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Cystic Lesions of the Female Reproductive System: a Review *

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Cystic Lesions of the Female Reproductive System: a Review * JBR–BTR, 2010, 93: 56-61. CYSTIC LESIONS OF THE FEMALE REPRODUCTIVE SYSTEM: A REVIEW * M. Dujardin, A. Schiettecatte, D. Verdries, J. de Mey 1 In order to avoid unnecessary therapy or treatment delay, it is important for the radiologist to be aware of the wide range of differential diagnoses for cystic lesions of the female reproductive system. This paper gives an overview of radiological findings in the variety of physiologic and pathologic cysts which may be encountered in this field. Key-words: Pelvic organs, cysts. Lesions of the female reproduc - great advantage in diagnosing and tion, but is not clinically significant tive system comprise a large num - staging tumorous lesions in this as both cysts are managed in a sim - ber of physiologic and pathologic complex area. ilar fashion: large symptomatic cysts cysts. In order to avoid unnecessary In this article, we discuss the radi - are usually excised (4). It is however therapy or treatment delay, it is ological findings for pelvic cystic important for the radiologist to be important for the radiologist to be lesions in the female reproductive aware of the association between aware of the wide range of differen - context and emphasize some key Gartner cyst and metanephric abnor - tial diagnoses in this particular field. points each radiologist should be malities such as unilateral renal age - Since clinical symptoms of pelvic familiar with. The cystic findings dis - nesis, renal hypoplasia and ectopic cystic lesions are often non-specific, cussed include vaginal cysts type ureteral insertion (5). a correct state-of-the-art radiological embryonic cysts, inclusion cysts High resolution multiplanar T2- work-up is all the more important. and bartholin gland cysts, uterine weighted MRI imaging is the modali - Transabdominal and more specif - endometrial, as well as myometrial ty of choice for evaluating such ic transvaginal ultrasound (TVUS) cysts, cervical benign and malignant vaginal cysts, as it exhibits the cystic are definitely the first line exams in cystic lesions, the non-significant nature of the lesions and differenti - the work-up of lesions of the female paraovarian cysts, physiological and ates them from urethral diverticula. reproductive system, because of complex ovarian cysts and the wide Signal intensity on T1-weighted imag - three major advantages: conven - variety of benign, borderline and ing without contrast varies from low ience, low-invasiveness and cost malignant ovarian tumors. Finally, to high, depending on the mucine or effectiveness. Magnetic resonance we end by emphasizing some acute hemorrhagic content. No contrast imaging (MRI) on the other hand is problems, that may be of interest for enhancement is to be expected. known to be a valuable adjunctive the radiologist in an on-call setting. The most frequently encountered modality for the cystic lesion work- cyst on cross sectional imaging, the up (1). High-resolution multi-planar Vaginal cysts bartholin cyst, is typically located MRI imaging using a dedicated more posteriorly and caudally, in the phased array coil allows detailed Vaginal cysts may be embryologic posterolateral introitus and medial anatomic pelvic evaluation. More - or acquired. Acquired vaginal inclu - to the labia minora. Bartholin gland over, MRI is considered an ideal sion cysts or epidermal inclusion cysts are typically retention cysts additional modality in this area cysts can form at a given site follow - from chronic inflammation, which because of its superb soft-tissue con - ing former trauma or surgery. leads to ductal obstruction from pus trast, its lack of radiation exposure Müllerian and Gartner cysts, both or thick mucus within the bartholin and high sensitivity for fluid detec - embryonic cysts, are typically locat - glands. In a bartholin cyst varying tion. In our opinion, CT should be ed in the anterolateral vagina. contents of mucin and hemorrhage reserved for oncological staging and Usually, they present as asympto - may lead to spontaneous high signal emergency settings where the quick matic simple cysts with sizes rang - intensity on T 1 (Fig. 1). Whenever availability of MRI is lacking. ing from 1 to 7 cm (2). Occasionally, superimposed infection occurs, it The use of contrast should care - they cause a variety of symptoms presents as air-fluid levels within the fully be considered for each patient such as pain, dyspareunia, voiding cyst and an irregular rim enhance - individually, since not every physio - complaints, sense of vaginal pres - ment on CT or MRI. logical cyst requires a contrast sure, or a palpable mass (3). While enhanced study. Contrast enhanced the commonest type, the Müllerian Uterine cysts dynamic MRI studies however offer cyst, is a remnant of the para - great help in detecting and charac - mesonephric duct, the Gartner cyst Occasionally in the elderly, ultra - terizing solid vascularized compo - originates from the mesonephric sound (US) or MRI reveals a cystic nents of pelvic neoplasms and peri - duct. Distinction between the two gland dilatation combined with toneal spread of malignant disease. embryologic cysts can only be made endometrial atrophy: cystic endome - Therefore, the use of contrast offers by means of histological examina - trial atrophy (Fig. 2). The endometri - um presents in such case as a very thin atrophic layer of 4 to 5 mm. Cystic endometrial hyperplasia, on the other hand, is characterized by similar small endometrial cysts in an From: Department of Radiology, UZ Brussel, Brussels, Belgium. evenly thickened endometrium of Address for correspondence: Dr M. Dujardin, Department of Radiology, UZ Brussel, over 5 to 6 mm. Both entities are not Laerbeeklaan 101, B-1090 Brussel, Belgium. E-mail: [email protected] premalignant, provided the endome - * Paper presented at the RBRS Annual Symposium, Ghent, 14.11.2009. trium is evenly echogenic. CYSTIC LESIONS OF THE FEMALE REPRODUCTIVE SYSTEM — DUJARDIN et al 57 Fig. 1. — Follow-up MRI in the context of cervix carcinoma in a 80-year old female: unenhanced sagittal T1-weighted (A) and T2-weighted (B) images made in the context of a follow-up for cervix carcinoma in complete remission shows fluid accumula - tion in the uterus (*) caused by cervical stenosis post radio - therapy. The hyperintense cystic lesion at the introitus (arrow) which is hyperintense on T1 and hypointense on T2 is an uncom - plicated bartholin cyst and an incidental finding. Hypointensity on T2 is caused by a hemorrhagic content of this cyst. Fig. 2. — Sagittal T2-weighted image in a 81-year old woman in the context of a staging for rectal carcinoma: incidentally, the small endometrial cysts of cystic endometrial atrophy are present throughout the uterus. Junctional zone myometrial cysts can be encountered in the uterus and are highly specific for adeno - myosis. These small and easy to depict myometrial cysts may be the first to draw attention on either US or MRI to the associated thickened junctional layer of Ն 12 mm in ade - nomyosis. Such high T2-weighted signal intensity cysts within the junc - tional zone may have high signal intensity on native T1-weighted imaging as well and are in fact trapped endometrial glands. Cervical cysts On cross sectional imaging of the Fig. 3. — Contrast enhanced CT in venous phase (A) and corresponding T2-weighted cervix, common retention cysts are a high resolution MR image at 3T shows a typical nabothian cyst in the cervix (arrow) with clear cystic content and sharp edges and without any contrast enhancement. typical incidental finding and range from a few mm to 4 cm. They are called nabothian cysts and typically present as a sharply delineated cer - vical cyst, without contrast enhance - entities with adenoma malignum, a to the fringes of the tube, are merely ment (Fig. 3). Signal intensity is high rare minimally invasive adenocarci - an incidental MRI finding and pres - on T2-weighted imaging, while high noma, is occasionally difficult (7). ent as thin walled unilocular simple signal intensity on unenhanced T1- Besides a watery discharge, which is cysts filled with clear serous fluid. weighted imaging can occasionally the most common initial symptom They are of low significance to the be produced by the presence of pro - of adenoma malignum, solid com - radiologist, since they are harmless. tein content or hemorrhage. ponents in the deep cervical stroma A tunnel cluster is a special type with enhancement in a complex Physiological and functional ovarian or cluster of nabothian cysts that we multicystic mass filling the endocer - cysts may encounter as a complex multi - vical channel are suspicious of ade - cystic mass filling the endocervical noma malignum (7, 8). The Graafian or dominant follicle channel (6). Moreover, there exists is found at mid cycle and its size an overlap in imaging characteristics Paraovarian cysts ranges up to 25 mm (1). After ovula - between such a tunnel cluster, a tion, the corpus luteum remains and severe endocervical hyperplasia and Paraovarian cysts like is typically a cystic structure of less a cervical polyp. Unfortunately, since paraöphoron, epoophoron and than 15 mm. While follicles and the imaging findings overlap, exact dif - hydatids of Morgagni or appendices dominant follicle are anechoic and ferentiation of the latter three benign vesiculosae, the latter being attached thin walled, corpus luteum is typical - 58 JBR–BTR, 2010, 93 (2) Fig. 4. — Contrast enhanced CT in the venous phase in a young female performed to exclude acute appendicitis in an emergency setting,
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