shows a unilocular cystic mass(C)with ec
21、centric smooth wall thickening along the anterior aspect(arrows).Torsion of a left ovarian dermoid cyst with hemorrhagic infarction in a 57-year-old woman.(a)Unenhanced CT scan shows a large mass(M)with a fat-fluid level and focal wall calcification.Note also the ill-defined tubular structure adheri
22、ng to the cyst wall(arrowheads).This structure had an attenuation of about 64.3 HU,a finding that suggested a tubal hemorrhage.(b)Enhanced CT scan shows the uterus deviated to the twisted side.Torsion of a serous cystadenoma of the right ovary with hemorrhagic necrosis in a 37-yearoldwoman with a 2-
23、month history of recurrent lower abdominal pain.(a)Sagittal T2-weighted MR image shows a large,multiseptated cystic tumor with a beaklike protrusion inferiorly(arrows).(b)Sagittal contrast-enhanced fat-suppressed T1-weighted MR image shows linear peripheral tumor enhancement but lack of enhancement
24、of the internal septa(arrowheads)and vascular pedicle(arrows).(c)Axial T1-weighted MR image shows a masslike tubular structure abutting the inferior margin of the mass(arrowheads),a finding that suggests a thickened fallopian tube.f fluid,U uterus.(d)Photograph of the gross specimen shows a large,mu
25、ltiseptated cystic tumor with extensive hemorrhagic necrosis.At surgery,the pedicle(arrowheads)was found to have a torsion of 900 in a counterclockwise direction.卵巢肿瘤卵巢上皮肿瘤卵巢上皮肿瘤v占卵巢肿瘤的60，卵巢恶性肿瘤的85v青春期前较少见，高峰在6070岁。v亚型：浆液性，黏液性，子宫内膜样，透明细胞及卵巢纤维上皮瘤（Brenner tumors）v良性60，恶性35，临界5囊腺瘤v浆液性和黏液性v单房和多房囊肿，囊壁及囊内
26、间隔薄而规则。Benign serous cystadenoma in a 49-year-old woman.Benign mucinous cystadenoma in a 26-year-old woman.Borderline mucinous tumor in a 20-year-old woman.Contrast-enhanced CT scan shows a large,multilocular cystic mass with variable attenuation in the locules and enhancing solid-tissue elements(ar
27、rows).囊腺癌v厚壁，间隔厚而部规则，囊内结节状突出，软组织成分，其内可有坏死，向盆腔器官侵犯，种植转移，腹水，淋巴结转移。v多房，厚壁及间隔改变，诊断恶性不可靠，可见于纤维囊腺瘤，黏液性囊腺瘤和子宫内膜瘤。v良性的黏液和浆液瘤较多见，良性的子宫内膜瘤极少见，透明细胞瘤均为恶性。Bilateral serous cystadenocarcinomas in a 50-year-old woman.Contrast-enhanced CT scan shows bilateral ovoid tumors(T)with some septa and mural nodules.囊腺癌Sero
28、us cystadenocarcinoma of the ovary with peritoneal carcinomatosis in a 60-year-old woman.Contrast-enhanced CT scans obtained at the level of the liver(a)and upper pole of the kidney(b)show a subcapsular hepatic implant with a scalloped margin(arrows in a).Diffuse multilocular cystic implants are see
29、n along the greater omentum,parietal peritoneum,gastrosplenic ligament,and lesser sac(arrowheads),and calcified peritoneal implants are noted in the gastrosplenic ligaments(arrows in b).子宫内膜癌v子宫内膜癌占卵巢恶性肿瘤的10%15%，15%30%合并子宫内膜的癌和增生。v影像学物特异性，表现为大的囊实性肿瘤，可有子宫内膜的改变。Endodermal sinus tumor in a 29-year-old
30、woman.Contrast-enhanced CT scan shows a large,complex pelvic mass with solid and cystic components(arrows).Associated ascites is also seen(*).The patient had an elevated serum -fetoprotein level of 58,000 IU/mL(normal range,0-15 IU/mL).卵巢的生殖细胞肿瘤卵巢的生殖细胞肿瘤v起源于生殖细胞，占卵巢肿瘤的第二，g 15%20%。v包括成熟的畸胎瘤，未成熟畸胎瘤，无性
31、细胞瘤，内胚窦肿瘤，胚胎癌，绒毛膜癌。v恶性生殖细胞肿瘤无特异性，通常体积较大，实性成分为主。vHOG和AFP升高有助于诊断。畸胎瘤v常见于小于45岁女性v含有脂肪密度厚壁囊性肿块，v囊壁可有钙化v脂肪平面，脂肪液体平面vRokitansky nodule，CT典型特征v未成熟畸胎瘤，发病年龄小，包含较大实性成分，表现为大的囊实性占位，可见少量脂肪成分，可有散在的钙化，肿瘤壁显示不清。Mature teratoma in a 21-year-old woman.(a)Conventional radiograph shows a large mass with fat opacity and
32、multiple toothlike calcifications,findings that indicate a typical mature teratoma.(b)Axial turbo spin-echo T1-weighted MR image(800/12)shows a well-defined round,hyperintense mass with hypointense calcifications and a mural nodule(arrows).(c)On a sagittal turbo spin-echo T2-weighted MR image(3,800/
33、99),the tumor is isointense relative to subcutaneous fat.The calcifications have low signal intensity(arrows),whereas the Rokitansky protuberance has high signal intensity(arrowheads).(d)Gadolinium-enhanced fat-suppressed FLASH T1-weighted MR image(147/4.8)demonstrates the mass with markedly decreas
34、ed signal intensity compared with the non-fat-suppressed T1-weighted image(cf b).Immature teratoma in a 23-year-old woman.(a)Contrast-enhanced pelvic CT scan shows a large mass with a large soft-tissue component,a cystic portion,small foci of fat,and scattered calcifications.(b)CT scan obtained at t
35、he level of the renal hilum demonstrates extensive retroperitoneal adenopathy.无性细胞瘤Dysgerminomas v常见于年轻女性。v 5%无性细胞瘤可引起HCG升高。v可有斑点状钙化。v典型表现为分叶状实性肿物，其内可见纤维血管分隔，有出血和坏死。Dysgerminoma in an 18-year-old woman.Contrast-enhanced CT scan shows a large,multilobulated solid mass with highly enhancing fibrovascu
36、lar septa(arrows)and cystic change(arrowheads).Dysgerminoma in a 17-year-old girl.(a)Axial turbo spin-echo T2-weighted MR image(3,800/99)shows a large,multilobulated mass with intermediate signal intensity and persistent low signal intensity of the septa(arrows).The irregular high-signal-intensity a
37、reas(arrowheads)indicate necrosis.(b)Axial gadolinium-enhanced turbo spin-echo T1-weighted MR image(782/14)demonstrates relatively homogeneous enhancement with persistent low signal intensity of the septa(arrows)and unenhanced necrotic areas(arrowheads).Endometrioid carcinoma of the ovary and endome
38、trial carcinoma of the uterus in a 38-year-old woman.(a)Contrast-enhanced lower abdominal CT scan shows a complex cystic and solid tumor with enhancement of the solid-tissue elements and a thick,irregular wall.(b)Contrast-enhanced pelvic CT scan shows a widened endometrial cavity with a nodular enha
39、ncing solid mass(arrowheads).性索间质肿瘤Sex CordStromal Tumors性索间质肿瘤Sex CordStromal Tumors v占卵巢肿瘤的8%，可累及各种年龄。v最常见的：粒层细胞肿瘤，卵巢纤维泡膜细胞瘤，and Sertoli-Leydig 细胞瘤 v引发激素水平的改变粒层细胞肿瘤v最常见的卵巢性索细胞瘤。v常见于更年期和绝经期，3%25%患者高雌激素血症。v影像学特征：实性，多房囊性，囊性肿瘤，和上皮肿瘤比较无囊内结节，子宫改变。Granulosa cell tumor in a 71-year-old woman.(a)Sagittal t
40、urbo spin-echo T2-weighted MR image(4,275/138)shows a lobulated multilocular cystic mass that resembles a cystadenocarcinoma.However,no evidence of a papillary projection is noted.The endometrial cavity(arrows)is unusually prominent for a patient this age,a finding that is consistent with endometria
41、l hyperplasia.(b)Gadolinium-enhanced fat-suppressed FLASH T1-weighted MR image(148/4.8)demonstrates multiple well-enhanced septa,with numerous large cystic spaces lined by granulosa cells.These findings represent an extreme example of the macrofollicular pattern.卵巢癌的分期卵巢癌转移v局部浸润对侧卵巢转移浸润盆壁，直肠，乙状结肠或膀胱
42、。v腹膜种植转移，最常见的转移方式 Pouch of Douglas Paracolic gutters Surface of the small and large bowel Greater omentum Surface of the liver(perihepatic implants)Subphrenic space(right greater than left)v淋巴转移卵巢血管上腹部后腹膜淋巴结阔韧带盆腔髂内和闭孔淋巴结圆韧带髂外和腹股沟淋巴结v远处转移常见肝、肺、胸膜、肾上腺和脾等。转移瘤v结肠、胃肿瘤为最常见的原发肿瘤，其次为乳腺、肺和对侧卵巢肿瘤。vKrukenberg tumors are metastatic tumors to the ovary that contain mucin-secreting“signet ring”cells and usually originate in the gastrointestinal tract.
